- Collection:
- Georgia Health Sciences University Historical Collections in the Internet Archive
- Title:
- Southern Medical and Surgical Journal, 1861
- Date of Original:
- 1861
- Subject:
- Medicine--Periodicals
- Location:
- United States, Georgia, Richmond County, Augusta, 33.47097, -81.97484
- Medium:
- periodicals
- Type:
- Text
- Format:
- application/pdf
image/x-djvu
text/plain - External Identifiers:
- Metadata URL:
- https://archive.org/details/southern1861medi
- IIIF manifest:
- https://iiif.archive.org/iiif/3/southern1861medi/manifest.json
- Original Collection:
- Southern Medical and Surgical Journal, Medical College of Georgia, 1861
- Holding Institution:
- Augusta University, Robert B. Greenblatt, M.D. Library
- Rights:
-
SOUTHERN
fttcMcai avto Surgical Imtttutl
D BY
HENRY F. CAMPBELL, A. M., M. !>..
U BFICIA1 iX" roiii-ArATlVi- IXATOXl IN TV.
ItOBERT CAMPBELL, A. M., M. D.,
1 IX THE Mi"
./, prends h bi n ou je U trouve.
VOLUME XVII. X<>. X 1 1 . 1861.
AUGUSTA, GEORGIA:
DH. WILLIA PUBLISHER,
1861.
1402
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
(sew series.)
Wl. XVII. AUGUSTA, GEORGIA, JANUARY, Ml. NO. 1
ORIGINAL AND ECLECTIC.
ARTICLE XXIV.
FIRST UKPORT TO THE "COTTOX PLANTERS'
CONVENTION" OF GEORGIA.
On the Tert/iary Zdrru Formation of Georgia., by Joseph
Jonsb, M. D., Professor of Chemistry in the Medical Col-
lege of Georgia, and Chemist of the Cotton Planters'
Association.
(continued.)
From these several analyses of the rocks from which
these valuable wheat soils have been derived, it will be
-1
First, Lime enters largely into their composition. The
lime is found in combination with sulphuric acid, carbonic
fcwid and phosphoric acid, and with chlorine. The sulphate
of lime appears to he derived principally from the beds of
Mini, which are found amongst the shales,
ond. Magnesia is an important and constant con-
stituent of the shales and limestones. These observa-
tions in New York demonstrate that this element,
when not in the caustic condition, but combined with
carl. | other acids exerts beneficial influences upon
cereals. Observations upon the influence of dolomites
(lim< containing a large amount of carbonate of mag-
in K- ' v :rc, Massachusetts, in England, and in other
countries, f^M^istrate the cor of the conclusion
Tertiary I /' [January,
that magnesia saturated with carbonic acid gas is aol inju-
rious to vegetation.
Third. These rocks contain all the salts of soda and
potassa, as well as those of lime and magnesia, necessary
for vegetables and animals.
Fourth. These rocks also contain organic matters which
are supposed to have been derived from the plants and
animals which lived at the period of the deposition of these
rocks.
According to the returns of the wheat crop of New York
from 1*44 to 1845, the soils resulting from the decomposi-
tion of the older and harder rocks, as those of the Taconic
and Hudson and Mowhawk districts, yielded only from 8
to 9J bushels to the acre, whilst the soils of the western and
central wheat district yielded on an average L5| bushels to the
acre. The differences in the yield of the lands in these regions
have been shown by Professor Emmons to be due to differ-
ences in the physical and chemical constitution of the soil,
and to differences of the chemical and physical constitution
ot the rocks from which they have been derived.
We might multiply examples to show that a deficiency
n\ lime causes sterility, whilst its abundance promotes fer-
tility. The following examples, however, in addition to
those which we have just recorded, will be sufficient to
place the question of the value of lime beyond all doubt or
dispute.
Long bland, if we except the drift upon its northern
r that which faces the sound, lias been recovered
from the ocean it is based upon a reef of rocks upon which
Band has been washed up by the waxes, the soil is therefore
ed almost entirely of washed sand, which is exceed-
ingly porous, and contains hut little lime. Tt yields but
pom- returns to the agriculturist, unless highly manured.
The sea islands upon th >a8l o\' Georgia have a sim-
stitutiou to Long Island, but they are in many cases
e productive, on account o\ the vasl number of shells
deposited upon them by the Indian-, and left upon the sur-
ifter the last elevation of the Atlantic co
1861,] Of Georgia. 3
The soil from Schodack, New York, the analyses of
which are recorded in the tahle, contains only a trace of lime
and magnesia, is a very poor soil and is soon exhausted by
culture.
In Smitkfield, Rhode Island, a very luxuriant soil has
resulted from the mixture of the detritus of hornblende
rock and limestone. The effects of lime in rendering this
soil fertile, is demonstrated by the fact that white and red
clover, and other sweet grasses spring up upon it as they
would do upon carefully limed soils.* The tertiary soils of
Rhode Island, on the other hand, are wanting in vegetable
matter and lime, and are correspondingly poor and easily
exhausted.
The Black Jack lands of York and Chester, South Caro-
lina, which have resulted from the decomposition of porphry,
and which contain, according to the analysis of Professor
Tuomey, near three per cent, of carbonate of lime, and an
appreciable amount of soda and potassa, prove, when pro-
. perly drained and cultivated, to be equal to the best grain
lauds in the State of South Carolina.
From the disintegration of " rotten limestone " are pro-
duced the richest prairie soils of the counties of Green,
Sumpter and Marengo, in Alabama.
In a still farther examination of these tables, the next fact
which strikes our attention is :
(b.) The proportion of Sand and Clay varies greatly in differ-
ent soils.
The texture of soils depends in great measure upon the
proportions of sand and clay.
Pure sand forms a soil without any tenacity. The effects
of manures speedily vanish upon sandy soils.
Pure clay forms a soil of the greatest tenacity, and a soil
which is with difficulty drained.
It would be important and interesting to consider these
properties of soils in their relations to drainage, but we
most defer the thorough discussion of this subject to the
Jackson's Agricultural Report on Rhode Island, p. 128.
4 Tertiary Lime Formation [January,
report upon the soils of Georgia, and confine our attention
to their relations to lime.
The texture of the soil has important bearings upon the
action of lime, and determines in a great measure the
amount which should be applied.
And here again a knowledge of the chemical constitution
of the rocks from which the soil has been derived is of
great importance. The proportion of hard insoluble coarse
particles in soils which are generally denominated sand,
difter both in physical and chemical characters, according
as the rocks from which they have been derived differ in
these characters. Thus, we may have a coarse or a fine
sand. Thus in the highland or primary districts of New
York, the soil is coarse and the quantity of finely divided
matter is evidently deficient, because derived from hard
rocks which decompose slowly; whilst the soils derived
from theTaconic rocks are finer than those of the Primary,
and contain a greater proportion of finely divided matter,
and yet they are inferior in fineness of division, from the
soils of central and western New York, which have been
derived from Sedementary rocks of a newer date, which arc
still more rapidly decomposed. That texture alone will
influence the fertility of a soil, might be illustrated by nume-
rous examples; the following well established facts will,
serve to show the effects of division: Soils composed almost
entirely of coarse sand silex, allow the salts applied to
enrich the soil to be washed out by the rains, and both their
capillary power for fluids, and their absorbent power for
gases are weak. The power of such soils to absorb moisture,
and ammonia, and other leases from the soil, and to draw
up by capillary attraction the water from beneath will be
greatly increased by comminution or by adding sonic
material which will absorb readily moisture, which will de-
compose the coarse particles, and thus give tenacity to the
soil. Now lime is precisely the substance which accom-
plishes these effects.
It has been calculated bv Professor Leslie that in a soil
L861.] Of Georgia.
o\* gravel, the pores of which are l-100th of an inch in
diameter, water will ascend in these pores by capilliary
attraction not more than four inches; whilst if the coarse
sand have interstices oi only l-500th of an inch, water will
rise through a bed of this sand sixteen inches ; and if the
pores he still farther diminished to the l-10000th part of an
inch, water will rise in such minute capillary tubes twenty-
live and a half feet. The effect of the addition of lime to
the soil is to diminish the size of its pores, and thus increase
its power of capillary attraction.
The effect of fine division upon gases is well shown in
the case of spongy platinum if a solid piece of ordinary
platinum be plunged in a stream of hydrogen gas no effect
whatever will pe produced; whilst if finely divided pla-
tinum be plunged in the hydrogen, it will condense
the gas with such rapidity that it will become red hot,
and inflame the gas almost instantaneously. In our
own bodies the great changes of life take place in
the delicate capillaries and in the minute blood corpuscles,
not more than the l-3000th part of an inch in diameter.
Division promotes contact, and close contact allows the
play of those molecular forces which act only at infinitely
small distances, and the greatest of these forces, which can
alone be excited by close contact is chemical affinity, which
generates electricity, and is the great force in all animal and
vegetable existence. Chemical action is inseperable from
activity upon our globe it is the great source of force in
animals, and whether excited by the sun or by the secon-
dary electrical forces generated in the bowels of the earth,
it is the great force upon which vegetation absolutely de-
pends.
The following table will present a condensed view of
many of the important physical relations of Lime to Soils :
Tertiary Lime Formation
[January,
<4H
o
s
s
p
p*
0
3Q
pa
0
9
'~
^3
c3
P
>ri=
U
r-^-
X
0)
o
d,
fcJO
J
C S
222
IP
Pi
Hi
B2*
-/. 3
I~a:
a S
)
1
0
GO
b
p
o
CQ
E
i -
s
il
i
i a
B2fc fiaB'S*
hh t. -. o o>j?
T.l'4I-f l-l- - -
' =
5M
J
g-S.S^c-^
>, -
r. - -
6u
I I
gS83$S98S ;
z z jHO^oxet-e
i : : BG -r -r S G i 10 1 rr
_ . - i - z -ci-r'f-c
s i -- r -I - . : -. ' : ".
c)' e> od oo oo<
CflOCOISflCI
4iflietiootoiain9H
tie<c-ff't .-: .-: n .-: *
0O&) - 'T i -
I <T) OS C C".
II It'--
onr-tooomocoo
2 9
: :
III
^*9 5 ' ii
k55oS.
c-=5tafcic-S--e
7.-: = /:v:j>:- I
61.] Of Georgia.
From a careful comparison of these results, the following
conclusions, bearing more directly upon the employment of
Calcareous manures in agriculture may be drawn :
First: The tenacity of fine calcareous earth is less than
one-tenth of that oi' sandy clay soil, less than one-twelfth
of stiff clay soil, less than one-sixteenth of the tenacity of
Btiff clay, and twenty times less than the tenacity of pure
clay.
The tenacity of calcareous earth is Less than one-four h
the tenacity of arable land, and approaches more nearly
to that of Humus, and of the richest and best garden earth.
In wet weather stiff clay lands, o)i account of the rapid
ity and extent with which they absorb, and the obstinacy
with which they retain water, are soon converted into a stiff
cohesive mud, which is worked with great trouble and dif-
ficulty on account of the increased tenacity. In long con-
tinued dry weather, stiff clay lands on account of the extent
to which they contract and of the consequent increase of
their tenacity, not only become so hard that they are with
difficulty worked, but the roots of corn and cotton and of
all vegetables penetrate the hard dry soil with great difficul-
ty, and are greatly exposed and injured by the shrinking
and cracking of the clay during drying. Not only theory
and philosophical experiments performed in the Laboratory,
but more especially practical agricultural experience, de-
monstrate in the clearest and most indisputable manner,
that the addition of marl and of calcareous manures gener-
ally to clay soils, diminishes their tenacity in both wet and
dry weather, counteracts the tendency to shrink and crack
during dry weather, and thus renders them more easy of
cultivation, and more suitable to sustain vegetation.
oinl : Inasmuch as calcareous earth absorbs water far
more rapidly and to a much greater extent, and retain.- it
much more tenaciously than sandy -oils, and than even
1 arable land, it is evident that the addition of marls
and calcareous manures generally to sandy lands will in
crease the power of absorbing and of retaining water, and
8 Tertiary Lime Formation [January,
thus remedy a most prominent and injurious defect in this
class of soils. Here again the results of experiment and
the deductions of reason, correspond with those of actual
agricultural experience.
Third: The Ilygrometic power of calcareous earth, is not
only far greater than that of sand and sandy soils, but it is
nearly twice as great as that of good arable land. The abil-
ity to absorb moisture readily from the atmosphere is a most
valuable property in its relations to the germination and
development of the vegetable kingdom. The moisture in
the atmosphere contains not only water, which enters so
largely into the composition of all plants, but it also con-
tains small quantities of Carbonic Acid gas, Ammonia, and
in certain conditions of the atmosphere, Xitric Acid com-
pounds which play an essential part in the economy of vege-
tation. It is evident, therefore, that the addition of marls
and of calcareous manures to sandy soils, and in fact to
almost all arable lands, will increase their fertility, by in-
creasing their power of absorbing water and valuable com-
pounds from the atmosphere.
Fourth : Calcareous earth absorbs heat less rapidly, and
is far less subject to variations of temperature than sandy
soils, and in fact, even than good arable soils.
The rapidity with which soils allow their water to evapo-
rate influences their temperature, for during the evaporation
of the water the thousand degrees required to change the
water to the state of vapor, is abstracted principally from
the surface of the soil, upon which the evaporation is taking
place. It is evident from this fact that soils which retain
their moisture with tenacity, and consequently allow
their water to escape by evaporation slowly, and at
the same time absorb heat slowly and part with it cor-
respondingly slowly, must necessarily possess a far more
uniform temperature, and must as a necessary consequence
be far more favorable to vegetation than soils which allow
of rapid evaporation, and rapid aborption and radiation of
)ieat.
1861.] 0/ Georgia.
The addition of marls and of calcareous manures, gen-
erally to sandy soils will render their temperature more
uniform.
A still farther comparison of the results embodied in the
tables of the composition of the soils of various countries
and States in Europe and America, leads to the observation
that soils differ greatly in the proportion of organic matters.
An accurate knowledge of the amounts of organic mat-
ter in soils, is essential to the intelligent and successful ap-
plication of calcaceous manures to land.
The intelligent and successful application of calcaceous
manures must depend upon a knowledge of the chemical
relations of lime to the inorganic and organic constituents
of the soils.
(c) Chemical Relations of Lime to the Inorganic and Organic
Constituents of Soils.
The effects of lime upon the constituents of soils are not
merely physical effects ; as marked and as important as are
the physical effects of calcareous manures upon soils, the
chemical effects are still more decided and important.
l>y the following simple experiments, the planter may
demonstrate to himself, that lime exerts chemical effects
upon manures, soils and rocks.
If lime be mixed with Peruvian Guano there will be pro-
duced, almost immediately, a strong smell of Ammonia;
the Hnie has displaced the Ammonia, and combined with
the Carbonic Acid and other organic and inorganic acids
which had formed with the Ammonia of the Guano, solid
compounds; the same effect will be produced by the addi-
tion of lime to stable or cow-pen manure. This effect of
lime upon the compounds of Ammonia, is exceedingly in-
teresting to the planter, as indicating the impropriety of ad-
ding quick lime to manures which contain the valuable
ingredient Ammonia.
If we carefully wash out all the soluble matters from
manure of any kind, and then add lime, we will obtain,, at-
10 Tertiary TArru Formation [January,
ter allowing the mixture to remain for several hours, an ad-
ditional amount of soluble matter.
[f we place a definite quantity of soil upon a filter, and
pass pure water through it until every trace of soluble mat-
ter is removed, (which may be determined by evaporating
the distilled water after its passage through the soil, in a
clear watch glass or silver plate,) and then add to the soil
lime, and allow the mixture to remain in a moist state for
several days, and again pass distilled water through the
mixture, we will obtain an additional portion of soluble
matter, together with a portion of the lime which has been
rendered soluble by chemical combination writh the ele-
ments of the soil.
[f we boil Felspar, one of the constituents of Granite,
which contains the silicates of Potash and Alumina, with
water, or even with acids, they will dissolve but little out
of it, even after days and weeks ; if however, the Felspar be
mixed with lime, the alkali Potash maybe readily dissolved
out by means of acids, and even by water.
These experiments clearly show that when lime is added
to the soil it causes chemical changes in both the inorganic
and the organic compounds of the soil.
It is important that we should examine more closely the
chemical effects of lime upon these twro great classes of
compounds, which exist in all fertile soils.
(d) Chemical effects of Lime upon the Inorganic Constituents
of Soils.
Every fertile soil is composed in large measure of insolu-
ble Silicates, which are commonly called clay. The differ-
ent varieties of clay, although possessing many properties
in common, still differ in chemical constitution, and each
variety, although apparently nothing but a plastic mass >!
a homogeneous simple substance, is in reality composed of
eral different substances. The varieties of clay will differ
with the rocks from which they have been derived, and with
the various changes through which they have passed. Thus
kaolin or china clay may arise from the decomposition of
1861.] Of Georgia. 11
the same rock Felspar, under two different conditions; and
the kaolin will be different in each case. When felspar,
which consists of one atom of the silicate of potash, com-
bined with two atoms of silicate of Alumina, decomposes
in a wet or rainy atmosphere, the silicate of potash appear
to be simply washed away by the water, and the resulting
clay has the composition of three atoms of silica and two
atoms of alumina; when however, the felspar decomposes in
a moist, but drier atmosphere, the silicate of potash, instead
of being entirely washed away, is first decomposed, the
silicic acid combines with the silicate of alumina, and the
potash escapes as a carbonate, and the clay resulting is
composed of four atoms of silica and two of alumina.
There are nnmerous other minerals which, during their
decomposition, afford clay of various constitutions.
To illustiate this important truth to the agriculturist,
that clays are composed of a great variety of substances,
we have selected as examples three specimens of clay,
from one country (the Netherlands) taken from the Zuider-
zee, and analyzed by E. H. Von Baumhauer.
We shall, at a subsequent part of this report, present
analyses of the Joint clays of Georgia, and not only illus-
trate the propositions here announced, but also demonstrate
their great value in agriculture.
TABLE 30. CHEMICAL COMPOSITION OF CLAYS FROM THE ZUI-
DERZEE.
First. Second. Third.
Insoluble Quartzose
sand, wit
h
Alumina and Silica,
- 57.646
51.706
55.372
Soluble Silica,
-
- 2.340
2.496
2.286
Alumina,
-
- 1.830
2.900
2.888
Peroxide of Iron,
-
- 9.039
10.305
11.864
Protoxide of Iron,
-
- 0.350
0.563
0.200
Protoxide of Manganese,
- 0.288
0.3f>4
0.284
Lime,
-
- 4.092
5.096
2.480
Magnesia,
-
- 0.130
0.140
0.128
Pota
-
- 1.026
1.430
1.521
L2
Tertiary TJme Formation
[January,
First.
Second.
Third.
Soda,
-
-
-
1.972
2.069
1.937
Ammonia,
-
-
-
0.060
0.078
0.075
Phosphoric Acid.
-
-
-
0.46G
0.234
0.478
Sulphuric Acid,
-
-
.
0.896
1.104
0.576
Carbonic Acid,
-
-
-
6.085
6.940
4.775
Chlorine,
-
-
-
1.240
.1.302
1.418
Ilumic Acid,
-
-
-
2.798
3.991
3.428
Crenic Acid,
-
-
-
0.771
0.730
0.037
Apoerenic Acid,
-
-
-
0.107
0.160
0.152
Ilumic, Vegetable
remains
and
Water chemically
combined
5
3.324
7.700
9.348
Wax and Resin,
-
-
-
trace
trace
trace
Loss,
-
-
~
0.512
0.611
0.753
100.000 100.000 100.00
We are .at once impressed with the important fact that
these clays contain all the elements necessary for the growth
and development of plants and animals. We shall hereafter
show that the Joint clay not only in like manner contains ail
the elements necessary for the constitution of plants and
animals, but also contains a much larger proportion of
Phosphoric Acid, than theseclays; and has by the abundance
of this fertilizing element rendered the soils with which it
has been mixed exceedingly fertile and durable, and has
through the vegetable kingdom exerted most marked and
o o o
important influences upon the physical structure ot^ the in-
habitants.
Xotwithstanding that many clays contain all the inor-
ganic compounds necessary for the production of vegeta-
bles, Btill, in almost every case, these compounds are insol-
uble, andean be obtained by the plants growing in the soil,
only in small quantities.
Carefully conducted experiments have demonstrated con-
clusively, not only that these inorganic salts are absolutely
accessary to the existence of the higher spe* ies of plants
QSed by man for food and clothing, but also that these salts
1861.] Of Georgia. 13
to be available to plants must be in a soluble condition.
It is evident therefore, that whatever tends to decompose
and render soluble the insoluble constituents of clays, will
add to the fertility of the soil.
This is precisely the effect accomplished by lime. By its
action upon the inorganic constituents of the soil, the in-
soluble silicates of the clay are decomposed, and alumina
and magnesia, and the alkalies, potash and soda, are set
free, and silica is rendered soluble.
In adding lime to the insoluble silicates of the soil, the
agriculturist acts in precisely the same manner that the
chemist does when he wishes to separate the constituents of
some insoluble and apparently undecomposable mineral as
felspar. In both cases the silica is separated and the alka-
lies liberated; and it is well known to agriculturists that
these alkalies are of the greatest importance in the success-
ful cultivation of corn and cotton, and in fact, of all plants.
To substantiate the value of these alkalies combined with
silicic acid, we need look no farther than to the valuable
effects of the Green Sand of New Jersey, the chemical
composition of which we have before given. See page 4(3,
table 12.
(e) Chemical effects of Lime upon the Organic Constituents
of Soils.
The organic matters existing in the soil have been derived
from both the vegetable and the animal kingdoms. It is
well known that these two kingdoms are mutually depen-
dent the vegetable kingdom is a great laboratory, worked
by the forces of the sun and fixed stars, in which materials
are prepared and elaborated for the animal kingdom; whilst
the animal kingdom' consumes these materials prepared by
plants, and derives from their chemical changes precisely
the same amount of force which was expended by the sun
and fixed stars in the vegetable laboratory, it does not
destroy this matter, but merely changes its form. The
vegetable products, the starch, the sugar, and all the
various compounds consumed by the animal kingdom, are
14 l\i !' i r >i L> me Formation [January,
converted into various compounds and restored to the soil,
and to the atmosphere. The principal portion restored to
the atmosphere, the poisonous Carbonic acid gas constitutes
an important element of the food of plants the same is
true o{' the ammonia resulting from the decomposition of
the feces and urine, and bodies of animals. It is admitted
thai from the atmosphere, Carbonic acid gas, water, ammo-
nia and the inorganic salts, furnished by the animal king-
dom, all the various vegetable products may be formed.
The vegetable kingdom in like manner with the animal
kingdom, is liable to constant change, generation succeeds
generation ; and as in the case of animals, the dead are ad-
ded to the soil and atmosphere. The products of the de-
composition of the vegetable kingdom which we call Hu-
mus, have all existed in the atmosphere, at some former
period in the form of gas, and will exist in some future
period again in the atmosphere in the form of gas, and will
again be sbsorbed by the vegetable kingdom, and under the
influence of the heat and light of the sun these gases will
again be decomposed, the elements combined with other
elements so as to form solids, destined to go through the
same round of changes.
The great fact which we wish, by these well established
facts, to illustrate and impress upon the minds of the plan-
ters is, that the organic matters of the soil are in a state o\
change, and that this change is absolutely necessary to
the existence of the vegetable and animal kingdoms. If
the organic matters of the soil remain unchanged, vege-
tation would go ow consuming the Carboni3 acid and
Ammonia, and the nitrogen <A' the atmosphere, and convert-
ing the great proportion o\' the compounds resulting from
the action of the vegetable kingdom into insoluble useless
forms. Whilst it would be true that the animal kingdom
would convert a certain portion of the compounds formed
by plants into those gaseous compounds necessary for the
existence ^\' the vegetable kingdom, still it is evident that
there would be a constant diminution of the matter circula-
1861.] Of Georgia. 15
ting between the two kingdoms, for every leaf and tree that
died would abstract a certain portion of this changing mat-
ter, and place it in a state of permanent rest.
Humus then is one of the states through which matter
passes during its circulation between the animal and vege-
table kingdoms.
The principle of practical importance which we derive
from these facts is, that the rapid change of vegetable and
animal matters into gaseous products is favorable to the
development and perfection of crops.
If wood, leaves and vegetable matters generally be ex-
1 to the action of the air, they gradually undergo de-
composition, and various products as humic, ulmic, geic,
crenic and aprocenic acids are formed, together with Car-
bonic acid that most important gas to plants. The rapidi-
ty of the decomposition of the vegetable matters will de-
pend upon the temperature, the moisture of the air, and the
thoroughness with with the matters undergoing decomposi-
tion are exposed to the action of the oxygen of the atmos-
phere. When the atmosphere has free access, the oxygen
of the air is converted into an equal volume of Carbonic gas,
and a large quantity of water is evolved, whilst also a small
portion of nitrogen is absorbed, and ammonia, that most
valuable food of plants is generated. If on the other hand,
the supply of air be cut off and the decomposition of the
vegetable matters takes place under water, but a small
portion of Carbonic acid will be generated, and the pro-
ducts of the decomposition will be far more insoluble and
stable than those resulting from the decomposition of the
table matters freely exposed to the atmosphere. The
insolubility and indestructibility of the products resulting
from the slow changes of wood and vegetable matter in gen-
eral, in positions where they are in great measure excluded
from the action of tne oxygen of the atmosphere, may be
readily seen in the varieties of coal, lignite and peat, which
exert little or no effect upon plants, unless they be first de-
composed by the action of some substance possessing power-
1G Tertiary Lime Formation [January,
ful chemical affinities and capable of exciting decomposition.
Whilst peat in its natural state, on account of its insolu-
bility and its power of resisting chemical change, is com-
paratively valueless as an application by itself to land, still
when mixed with lime, it acts most beneficially not only
by the compounds resulting from the decomposition of its
organic carbonaceous compounds, but also by the liberation
during this decomposition of its inorganic salts.
Insoluble organic compounds analagous to peat and com-
paratively valuless in themselves, exist in every soil ; and
the value of the organic matters of soils depends not only
upon the quantity, but upon the state in which they exist.
We conclude from these facts that any substance which
is capable of exciting chemical changes in the various or-
ganic constituents of the soil, will render, the soil more fer-
tile bv assisting in these changes which result in the forma-
tion of gases and soluble compounds, and in the liberation
of inorganic salts, which are absolutely necessary to a luxu-
riant vegetation.
It is evident, therefore, that the effects of lime upon the
organic constituents of the soil are as important, if not even
more important than upon the inorganic constituents ; for
it occasions the decomposition of the organic matters, and
thus gives rise to the formation of carbonic and nitric acids
and ammonia, and at the same time liberates the saline
constituents of former vegetation, in states of combination
well fitted for assimilation by the growing crop.
In the application of lime to the soil it is important that
planters should bear in mind the following principles :
First, As lime promotes the decomposition of the organic
matters, they must be carefully supplied to the land under
cultivation, yearly, for if they be not, then the land will be
exhausted more rapidly than if no lime had been applied.
Second, As the organic matter of the soil is decomposed
by the simultaneous action of the lime, atmospheric air and
moisture, and as the formation o( the nitric acid and am-
monia takes place at the expense, in part, of the nitro-
1861.] Of Georgia. 17
gen of the atmosphere, it is not necessary to add immense
quantities of lime to the soil ; it is not necessary to in-
corporate the lime with the soil to a great depth. It would
be best to make yearly applications, and apply the lime near
the surface.
Third, Lime in the caustic state (quick lime from the
kiln) acts more rapidly upon the organic matters than the
carbonate of lime, which is the form in which it invariably
exists in nature, hence quick lime may be employed in
much smaller quantities than marl or shell limestone in its
natural state ; hence quick lime should not be added to the
manure pile, while marl and shell limestone may in many
cases be mixed, with beneficial effects, directly with the
cow-pen and stable manure ; and hence the effects of marl
and shell limestone in their natural conditions upon vege-
tation are slower than that of quick lime.
Fourth : "Without a sufficient supply of lime to the soil
we can never obtain the full effects of manures.
A still farther examination of the chemical constitution
of the soils of various countries establishes the following
proposition :
(f) Soils differ greatly in the proportion of Phosphate of Lime
and of Phosphoric Acid, both in their natural and in their
cultivated states.
In the majority of the analyses of American soils, Phos-
phate of Lime and Phosphorie Acid has not been separated,
and in those in which its presence has been indicated it has
been in most cases represented simpfy as a trace.
In almost every American soil yet examined, Phosphate
of Lime and Phosphoric Acid are deficient.
Phosphate of Lime and Phosphoric Acid enter into the
constitution of all plants and animals, and is absolutely
essential to their development and perfection.
Careful experiments in Europe and in this country dem-
onstrate that the Phosphate of Lime is a valuable fertilizer
to all lands. The fertility of the lands of England are due
in great measure to the extensive employment of marls,
rich in the Phosphate of lime; and the most wonderful
is
Tertiary Lime Formation
[January,
sta have been produced upon the exhausted lands of
Maryland and Virginia, by the application of marl contain-
ing, it" not as great an amount of Phosphate of Lime as
those of England, still a quantity greater than that contain-
ed in a Libera] application of the best Phosphatic Guanos.
If we institute a comparison between the amounts of
Phosphate of Lime contained in the soils of Europe and
A a srica with the amounts of this substance existing in the
various marls and shell limestone of Georgia, we will be
convinced of the great value of these native deposits.
We will consider the value of Phosphate of Lime more
fully under the following division of our subject:
VII. Relations of the Shell Limestone and Marls of
Georgia to Plants and Animals.
Lime is indispensable to the healthy constitution of
plants and animals.
This proposition will be conclusively demonstrated by the
following tables, which will prove of great value to the
planter, not merely in their present use, but also as afford-
ing important information upon the constitution of the ashes
of various plants and animals.
Table 31 Showing the proportions of Phosphate of Lime,
Phosphate of Magnesia, Carbonate of Lime and Carbonate
of Magnesia in various vegetable and animal structures.
' 1
NAUE or BUBBZAirOI.
NAME Of CHEMIST.
-3 3
So So
li H-
oB pB
6 '
i SftK
si
- ^
:c
a
: E
' r
s.-:
0.41
10.60
5.88
- p
If
S"B
7
Prof. Shcpard
36.44 tract
61.64 ....
1
17.1T18.88
6.86
do do
0.96
Stalk
J. 1.. Smith, M.D
Dr. Ua
pard
do do
do do
do do
S.00
urn
tato
ir
J. 16
8.80
51
3.00
3.56)
3.00
1 26
do
0 99
'. 67
do
0.47
do
do
0.30
ii 83
da
1.2]
do
6 '.:J4 '.'.'.'.. '.
0 '"7
1.16
do
1.19
86.00 3.1)0
83.071 2.8
84.89 2.16
86.02] 1.78
6.00
10.07
9.43
9.06
9.19
do
do :...
1861.] Of Georgia. 19
ANALYSES OF THE ASH OF COTTON, WOOL AND COTTON SEED.*
Wool. Seed.
Carbonate of Potassa. (with possible traces of Soda) 44.19
Phosphate of Lirne, with traces ot Magnesia 25.44 61.64
Carbonate of Lime 8.85 0.41
Carbonate of Magnesia 6.87 0.26
Silica 4.12 1.74
Alumina, (probably accidental) 1.40
Sulphate of Potassa 2.70 2.55
Chloride of Potassium 0 25
Chlorides of Potassium. Magnesium, Sulphate of Lime, Phosphate
of Potassa. Oxide of Lime in minute traces, and loss 6.43
Phosphate of Potassa, (with traces of Soda) 31.51
Carbonate of Potassa, Sulphates of Lime and Magnesia, Alumina and
Oxides of Iron and Manganese in traces 1.64
Or the composition may be expressed thus :
Phosphoric Acid 12.30 45.35
Lime 17.05 29.79
Magnesia 3.26
Potassa 31.09 19.40
Sulphuric Acid 1.22 1,16
From these data Prof. Shepard calculates that for every
10,000 lbs. of Cottou Wool, about 60 lbs. of saline matter
would .be abstracted, having the following constitution :
Potassa, 31 pounds.
Lime, - 17 "
Magnesia, 3 "
Phosphoric Acid, 12 "
Sulphuric Acid, 1 "
ANALYSIS OF A COTTON STALK BY J. LAWRENCE SMITH, M. D.
The ashes of a healthy cotton-stalk, six feet high, and an
inch in diameter, at the largest part, with some leaves and
empty pods, consists of, in 100 parts :
Lime, .... 30.3
Potash, - - - - 24.3
Phosphoric Acid, - - - 9.1
Magnesia, - - - - 5.8
Oxide of Iron, - - - 0-4
Sulphuric Acid, - - - ,1.3
Chlorine, - - - - 0.8
Carbonic Acid, - - - 27.0
Sand, .... 0.5
ANALYSIS OF THE FIBRE OF SEA ISLAND COTTON, BY DR. URE.
Carbonate of Potash, - - 44.8
Chloride of Potassium, - - 9.9
Sulphate of Potassa, - - 9.3
Phosphate of Lime, - - 9.0
Carbonate of Lime, - - 10.6
Phosphate of Magnesia, - - 8.4
Peroxide of Iron, - - - 3.0
Alumina, a trace, and loss, - 5.0
20
Tertiary Lime Formation
[January,
.2 % OTJ
jn a o
. at c
z
o>
go
o *
U
Eh
-a -J
3 T3
:2 a
= 2
c
T3^
p hO
<3
S
|g KH3^
9a
o
o
jM
is y S i> i- >.
3 > T3 T3 fcci
c C5
Chloride of Sodium,
Peroxide of Iron
E0 r-H CO O 04' fc-OJ CO O - C tJ* CO . W a. QO 00 ^i
CiCOSOiCO <3S CO r-i D i-tCOOt- -MMOOW
i-h O i-H O O O 'HO i-J 04 rH O O CO
Silica,
NfflHHW00ON'<tiJ)
co ->t< ~. coo-^ocnoO'ji
:: r r-:^^xJi^-M i
OQOiMWiOMOOirt
5 M "* -+ 90 <G eo SO S3
Sulphuric Acid
r-( <M 'OM CN i-H CN >*<
. r- C4 0 US i-H 00 -00
0>MCH !M rH O
O i-h o
rH o o o o o
Phosphoric Acid
W<MWHOCOt)*00-*OOH
NMONWOOH^rl
J>050CWOOW10-*HN!0
Lime,
s C r.soo^HOMJioo
HMHMMWOlT)IKJl
oj O oo co rf a. ' ; 3*. -*
<4<.C4 r-4 rH ng( rH Tia rH
Magnesia.
Soda.
Potash .
oeo0(Neoflo5'*'>*rHcqec
MCJlMJiHUOia
C >^A4l M O 'J M .t-
t- * l- co . 00 OO US
00 C CO 04 0C t- r~ Tf tK
ooococoa z >.
rH SH
*-*OTt<ecHONN
00 00 Oi Tf rH H W N '- ^ S
to** M eo to i-H 04 4< C
JNSi^OOCOrHO
Ishes in dry plants when all I : :
tyateris artificially removed | : :
Ashes in 100 parts of crop
as taken from ground . . .
. ,_ _ ^_ ;, -m _
i|jA\n.ir! osiajoj 't^u.W puBi^ii^j ui
u.uoalt 'H'^MAV uo^adojj
1861.]
Of Georgia.
21
% 6
~ -, a a a
bfl
br. .
~ - -
X? pfi-Ja
a a -3
2 215
2 o * o
I * 5.2 2
* a
*' |
a 'o
53 -S J3
n
w C oa a
) 9) 9) S 'J
o^>o
Chlorine
x eo -.o
* CC Lt
Chloride of Potassium ,
Chloride of Sodium
iOO ^ O h K O O '-O tJ< co >o eo
Peroxide of Iron w.* :T ra. <^ : w. "*. ~ =!
'(MNH .-< i .-i O O O t-I O i
Silica.
Sulphuric Acid.
>> ~ ~
O i-l i-i
O r* eo .-H <m
Phosphoric Acid.
SC X
CO r-t CO -* Tt< .
to *c co :r ct>
Lime.
CO<MCNl-*!MiO->*COrH
HHOlOMt-lt SO
Magnesia
- r .- c ..-:^OL'5Ho>-fO09e'OHM'*
OOhooonoiOO-* ?) c c; * 30 c t|i
i>-
Soda.
t x -> x ec eo x co
tc: WOSNON
so
OrlrlW^SHH
Potash.
cc eo 00 eo
Ashes irf artificially dried plants;
co o3 tj< -^ o*
Ashes in 100 parts of crop as
taken from the ground
Ol ->1 "M ?1 "^
:.5-a
. si ^
fcc5
J3 :**
2 33 '.2m
TS 0
sc.2 - -
' o M>o o
E O
i ca m t. <w ^
s
-^ d
a ss;
3 5
c *
'.2.22
p5tfapL,PHi
00
71 rtiary Lime Formation
[January,
p
u
g
&
C
o
I
CO
CT
w
pq
<
r.
55 5
HJ2
o
CCS
C3 v'fi
73
6
2 o o o o o o
<
l^Joo
a
C3
3 "O "C "^ T3 *C "O
A
i ^^ '>
O O O
a
Mfe Q (-3
P?
EC
o
! a
S
a -a
5 J?
eg
o .
M = 73
g o So
3
~ c o o <y o o
-J
Z$1*h%*
fe^Cio
a &h
t- eq
0!
Chlorine
J- S 00-^ ::
r-
0-1 r- X VC
05 Ol tJ<
Chloride of Potassium. . .
;:;;:;;
TlXHJ
OJ to e -^
Ol O-l ~H CO
H !: -i B t 55
cs> crj a ~. > ^
Chloride of Sodium
CM -tJISMO
>C 0OHO4N
O Ut CO !N Tt< CO
Peroxide of Iron
' ~ rji 1G CO i i 00 iO c>
o" eo *n eo o
)
01 X i.". i- (>
LO fO CO Tf H
(OMHOCO
t- ao n oi ua oo
eOHHO^^er
Silica
C O Tit 5) H ffl O) 5
tt CO >! rn 1> * CO
NXiOJ)NtO
lO CM u-0 O CO OS t*
^t ^^ "^ ^ *^ *^ ^F
i i r 1 1 i r <
u
i)
o
NCOtHWNC)^ s.
Ci
SmoiHhoo
-* n -o c x t t-
Sulphuric Acid
T) 3 O ' M CO
, .J3 "*J* CO 1 1 T ICffCO^T
r ec - ic X
00 tJH X * oi CO .
J3.
eo >0 *- >c ec - .~
<;- o t? o t- o n
oj
QD
a>
o
o x o o ic n r
SoocOOOOiOO-
' iC N "J CO M CO t)I
Phosphoric Acid
p.-- *
cc - ec so ?J ec
^XtOt-tOiOO o
^COt-XTj^Xi^^
Ph
-
CSt-Hf-H-^*-M
t-asMcoc
CO W CO IC N iC
OQ0NH Oct
totr. _ MO
*- * t- t- a *C
HHNr.t-Oi)(
CO OC X lit lit xrj<
m m * tj* ^
1 <
CO CO CO 'C lit OC O
O) t- N *- CO OS
- -o -^i co tj< a
Jl CON/ X . !
oi '- t~ r- uo o
fr- co o C* * CO
C X * X iC C5 N
CO Q -^ CO >0 C3 t-H
r- 1 < i
. to co
*< o c
-o -co -
CO -O --T CO >1 t-- CO
Soda
eo as
co '0oj>
<N i.O o
C M tr- i-h co co ^J
eo t-H
i-l *
T-H
OJ o o
r i CjpJ ^1 1 I C4 CO U3
co oooo oo o w *
OONtCr-lXTt
oi -. : cr. n oi r-
Potash
as iC i - . o x n n
O* M CO rH
:t OttOCC '
1 D OiH r. -i
t llOHH ct
eo
'.'.'" -H* T '~ "7* '0 O
CI -H rl J) -I -
Oni >
ooc X X
=>oo
Ashes in artificially dried
= - I -
. 93
<73 C^l 3^ CO ^ CO
CO X CO Tji CO
Plants
* t}< CO
CO
CO CSI
-r^rlOICO
Ashes in I'M) parts of crop
i- r ec
us taken from the ground
i-t i-i o
a
PL,
o
v.
. /
, -
! ! or
~E
' \b
>. '"
>
l_
qj O O O O O q
.O 73 "C "2 7T ~ -
2
a
oSgoS
C
-
o c
0
e
a
o
&IT3*~ w-t
~ ~ rs ~ ~ "^
/.'
<M
o *- o c
-
cs o o o o o 5^:
" 73 'O "C "^ T3 a>"r
o O o G
-
o75.- c - -
.
?, o o o c o o
-'- T3 -c 73 13 73
=M
>\'~
E-
p
H <
Of Georgia.
wOOOOP-Wuu
~1
CO
-
pq
<
Chloride of Sodium 1 :::::::::::?
Peroxide of Iron ' -!'".=. ~. =. :t. = -'. -J ^
r 300003OOOt-iO
Silica, * ! 2 ho ! 5 3 <
1 U H ?l cc :>! n l- M vt rs cc
>o -- . --.-
Sulphuric Acid : : "* :'. 1 ;
o c o c c ~ o
Phosphoric Acid
X <* X ~ -. I K Z>
- <4 cr i- ~ ~. -r. 7-1 ^r - -. ~
*- r ^r -r
,i- -. i- .- - X X C <X5 ?! o
Lime, "! .*r .*:*: "*
eoooeorH - to cc ?i - c: cc
Magnesia
-..--~. T! -- CC CO ~ COtHO
1 - ~ : 0 3 1 i - a C H C 1 - '. a
X *# X ~r B i r. N rt S3 ?!
,#-lC "M ?l CT CO 94 O a 3
Soda ! - x. -1. x -! -. ". -!. * "* ?J. ~:
C - - K -M -Jl 't T) - ri M
Potash.
water is artificially removed _: _ _j _' ~;
- ID 100 parts of crop as g g g = => g ~ 7 g g
taken from grotnd _; ^ ^ ^ ^ ,_',_',_;_;_; ,
puB[8a3 3 : :
ui uMoxa c :
rfiaq.u ajiq.u"^ -^ "S
'jMU*g pan
- > '
ooob
o o
24
Tertiary Lime tbrmation
[January,
Table 34 Proportion of Sulphur and Phosphorous in Plants and
Grain, according to II. C. Sorby. Liebigs and Kopps, A. R. P. of 0.
vol. 2. p. 12*. Sulphur and Phosphorous in 100 parts of substances,
dried at 212.
Poa palustrls and trlviaUs
Lolium perenne
Italian Rye Grass
Trifollura pretense
do (In
Trifolium repens(very fine kit
do do (ordinary do )
M go lupulina (very fine)
Medicago Sativa
do do
do do
tiva
Kidnej Potatoes (solanum tuberosum).
Top* of Kidney Potatoes
Fruit of Kidney Potatoes
American Potatoes
Danous Carota, roots
do do tops
Beta Altesshna, roots
do dc tops
Delta do do
do do tops
Brasdca < Ueracca, (Swedish Turnip)
do Oleifera, (Rap< .
;-, i Drumhead Cabbage.
Wheal Plant entire, (Triticum Vulgare,
after fiowerin
do do do do
Ear of the Wheat when the Grain was
formed, but still milky
Straw ofWheat when grain was formed. .
1.166
1.810
1.829
.107
.087
1.274
1.452
1.17
0 164
0.188
0.145
0.149
0.046
0.215
o.-Jl."
(1.:.. -,7
I.05E
1.851
o.4il
15
0.075
II.. 'is-
0
0.860
0.4480.233
0.421
0.140
0.271
0.1. s:
Ear of Wheat when ripe
'traw of Wheat when ripe
Red Wheal
Straw of Red Wheat
White Wheal
Straw of White Wheat
Wheat
'harl' of Wheat
Very fine Barley, (Hordeum distichum).
traw of Barley
Poor Barley
riev
Barley PI
oat Plant (Avena Sativa) juat flowering.
I 'at Planl in Flower
Green Oats
Straw of Green Oats
B'ack Tartarian Oats
Straw of Black Oats
Si raw of White < )ats
White Oats
Straw of White < >ais
Rye ears (Secale cereale)when young.
straw of Rye
R
:ve.
Bean 1'lant (vica faba) in flower 0.045
Beans 0.01
traw of Beans 0.14)-
Peas I Pisium sativum 0.15
3traw i if Peas 0.214
Fine Hops (Humulus Lupulus) 0.1
Rind of Hops iO.OM
0.079
>,366
1.112
I. HO
0.262
0.498
0.087
0.066
L94
0.128
0.110
0.158
n.057
0.
0.160
0.258
0.600
0.206
0.076
0.574
Table 35. Ash of Yolk and White of Hen's Eggs Poleck.*
Chloride of Potassium
Chloride of Sodium
Soda
Potassa
Lime
Magnesia
Sesquioxide of Iron
Byarated Phosphoric Acid,
Phosphoric Acid ,
Carbonic Acid
Sulphuric Acid
Silica
Albumen.
No. 1 [No. 2
41.29
9.16
28.04
2.36
1.74
1,60
0.44
4.83
11.60
0.49
+2,17
14.07
L6.09
1.15
2.79
3.17
0.55
3,79
11.52
1,32
2.04
Yolk,
No. 1 No. 2
5.12
8.93
12.21
2.07
1.45
5.72
63.81
0.55
6.57
8.05
13.28
2.11
1,19
66.70
1.40
IE pp's annual report on i fee, for I860, vol. i, p. 879.
1861.]
Of Georgia.
25
TABLE 36. ASHES OP
MAN AND OTHER ANTMALS VERDEIL.*
DoS.
Ox.
No.llNo.9
23.2421.11
L8.00 L4.40
6.60 8.76
0.47 0.59
1. _>:, 1.16
8.40 8.09
1.66 1.69
0.86 o.T'
9. IK) 8.80
6.571 6.49
Sheep.
Pig.
No. IN 0.2
Calf.
Man.
No.l
19.60
5.78
15.16
0.67
1.71
1-2.74
1.29
0.10
12.76
0.52
No.9
90.94
90.04
3.02
in. if.
4.:;s
1.08
9.S4
2.86
0.70
8.65
0.37
No.l
84.66
22.46
18.88
5.29
0.30
1.65
3. S3
L.88
1.00
S.70
7.09
No. 9
80.72
19.90
13.40
7.93
0.8-2
1.91
3.41
1.58
1.10
9.17
6.35
No.l
30.46
19.73
10.39
11.74
1.15
1.34
4.91
3.45
1.88
8.69
3.77
No. 2
86.18
23.40
10.41
9.81
1.19
1.21
3.76
2.97
1.60
7.80
3.57
No.l
87.60
24.49
2.03
12.10
0.99
1.70
7.48
1.87
1.68
8.06
1.48
No. 2
{Chlorine
} Sodium
25 07
16.24
7.6-2
29 -21
l.'ai
1.71
10.61
1.68
1.20
9.10
0.61t
80.06
19.46
5.88
18.54
0.97
1.34
11.48
1.27
1.90
9.52
0.86
88.76
21.87
6.27
11.24
1 -16
1 64
Phosphoric Acid
9.74
1.36
1 85
8.68
Carbonic Acid
0.95
'Annual Chemical Pharmacy lxix
vol. 3.
89.
Leiblg and Kopp's Annual
Report on
Chemistry for 1849,
Table 37 Composition of the Blood of Man and Animals
in normal condition, in 100 parts, according to Poggiale.*
Water
Klxod Corpuscles
Albumen
Fibrin
Fatty Matters
Extractive Matters and Salts
The Salts contain
Chloride of Potassium and Sodium.
Chloride of Calcium
Phosphate of Soda
Sulphate of Soda
ite of Potasaa and Soda
Phosphate of Lime
\ide of Iron
:ite and Sulphate of Lime...
5^
O
o*
a
H
B
o
89
o
3
3
4
r5
2
V
3
779.9
767.6
796.1
788 2
835 6
798.0
831.0
798.0
812.0
785.0
130.1
143.0
1-23.1
1 26 . 2
92.6
10-2.0
91 .5
126.0
109.2
150.3
77.4
74.0
65.5
67 2
55.3
85.C
63.8
63.0
64.1
47.2
2.1
3.8
5.4
6.3
4.1
8.S
3,2
2.2
2.2
5.1
1.1
1.8
2.2
2.2
1.3
1.8
1.6
2.3
2.1
2.3
9.3
11.8
8.7
10.0
11.3
10.0
8.9
8.5
10.3
9.1
4.7
6.4
4.7
4.8
6.1
5.7
4 6
4.4
5.6
5.0
0.2
0 2
0 3
0 -2
0 3
0.2
0.3
0.1
1.4
1.7
0.8
0 8
1 1
1 0
0 8
0.8
0.9
0.8
0.4
0.4
0.6
o..",
0.8
0.6
0.6
0.5
0.7
0.4
0.5
0.6
0.4
0,9
0.4
0.?
0.4
0.3
0.5
0.4
0.7
0.7
0.5
1 0
0,8
0.7
0.6
0.5
0.7
1.2
1.3
1.5
1.8
1 4
1 1
1 1
1.0
1.5 1.2
0 8
o.a
0.4
0.2
0.4
0.3
0.2
0.3
0.1 0.2
0.3
0.1
0.2
0.2
0.2
0.3
0.2
0.4
0.1
0.2
0.2v
95.0
143.1
48.1
5.1
1.7
8.9
5.4
0.2
0.8
0.3
0.2
1.1
0.6
0.2
0.2
Annual report of the Progress of Chemistry, by Liebig and Kopp, vol. 2, 1847, 1848, p. 154.
Table 38. Ash of Blood, according to Henneberg, 100 parts contaiu.
Chloride of Potassium,
Chloride of Sodium . .
Soda
Sesquioxide of Iron . .
Lime
Magnesia
Blood
Blood
of
of
Fowls
Turkey.
29.14
36.81
16.87
3.31
21.04
24.02
3.89
4.77
1,03
0.93
0.22
0.46
Phosphate of Soda and
Potassa
Phosphates of Lime,
Magnesia and Iron.
Sulphuric Acid
Blood
of
Fowls
19.63
6.99
1.19
20,24
8.49
0.97
'Liebig and Kopp's annual report on Chemistry, vol. 2, p. 159.
26
lerUary Lime Formation
[January,
Table 39. Ash of Blood, according to Enderlin. In 100
parts of Ash.
0
r.
i *"
M
-
. _. >r; , m
o
a 2
B|
-
7?
t;
A
?T3
7?-
TTr;
7? =
3
K
tna
n
K
. ite ut"
1 r< >ii
11.07
.
8.70
:.:>
7.6
9.4
10.0
9.8
10.0
9.61
10.6
9.6
19 M
| 13.26
J14.79
jl4.58
jlB.O
J16.9
r iate of
6.04
8.47
13.2
12.1
13.4
17.8
7.!'
9.6
26.24
86.88
63.84
60.48
35.0
24.4
20.4
'
34.9
28.0
m o
Phosphate of
Soda
6.1
8.11
7.19
26.4
31.3
17 1
(fl 4
Sulphal
2. 34
0.66
3.30
1.9
4.0
1.6
1.7
of
Sodium
46.56
87.9
88.4
7.5
21.6
81.8
13.4
Silicate of
.
Silicate oiJPo-
taBM
3.53
2.75
14.6
11 .4
Ash in 100
p:irts
1.519
1.28
1.23
1.18
1.20
1.29
1.55
L.08
0.84
1.11
*Loc. (Jit., vol. 2, pp. 15'J 160.
The results embodied in these tables, not only sustain
the proposition that lime is indispensable to all highly
organized plants and animals, but they also establish nume-
rous conclusions and principles of the greatest value to the
agriculturist. We shall at present notice only those which
have an immediate connexion with the commercial and agri-
cultural relations of the tertiary lime formation of Georgia.
(a). The proportion of lime varies in different plants and
animals.
(b). The proportion of lime varies in different parts of
the same plant or animal.
It follows from these two propositions : First, different
crops abstract different quantities of lime from the soil, and
if these crops be sent off the plantation, the loss of lime to
the place will depend not merely upon the amount, but
also upon the character of the produce.
Second, if animals be raised tor market, the amount of
lime abstracted from the soil through the vegetable king-
dom, will depend upon the mode in which they are pre-
pared lor the market. If they he driven oil' in the living
condition, all the lime which they have abstracted from the
soil 'will be losl to the place. If they be killed upon the
place, quite a large proportion of the valuable salts which
1861.] Of Georgia. 27
they have abstracted from the soil will be restored in the
form of blood. If they be consumed upon the place, the
greatest proportion of the lime which they have abstracted
from the soil will be found in the bones.
Third, as animals, whether carnivorous, herbivorous, or
graminivorous, subsist ultimately upon the vegetable king-
dom ; and as the salts which they derive from the soil
through the vegetable kingdom, are thrown oft' in the urine
and faeces, it is evident that the lime will be transported in
the bodies of the animals from one part of the place to the
other, and will accumulate principally at the stables, cow-
pens, and the habitations of man.
(c). The proportion of phosphoric acid and of phosphate
of lime, varies in different plants and animals, and also
varies in different parts of the same plant or animal ; and
hence different crops and animals abstract different quanti-
ties of phosphorous and phosphate of lime from the soil.
(d). Lime and phosphoric acid, although entering largely
into the composition of plants and animals, are by no means
the only inorganic elements necessary for the development
and preservation of the animal and vegetable kingdoms.
The salts of soda, potassa, magnesia and iron are equally
essential to the perfection of plants and animals, and, as in
the case of lime and phosphoric acid, they vary in amount
in different plants and animals, and in different parts of the
same plant or animal ; and hence different crops and ani_
mala abstract different quantities of these salts from the soil.
(e). The quantity and character of the inorganic salts,
although varying within certain limits, are still remarkably
uniform in the same class of plants and animals. We have
selected in these tables, to demonstrate this important agri-
cultural fact (that each class of plants and animals must
have a definite amount of inorganic salts of a definite con-
stitution), numerous analyses of the same plant by different
ob-ervers.
It follows from this that the farmer can calculate not
only the amounts, but also the character of the salts annu-
ally removed from his lands.
28
lertiary Lime Formation
[January,
Tims in the following crops the amounts of ash in the
right hand column would be removed from each acre pro-
ducing the amount of produce to the acre, assumed in the
table :
Table W.
Weight of crop
per acre in lbs.
A si i es per
As gath-
ered.
Dried at
212.
acre in lbs.
Indian Corn Grain
" Stalks, leavefe and fod-
der
"Wheat Grain
2250,
9000.
1000.
2000.
1450.
1500.
2200,
3500
2000.
8000.
900.
1900.
1300.
4300.
2000.
3200.
750.
550.
2700.
27ilO.
3000.
1000.
12.
288.
is.
u Straw
Rye Grain
76,
29.
Straw.
236.
( lata Grain
64.
Straw
241
Tobacco Loaves
son.
600.
3000.
3000.
9000.
3000.
108.
Stalks
Red Clover Hay
50.
236.
Timothy Hay
Potatoes Tubers
Tops
153.
124.
150.
Table 41. Table illustrating the proportions of the various
inorganic matters, abstracted from the soil by 1,000
pounds of various kinds of produce.
o
i
/.
1
5
a
\
-
>
c
3
s
"2.
c
3.
i. :
/. ^
ft
NAMK OF CROP.
9
9
: c
->
9-
~.
; ."
: B
lbs.
Lbs.
lbs.
Lbs.
lbs.
lbs.
lbs.
lbT
lbs.
lbs.
0.40
Lbs.
0JL0
lbs.
A sh of Wheat-Grain
-.1 ?.r>
1 -til
0.96
0.90
0.86
4.00
o..M
11.77
" " Straw
it 20
:.v
0..-7
0.80
85.18
Ash of Barley Grain
3 7"
2.90
1.80
Irur
2.10
0.19
28.49
Straw
5.54
o.T,;
1.46
0.11
O.'JO
1.1*
L.60
".7o
53 49
Ash of Oata Grain
6 . -'.7
0.14
19.78
0.10
38 80
Straw
o OS
0.22
0.06
0.0-2
o OS
o 7:'
0.12
^.or.
Asli of Rye Grain
r, 83
1 2S
1.78
0.24
0.4-J
L.64
0.46
] 09
10.40
Straw
0.11
1.78
0.12
0.25
::.:<:
1.7i
0.51
0.17
37.93
Ash Of]
4.15
B.16
1.68
1 . 34
O.K.)
2.93
o.U
01.36
" '" >tr:iw
If. ,v,
t; 24
o.ot
2 26
0.80
1.31
Aab of Field Pea -Seed
6.10
0.30
0.10
4.10
O..V
1.90
0 88
24.64
Straw
S 85
.... 27.31
0.60
0 07
9.98
2. i"
II (H
49.71
Ash of Vetch -8eed
6.22 L.<H
L.42
0.33
0.61
1.40
0.48
22.90
Straw
18 1(1
0.15
0.09
0.08
1.42
1.3S
0.84
51.01
L.04 ".:"
0.0.-'.
o 17
0. -.'
0 B7
6 308
18.09
Carrot Root*
0.089
0.51
n 07
6.619
3.07
0.27
0.005
o.iolo.io
0.10
0.40
0.17
0 16
1.180
B 19
1.7"
0.04
1.940.43
1.97
0.50
0.06
IS 95
:, 29 27 80
0.1 1
:.'! 4.47
n m
H B2
7 1 . 78
5.06
3 11
0.30
l."'
18.07
0 "7
5.00
',11
9.16
1.88
L.67
80.57
1.7"
o.io
1.90
1861.] Of Georgia. 29
These tables illustrate in a forcible manner, the exhaust-
ing effects of crops, and demonstrate that, whenever the
vegetation in any form whatever, as grain, or hay, or fruit,
or timber, is removed from the soil the land is gradually
impoverished, by the removal of those salts which are ne-
aary to the fertility of the soil.
The great question with the planter is, how can this drain
be stopped, and from whence can materials be obtained
which will restore to the soil these salts which are carried
off in every pound of cotton, and corn and beef.
The preservation of the soil permanently in a state of the
highest fertility, is the great problem to be settled by the
Southern Agriculturist.
Up to the present time, the Planters of Georgia have at-
tempted no solution of the problem, but have cleared tract
after tract of virgin soil, abandoned the worn out lands as
soon as they proved unprofitable, and pursued their course
of reckless devastation and exhaustion of one of the finest
countries in the world, until nothing but furrowed, washed
gullied and barren red clay hills, and barren sandy plains
are left to the present generation.
The great question of the regeneration of the worn out
lands will find its solution in the proper use of the Tertiary
Lime formation'.of Georgia, and of the natural sources of
organic matters so abundant in our State.
If we institute a comparison between the amounts of
Lime and Phosphoric Acid abstracted by the various crops
from each acre of land and the amounts of lime and of
Phosphoric Acid contained in a moderate application of the
marls and shell limestones of Georgia, we will find that a
single application is capable of supplying Lime and Phos-
phoric Acid equal to the amount removed by the most pro-
ductive crops of cotton, corn, wheat, rye, oats, potatoes,
beans and peas for more than one hundred years.
This demonstration of the value of the marls and shell
limestone of Georgia should, we think, lead to their imme-
diate ami extensive employment.
30 T( rtiary Lime Formation [January,
We do not for oue moment contend that the Te'rtiary
Lime formation of Georgia contains all the ingredients
essary lor the entire restoration and preservation of the
fertility of the soil.
Whilst Lime should in Georgia, as it does in England,
and in every well cultivated country in the world, form the
basis ot all permanent agricultural improvement and of all
husbandry, still it represents only one class of the salts
needed by plants and animals, and if, therefore, it be ex-
clusively relied upon disappointment will surely follow,
sooner or later.
This leads us to the consideration of the following well
established proposition :
The absence from the soil of any one of the constituents
of the Ash of Plants, will jrrove adverse to vegetation.
The Prince of Salm-IIorstmar performed a series of
careful synthetic experiments to determine which of the
ash constituents are necessary to the growth of plants. lie
chose for his experiment the oat plant, sowed the grains in
an artificial soil of ignited sugar-charcoal, watered it with
distilled water, and supplied the ash constituents by means
of the following preparations, which were partly dissolved
in the water and partly incorporated in the sugar-charcoal :
Silicate of Potassa and Soda, Carbonate, Phosphate and
Sulphate of Lime, the Salts of Magnesia, Sesquioxide of
Iron, oontaining Protoxide, with and without Manganese,
Sulphate of Protoxide of Iron, Carbonate of Manganese,
Carbonate of Ammonia, Nitrate of Lime, Magnesia, and
Ammonia. By modifying the experiment in various ways,
omitting one, and sometimes all of these preparations
adding them at one time in increasing proportions, and at
other times in decreasing quantities, and in each instance
accurately observing the growth, appearance and character
of the plants thus cultivated. Balm-Horstmar arrived at the
following rosults : without the addition of any of the above
mentioned Sails the plants remained dwarfish, but without
any abnormal development. For the successful growth of
1861.] Of Georgia 31
plants Xitrogen (Ammonia) and the vegetable Ash, con-
stituents must be added at the same time. Absence of the
one, especially of the latter, enfeebles the action of the lat-.
ter. In the absence of Phosphoric Acid, Sulphuric Acid,
Potassa, Lime, Iron and Manganese, the plants in every in-
stance, attained an abnormal growth, were feeble and of
unnatural softness, and rapidly faded away; they were par-
ticularly weak when no Silicic Acid and Magnesia were
present. Iron acted most surprisingly upon the luxurious
and vigorous appearance, especially in regard to the color,
strength of stem and roundness ; but when an excess was
added it produced dry spots on the plants. Too large a
proportion of Manganese caused the leaves to curl up in a
peculiar manner. Without weakening the plants, neither
the Potassa could be replaced by Soda, nor the Lime by
Magnesia.
In the whole of these experiments the plants were placed
in abnormal circumstances, and only in one single instance
(and in that only a single grain was produced) did they
yield corn.
It is evident, therefore, that my duties as Chemist to the
Cotton Planters' Convention do not end with the develop-
ment of the inexhaustible stores of fertility in the Tertiary
Lime formations of Georgia other sources of fertility sup-
plying the salts wanting in the Marls and Shell Limestone
of Georgia must be supplied.
CONCLUDED.
Study on the Stoic Poisoning by Preparations of Lead, and its
Influence on the product of Conception. By Constantine
Pa.il. (Arch. Gen. de MeidL, May, , 1860.
M. Paul, an interne of the Paris hospital, has drawn up a
valuable memoir on the effects of lead-poisoning upon the
product of conception. We will relate one of his observa-
tions as an example, and present a summary of his research-
In February, 1859, a woman entered the JSTecker Hos-
pital, who had been for eight years working as a polisher of
printing type. She was suffering from metrorrhagia, and
had an evident satornine cachexia. She sad enjoyed good
82 Pregnancy. [January,
health, and had been delivered of three children, happily
before taking to the occupation of polisher. Since then
her health had been much shattered by lead-diseases. Three
months after entering upon this trade she had a first attack
of colic, and Pour years later another. At this time she
became pregnant, and bore a dead child. Three years later
still, she bore a child which died at the age of five months.
She had eighl pregnancies all terminating in abortion at two
or three months, attended with excessive metrorrhagia. She
recovered in M. Bouley's ward, under tonic and restorative
treatment
This case led M. Paul to extended inquiries in the type-
foundries and elsewhere. He found that those women almost
alone who handle the type are affected by saturnine diseat
In a first Beries of observations, lue found that 4 women had
had 15 ascertained pregnancies of these, 10 ended in abor-
tion, 2 in premature labour, 1 in still-birth, and 1 child died
within twenty-four hour.-.
In a second series of cases, 5 women had borne an aggre-
gate o\' 9 children at term before exposing themselves to
lead, and had no abortion or accident of pregnancy. Since
exposure to lead they had 86 pregnancies; of these, 26
em led in abortion at from two to six months ; 1 in premature
labor: 2 in still-birth; 5 children died, 4 of which within
the first year ; and '1 children were living, 1 being puny and
ailing, the other only three years old.
In a third order, a woman had during her employment in
a type foundry live pregnancies, all ending in abortion.
She quitted the business and bore a healthy child.
In a fourth order, is tlie ease of a woman who, having left
the trade for two periods, bore during these intervals of
freedom two healthy children ; returning to the trade had
two abortions.
In a fifth series M. Paul shows that the same disastrous
influence 18 felt when the fathers handle lead. In 7 c;i
every woman had an abortion : of 32 pregnancies occurring
luring the husbands' exposure to lead. 12 children were
bom prematurely. Of twenty living children, 8 died in the
iir>t year, 8 in the second, 5 in the third, 1 after the third
year, m2 remained living.
In the Birth series the author shows that where the lead
affection was Less marked there was a corresponding dimi-
nution of the Injurious effect upon the product el' conception.
1861.] Kyi:. /. v 3 on 'Jun 88
ARTICLE II.
ires on Tumors and Outgrowths of the Cervix Uteri, By
Joseph A. Eve, M. D., Professor of Obstetrics and Dis-
eases of Women and Children in the Medical College of
Georgia.
Lecture First Uteeine Polypi.
Gentlemen: The subject of our present lecture will be
Tumors and Outgrowths of the Cervix Uteri. If time
would permit, we would prefer to treat of these affections
in reference to the uterus generally, body and fundus as
well as the cervix, but that would require a series of many
lector
At present, our attention will be restricted to those of
the cervix, because they most frequently occur in practice,
are most accessible to investigation and most amenable to
treatment.
The most useful and natural classification is into pedi-
culatcd and sessile simple and malignant. Another di-
vision might be instituted into those which arise externally
and those which, originating in the body of the uterus, or
in the cervical canal, either grow downwards into the va-
gina, or becoming developed internally, are afterwards, by
the contractions of the uterus, expelled into the vagina.
We will, in the first place, call your attention to non-
malignant, pediculated tumors, generally designated polypi
from having a pedicle or footstalk, by which they are at-
tached to some portion of the internal surface of the ute-
rus. The term polypus is derived from two Greek words,
Polus and Pous. Strictly speaking, it does not apply to
the tumors in question, as they very rarely have more than
one origin; although it is said one polypus has been known
to have two pedicles, and on the contrary, two polypi have
.filiated from one pedicle. They are called polypi from
a supposed resemblance to the animal called polypus. Dr.
T. S. Lee's definition of a polypus is a tumor growing from
the internal surface of the uterus, attached to it by a stalk,
and usually having a pyriform shape ; it is smooth, hard
84 Eve. Lectures on [January,
and insensible, and gives rise to violent and frequent hem-
orrhaj
Causes. The causes of polypi are so obscure that we
will not waste time with any discussion of the subject.
They arc found at all ages, and under all circumstances,
from early childhood to advanced age ; they are mostfre-
quenl during the reproductive period, but rather more fre-
quently, it is thought by some, in the unmarried than the
married. I have found them Tnore frequently in married
women and widows.
Pathology. Our limits will not allow us to say much of
the pathology of polypi. There are several varieties of
polypoid tumors ; but there are three principal species
which include much the larger portion of all polypi: the
glandular, the cellular, and the fibrous. This is the divis-
ion made by Dr. Churchhill, in his excellent work on dis-
eases of women. We may occasionally meet with a case
that may not conform strictly to the description of either of
these species, but I believe they are very rare, such, at least,
is the result of my own experience.
i^t. The glandular polypi are enlarged Nabothian glands
in the cervical canal. They may be found single, or two
or more may exist together ; they are generally about the
size of small grapes, attached by small and short pedicles ;
they are usually of the color and firmness of glands ; it is
-aid they sometimes contain some mucilaginous fluid.
Some very small polypi about this location are found to
consist altogether of mucous membrane, others of some-
what larger size, consist of mucous membrane with the ad-
dition of cellular tissue.
I'd. The cellular polypus is the least frequent. I only
remember to have met with two cases. They are said to
appear singly or in clusters. The two which occurred in
my practice were single. They bear some resemblance to
the polypi of the nose ; they are described as of a violet or
vellow color ; the two met with were not unlike a large oys-
ter in color and consistence : their attachment to the ute-
1861.] Tumors^ 35
rua was exceedingly slight. I will refer to them again
when detailing cases of each species.
8d. The fibrous polypi are by far the most common.
They resemble fibrous tumors in the body of the uterus
and other parts of the system. They are generally hard,
but vary in consistence and density ; there will sometimes
be a difference in different parts of the same polypus. It is
said they arc sometimes hollow, and contain a fluid; such
instances, however, I have never seen ; they are also said,
in some rare cases, to contain hair and other substances.
The same polypus, in different stages or periods of develop-
ment, will be of different degrees of density ; from being
very soft, it may become harder progressively, until it shall
have assumed an osseous or calcareous hardness. They are,
at least generally, covered bv the mucous membrane of the
uterus. The connection with the uterus is, in some cases,
by fibrous tissue extending into, or continuous with, the
proper substance of that organ ; in others it consists simply
of mucous membrane and cellular tissue.
Except in rare instances, polypi are insensible ; I have
not known an exception. I do not, however, doubt the ex-
istence of such cases. 'Insensibility lias been consider-
ed a means of diagnosis between a polypus and an inverted
uretus, but it is not absolute, as polypi may possess sensi-
bility. When this is the case they doubtless have an en-
velope of uterine fibres ; in some instances this covering
only extends to the pedicle, and then, although the body of
the tumor may be insensible, the application of a ligature
causes great pain. Their shape is usually ovoid or pyri-
form, but it may be modified by the uterus or vagina, in
which it is contained. They are of all sizes, from that of a
pea to a child's head, and sometimes much larger. Fibrous
polypi generally are found single, but there may be two or
more, and after the removal oi one, another may descend
into the cervix, or through it into the vagina.
When a polypus has a pedicle continuous with the fibrous
or muscular coat of the uterus, it is doubtless an outgrowth
Eye. Lectures on [January,
from the internal surface of the cervical canal, body or
fundus of the uterus. But when it is merely attached by
mucous membrane alone, or with the addition of some cel-
lular tissue, it is most unquestionably a fibrous tumor which,
originating in the walls of the uterus, has been enucleated
therefrom into its cavity, and by its active contractions ex-
pelled through the cervical canal into the vagina.
This variety of fibrous polypus, I believe, occurs as often
as that with a fibrous pedicle, if not oftener. These enu-
cleated fibrous tumors have very short pedicles, are held
very closely to the surface to which they are attached, and
with difficulty expelled from the cavity of the uterus ;
they frequently remain a long time partially expelled and
require to be removed by passing the ligature, scissors, or
polyptome, within the uterus. When separated, the tumor
is generally more globular and has no neck or pedicle; and
the portion by which it was attached to the uterus is only
known by being denuded of mucous membrane ; whereas,
the other variety is more pyriform and has a portion of its
fibrous pedicle remaining. The uterine portion of the pedi-
cle always sloughs off. It never has, I believe, been known
to grow again.
The polypus with fibrous pedicle is said to be generally
denser than the enucleated fibrous tumor, and denser than
the uterine walls with which it appears identical, with the
addition of some cellular tissue ; this is, however, not al-
w ays the case. These polypi, when developed in the ure-
tus, are more easily expelled by its contractions into th
vagina, and sometimes even through the vulva, as I have
known in a remarkable cas-, which shall he related at the
proper time.
It is said the pedicle sometimes gives way, and the poly-
pus thus becomes spontaneously detached. T have never
known an instance of this kind, but consider it quite pro-
bable, as I have known cases, in which the pedicles, wheth-
onsistiug of fibrous tissue or mucous membrane, were
wry slight, and easily divided, sometimes being ruptured
1861.] Tumors,
by tractions made on the polypus, for the purpose of excis-
ion. The spontaneous separation of polypi may he ac-
counted for in various ways. The neck of the uterus may
act as a ligature on the pedicle, suspend the circulation, and
thus cause it to slough off; inflammation may produce the
same result, or the weight of a large polypus may possibly
hreak the pedicle, when very small.
It is said by Dr. Lee, that -polypoid tumors may uuder-
.11 the effects of inflammation." though "very rarely."
"An abscess," he says, * -may he formed" in their substance
and produce great discharge; ulcerations may arise in their
surface, sloughings may occur, and even cancerous degen-
eration may commence." Dr. Churchhill says "they are
seldom attacked by inflammation or ulceration, and they
never degenerate into malignant disease." While I concur
with Dr. Churehhill in this opinion, I am ready to admit,
with Dr. Lee, that sometimes "the pressure of the foreign
body in the mucous canal excites a profuse and foeted pur-
ulent discharge, under which circumstances, it has been
mistaken for malignant disease," a mistake I once made
self in consultation. This case will be stated at the close
of the next lecture. The detention of clots in the vagina may
also produce the same effect, and lead to the same error in
diagno:-:
Symptoms. The principal and most constant symptoms
of Polypi are hemorrhage and leucorrhsea. But as these
depend on so many other causes, they cannot be considered
as diagnostic.
The first indication is generally monorrhagia, which, af-
ter a time, becomes usually very frequent, irregular and so
profuse as to constitute alarming hemorrhages. There i-.
generally more or less leucorrhoa, in the absence of
the sanguine discharge. These losses of blood are attend-
ed by their ordinary consequences, pallor of the face, orde-
ma, disorder of the digestive organs and all the symptoms
attendant on anemia. Hemorrhage is one of the most
common symptoms attendant on polypi, whether con-
38 Eve, J Art arc* on [January,
tained in the uterus or the vagina. It is also veiy frequent-
ly present in the cases of fibrous tumors embedded in the
uterine walls ; and there are some cases wherein there is no
hemorrhage, at least for a long time, after the polypi have
commenced t<> grow.
Levrel and sonic of the older authors believed that there
was no hemorrhage attendant on polypi, while contained
within the uterus, but they had evidently mistaken the ex-
ception tor the rule. I have, however, known at least one
remarkable instance, in which there was no material hemor-
rhage, until after the polypus was expelled into the vagina.
When there is little or no hemorrhage, there is generally
more leucorrhceal discharge.
There is often as much, and sometimes very much more
bleeding from a very small than a large polypus. This is
positive proof that the bleeding is not always or altogether
from the polypus ; for if so, it ought to be in proportion to
its size.
Polypi, doubtless, induce a very vascular condition of the
uterus in the vicinity of their origin a congestion and de-
termination of blood to that part, similar to what occurs at
the time of menstruation.
And this, I verily believe, is at least the principal source
of the hemorrhage, although it may sometimes take place
from the polypus or its mucous covering. Formerly, I sup-
posed the bleeding was lrom the polypus itself, because
when the polypus is removed or ligated, the bleeding
ceases, but this results from the fact that when the polypus
is removed, or its life destroyed by ligation, it no longer ex-
cites that irritation which causes an afflux of blood to the
uterus. They often cause more hemorrhage, while contain-
ed in the uterus than after their expulsion into the vagina,
an unanswerable proof that it depends on the irritation
while internal: for it' the hemorrhage was
mainly, or altogether from the polypus itself, it ought to be
trained, while compressed by the uterus and much freer
1861.] lumors,c.f 39
after the compression is removed by its expulsion into
the vagina.
After fair and ample discussion of the subject, Dr. Lee
arrives at the conclusion, "that the hemorrhage arising, iu
the- may he attributed to the very vascular state of
the mucous membrane, at the insertion of the polypus with
the uterus: that the veins of the parts are the principle
sources of bleeding, and when the mucous membrane is
absorbed, the vascular net-work which envelopes these
growths may add materially to the result. Even when the
mucous membrance is uninjured, this envelope may mate-
rially increase its vascularity."*
Diagnosis. A vaginal examination is essential to diag-
nosis. But when the polypus is contained within the ute-
rus, a digital and eve 1 a specular examination will often
throw little or no light on the subject. The uterus will
feel larger and heavier, but to determine the cause of the
increased size and weight will require further investigation.
The speculum, especially with the aid of the speculum for-
ceps to open the os, will sometimes reveal the existence of
small polypi in the cervical canal, which the finger had
failed to detect, or to afford a satisfactory idea of their form,
size, cVe. When the polypus is in the cavity ot the womb,
and the cervical canal not patulous, these means are totally
inadequate : and a certain diagnosis would be impossible,
were it not for other methods of exploration, for which the
profession is indebted to the genius and enterprise of Prof.
Simpson, of Edinburgh. I have reference to the uterine
sound and the dilatation of the canal of the cervix by
sponge tents. But a consideration of these valuable means
of diagnosis must be deferred to another lecture, as we are
now concerned with affections of the cervix, not of the
body of the uterus.
After the polypus has descended into the vagina, the di-
aterinetu] - 4-1.
40 Eve. Lectures on [January,
agnosia is genera1];: easily enough made out by a vaginal
examination. J)r. T. Salford Lee says "when a polypus is
found in the vagina, it is known by its being a smooth,
bard, and generally an insensible tumor. This last char-
acter, however, does not apply to all eases. When the poly-
pus is form:",] by a tumor of the uterus, it may possess great
sensibility. This is greater when the pedicle is thick, and
becomes very great when a "muscular layer of the uterus
covers the growth." If a polypus is attached by its pedicle
to any portion of the body or fundus, the mouth of the ute-
rus will form a soft ring all around the pedicle. If attach-
ed to the cervix, the linger cannot pass all around the pedi-
cle. If attached to the os itself, the pedicle does not enter
the uterus at all, but the portion of the lip from which it
arises seems to extend into the pedicle.
We cannot conceive how a polypus in the vagina can
possibly be mistaken for pregnancy, but an abortion slowly
taking place might, by an inexperienced person, be mis-
taken for a polypus ; thus if the membranes were contain-
ing a firm clot of blood, or some round portion of the foetus,
as the head, &c, were to protrude and remain some time
stationary, without a knowledge or suspicion of the exis-
tence of pregnancy, such a presentation would not appear
very unlike a polypus. There might possibly arise some
difficulty in distinguishing between pregnancy and an inter-
nal polypus, but that does not appertain to our present sub-
ject. The absence of all the signs of hernia would distin-
guish a polypus from this affection. A vaginal hernia, too,
I believe, is extremely rare.
Vaginal eystoccle or prolapsus of the bladder into the
vagina, or through the vulva, is of much more frequent oc-
currence than vaginal hernia of the intestines. I have
known Buch an error, but the diagnosis is easily determined
by tin' variations in the position and size of the tumor, be-
coming large and protruding through the vulva when dis-
temled with urine ; again becoming small and receding
after micturition, by its softness and elasticity, and by its
1861.] Tumors, $c. 41
being covered by the mucous membrane of the vagina.
But if any doubt were to remain, it could be readily re-
moved by the catheter, which, instead of passing as usual
upwards behind the symphysis pubis, would descend into
the tumor and cause it to disappear, by evacuating its con-
tents It will be extremely difficult, sometimes, to distin-
guish polypi from certain malignant polypoid outgrowths of
the uterus, especially when the former arc in a state of ul-
lccration. In general the absence of the peculiar symp-
toms of malignant disease will suffice, but in some instan-
ces, so many of those phenomena are present, that the dis-
tinction can only be made by the microscope, determining
the presence or absence of cancer cells.
A polypus may be distinguished from a cauliflower ex-
crescence by its greater smoothness and density, and gen-
erally bv not bleeding: when examined by the finder ; but if
one were mistaken for the other, it would not be important,
as removal in either case would be proper. In cauliflower
excrescence, however, no portion of the pedicle ought to be
left, as it would be likely to grow again, and sometimes, at
least, it assumes a malignant form.
Prolapsus and procidentia uteri and the different flexions
and versions, except inversion, could not, we think, be easily
mistaken for polypi, for if a digital examination were to
leave a doubt, it would certainly be dispelled by inspection
if external, or by the speculum if m the vagina.
Between polypus and inversion, the history of the case
will, in most cases, decide, especially when of recent or
sudden occurrence ; but when the case has come on slowly
and imperceptibly, and has become chronic, and no reliable
historv can be obtained, the diagnosis will sometimes be
extremely difficult. A polypus is generally smooth and in-
sensible, whereas the inverted uterus is rough and very sen-
sitive, but as we have already said some polypi possess
sensibility. If the finger fail to decide between polypus
and inversion, the point may be determined satisfactorily by
the uterine sound which, if it be polypus, would pass by the
Eve. Lectures on [January,
tumor, through the os uteri, the usual length of 2$ inches
or more ; but if inversion, it could not enter the os at all,
and could pass very lijtle way into the vagina.
It' the question were to arise soon after delivery, the ab-
sence <>r presence of the uterine glohe in the hypogastrum
would he strong proof for or against inversion ; besides the
symptoms of inversion occurring at such a time are usually
well marked, and most decided, sudden collapse, severe
pain, hemorrhage, l>;c. In inversion, if a male catheter he
introduced into the bladder and the end turned downwards.
it might be felt by a finger introduced high up in the rec-
tum, but could not be felt if the body of the uterus were in
its proper place, intervening between the extremity of the
catheter in the bladder and the finger in the rectum.
A polypus and inversion may exist together, the former
being the determining cause of the latter, less perhaps by
its weight, than by exciting the uterus to stong and long
continued contractions for its expulsion. The polypus
ovght fo be removed as quickly and easily as possible, and
means promptly adopted to correct the inversion if practi-
cable.
Other methods are suggested by authors to determine the
diagnosis between a polypus and an inverted uterus, but as
they are uncertain and unreliable, we will pass them by.
There are some polypi, which, though internal, occasion-
ally protrude, and are therefore sometimes perceptible and
at other times not discoverable to the sight or touch. The
gnosis in such a case might require repeated examina-
tions. This ought to make us guarded in our opinions in
3 wherein although the symptoms indicate a polypus,
ii- presence cannot be readily detected.
Tiic principal danger to be apprehended from polypi de-
pends immediately, or remotely, <m the hemorrhage, almost
always consequent on them, that is from either the direct
of the loss of blood, ov the impairment of health
COnsequenl on the long continued or oft repeated drain on
tin- constitution.
1861.] Tumors. c. 43
But other bad effects sometimes result. They may pre-
vent conception, or they may interfere with the regular pro-
cess, or the safe termination of gestation. There are, how-
ever, exceptional cases in which conception is not prevent-
ed, nor is gestation or parturition materially affected by
their presence, even when large.
At the time of labor, a large polypus may obstruct the
passage of the child or may cause dangerous flooding, by
preventing the regular normal contraction of the uterus.
We have already had occasion to refer to inversion of the
uterus consequent upon the presence of a polypus. They
are said sometimes to contract adhesions to adjacent parts,
or by pressure, to cause ulceration through the rectum or
bladder. They sometimes cause constipation, retention of
urine and severe pains in the back and pelvic region, espe-
cially during their expulsion from the uterus into the va-
gina, and sometimes from the vagina through the vulva.
Treatment. Besides the employment of such remedies
as may be indicated to restrain hemorrhage, and to improve
the general health, the treatment of polypi consists in the
use of the different methods devised for their removal.
These are caustics, tortion, or avulsion, ligation and excis-
ion. The first two are principally applicable to the removal
of the small polypi, although some of the larger, having
very small pedicles, may be torn or twisted off, and are
sometimes thus cetached when not intended. Caustics are
very seldom used, but some of the small and soft polypi,
found in the cervical canal, may be destroyed by the stronger
caustics, such as caustic potash, potassa cum calce, or the
actual cautery. They are, however, more promptly and
easily torn off by a suitable pair of forceps, or cut off by a
long slender pair of scissors ; or if not turn off or cut off,
they may be crushed and destroyed by the forceps.
Some of the softer polypi, though of considerable size,
may be twisted off by the fingers, or may be drawn away by
a ligature applied around them as high up as practicable,
by means of Gooch's double canula.
44 Eve. Lectures on [January,
The most convenient and advantageous mode of opera-
ting ^n these small polypi within, or attached to the cervix,
19 to introduce a glass mirror speculum, by which they may
be broughl into view, and then nipped oif by the scissors,
or twisted off by the forceps, passed through it. . It is ad-
visable, after their removal, always to apply nitrate ot silver
to the cervical canal, for the threefold purpose of more
thoroughly destroying their pedicles and subduing inflam-
mation which is very often coexistent, of also of prevent-
in;;' oi restraining hemorrhage. Excision by the scissors is
far preferable^*) torsion oravulsion. Soit polypi of large size
rding to my own experience, are of rare occurrence.
Two are all [ remember to have seen. One I saw, in consulta-
tion with Dr. McKie, in Edgefield District, S. C, May 11th,
1 355. The patient was a negro woman about thirty years
of age. The polypus was rather larger than a hen's egg,
very soft, feeling somewhat, to the touch, like a small pla-
centa ; it had been attended with considerable hemorrhage;
its attachment was within the os tincae. I succeeded in de-
taching and bringing it away by my fingers. There was
no hemorrhage after its removal, and the patient rapidly re-
covered good health. The other ease, I sawr in consultation
with Dr. S. B. Simmons, in this city. The subject ot it
was an old mulatto woman, about sixty years of age. This
polypus wras four or five inches long, and about an inch and
;i half in thickness. It was very soft; this was attached
within the os. Dr. Simmons applied a ligature to it, by
means of Gooch's double canula, as near the uterus as prac-
ticable, intending to draw it through the vulva and cut it
but its attachment was so frail, that it separated on very
gentle traction, and came away with the ligature. Dr.
Simmons had, some months previous, removed a large
iibi' lypus from 1 1 i i - patient, to which case we will
have occasion to refer again, after having made some re-
marks on the removal of fibrous polypi.
[to be continued.]
1861.J Emory. Starnmonium Poisoning. 4">
ARTICLE III.
Laudanum an Antidote to Starnmonium Poisoning. By A. G.
Emorst, M. D., of Roanoke, Ala.
Was called, on the loth of October, at night, to a mulatto
boy, aged rive years, who was supposed by runner to be
having fits.
After my arrival I learned that, in the evening, an older
negro had given the boy a handful of the shelled seed of
Strammonium to play with, as he said, thinking them
harmless. There had been an elapse of some hours (four
or five) after this before I saw the patient, who was labor-
ing under delirium of a lively, active, vivid character, alter-
nating, in short periods, with the most apparent horrified
fright ; seeming to dread the approach of some imaginary
monster, and giving utterance in the most piteous appeals
for help protection. His hearing was obtuse at times ; at
others, natural. Pupil dilated to almost full size of iris ;
tongue, mouth and fauces dry, with considerable diffi-
culty in deglutition ; heat of surface elevated and dry ;
pulse and respiration somewhat quickened (not more than
could be accounted for from the fright and violent muscu-
lar actions it had, which actions were very irregular.) The
patient seemed to me to have very little control over the
movements of the upper and lower extremities.
From the circumstances, that the child had the seed, and
the symptoms above, I was at no loss in forming a correct
diagnosis that of Strammonium poisoning. Actuated by
this, I immediately administered an emetic of Ipecac, though
with some difficulty, from spadmodic action of muscles
ahout the throat at each attempt to swallow. This emetic
brought up a little mucus and persimmons.
Ordered an enema of warm water, strongly impregnated
with salt and soft soap, which produced a small fecal evacu-
ation. Having noticed, previously, in your journal, an ac-
count of this poisoning successfully treated with small and
often repeated doses of laudanum, I determined to test its
4G Groover. Puerperal Fever. [January,
efficaey in this case. I commenced "by giving three-drop
doses, when, seeing no amelioration in the symptoms, I
gave Beven or eight drops, and in one hour the child was en-
joying a calm and profound slumber.
Being called oft* at this juncture, I left a powder of calo-
mel and rhubarb, to he given as soon as the child should
wake, with instructions to re-commence with the laudanum
in three-drop doses every hour, should there he a return of
former symptoms, until relieved or sleep came on. Patient
slept three hours and, on waking, there was a return of the
same symptoms slightly ameliorated. The cathartic dose
was given and laudanum resumed as directed; but before the
second dose was given, voluntary emesis occurred, which
brought up a great many seed, and in no great time, dis-
charges, per rectum, showed that they were not in the least
afraid to "follow suit," as they produced a teaspoonful of the
little fellers/'
Laudanum, in the meantime, being continued, soon
brought rest to the little sufferer again ; after which there
was no return of unfavorable symptoms, except some un-
steadiness of gait and imperfect vision, from dilated pupils,
which continued three or four days and left the patient well,
thus giving an unmistakable demonstration of the thera-
peutic autidolal power of opium over strammonium.
ARTICLE IV.
Pm r/h ral Fever Successful!)/ Treated by Blood-letting and Colo-
mi I and Opium. By J. S. Groovkr. M. P., of Groover-
ville, Qa.
Linday, (negress), act 24, (belonging to C. G.,) confined
September 12th, 1860. Labor natural, easy and of ordinary
duration. Convalescence progressing normally up to the
I'.'tli. At this time she was seized with chills about 8 a.m.;
:it :>> p. in., 1 Baw her with the following symptoms : Fever;
pain in Lower portion of abdomen, extending upwards ; in-
1861.] Umbilical Hcemorrhage.
creased on taking long inspiration, or on pressure : pulse
12"): respiration 36 ; expression of countenance anxious;
tympanitis well marked ; lochia scanty, but not offensive.
I abstracted twenty ounces blood, when the premonitory
symptome of syncope appeared. In fifteen minutes she was
in gentle perspiration and pain very much relieved
Ordered Ilydrary, Gub-mu, grs. ji, pulv. opi. 8J, every
two hours, which was continued with an intermission of
two doses at night, up to 9 a. m., 20th. I found her so well
that the medicine was stopped, and ordered castor oil jg,
and opium gr.j at night. Patient was discharged and con-
valesced finely. The post-blood-letting debility required no
tonic or stimulants.
I have been induced to write out this case from seeing-
two reported in the Xew York Medical Times, treated by
infusion of digitalis, in Bellevue /Hospital, so as to show
the superiority of the lancet over other means. The first
case was under treatment from August 3rd to 17th, when
convalescence began. The second, from August 4th to 13th.
The opposition to the lancet, and the endeavors to find a
substitute for it in that Institution and others, are turning
many from the path of nature.
Umbilical Haemorrhage. In the Charleston Medical Jour-
nal and Review for November, Dr. A. X. Talley reports three
cases of this unfortunate and troublesome accident. The first
two were treated in the usual manner, not omitting the plaster
of Paris recommended by Dr. Churchill. Remedial means
were ineffectual, and both patients died. The third case was
treated with Squiblrs liquor of the persulphate of iron. "The
effect was instantaneous ; the haemorrhage, which, despite
every appliance, had continued fearfully rapid, was at once ar-
rested, and did not again recur. The child is now quite well,
and has entirely recovered from the prostration consequent
upon the excessive loss of blood."
This one case is not sufficient to establish the merits of the
agent employed ; but as the result was characteristic and in
keeping with its well-known properties, hopes may be enter-
tained of its usefulness in these formerly intractable cases.
48 (lent and Articular Rheumatism, &c. [January,
On (If Employment of Saccharate of Colchieum in the Treat-
:,! qffeout and Articular Rh umaiism. By Dr. Joyeux.
From a great number of cases which have come under the
author's observation, he draws the following conclusions :
1. That tin- Baccharate of colchieum, prepared with the fresh
juice of the flower, is oneof the most reliable remedies whioh
the physician can employ in order l< combal the symptoms
which depend upon the gouty or rheumatic diathe
2. That the curative effects of colchieum are not owing to
its irritating action upon the alimentary canal, but to the se-
dative power oi the alkaloids which it contains; and that,
lequently, it is of advantage to administer it in fractional
and graduallv increasing doses, so as to avoid its purgative
i ffect
The saccharate of colchieum employed by M. Joyeux is
prepared with 100 grammes of fresh juice and 500 grammes
of sugar, and evaporated to dryness in vacuo, lie uses ako
an extract of the juice of colchieum, evaporated in vacuo, as
an external application, directing it to be rubbed on the pain-
fid parts. The saccharate is given in the average dose of four
grammes per diem, divided into ten parts, one of which is
taken every hour.
" Since I have made use of these preparations," says the
author, " I have not met with a single case of gout which
did not yield to treatment in two or three days. Acute arti-
cular rheumatism disappeared in the space of fifteen or twenty
davs. In subacute rheumatism, without an equally satisfying
result, I have witnessed a great amelioration. I have found
it of advantage, in the majority of cases, to let the parties
take, as adjuvant, an infusion of lime-tree blossoms, contain-
i,itre, in the proportion of two grammes to one litre of tea.
Natural History of Stoni in the Bladder. A fisherman
presented, says M, Zennaro, of Chicago, {Oaz. 3f< d ItaL, 1859,)
symptoms ol stone in the bladder at the age of 54r, and refused
all surgical interference. Seven years afterwards, a fistulous
rture showed itself in the scrotum, and the man was obliged
t. keep his bed. During the following 14 years live more
apertures formed between the scrotum and penis, the patient
Buffering, in the meanwhile, great torture. When 75 years
..Id, he iiad suddenly a sharp attack of pain, and during the
piercing cries he uttered, calculus weighing s ounces escaped
from oneof the perineal openings. The urine then freely es-
caped by this aperture: but the man stil! refused all interfer-
ad put up with this inconvenient mode of micturition.
1861.] Rabies in Early Ages. 49
Rabies as an Epizootic in Early Ayes. By Dr. Huseman.
Rabies has found, on more occasions than one, some
special historians, Among these may be mentioned Kru-
gelstein, on account of his k' History of Rabies Canina and
Hydrophobia/' Gothn, 1826 an account of which deserves
all approbation for the labor spent on it. All writers on
rabies canina, however, take their notes of it from modern
times Krugelstein himself citing those only from the 18th
century. And yet there were cases in earlier times, which
came under the observation not only of contemporary
medical men, but also of the chroniclers of those days.
Thus, in the first part of a familiar historical book
"Theatrum Europium," by Joannes Phillipus Abelinus
(or Gottfried), Frankfort, 1634 we find the following in
page 712 : " In addition to all the distress, and war, and
great famine, which extended over almost every place at
this time, still another plague appeared, from harvest to
November, 1621, in Rheinthal and the the territory of Ap-
penzoll, and the surrounding country. For, during the
previous summer, the bodies of many thus dying having
been thrown into the Rhine and then cast upon its shores,
the dogs fed upon thern ; on which account they became
mad, and afterwards attacked the cattle in every direction,
and destroyed them. The loss of the people in this way
was estimated at 25,000 gulden. At last they were obliged
to turn out with spears, rifles, and poles, and destroy every
animal thus affected.
At this period, the trees, as in spring, both in these and
in other places, blossomed, and the birds laid their eggs and
hatched forth their young.
" In Siebenburgen the dogs also run mad, and not only
bit cattle, but even men, causing them to go mad ; so that
they were obliged, with great labor and grief, to put such
infected men and cattle along with the dogs, out of the way,
to prevent still further misfortune and peril, which could
not otherwise be avoided."
It is worthy of remark, that Siebenburgen was specially
affected, since, according to Beecher's statistics of the Aus-
trian Empire, it still suffers, most of all the provinces of
the empire, with rabies. That, in the year 1621, men af-
fected with rabies "were put out of the way to prevent still
further misfortune, and peril," is perfectly credible, when we
think of the manners of the age and the country.
50 Rabies in Early Ages. [January,
The erroneous idea, thai rabies, canina arose from de-
vouring dead'bodies, was extensively believed in the 17tli
and 18th centuries, and even finds an expression in the
laws of the time. Tims, in the "Laws of the principality
of Lippe," vol. iii, 1<>, the following circular may he found
relating to the interment of dead cattle :
" A> it is reported that the required interment of dead
cattle has been neglected in some parts of the country, and
in others it is not made deep enough, so that the dogs can
dig the carrion out of the earth, eat it, and become mad;
the authorities will take care to have a more strict compli-
ance with the edict of May 4, 1771*, and bring those violat-
ing it to punishment."
That, by the consumption of carrion, a true epizootic
might be produced in dogs, which should have a great re-
semblance to contagious rabies, later investigations have
shown.
In the other volumes of the European chronicles of Abc-
linus (the work is in 16 volumes) which Dr. lluseman has
examined, he finds no record except that of this epizootic,
among the dogs in the 17th century. But the misdeeds of
wolves, that had gone mad, are recorded in various years.
Thus, in 1651, it is stated that in Cologne, on March 31, a
wolf, having lately gone mad at Ververs, destroyed twelve
men before he could be slain. In his throat there was found
a large piece of fresh human rlesh, which might have been
from a soldier of Lothingia, as these were lying unburied
in quantities in that region. In the woods or forests be-
tween the Italian States of Pisa and Luca, six large, tierce
wolves were seen together, who had become so famished
that they not only attacked sheep and other flocks, but also
their shepherds and herdsmen, destroying twenty of the
latter. Hence, the Grand Duke of Florence despatched
his upper master of the chase, with all his dogs and 400
soldiers, to exterminate these wolves, hut they were not to
he found.
Similar wolf stories are related of Bohemia, Erfurt, and
Touraine, in the years 1652, L653, and 1671, which cannot
here he discussed, since they possess no special interest, and
the proofs alleged, merely illustrate the characteristics of
the Btyle employed in the "Theatrum Europseum."
1861.] ' for Diabcs. 51
A I it for h By E. C. Bidwell, M. P.
The only test for glucoscuria which I luive hitherto found
satisfactory fermentation involves a delay which is often
edingly annoying, and sometimes fatal to a ory
and seasonable diagnosis. Those founded upon the reduc-
tion oi% metalic oxides, besides being complicated and incon-
venient for clinical use, are liable to various fallacies. A
better test than any I have seen described, seemec! to me a
desideratum one which should be delicate and conclusive,
and at the same time ready and convenient. Moved by this
sense of a want, to experiment for a new process, I have
discovered one which seems to meet fully the needs of the
: one, which, if it be not pre-eminently scientific, is
nevertheless facile and reliable. For the benefit of any
others who may have felt the same want, I herewith com-
municate the result of ray investigations.
Technically described, it is simply the conversion of the
saccharine element of diabetic urine into caramel by heat.
My mode is this. Upon a clean slip of tinned iron, place
(me or two drops of the suspected material, and hold it over
a spirit lamp : the fluid will speedily evaporate, leaving, if
the process be arrested at that point, scarcely a trace upon
the metallic surface. Continue the application of heat; in
a few moments after the desication is complete, a spot of an
inch or so in diameter, over which the drop had spread with
the first ebulition, will gradually assume a rich reddish-
brown color, with a brilliant lustre, as if coated with a film
of varnish or Japan lacquer. A strong heat produc
darker color, but the lustre continues till the heat becomes
sufficiently intense to decompose the substances.
This experiment has succeeded perfectly in my hands,
when the urine on trial, previously known to contain glu-
specific gravity less than 1030, and still further
reduced by the adition of three or four times as much of
water. It is thus proved to be a delicate test. I suppose it
io be conclusive, also, for I have never yet found any other
LStituent of urine, normal or abnormal, capable of pro-
ducing anything at all like the same appearance under the
treatment. The nearest approach is this : some
oples of urine not diabetic, when treated in this way,
leave a faint, dull, yellowish stain, easily distinguished from
caramel by its paler color, and the entire absence of lustre.
1 need scarcely add, that a solution of sugar, uot diabetic,
exhibits almost exactly the same reaction.
52 Action of Med Mental Faculties. [January,
With tht; augmented interest attached to glucosurJa, since,
besides being a Leading feature of a most intractable, but
fortunately rare, disease, it is found Bymptomatically asso-
ciated with several other diseases and injuries, an increased
facility lor its detection is almost a necessity of the profes-
sion. I trust they will find it in the simple and beautiful
experiment above described.
Action of Different Medicines on the Mental Faculties. By
Professor Otto.
All stimulant and exciting medicines increase the quan-
tity of blood sent to the brain. If this quantity exceeds a
certain amount, then most of the faculties of the mind be-
come over-excited. Nevertheless the degree of this action
is observed to vary a good deal in different cerebral organi-
zations ; and it is also found that certain stimulants exercise
a peculiar and characteristic influence upon special or indi-
vidual faculties. Thus ammonia, and its preparations, as
well as musk, castor, wine, and ether, unquestionably en-
liven the imaginative powers, and thus serve to render the
mind more fertile and creative. The empyreumatic oils are
apt to induce a tendency to melancholy and mental halluci-
nations. Phosphorus acts on the instinct of propagation
and increases sexual desire ; hence it has often been recom-
mended in cases of impotence. Iodine seems to have a
somewhat analogous influence, but then it often diminishes
at the same time the energy of the intellectual powers.
Cantharides, it is well known, are a direct stimulant to the
sexual organs, while camphor tends to moderate and lull
rhe irritability of these parts.
Of the metals, arsenic has a tendency to induce lowness
and depression of spirits, while the preparation of gold serve
to elevate and excite them. Mercury is exceeding apt to
bring on a morbid sensibility, and an inaptitude for all ac-
tive occupation.
Of narcotics, opium is found to augment the eratic pro-
pensities, as well as the general powers of the intellect, but
more especially the imagination. Those who take it in ex-
are, it is well known, liable to priapism. In smaller
doses it enlivens the ideas and induces various hallucina-
tions, so that it may be truly said, that during the stupor
which it induces, the mind continues to be awake while the
body is asleep. In some persons opium excites inordinate
1861.] Phosphorus and Phosphorus Add. 58
loquacity. Dr. Gregory Bays that this effect is observed
more especially after the use of the muriate of morphia.
He noticed this effect in numerous patients, and he then
tried the experiment on himself with a similar result.
Ee felt, he tells us, while under the operation, an invincible
desire to speak, and possessed, moreover, an unusual fluen-
cy ot^ language. Hence he recommends its use to those
who may be called upon to address any public assembly,
and who have not sufficient confidence in their own unas-
sisted powers.
Other narcotics arc observed to act very differently on
the brain and its faculties from opium. Belladona usually
impairs the intellectual energies; hyoscyamus renders the
person violent, impetuous and ill-mannered ; conium dulls
and deadens the intellect, and digiialis is decidedly anti-
aphrodisiac. Hemp will often induce an inextinguishable
gayety of spirits ; it enters into the composition of the in-
toxicating drink which the Indians call bauss. The use of
amanita muscaria is said to have inspired the Scandinavian
warriors with a wild and ferocious courage. Tobacco acts
in a very similar maimer with opium, even in those persons
who are accustomed to its use ; almost all smokers assert
that it stimulates the powers of the imagination.
If the psychological action of medicines were better
known, medical men might be able to vary their exhibition,
according to the characters and mental peculiarities of their
patients. The treatment of different kinds of monomania-
cal derangement also might be much improved, and it is
not improbable but that even a favorable change might be
wrought on certain vicious and perverse dispositions, which
unfortunately resist all attempts at reformation, whether, in
the way of admonition, reproof, or even of correction.
On (he Detection and Estimation of Phosphorus and Phosphorus
id. By Professor Scherer.
Within two years the author had occasion to gather much
experience from a number of cases of poisoning animals,
and of two men ; also from several attempts of poisoning by
phosphorus. In one case, the phosphorus from thirty to
forty matches, equivalent to half a grain, proved fatal to
a woman in forty-eight hours. He establishes the presence
of phosphorus by Mitcherlich's method, with the modifica-
54 Apoplectic Affections of the Retina. [January,
tionof filling the apparatus with carbonic acid, generated
from a fewpiecesof calcarious spar introduced into the acid
liquid. No luminous vapors arc obtained, but little of the
phosphorus is oxidized, and if the tube dips into distilled
water, this is phosphorescent when agitated in the dark,
and its vapor blacks nitrate of silver.
To estimate the phosphorus, the last bottle containing the
water is connected with another phial containing either
neutral or slightly ammoniacal nitrate of silver, which ab-
sorbs all the phosphorus vapors that have not been retained
by the water. Any globules of phosphorus which may have
been obtained are fused together and weighed; the water
is added and then evaporated ; the chloride of silver is
filtered off: the phosphoric acid, which is contained in the
filtrate, is estimated in the usual manner, and calculated for
phosphorus.
Very minute portions of phosphorus may be recognized,
after first ascertaining the absence of sulphhydrie acid, the
vapors of which will turn sugar-of-lead paper black, and
paper moistened with nitroprusids of sodium blue ; papers
moistened with nitrate of silver are suspended over the acid
liquid, which gently heated; in the presence of phosphorus
the silver will be reduced with a black color. The papers
may now be macerated in chlorine water or aqua regia ; the
filtrate will, after evaporation, contain phosphorus acid, to
be recognized as ammonio-phosphate of magnesia, or as
phosphomolybdatc of ammonia
If phosphorus has been wholly or partly converted into
phosphorus acid, the residue from the first distillation is
heated in Mitcherlich's apparatus with sulphuric acid and
pure zinc, until the hydrogen ceases to be contaminated
with phosphurctted hydrogen, which is conducted into the
silver solution, and estimated as indicated before. Ameri-
can Journal of Pharmacy.
- m m
Apoplectic A /Fictions of the Retina. Under the care of Dr-
Dixon, Royal London Ophthalmic Hospital. London
Ophthalmic Hospital. (London Medical Times and Ga-
zette, June 23, 1860, p. 02:3.)
The value of the ophthalmoscope is well illustrated in
eral cases where diagnosis would have been difficult in
the absence of this means of assistance. The instrument
in fart completed the history of the disease, so far as the
eye was concerned, and furnished information which for-
1861.] Apoplectic Affections of the Retina. 55
merly could only have been obtained by actual dissection .
In Que 1, the patient noticed while at work that there was
"a dimness before his sight," and, on closing the eves alter-
nately, he found lie could not see with the left. The next
morning the right eye tailed in the same manner, and, on
further trying the eye, he could only make out very large
capital letters. Ten days afterwards vision in his right eye
had improved, but in the left it was not materially affected,
strong light he could not see at all. The optbalmoscope
showed traces of effusion from the choroid beneath the re-
tina, at the yellow spot in both eyes, the most in the left.
This was a well-marked illustration of symmetrical apo-
plexy beneath the retina occurring in an apparently healthy
man.
Cast '2 commenced *-as a little dimness like a mist before
the eye," followed by the appearance of black spots float-
ing before it. * His general appearance on admission was
not the blank look of total blindness, but he could find his
way in the hospital, only slowly, and not without directing
himself somewhat by feeling. The pupils were unusually
large, and did not contract by light. He could see better
with the left eye. The eyes were examined at the time by
the opthalmoscope, and clots of blood were distinctly seen
in the fundus. Xo marked improvement followed the treat-
ment. Constant headache presented a complication in this
. the pain being chiefly in the forehead.
3 afforded an example of apoplexy of one retina on-
ly, but attended with frontal headache and epistaxis. The
failure in the right eye appeared to have followed soon after
a violent attack of bleeding from the nose. The headac
were wholly relieved by the epistaxis. When last examin-
ee described his sensations at night as follows : On look-
ing at the ceiling, he sees a large "block," the size of two
heads, the rest of the ceiling appeared pretty clear. (The
pupils dilated by atrogine.) Upon making an examination of
the eye with the opthalmoscope, a large irregularly circum-
ibed patch was discovered, extending over and around
the yellow spot, the ground of which was lighter colored
than the surrounding parts, and on which were numerous
dots of extravasation, very irregular, and in many pla
consisting of five or six spots running into each other. Be-
tween this patch and the margin of the optic entrance was
found a large and apparently thick coagulum of a deep
purple tint. Over the whole of the patch arc Small white
56 rate of Iron. [January,
Boots, appently about the size of pins' heads. Several dis-
tinct apoplexies lnust, in this instance, have occurred at dif-
fereut periods. The whitish patches were, no doubt, those
of oldest date. The case is of interest on account of the
age of the man being exactly that at which a sister of his
had died of crebral apoplexy, and because in his own case
severe frontal headache and epistaxis had preceded the effu-
sion into the eye.
On the Employment of Stearate of Iron in the Treatment of Soft
or Phagendic Chancres. By M. Ricord, (Pharmaceutical
Preparations of M. Braille.)
From a communication of M. Calvo, nephew of M.
Ricord, we learn that the latter has employed for several
months, in the Ilopltll da Midi, an ointment or plaster of
stearate of iron, prepared by M. Braille, pharmaceutist of
the institution, to whom we are indebted for excellent means
of dressing soft or phagedenic chancres.
This new preparation, which can be prepared at a low
price, and is of easy application, is destined, without doubt, to
render great service in all those cases of so serious a char-
acter where the phagedenic action seems to resist the
numerous means which science directs against it, and con-
tinues its destructive march without interruption. Up to
the present time, at least, it has fulfilled, in the hands ofM.
Ricord, all that it seemed to promise, and has become of
daily use in his hospital as well as in private practice.
The modus facienai of these new preparations, as commu-
nicated by M. Braille, is the following:
O'ndmcnt of Stearate of Iron. IJr. Sulphate of Iron, 500
grammes; Marseilles Soap, 1000 grammes.
Dissolve the sulphate of iron in about 1500 grammes, of
water, and dissolve the Marseilles soap in an equal quantity
of water. On pouring one solution into the other, a whitish-
green precipitate is obtained, which is dried, and then melt-
ed at a moderate temperature of 80 to 84 K.; add to the
melted mass, <-;i cooling, 40 percent, of essence of lavender,
jtir it constantly until it becomes perfectly cold.
Sparadrap of StearaL of Iron, (Braille's Plaster.) ]{. Stea-
>btained by the process directed above.
ii at a moderate temperature, and spread it on muslin
1861.] Hydrochloric Arid in Chronic Dyspq>& 57
like the ordinary sparadrap. This mass gives an adhesive
sparadrap, which does not crack like the soaps of lead ob-
tained by double decomposition. Journal dc harm\
dochloric Acid in Chronic Dy& By Dr. Schottin, oi
Dresden.
Dr. Schottin has used hydrochloric acid with great suc-
- of chronic dyspepsia. The curative effect of
the remedy is attributable to two circumstances : First, it
suspends, like other powerful acids, the process of fermenta-
tion ; and, secondly, it serves to dissolve the proteinaceous
compounds, being, to a certain extent, a substitute for the
disturbed secretion of the gastric juice ; it is therefore, the
most natural remedy. In children who suffer from gastric
and intestinal catarrh, the author prescribes the acidium
muriaticum dilutum of the Prussian pharmacopoeia, in
doses of six to fifteen drops, in a mucilaginous mixture, and
adds, until the bowels are regulated, a few drops of tincture
of opium. lie orders the'medicine to be taken half an hour
after each meal, and confines the patient to a diet of milk
and broth. In old age. when the stength of the system is
gradually falling, disturbances of digestion are very fre-
quent, the cause of which is to be found, in many instances,
solely in a diminished secretion of the gastric juice. A
double indication is to be fulfilled in these cases : to arrest
the process oi fermentation, and to stimulate the stomach,
in order to increase the secretion of the gastric juice. Dr.
Schottin recommends for this purpose small doses of chloride
of sodium and sulphate of quinia, to be followed, a short
time aiterwards, by sulphuric acid. The chloride of sodium
is decomposed by this means into sulphate of soda, and hy-
drochloric acid. lie prescribes ten grains of chloride of
sodium and one-third of a grain of sulphate of quinia, to
be taken four times a day wrapped up in a wafer, lets the
patient drink some water, after it, and administers, about
five minutes later, eight to twelve drops of the elixir acidum
Halleri in half a wineglassful of water.
The dyspepsia of drunkards requires a double dose of
sodium and sulphuric acid. Dr. Schottin attributes the ef-
fect of hydrochloric acid in typhus, anaemia, and chlon
likewise to its property of suspending the process <.t* fer-
mentation within the stomach, and i ing the deficient
secretion of the gastric juice Archie der Houkunde.
Prolapse of th Rectum.
[January,
onneckd with the Pathohqy and Treatment of
i ' ' the Reetwu* By Henry Smith, F.R.C. S.
It is not my intention in this paper to treat generally of
the important subject under notice, but I am going to re-
quest your attention to one or two particular points connect-
ed with the pathological features ol prolapsus of the rec-
tum, and with the treatment which is suited to certain forms
i>\' the disorder.
There has not been much room for discussion respecting
the main pathological changes which take place in the pro-
duction of this disease, for the simple reason that a prolaps-
ed rectum can be readily examined on the living body,
both by the eye and the fingers, and some most able sur-
as have described in their works with remarkable ac-
curracy the principal features ; but on one point there has
been, and is now, a strong divergence of opinion as to
whether most frequently the prolapsed part consists of the
mucous and muscular coats of the rectum, or of the mucous
membranes simply. Some of the older writers have leaned
strongly to the opinion that the mucous membrane of
the bowel alone was involved, while of late there has been
an opinion expressed as strongly on the opposite side.
There cannot be a doubt in the mind of any one who has
investigated the subject by studying morbid specimens
taken from the dead body, that, although in the majority of
instances the prolapsed part consists of the mucous mem-
brane alone in a relaxed and thickened condition, yet, in-
some cases, the muscular coat of the bowel is protruded be-
yond the sphincter as well as the mucous membrane. It is
nol only an interesting hut an important fact to ascertain
properly, because it will happen that the treatment which
will be adapted for the one the form of disease will not suit
the other. In cases where the mucous membrane is pro-
lapsed lo.al measures, and those of a less energetic nature,
are Buffich nt tor a cure, whereas in instances where the
muscula is brought down beyond the spincter, local
measures alone will either fail, or it will be necessary to
loy means mmv decided and more severe. As an ilus-
tration of the prolapsus consisting ^\' all the tissues of the
bowel 1 may refer you to those large descents which are
mtli Hants Medical and Chirurgical Society,
2, I860. !;. Wiblin, President, in the Ohair.
Sept.
1861.] Prolapse of the Pedum. 59
somestimos seen in children as the result of some irritation
in the intestinal tract or in the bladder. ~\\re know what a
difficulty there is occasionally in keeping np such a prolapsus
after it has been carefully returned, and that the best regu-
lated local measures will not suffice for a cure until the
general health of the child is improved by nutritious diet
and powerful tonics, which especially tend to enhance the
power of the muscular system. We know how elaborately
the muscular tissues are supplied with blood-vessels, and
how largely their nutrition and power of action are under
the influence ol remedies which increase the tone of the
system.
The other instances in which we find that there is pro-
trusion of the entire structure of the bowel are seen in those
cases of long standing pro]apsus in adults, where the pro-
trusion is of immense size, as large as the fist or a foetal
head, and coming down on the least exertion of the patient.
Within the last week, I have been consulsed on a case of
this description, occurring in the case of an old gentleman,
of a weak frame and feeble circulation. The prolapsus had
existed for forty years, and it has reached its present enor-
mous size in consequence of neglect of proper surgical treat
ment. In such cases as this, there is no doubt that at first,
the mucous membrane of the bowel was simply protruded,
but afterwards the other tissues became involved, and at
length the tumor consisted not only of thickened mucous
membrane, but the muscular coat also was extended beyond
the sphincter.
In those cases of prolapsus of the rectum of much more
frequent occurrence, where the disease is more limited
in extent, and where the mucous membrane alone is pro-
truded, there is a considerable difference in the pathological
features, and that, too, of considerable practical importance,
ially when viewed in relation to a mode of practice I
am in the habit of adopting. In some of these cases it will
be found that the mucous membrane is simply extended
beyond the sphincter, in but a very slightly altered con-
dition, the whole circumference of the lining membrane of
the bowel may be down, or only one or two semi-circular
folds may be prolapsed ; in either instance, however, besides
this prolapsed membrane, the protruded part may consist of
the muco-cutaneous lining of the sphincter, in a highly con-
gested and thickened condition, forming in fact, the greater
portion of the disease. This is protruded first, and may
60 Prolapse of the Rectum. [January,
be scon as a dark blue ring around the anus, while situ-
ated above it is the proper mucous tissue of the bowel
simply relaxed and prolapsed, but otherwise in a normal
Btate.
There is a point of considerable importance, both patho-
logical and practical, in connection with prolapsus, to which
I wish to call your attention, and which has not been suf-
ficiently alluded to by writers; this is the condition of the
sphincter ani. In some cases we shall find that this muscle
acts in a normal manner and that the anal aperture is not
larger than ordinary, although there may be a considerable
prolapsus of the mucous membrane ; in other instances the
sphincter seems to have losta considerable degree of its con-
tractile power, the aperture is enlarged and easily distended
eel ; in a few cases to such an extent that the whole fingers,
when formed into a cone, may be passed into the rectum. In
these instances this laxity of the sphincter is the chief cause
of misery, for when it exists in a great degree the patient
loses, either partially or entirely, control over his rectum,
and the frees escapes involuntarily. A remarkable instance
of this fell under rny care in the person of a patient, aged
TO, who had suffered for twenty years with prolapsus, and
indeed it was this circumstance which drove him to consult
me. When there is a partial loss of the power of the
sphincter the patient is continually harassed by calls to the
closet night and day, although there may be any actual in-
voluntary discharge of faeces. Of course this loss of power
of the sphincter is the greater misfortune of the two, but in
e instances of prolapsus of the mucous membrane when
the sphincter is in a healthy condition, the following acci-
dent may and does occur, especially when the protruded
membrane has on its surface one or more distinct hemorrh-
oidal tumors, the protrusion occurs on one occasion, to a
larger extent and the patient cannot return it as usual, the
mosl severe symptoms of course rapidly set in, and although
this accident is very likely to be followed by a cure in con-
ce of sloughingof the constricted parts, yet one would
b very unwilling to bring about this condition purposely,
for death has followed upon the intense amount of inflam-
mation which has occurred. X<>t long since! was called to
Id lady, 7< years of age, to whom this accident liappen-
and not being in a healthy condition she was reduced
to a great amount of suffering, for violent in ilammation and
ighing of the protruded membrane had taken place;
1881.] Prolapse of the Rectum. Gl
this latter process was hastened hy placing ligatures around
the diseased parts, and she made a good recovery.
The treatment which should he adopted in case of pro-
lapsus of the rectum must differ according to the pathologi-
cal condition of the part, especially as regards size and the
state of the sphincter. It lias hitherto heen customary
anions: surgeons to use the ligature in most of the cases of
prolapsus requiring surgical operation, and of these I am
only now talking : and undoubtedly, where the disease has
become very extensive, and particularly when associated
with distinct hemorrhoidal tumors, 'the ligature must be
used, if there be not any contraindication to a surgical ope-
ration. This is especially .the case when, from the large
size and the peculiar feel of the tumor, there is every rea-
son to believe that the muscular coat of the bowel is protru-
ded as well, for any operation short of the ligature will be
useless in removing the disorder. In some f the cases also
alluded to, when the prolapsus is voluminous, and there is
a very relaxed state of the sphincter, the ligature alone can
be depended upon ; but for such instances, which are by no
means nncommonly met with in old people of the middle
and upper classes, I have lately put in practice an operation
which I do not wish to claim as particularly new, for it is a
combination of two agencies employed before for similar
conditions, but which I particularly wish to bring before
your notice. It consists in first applying the strong nitric
acid, on one or more occasions, to the mucous membrane ;
and subsequently, when this agent has had some decided
effect, to remove with curved scissors narrow strips of skin
and mucous membrane frem around the verge of the anas
at right angles to the orifice. The latter remedy alone was
employed both by Hey and Dupuytren, and lately recom-
mended by some ; but my experience tells me that alone it
is not to be depended upon ; but if the mucous membrane,
which is always in such cases in an extra-vascular and re-
laxed condition, is first brought into a more healthy state
by the contracting and slightly escharotic powers of an agent
like nitric acid, the effect of removing the loose fold of skin
which are so generally associated with the relaxed state of
the sphincter, is very admirable. Two objects, in such in-
stances, are sought by the surgeons, and indeed are abso-
lutel}7 necessary for an efhcieient remedy, viz : the contrac-
tion of the mucous membrane, and the biacing up of the
sphincter : these two results are brought about by the com-
62 Prolapse of the Rectum. [January,
biiicd proceedings mentioned. I must, however, not omit
to state thai it is perfectly useless to employ the nitric acid
in those instances where the prolapsed mucous membrane
has become tinned and indurated, as is very often the case:
the agent will produce no good effect; both patient and
surgeon will be disappointed. The application of the acid
is more especially advisable in those cases where the mucous
membrane is granular, very vascular, and readily bleeds :
the effect of one application in such an instance is sometimes
really astonishing. But there is one caution I wish to im-
press; and that is, that the surgeon must not be misled in-
to the abandonment of further measures because after one
application of the nitric acid he finds that the bleeding and
prolapsed bowel suddenly disappears. It will sometimes
happen that one application will be followed by remarkably
good results like these, and that afterwards the symptoms
return. It is better, in cases of extensive prolapsus, that
the acid should act gradually than suddenly; the effect will
be more permanent. It will be necessary to apply the nitric
acid when the disease is extensive, on several occasions per-
haps four, six, or eight times ; but it is generally attended
with so little pain, that the patient does not object to sub-
mit to it. If the sphincter ani be not in a weak condition,
but acts normally, there may not be any necessity of cutting
away the thin slips of muco-cutaneous covering; but if
there are any pendulous flaps of integument, these should
be exercised. These operations, which should be effected
by sharp curved scissors, are of course painful; but the ap-
plication of the freezing mixture of ice and salt will much
deaden the pain.
This treatment may be considered as perfectly free from
danger, and is so admirably adapted for those cases where
the "patient will either not submit to the ligature, or where
there is some contra-indication to this proceeding. For
instance, many of the worst cases of prolapsus oecur in
aged people who are, or who consider themselves too old to
undergo the ligature; others have some symptoms of lurk-
ing organic disease about their brain or heart, and it would
be highly perilous to use the ligature, but the treatment I
advocate may be used with perfect assurance of safety. To
illustrate this important fact I will allude to two cases which
have lately lately been under my notice. The first wras a
gentleman aged 73. lie had a bad prolapsus, and when
told by me that I could only recommend the ligature with
1861.] Prolapse of the Rectum. 63
confidence, to destroy his disease, lie refused to undergo
it. I tried by some applications of nitric acid to remedy it,
but lie became dissatisfied and consulted a surgeon of great
eminence who strongly recommended the ligature and ap-
plied it; the patient died three or four days after from an
attack of apoplexy.
Tow, there were certain indications about this gentleman
which would have prevented a surgeon who knew them and
carefully considered them, as Iliad done, from frequent ob-
servation of his case, from performing this operation. The
patient was very peculiar in his manner and habits, and
thought by his friends to be very "strange," as the term
goes, and in addition to this he had almost entirely lost the
control over his bladder during the few last months of his
life, without the existence of any stricture or disease of the
prostate.
Xow, these two facts indicated some lurking mischief
about the nervous system, and should have prevented the
surgeon from operating. Xo doubt the stimulus of the
operation of the ligature which is much more severe than
is imagined, lit up the lurking mischief in his nervous sys-
tem and destroyed life. To this the eminent surgeon who
performed the operation readily assented when he was ques-
tioned by me.
The other instance is that of an old military man nearly
TO, who has had prolapsus with severe pain and bleeding.
He was anxious to get some relief; he had a peculiar nerv-
ous twitching about his face, and a feebleness of his lower
limbs; and on making inquiry of one of his family, I ascer-
tained that he had something approaching a fit on two oc-
casions. I at once decided against employing the ligature,
for this reason, and resorted to the employment of the treat-
ment I have advised with great benefit.
It is not to be supposed from the remarks I have made that
I am averse to the ligature in suitable cases, but if it can be
dispensed with, and a milder mode of treatment can be suc-
cessfully adopted, the surgeon is bound to put it in force.
For, although I believe, when properly performed and in
healthy subjects, the operation of ligaturing portions of the
mucous membrane of the rectum is by no means dangerous
still we cannot conscientiously tell a patient there is no risk;
independent of the peculiar danger attending the proceed-
ing, such as pycemia or tetanus, some serious and annoying
<;i Ptolapse of the Mectum. [January,
accidents are Liable to follow this operation, and I shall here
draw attention to some of these.
One very peculiar and unlooked-for sequence of this ope-
ration for prolapsus worthy of relation occurred in practice
not long since. I operated upon a fat old lady who had
not much stamina the circumstances of the ease were such
us to demand a speedy and efficient operation; I used the
ordinary precautions in the process, and the patient did
wvy well the first day or two. On the third day, however,
to the greal surprise of her medical attendant and myself a
severe hemorrhage suddenly took place from the part, and
had such an effect on the patient that it made me very
anxious. 1 was at a loss to account for this very unusual
occurrence, wherencither the knife or scissors had heen used;
hut on going to make an examination I found that there
had heen a rapid slough as large as a shilling formed by
the side of the rectum, laying hare the muscular coat of the
bowel for near an inch in extent, and no doubt one of the
inferior hemorrhoidal arteries had been opened up and
hence the bleeding which was so profuse and which occur-
red on a second occasion ; but fortunately by keeping up
pressure, and local application of strong nitric acid, the
sloughing process was stopped and the patient made a good
recovery. But this might have destroyed the patient had it
gone on further. The cause of the sloughing was this :
The patient, who wras very fat and heavy, lay a great deal
on her back after the operation, and the pressure of the bed
induced the sloughing of the part already of necessity irri-
tated by the close proximity to the ligature. We learn from
this interesting case the importance of not allowing patients
to lie much upon the back after this operation, they should
rather be induced to lie on their side.
There is another point connected with the operation of
the ligature of the mucous membrane of the rectum which
there is considerable divergence <A' opinion. I refer to the
-apposed danger of suddenly arresting the great discharges
which ;ire so frequently seen instances, the sudden arrest or
bleeding, or of a very profuse muco-purulent discharge by
tie- Ligature, is liable to be followed by fatal consequences,
although many erroneous notions have been promulgated
it this. In very robust or full-blooded persons, the sud-
den stoppage of the dis charges may predisposr to, or bring
ome internal congestions of the brain or lungs; and,
therefore, in BUch, one should be careful about employing
1861.] Prolapse of the Rectum. 65
the ligature. I have never had good cause, in my own prac-
tice, to suppose that any serious result of this kind has oc-
curred, but I will briefly detail one case which, if the cir-
cumstances had not been accurately investigated, would
have led one to the supposition that the operation produced
a disastrous result of this kind.
In March last one of the finest-looking officers in the
army, of large frame, in robust, ruddy health, and aged 50,
consulted me for the prolapsus and haemorrhoids of a severe
nature, which had existed for many years. lie was a caval-
ry officer, and had seen arduous service in various cam-
paigns, having to ride much ; and for many years, on such
occasions, the haemorrhage was very profuse; but and this
portant there had been scarcely any bleeding for the
last two years. I advised the ligature, which operation was
also strongly recommended by Mr. Fergusson, who, at my
request, was consulted. I performed the operation, which
was followed by no untoward symptom, and in the course
of seven or eight days, the ligatures had separated, and I
left the patient under the care of his medical attendant, Mr.
Coleman, of Kingston. The patient was out in a fortnight
but did not regain his strength so readily as is the case after
this operation; and one night, about three weeks after-
wards, he suddenly dropped down dead.
Xow, at first sight, one would be inclined to say that here
was the very case to prove the danger of suddenly stopping
the discharge from the rectum. And had I not investigated
the point, I should certainly have supposed that a sudden
<< ingestion of the brain had been caused by the cessation
of the discharge; but the fact of there having been scarcely
any bleeding during the last two years, militates against
this doctrine. Mr. Coleman, who is a very able and shrewd
practitioner, considered that it was disease of the heart that
destroyed life that the man had a feeble heart, and that
the low diet to which he had been of necessity reduced, had
further enfeebled it, and hence its action had suddenly
ceased. It was a most unfortunate thing that no post mor-
tem examination could he obtained.
Before I conclude these straggling remarks and imperfect
observations, I will make one allusion to the diagnosis of
prolapsus of the rectum. It may seem unnecessary to insist
upon the importance of making a correct diagnosis, but this
surprise will cease when I inform the Society that I lately
saw a morbid specimen taken from the body of a dead
66 Affections of the JBemaU Breast. [January,
woman, where the whole circumference of the prolapsed
rectum had been encircled by a ligature, under the suppo-
sition that the tumor was a prolapsus of the uterus. As
may be imagined, death was the result of the occlusion of
the canal. The proceeding, too, was effected by a man of
considerable repute.
Time will not allow me to make any further remarks,
although there are several other points of interest connected
both with the pathology and treatment of prolapsus; but I
trust that the few subjects I have hit upon so transiently
and imperfectly may be considered worthy of discussion.
Treatment of Inflamniatory Affections of the Female Breast.
By W. H. Byford, M. D., of Chicago.
After fully describing the character, of these affections,
Professor Byford comes to their treatment. lie arranges
that for inflammation of the nipples under the heads of pro-
phylactic, palliative, and curative. The nipple must be pre-
pared for its duties. The causes operating upon it produce
abrasions, and their actions is facilitated by the natural and
acquired tenderness of the structures, particularly the epi-
dermis and skin. Hence these must be hardened. The
nipple should be covered lightly during pregnancy and nurs-
ing ; the thinner and more permeable the covering the bet-
ter. It should freely admit the air. At the time the organ
''should be subjected pretty constantly to moderately rough
friction.''
An excellent dressing for the nipple for the last two
months, is a rough, coarse sponge, so cut as to cover the
areola ; surround and cover loosely, but touch every part of
the nipple. Over this there should be but one thickness of
clothing, so as to allow of the evaporation of fluid as fast as
secreted, and the free admission of air. In cold weather, of
course, the parts should be covered more when going out.
The nipple should be occasionally moistened with water,
and allowed to dry slowly ; friction with a dry towel or the
lingers will assist.
During lactation, the same rules should be observed, and
after nursing, the nipple should be wiped clean and dry be-
fore being covered. A little glycerin or olive oil will pre-
vent cracking. When inflammation comes on, palliatives
and curative measures are demanded. The healing pro-
being continually interrupted by the performance of
1861.] Affections of the Female Breast. 67
the functions of the organ, it is necessary to protect the
part from the effect of these interruptions.
Artificial means are required, which intervene between
the month of the child and the nipple. For this purpose
the shield must be employed. This should be made in the
form of a conical hat, having a rim, a crown cavity, with a
draught tube rising out of the top for the passage of the
milk. This rim should be large enough to cover the areola,
the crown passing over the nipple, merely touching it on
the sides. If the abrasions are on the summit of the nipple
the shield should be so deep that, when drawn, the top of
the ogan will not touch, or else it will cause pain. But if
the cracks are on the side or base of the organ, then the
cavity of the shield must be shallow, so that the top of. the
nipple touches its bottom in such a manner as to prevent
any stretching, and to bring the pressure entirely on the
top. In this latter case, the bottom of the cavity should be
as smooth as possible, and correspond in shape to the sum-
mit of the nipple, in order to prevent unequal pressure. A
soft linen rag, properly adjusted over the draught tube, is
preferable to any other envelope.
M. Legroux mentions the following ingenious contrivance.
He applies this mixture:
]J. Collodion, p. xxx;
01. Eicini, p. ss ;
01. Terebinth, p. jss.
This is quite adhesive, and dries less quickly than collo-
dion, on the areola with a brush, so as to encircle, but not
touch, the nipple for the width of an inch. While yet soft
the nipple is covered with gold-beater's skin, wThich is press-
ed well down upon the mixture. Thus is formed a smooth
and pliant covering. Holes are pricked through the skin
with a needle, to aliow of the passage of the miTk. Before
sucking, this must be moistened with sugar and milk.
The curative means for sore nipples are various. The
Bame will not do for abrasions as wrell as ulcerations. Na-
ture is to be imitated by forming a cuticle for the part.
Abrasions may be covered with starch and mucilage.
The following is a good mixture :
]-. Ceret. Alb. gij ;
01. Amyg. Hulc. 5j;
Mel. Despun. 5ss. M.
Dissolve with gentle heat, and add Bals. Oanad 5ijss.
68 Affections of the Female Breast. [Januar
Apply each time of nursing. WTienthe cracks are dee]
them by pressing their edges together, and coverin
with collodion in a thick and wide coat; this must be r
newed when found necessary. When ulceration exists,
will be acute or chronic. Act as for this affection elsewhere
ete, if acute, by leeches, and apply cold emollient pou
ticea ; or envelop the nipple in a thin layer of thick muci
covered with oil-silk, so as nearly to fit the organ, kej
cold by ice applied in a bladder. When these remedic
are not necessary, apply mucilaginous and bland ointmer
applications. Alum and tannin are good at first; sulphat
of zinc and borax came next in respect to time. On
scruple of tannin to one ounce of rose-water, five grains c
alum, or sulphate of zinc are useful in the early stagei
when the acute symptoms are subdued. The following ar
useful :
R. Soda? Subborat. 5ss ;
Glycerin, 5ij ;
At{. Rosar. f5jss.
M. Use as a wash after sucking.
R. Sodee Subborat. 5\j I
Cretse Prsep ?y ;
Spts. Vini,
Aq. Rosar. aa Siij.
Mix and dissolve.
The latter may be used when the ulcer is becoming ii
dolent. In the chronic form strong astringents and stimr
lants become necessary. .V skillful use of the sulphate c
copper and nitrate of silver will shorten the course of thes
ulcers. The laUer applied solid to the surface, not oftene
than onvtv in eight days, is excellent. In the interval th
sore may be dressed with tannin or alum in solution. Whe|
irritable, an ointment may be \\>^\, made of belladonu:..
ayoscyamus, or opium. One very good expedient, whio
will often entirely change the character of the ulcer, is I
anesthetize the part with ice, as practiced prior to opf
rating.
When the lymphatic glands become affected, antiphl
gistic measures must be employed; and when chron'
alteratives, tonics, liniments, etc., according to the peol
liarities of the ease. The treatment of milk abscess is F
ereal importance. It should be prevented if possible,
proper management at the outset. When the nipple 4
deficient, or, from any cause, apprehension is deemed ii-c
1861. J . [fections of (he Female Breast. 69
sible, it is decidedly improper to attempt nursing. In
other cases, prolonged and judicious efforts should be made
to render the organ useful. The first tiling is to take per-
pendicular pressure off the top of the nipple, by some device
to prevent the dress from forcing it in, and this, if possible,
should be commenced early in pregnancy. For this pur-
pose a shield should be employed, which will cause a pitting of
the anterior surface of the breast, and a projection of the
nipple. When called upon to treat a rudimentary nipple,
after parturition, the effect must be more prompt. In
many cases the organ may be made available by causing it
to erect itself by simple titillation by the finger, and imme-
diately applying the child : or by placing a thick layer of
collodion, around it on the areola, which, drying, elevates
the nipple. Then, by keeping the reservoirs empty, ab-
5S is prevented. To aid in this, we have various tubes
and pumps, but all of which are objectionable. A puppy is
often used, but it likewise is liable to irritate and exciriate
the nipple. The only proper way is by the mouth of an
adult, varying the pressure of force to suit the tenderness of
the part.
A very useful class of measures are those to suppress the
etion, and thus relieve the distention, as opium in large
)s, or applied as an ointment ; but belladonna seems to
have acquired most renown. Numerous instances are re-
ported of its great value in such cases. Much depends upon
it- strength and application by inunction till the production
of its characteristic effect upon the system. Cold, as a local
remedy, is beneficial. The temperature of the breasts for
this purpose should be kept steadily at about 40 or 4oc. as
by water running through an india-rubber enveloping the
organ, or the application of a bladder. No bad effects are
to be apprehended from it. Internally, a saline cathartic
may be given ovovy other day, and two grains of iodide of
3ium every four hours will materially assist.
\>ute inflammation, the effect of congestion, is apt to be
extensive, and will require energetic treatment. Warm
fomentations may be applied for the first few hours with
the hope of establishing the secretion of milk. A decided
ion will often turn the balance in favor of resolu-
Immediately after this, the use of the veratrum viride
may be commenced in doses of six drops every four hours,
till the pulse is brought down below the normal standard,
and kept there. One grain of calomel, with a quarter of a
70 Affections of the Female Breast. [January,
grain of sulphate of morphia, may he given, if the pain is
urgent, say every four or six hours. A lotion of one part
of sulphuric ether to two parts of alcohol will he a good
soothing adjunct, after the inflammation becomes perma-
nent. These measures should not he abandoned for warm
poultices until suppuration is clearly evident, by which plan
we may often limit the extent of this process. . In this state
of the gland, the most moderate means only should be em-
ployed to draw the breast. Retained milk is not the cause
of inflammation here, as in milk abscess. If glandular in-
flammation is complicated with that of the reservoirs, the
treatment for both must be combined, as local and general
antiphlogistics with means to arrest the secretion and empty
the reservoirs.
Chronic inflammation will be cured by treatment similar
to that for other glandular inflammations, as leeches, mer-
curials, iodine, and vegetable alteratives, internally and ex-
ternally. Much reliance can be placed upon well-regulated
pressure with adhesive straps, pressing the diseased part
against the ribs ; or with collodion thoroughly incasing the
breast. When pus forms, evacuate it early, though where
the abscess is deep, it is desirable to wait until the pressure
from within has caused condensation of the overlying tissues
otherwise a large opening will be required. In milk ab-
scess the earlier and smaller the opening the better. The
effect of suppuration and evacuation of a milk reservoir is
often to destroy its cavity, but in some cases a milk fistula
is formed. This may be closed by an occasienal application
of the nitrate of silver. Worse than these are the tortuous
lacuna1, that sometimes result from the deep glandular ab-
scess of the breast, and which are generally very difficult
to cure. Injection of iodine is most to be relied upon. This
may be done by inserting a soft, flexible catheter to the bot-
tom of the canal and throwing the injection through it so
as to apply it without dilution to the bottom of the fistula.
This favors the shallowing instead of the narrowing of the
cavity. Of course it is never advisable to slit up these ob-
stinate puriferous ducts, because of the amount ot tissues
that might be damaged, which it is desirable to save. Chi-
cago Med. Exam.
1861.] Leucocythamia. 71
A Gisc of Leucocythcemia. By Dr. George Sheaber, Resi-
dent Physician, Royal Infirmary, Edinburgh.
A young man aged twenty-four, a miller by trade, admit-
ted to the infirmary under the care of Dr. Gairdner, afford h
an interesting illustration of leucocythfiBmia. Three weeks
elapsed from his admission to the time of his death, and
k the following is a summary of the facts of the case in
regular sequence: Ansemi, languor and debility; epistaxis;
headache; bleeding from the gums; renal pain, with lithi-
asis ; febrile symptoms ; disappearance of lithic acid, and
appearance of lithates and albumen; diarrhoea; re-appear-
ance of lithic acid ; uncontrollable epistaxis; haunatemesis;
otitis; exhaustion and death."
The crystaline deposit in the urine, on third or fourth
day after admission, consisted mainly of hexagonal crystals
of the lithic acid, with a few of the ordinary rhomboidal
crystals. These, we have already said, afterwards disap-
peared. Post mortem examination revealed leucocythaemia,
enlarged spleen, fatty liver, petechia? on the mucous mem-
brane of stomach and on the serous surfaces of the pericar-
dium and endocardium.
The case detailed by Dr. Shearer gives him a field for re-
flection, which he discusses in the following suggestions:
1. Enlargement and activity of the spleen is not the only
condition involving increase of the white corpuscles, there
being at present a ease in the infirmary in which this con-
dition of the blood eo-exists with enlargement of the whole
lymphatic system -of glands, without detectable enlarge-
ment of the splenic organ.
2. The fact of a great excess of white corpuscles in the
blood in cases of leucocythsemia being accompanied by con-
stant diminution of the red discs, appears to militate against
the theory put forward by Wharton Jones, and supported
by Bennet and others, that the latter are derived from the
former by liberation of their included neuclei ; for, accord-
ing t<> their theory, increased activity in the formation of
the white ought, paripassu, to be attended by increased de-
velopment of red discs, while the reverse is the case.
Comparative increase of the white corpuscles is seen in a
variety of organic discuses, especially chest affection.- ; but
it also occurs in dysentery, diarrhoea, paraplegia, etc.; in all
of which one general condition was observed, viz: depreci-
ation of the appetite, and emaciation. These facts, Dr.
Shearer thinks, point to the blood itself as the primary
72 Santonin. [January,
source of origin of the red discs, and in the diseases men-
tioned there is either a deficiency of nutritive pabulum
taken into the blood for the production of the red corpus-
cles, or these are rapidly melted down to supply the ele-
ments of the discharge. In leucocythsemia, again, the
nutritive pabulum is appropriated for the formation of the
white corpuscles, the blood being thereby impoverished to
the extent to which these are increased ; development of the
red discs is consequently kept in abeyance, and anaemia is
again the result.
3. The deficiency of color in the urine and the salts ob-
tained from it depends probably upon the same cause as
the pallor of the general surface, viz : deficiency of red
globules and hsematin in the blood.
4. Careful study of the deposit of lithic acid seemed to
warrant the inference that the common or lozenge-shaped
crystals is derived from the perfect hexagonal form by
shortening of the lateral planes of the latter; but this does
not explain the formation of the true rhombic crystal,
which is an irregular form,
5. Hemorrhage from various mucous surfaces form as
prominent feature of this disease, and may depend partly
upon the increased tension maintained in vessels by the
absolute increase of volume in the mass of the blood, and
partly upon the imperfect nutrition of the walls of the capil-
laries from the inferior quality of the blood for histogenetic
purposes.
6. The white corpuscles, we know, are closely allied to
fibrin in composition and character ; fibrin is increased in
febrile and inflammatory diseases, and accompanying this
is an increased elimination of lithic acid, or lithates, by the
kidneys. Can any relation exist between the lithuria
present in this case, and the increase of white corpuscles in
the blood?
On Santonin. By Profssor Falck, of Marburg, and l)rs. V.
Hasselt and lieinderhoff.
Professor Falck communicates in his treatise the result of
fifteen experiments made by himself and Dr. Manns, with
the view of investigating the physiological effects of san-
tonin. The conclusions at which he arrives are the follow-
ing:
1. Santonin and santonin-soda arc poisons; at the same
1861.] - 7o
time it is not to be denied that they are valuable remedies.
'J. A solution o\' santonin in dilute alcohol, introduced
in proper quantity directly into the blood, rapidly causes the
death of a dog, and undoubtedly also that of any other ani-
mal.
3. Injected into the subcutaneous cellular tissue santonin
soda is absorbed into the blood. Also, if introduced into
the Btomach, santonin as well as santonin-soda may pass into
the blood.
4. ruder conditions not completely known, santonin as
well as santonin-soda are changed, within the animal body,
wholly or partly into a substance which is secreted with the
urine, and can be demonstrated in the latter by means
of caustic alkalies.
~>. The change of santonin, respectively santonin-soda,
into this substance which reacts, on the addition of caustic
alkalie-, with a red color, may take place under certain cir-
cumstances, in a very short time. The elimination of the
substance with the urine, lasts, under certain conditions, a
very long time.
o\ Under the influence of santonin and santonin-soda the
urine assumes readily a peculiar, yellow color. This color
is evidently owing to the substance which is formed, in the
animal body, out of the santonin.
7. On evaporating urine containing this substance, in a
water bath, the latter is changed so much that it does not
react any more with a red color on the addition of caustic
potas
8. The urine secreted under the influence of santonin is
not always of a saffron tint, but may occasionally assume a
red color, viz : if ammonia is formed by decomposition of
area, or if the santonin has been administered in combina-
tion with alkali'
Santonin and santonin-soda exert a remarkable influ-
ence on the brain and the organs of vision : they produce
incoherency of ideas and chromatopsy.
10. The chromatopsy caused by santonin or santonin-
soda is undoubtedly connected with the formation of the
substance, reacting with a red color on addition of caustic
notassa; we, t!: call this condition "xanthopsy."
more the blood contains of this substance, the greater
is the ehromatop
11. Chromatopsy can not be caused by dropping an aque-
ous solution of santonin-soda directly into the eye.
/tin. [January,
12. The phenomena produced by santonin poisoning are
different according to the difference of circumstances and
conditions, heath is almost always preceded by convul-
sions. Deutsche Klinik.
2. Messrs. V. Hasselt and Eleinderhofi* publish, in the
Nederl. Tijdschvoor GeneesL, 1860, " a contribution to the
toxicodynamic knowledge of santonin." They draw from
their experiments the following conclusions, important to
the practitioner as well as to the toxicologist :
1. Santonin can act as a poison.
2. As it seems to belong, in general, to the class of nar-
cotica spinalia, without leaving in the dead body any per-
ceptible sign of its irritating secondary effect, although
symptoms of it are observed in man during life.
3. Its action, on the administration of large dosei
analogous t<' that of tetanic poisons.
4. In relatively smaller doses, for instance of sixgrammes,
il produces, in dogs, slight symptoms of poisoning.
5. [n large doses of sixty to ninety grammes, it can act
fatally on these animals with relative activity.
antonin manifests its action then, at first, in the sphere
of the motory nerves, which action is shown by spasmodic
contractions of the muscles without an increase of sensibil-
ity. The course of the affection makes it evident that the
motory pail of the spinal narrow is acted upon progressive-
ly from below upward. Tin1 fatal termination seems to be
owing to spasms of the respiratory muscles and of the
muscles of the larynx. These spasms may be considered
the cause of the asphyxia which finally takes place.
7. The post-mortem appearance, hypenemia <>\' the
lungs, engagement of the heart, hypenemia of the eere-
bro-spinal membranes, and capillary injection of the medulla
spinalis and oblongata, arc probably in causal relation to
the spasmodic contractions of the muscles as well as to
the death by asphyxia.
Without having the intention of assuming, from their ex-
periments, that the effects upon man are equal to those upon
rs still believe that, considering their obser-
vations in regard to the action of santonin upon man, they
have sufficient reasons to conclude that santonin is, by no
rnea yarded as an innocent remedy. Med
X< uigh
1861.]. Mania a Potu. 75
Digitalis in the treatment of Mania a Potu. By G. C. Cat-
lett, M. D.
The experience of the physicians of this city, so far as my
knowledge extends in the treatment of Mania a Potu, lias been
very unsatisfactory. Most of the attacks assuming a remark-
ably accute fcrm; with great violence of delirium, furious
mania, and persistent mental aberrations, have generally re-
el the opium and stimulating as well as all of the former
established methods of treatment for this unfortunate class of
sufferers.
So great has been the mortality from this disease during
the last four or five years, notwithstanding we have attempted
to discriminate between the chronic and the acute forms, that
we have become apprehensive that we have not been treating
alcoholic poison. Indeed so general has become the impres-
sion that the various alcoholic drinks generally used, contain
a foreign poison, that those who are in the habit of becoming
intoxicated are significantly said to have taken passage on the
strychnine line for an unknown destination. While the symp-
toms of the numerous cases that have come under my obser-
vation do not, in the slightest, resemble those from the poison
of strychnia, yet, the great apparent difference in the charac-
ter of the Bymptoms as well as in the result of the disease
produced by excessive use of alcohol at the present and
former periods, that it would very naturally create apprehen-
sion and strike terror the spirituaily infatuated.
There have been a few persons, by a prolonged debauch
have induced inflammation of the mucous membrane of the
stomach or at least, such a degree of irritability that a continu-
ation of indulgence was impossible, -as nothing introduced in-
to it would be retained, soon, therefore, from the withdrawal
of the stimulous, delirium tremens would supervene, charac-
terized by intense hallucinations, great tremulousncss, incapa-
city to sleep, irritability of stomach, tender epigastrium, and
deticiency of the secretions. Counter irritation to the epigas-
trium, a mercurial cathartic, stimulants judiciously adminis
tered (I prefer Tinct. Serpentaria ; and Tinct. Valerian, equal
proportions,) and Morphia^ro re nata, will generally in my
hands relieve such cases. But that form of this disease that is
produced by the constant daily use of alcohol long continued,
poisoning the blood and resulting in acute mania, is the fatal
form, or properly Mania a Portu. in relation to this form of
the disease Prof. Stone of New Orleans says :
" Brain fever and apoplexy arc terms often kindly substitut
76 Mania a Pot a. [January,
ed as being more respectable; but names do not alter tacts.
Mania a Potll usually occurs with the robust who habitually
iN'1 alcoholic stimulants, hut not to any great excess, except
upon occasions, and when they are carried to a certain extent,
a necessity for their continuance is created, and their excessive
use cannot, or will not, he resisted until the stomach gives way
and finally reject them. During this process the mucous
membrane becomes engorged, the digestion, and finally the
a] (petite, entirely fail, and the patients is sustained for some
days after, by stimulants alone, until furious delirium sets
in.
"This madness is not due to the stoppage of an accustomed
stimulant, for it often sets in while the subject is in the full
use of it, but it is plainly due to alcoholic poison and the ab-
sence of proper nutritive matter in the blood. I think I may
add another cause which has often something to do in causing
the delirium, and certainly much to do in causing death, under
some modes of treatment, and that is suppressed excretions.
So long as the stomach is intact, and the apetite and digestion
good, an immense quantity of stimulant may be disposed of
without serious immediate consequences ; but when the organs
finally from constant excitation, became engorged, nutrition
ceases, and the alcohol is retained more in the blood, instead
of being carried off" by excretions, and a wild delirium soon fol-
lows.
"It is plain, under these circumstances, that the indication-
arc to establish the excretions, disgorge the system of the al-
coholic poison, and to introduce proper nutriment. The first
two are accomplished by one and the same means. The
stomach is generally irritable : at least, there is frequent vomit-
ing; but it is owing to the accumulation in the stomach of
morbid secretion, rather than from inflammation of even irri
tation; fur calomel in small doses, frequently repeated, arrests
it with great certainty. If the subject is governable, and will
take medicine willingly, calomel should be given in two or
three ^rain doses every hour, or oftener if the case is urgent,
until fifteen or twenty grains are given : if medicine has to be
given ; by force, it is best to give a full dose at once; and this
is the better, for in the worst cases the stomach is not nauseat-
cd. ami the eedative effect, of a large dose of calomel calms the
nervous excitement, and at the same time produces the ap-
propriate effect upon the excretory organs and mucous coat of
the Btomach and bowels. It requires some hours for this ef-
fect to be produced, and it is improper to give anything to
promote its action upon the bowels under ten or twelve bonis.
1861.] Mania a Potu.
and I think even a longer time would be better, if the case is
not urgent. Small and frequently repeated doses of saline
medicine are the best after calomel (sulphate of magnesia is
best), which promotes the excretions, disgorges the stomach and
bowels, and clears the system of its alcoholic poison, to its
great relief. An active cathartic may afford some relief, but
the system is not so well disgorged by it ; more or less serum
from the blood is carried off, causing weakness ; while, in the
other process, by giving time for the action of the calomel, and
then promoting it by gentle but continued means, the organs
exercise a selection in excreting, and thereby a large amount of
effete matter is discharged, and the patient feels the stronger
for it, being freed from an incubus that was weighing it down
and producing apparent exhaustion. After this process, we
should lose no time in introducing nutriment, and for this pur-
ducing apparent exhaustion. After this process, we should
lose no time in introducing nutriment, and for this purpose
milk is almost universally applicable ; and as the mucous
membrane of the stomach seems to be denuded of its eptheli-
11111, the addition of lime water renders it particularly grateful
and soothing. Patients in this condition generally loathe ani-
mal substance, but milk is almost always grateful to the taste
aud is particularly appropriate, for it furnishes the most inno-
cent solid for the bowels, that have been long deprived of
their wholesome stimulus. If it should happen that a patient
could not take milk, well boiled corn-meal gruel is the next
best diet most likely to be relished ; ond for something more
substantial, strong, well-seasoned broth, frozen, will be the
most likely to agree.
In all acute cases, alcoholic stimulants should be withheld,
for they act like poison and will often bring back delirium.
Should stimulents be thought necessary (and it is not often
really necessary) the carbonate of amonia, or the aromatic
spirits of amonia are preferable ; or it may be proper, in some
case, to allow malt liquor. Opium in all forms should be pro-
hibited, until the system is relieved of its alcohol and even
then I find it can generally be omitted : and when it can be,
the patient recovers sooner and better. The patient is not ex-
pected to sleep well, but if the blood is renewed by its appro-
priate nutriment, natural sleep will follow.
Occasionally, when, previous to the debauch which imme-
diately caused the mania, a free use of stimulants had been in-
dulged in some time, we have an exalted state of the nervous
system, attended with hallucinations and sleeplessness, which
rerpiire special attention. Potent stimulants operate badly,
78 Mania a Pot a. [January,
and opium alone docs not operate well, though in large doses
sleep may be forced, though not without some risk, in some
cases, to the brain; but equal parts of morphia and tart, anti-
mony, given in small and repeated doses, will soon calm the
nervous system and induce sleep without injury either to the
1 train or stomach. There is nothing that cools off the heated
imagination in these cases like nauseating doses of tart, anti-
mony, and opium in some form maybe added, if it is thought
necessary. The too general opinion that sleep is the all-im-
portant thing in the disease has led to fatal errors in treatment.
( )pium, given freely, as it often and very generally is, while
the blood is charged with alcohol, produces a very unfavorable
effect upon the nervous system, and tends to check the excre-
tions, which are already diminished, and the patient, without
being narcotized, often goes into a stupid state resembling the
effects of uremic poison ; and if about one-half (about the
usual proportion), by the vigor of their constitution, weather
it, in spite of all the poisons imposed upon them they recover
slowly, and their organs are left in bad condition."
We make this lengthy extract from Prof. Stone's communi-
cation on this subject, because he makes the important distinc-
tion between delirium tremens and Mania a Potu, and in his
usual clear manner points out the rational treatment in the two
forms of the affection, those views, we think, should be more
thoroughly impressed upon the profession, notwithstanding
Ave are satisfied that the difference in the two forms of alcoholic
poison is clear, the treatment of Dr. Stone is the rational treat-
ment, yet the Mania a Potu that has occurred in this city for
the last few years, has been remarkably fatal, and all methods
of treatment very unsatisfactory.
Therefore I determined to try the Tinct. Digitalis in large
doses, recently two cases presented an opportunity, The first
a man, the second a woman. A description and treatment of
one case will describe both in all essential particulars.
Mr. after a debauch of several weeks, and while yet
stimulated to as great a degree as all the varieties of alcoholic
drinks could produce: in attempting to light a segar, fell upon
the floor in the most frightful convulsions, raving and foam-
ing at the mouth, and mutilating his lips, tongue, hands and
arms with bis teeth. In a half an hour after this convulsion
he was furiously delirious, recognizing no one, muttering his
imaginary Pears, and now and then making fearful struggles to
escape from his bed, his face almost livid, eyes deeply inject-
ed and eyes greatly swolen, pulse one hundred and sixty, weak
and thread-like.
1861.] Cataract, Iritis, &c.
In the interval of the convulsions, and before my arrival.
one-half a grain of morphia had been administered to him. I
immediately administered five grains of Ipecac and two grains
Tarter Emetic, and repeated it every fifteen or twenty minutes
until he had ejected everything from his stomach. This occu-
pied several hours when his symptoms were not in the slight-
est improved. I then determined to watch the action of the
digitalis and commenced by administering a large spoonful
every half hour. The first dose improved his pulse, it dimin-
ished in frequency and increased in volume. The second dose
lessened his ravings and made a more palpable improvement
in his pulse. The third dose was increased one-half, when all
of his symptoms in one hour, were manifestly improving. I
then increased the dose and lengthened the time of adminis-
tration, in about seven hours from the taking of the first dose
his pulse was fult, slow and regular, his delirium had entirely
vanished, and he was sleeping though interruptedly, now and
then disturbed by his hallucinations. I then continued the
Tinct. Digitalis in smaller doses, giving a mercurial cathartic.
His sleep became sound and tranquil, he awoke in about six
hours, sane in mind and almost well in body. The only re-
maing vestage of disease, was extreme nervousness. I ' then
prescribed Tinct. Valerian and compound tincture of cinchona
in equal quantities. The second case was almost a severe as
the first and was treated in like manner and resulted as favor-
ably. If Digitalis acts by sedation, will not Veratria be a
more efficient remedv in Mania a Potu \
\tio Atropice Glycerinea; a P reparation for the Dilata-
tion of the Pwpil in Cataract, Iritis, &c. Br Charles E.
C. Tichborne.
Since atropia was first brought into notoriety for the above
application, by Heisinger, it has completely superceded bella-
donna where introduction into the eye is necessary, but the
extract is still resorted to for painting the eyebrow and cheek
in such operations as absorption of cataract or anything simi-
lar, where it is indispensable in order to prevent adhesion of
the iris to render the dilatation permanent ; no preparation of
the alkaloid yetintroduced being applicable to the exigencies
of such cases. A few of the objections to the use of the ex-
tract may be enumerated as follows : Liability to produce
cutaneous irritation ; secondly, its requiring great attention in
keeping the surface moist with some some lotion to prevent
Su tract. Iritis, &c. [January,
its drying; and thirdly, want of cleanliness, as the extraneous
manner of this inspissiated juice are certainly very much out
of place when manipulating with so delicate an organ as the
eye; in some. eases complete failure results either from the
use of a bad preparation or non-absorption from harshness of
the epidermis.
Some time ago glycerine was found to possess great solvent
properties, particularly as regards the alkaloids and some of
the nun-nitrogenous organic principles. The author has de-
termined its action and solvent power in connection with
atropia with a view to its use as an elegant and efficient mode
of exhibiting thissubstance where permanent dilatation of the
pupil is requisite. A saturated solution in glycerine gave, on
analysis, four per cent. (=gr. xvijss. ad. 5 i.) of the vegeto-
alkali. It does not dissolve readily in the acid, but is soluble
to almost any extent on applying a gentle heat ; the excess, if
it is not great, deposits on cooling in fine transparent colorless
prisms, but if the amount is considerable it becomes, when
cool, a solid mass. From this it is evident its solubility in
glycerine is much greater than in water, it requires 189 parts
of the latter menstruum to dissolve it in the cold ;* indeed the
atropia is recoverable to a considerable extent by precipita-
tion on the addition of water to the glycerolic solution. The
easiest method of making this solution is as follows : One
decigramme (1,553 grains.) dissolve in a few drops of alco-
hol is added to 20 grammes (=368.680 grains) of distilled
glycerine ; the mixture is then subjected to a gentle heat, viz:
110 Fah. for half an hour in an evaporating capsule to vola-
tilize the spirit. This will contain one-half per cent., i. <\,
2.187 grains to the ounce, and may be labelled "Fortior." On
smearing the surrounding parts of his eye the writer found
(without dropping in any solution) the dilation of the pupil
perceptible in 15 minutes, from which it steadily increased.
A weaker solution, i. e., one containing one-fourth per cent,
made by using one decigramme to 40 grammes, may be used
I'hv author was induced to enter into the examination of the solubility
in water from observing tin- non-conformity of works of reference on this
subject. Bis experiments gave as a mean result 1 part atropia, to be
soluble in 189, generally given as soluble in 800 parts, whilst Lowig gives
ii a- requiring 2000; the writer thinks this must be a typographical error
and must be intended for 200 parts. This diversity might he accounted
for in -ouie degree, a- an amorphous modification, produced by action of
atle heat, as apparently much more soluble. This uncrystallizable
variety ia equally efficient with the other in dilating the pupil.
II.] < Si
to determine the dilation, by an-occasional application, and
also to allow for absorptioi olution inglycerine ofatropia
may be made containing 16 grains to the ounce, without any
danger of its crystallizing out.
The advantages to be derived from the use of this pre
ation, ar properties of the glycerine,
which, by softening and relaxing lows
fption of the active principle ; secondly, the certainty
of ab ie alkaloid in the soluble form, and .
Lai distribution from the hygrostatic properties of
of the glycerine, which could not be obtained from the u-
anyscqueous solution, even in the form of a malate, as in the
extract, and also itse pplication, freedom fr ntion
as it always remains moist; and lastly, the certatnty appertain-
ing to the employment of all medicaments of a definite cohi-
ion. ( ' W8.
[Many of the following extracts are from the valuable month-
ly summary prepared by Dr. 0. C. Gibbs, for the Ameincan
'lied Monthly. Eds. S. M. & S. Jo:
.In the Chi Medical M , for No-
vember, there is a published report upon praetici cine,
furnis Dr. C. Goodbrake, for the Illinois St; deal
Society. Under separate heads we shall allude to a few of
the more novel opini , then, of scarlet
fever: Dr. J. N. Niglas' trea
and contains nothing local treatm
- : -'The region of the paroti 1 and submaxillary glands,
from the beginning, I advise jd with cotton, and
mel wrapped around the neck n as the slightest
swelling com to be pe . -. a liniment composed of
_ la!, dale, oij., liq. ammon. 5>j.5 nii. 5j., gum
camphor gr. x , is repeate bed ('faring the day. tin
I around ; and glad am i that
, nunc of the C
under my charge were lost by consecutive suppuration."
Dr. Prince would control the pulse with the veratrum viride
and then use the stimulating trea sly and fr<
Dr. Hiram recovi .
full .' carbona e of ammonia, that he thii kJ must have
ation. 1: (ammonia) \va
Lmended by a French physician, and Dr. X:
ria. [J
iiiiuai'v
ly allied in nature, or in
thera ' -. and sclarlet fever.
ific poison, affecting the system
ically. We have noi Bpace to enlarge
ic tincture of iron, quinine, and
rvice in ml diph-
ng benefit in Bcar-
V- no doub 3 of quinine
ents that can be
fever. Though foreign from our
excused for quoting from a trans-
journal in support of these views. In the London
American reprint,) Dr. J. Hawkes,
For those who may
have such cases to m >ul t they occur only too
recommend the use of quinine. My at-
> it in thi by the excellent
Eood, in which lie so strongly urges
ion in all forms of scarlet fever. I have put his plan
.1 a large dispensary practice, and have
every reason to bear
- an addi \ idence in support of the tonic and stimu-
lating treatment in scar! ain (juote from the
number of the 1 Dr. T. J. Graham, speaking also
<>f malignant scarlet fevei . is abundant evidence
ie profession in proof that the sesquicarbonate of am-
monia p pecilic powers over the worst forms of scarla-
tina, and that, when the eruption recedes, no means known
iwer in repi : it, and relieving the
lent." ::' fully con vinced that this
prep of ammonia, administered regularly, day and
.':. and trusted to alone, with a mild aperient and a suitable
. will be found fully equal to the restoration of the patient.
nt medicine in
half apprehended."
J)i new or
Dr. P ays that the local applica-
tion 'this ex; 3! "A
fusion of capsicum and a saturated solution <>!' chlorate
.f p 1 m, have proved more satisfac-
ocal application to the
mur. tr. iron to answer the
all ; that came under our treatment. We
II.] Diarrh Uldren. S8
tried the nitrate of silver, sulph. of copper, alum and sulph
copper combined ; but the ti the
ilVct in our hands.
The best remedies internally seemed to be quinine, tinct. of
iron, chlorate ofpotassa, and good porter or brandy, with good
nutritive diet." No allusion is made to asaturated solution of
tnon salt, ,s a wash or gargle to the throat; this, of all
means, has pleased us the best. WYhave applied tins remedy
to the throat for another trouble, which we may as well men
tion here as elsewhere. A lady of oar acquaintance had, for
man years, been subject to frequent attacks of quinsy, which
always passed on to suppuration, hi tin.' last year, we have
aborted two severe attacks by the local application of muriated
tincture of iron, applied several times a day. We have re-
duced the remedy with about two parts of water to one of
tincture.
Diarrhea i of Children. In regard to tl tse, wo .-hall
quote that one remark from the report. Dr. J. O. Harris re-
marks upon the treatment as follows :
"I found that after exhausting all the usual remedies ad-
vised by our standard authors, and by my brother physici
that quinine in full doses, frequently repeated, (acted or seem-
Imirably. lthou me that I was pre-
scribing empirically, and now I do not. pretend to explain the
of the remedy. [ only know this, thai my
patients recovered under the use of quniue, and I still frequ
. it. when I see no particular indications for its
Typhoi I Dr. Nance's treatnn
of this form of fever:
My treatment, stated in brief, con-:-:* .1 of spts. nitri. dale,
5viij., Norwood's tinct. veratrum viri
one teaspoonful to an adultevery tin . the
active stage rem reasing i
requires. It may be ne< mtinue this medicine
for eight or ten <h\x>, or more. rescribe at the e
time turpentine emulsion, usuall combined with tinct. opis.:
prescription the activity of the ]
favorably npon the urii iratory . the
latter, containing laudanum, q . promoti
and the spts. turpentine has its ^jx-c-i ii<- action npon th" glands
of the mucous membrane of the When conva es-
cenc* iblished, or if the
mpport. "My pi Ion during the fall, un<
If- mop/ . [January
circumsti nl. conchonia, grs. iij.; camphors
. iij. Mix, and give every four hours
and alteraatc from two to three teaspoonfuls."
We apprehend 1 in the treatment of ty-
hoid fever consists in "prevenfing" rather than "treating" bad
symptoms. Many p re turpentine only when the
tongue is dry and the bowels tympanite will heal* the ulcerated
state of the bowels, which ' . in the late
asonable to suppose that, in
:' this condition, ii may act curatively and
prevent the diarrhoea, tympanitis, the red and dry tongue*, &c.
Many only support the syst< death seems imminent
Tonic-, such as quinine modified by opium and wine, can he
irted to much earlier than they often are in this disease.
When prostratio decided, we think Dr. Nance's two
or three teaspoonfuls of wine will nol bring out the full influ-
atment.
We have given n tolerably full synopsis i I this report, be-
cause i f modern treatment, among
rn physi( some of our more common disea
.// r, of Iron, dkc.
In the ( Examine?1, for November, Prof. N.
avis reports an alarming ease of hemoptysis, occurring in
a lady l; ! years old, who had a decided hemorrhagic diath(
inasmuch as the father of the patient and one sister had previ-
ously died from hem unon salt, gallic acid, acetate
of lead, opium, alum, tinct matico, gelseminum, oil turpentine
and quinewere thoroughly tried, with partial and temporary
benefit. "Atthi of the case," he says, "we advised
the tinct. ferri muriatis, and tinct. o . equal parte
which forty drops were taken every two bours. Under the
use of this mixture the hfiemorrha than 24
hours, and In
Diphtheria. in "October,
Dr. S. P. iencewith diphteria. With-
in the la In these c
all b culiar diphteritic exudation. We
Dr. Bryan's remarks upon the treat-
ment in lull, for [uite judicious; and, besides,
3 hut one: but want of space
will prevent. We simply copy his recapitulation :
limited ( n the light in
rard meaeleB, variola and typhoid fever, bu1
duration may be materially abridged, as well as its
1S61. menorrhcea.
violence greatly mitigated, by prompt and proper I
ment.
2. "The milder cas ui-re no
than the local appli
and the internal use of chlorate of potash, together with -oner-
ous diet and the cautious use of such mild aperient m
vll maintain a soluble condition of th
mon - may generally be very promptly controlled,
if -the treatment is early i ced, by the addition
quinine, and occasionally of brandy and ' - the for
ing.
"Depletion in this d whether din [-let-
ting, or indirect by purgation, &c, is not only a vain.
pedient, but, in consequence of its debilitating effects, is posi-
tively injurious, by favoring the accession of typhoid symp-
toms, and preventing .1 rapid and
cenc
The nitrate of silver is applied 20 grains to the ounce by
thorougly in the thr< r four times a 1
This followed, hall' an hour later, with a solution of chlorate or
potash 5ij- to iv to water Oj . In severe
is main di [uinine, which, to
adjal ins a day. "T
5, "appeared I the fever, ai
of the di
rred to, in from two to five days." ! [e says further :
"It ; the quinine urative influ-
inferior to thai whic srts in ordinary malarious
hich before -1 rapid.
numbering in - Von: L20 to 140 heats per
mini ce, fuller,
stronger and sloi
Dysm rg. Jou\ .
mber,Dr. J. B. Snelson has an articl u dysme-
norrhoea, in which he recommends quinine in combina
with pri 1, particularly in tic or neural-
He would treat the menstrn pium
and the warm bath, and the in' with the
followin
Iph. Quinine,
M .
Divide into pills No. xx. On 1 be tal
morning, noon and night ; tl mtinued dur-
le intermenstrual ." [f we rightly remem-
Throat Di nary,
p, : hi the /. ! L851 . re"
line in < with sulphate of iron
or most of the unnatural manifes-
We are not certain that
From the change which strych-
mr hands over the rheumatic or neuralgic difficul-
p, we would suggest it in connection
. in dysn oea.
/' morrhage. in the Lancet and
tber, Prof. G ML"endenhall reports a
of post-partum uterine haemorrhage. The usual
mean tout benefit; the hand was inserted
the uterus, also lumps of ice, but still with no check upon
ren, but with no perceptible
atheter was introduced to the uterine
three ounces of the saturated solution of
of iron injected through it into that organ."
ion was I for a few minutes by the hand in
the nterud. The injection produced no pain, but
>m that moment not another drop of fresh blood was dis-
charged from the uterus and vagina.'' The patient "recovered
without an unpleasant symptom."
it Distemper" of the Last Century. In the
Surgical Journal, for November 15th,
Dr. Q. II. Gay republishes a paper upon the above subject,
written by Jonathan Dickinson, of Elizabethtown, }\. J., in
the year 1738, and published in Boston in 1740. Dr. Gay
3 that ti use described, and for which direc-
given for treat was none other than diph-
ia. Dr. Dickinson d ss no less than six varieties
ud some of the symptoms do conform very
irately to those of the last named d When he
whole throat,and sometimes the roof of the
ith and nostrils, vered with a cankerous crust,
whic us parts, and frequently tcrmi-
sonable applications
embling diphtheria.
3 mi epidemic, often
it fatality ' hoarseness, difiicull
mal bubo-like ulcerations,
>n of large quantities of tough, whitish
we also recognize con-
Li in diphtheria. Again, in uni-
rmptoms, L
L] ST
"The tonsils first, and in a Little time the whole throat, is
red with a whitish crustula; the tongue is furred and
the breath foetid." Bu1 other symptoms rationed
that show a dissimib diphtheria, as '
itself; thus, the 2nd, 3d or 4th day, if pro-
per methods are used, the patient is covered with a ml
eruption,ins mblingthe measles; in
like the scarlel fever, (for whic mper it
has frequently been mistaken,) but jn very much
resemble* influent small pox."'
It may be interesting to notice, in this connection, a
remark or two in regard to treatment. local means
to the throat, h< found the following method
most successful : Take Koman vitriol,!
lie as near the fire as a man can bear h id, till it be
thoroughly calcined and turned white ; put about 8 grains
of this into halfapinl of water; lay down the tongue >
a spatula, and gently w. s much of the crust as will
easily separate, with a line ra< lo end of a pi
or stick, and wet in this liquor, made warm. This opera-
aid be i py three or tour hours."
Ln conclusi Dickin
treatment of which is reported to
larkably d in all forms of the dis-
administration of a
"de< [uaw-root," pre-
pared in the foil
of this I in a quart of i he
adds, when two ounces of loaf
ar, and b the consumption of one-quarter
tienfs frequently to drink, and
i gargle their thr< i
alio-. the
conclusion."
. Jn the Medical and tfurgu
. 27th, and November 3d, the pape ilton
i which
only
Lts in the argument. [1
I
ally ecretion the
of opium ; yet there
practical importance, and \ tate it in
Vm [January,
Dr. Hamilton. "P< ion is nearly al-
wa\ 3ed by a moderate or full dose of opium, and
d activity of the cutam halents is gener-
! by an n of the heart and
wu in such ised color of the
Dr. Hamilton considers the various
in which opium is appropriate. Wehave notspace
lor an abstract. We will only instance peritonitis, dyi
bery, typhoid fever, and various forms of inflammation. In
his paper various distinguished physici-
ans took part. We will here refer to only one idea: Prof.
taking upon this subject in reference to conges-
lion and inflammation, says, that in congestion of the lut
the administration of opium has always a tendency to in-
crease it. We wry much doubt the correctness of tins
rtion ; we believe that opium has a tendency to relieve
all internal congestions. We know of no remedy that will
he cutaneous circulation, and produce free per-
spiration, as will opium, lu congestion of the lungs, a
harassing and perpetual cough but ii the congestion.
Opium, by allaying this cough, determining the circulation
to the superficial blood-vessels, and the free perspiration
consequent upon this, can have no other influence than to
tie internal congestion, Here we leave the subject,
referring our readers to the paper of Dr. Hamilton, and
the discussion following, as worthy of attentive consider-
Vari ins of the Leg. In a former number, we re-
ferred to the treatment by subcutaneous ligation, as prac-
I by Dr. R. J. 1. Philadelphia. In the Med
and Surgical Reporter, for Xovember 17th, Dr. Levis has an
ani i this subject. Ee regards varix of the log as.
practically, a disease of the saphena veil proper treat-
ment he beli consist in the obliteration of this vein.
manner of its accomplishment is described in the paper
I to. lie thinks the operation is best performed
while the pa tanding. To have the limb at a con-
venient height, he would have him stand upon a chair or
table, and so placed that the patient can steady himself
insl the wall. He prefers a round, straight needle, to
i one with the common surgical
needle | I the n< inserted
licularly, until ii reaches the under service of
i. The - then de oint pa-
L861.] Broncl
under the vein, and passed out on the opposite side. The
needle is now made to enter at the orifice of exit, and pi
ing now ahove the vein, em I the point o[' original
entrance, it should have been observed that the needle
should previously be armed with a silver or iron wire of
small size. The wire is now drawn down upon the vein.
tightened, and fastened by twisting. Adhesive or isinglass
piaster is novv* applied over the wounds, and the limb is
bandaged from the toes to the knee. Dr. Levis regards this
treatment as eminently - ul, and accompanied with no
danger.
onic Bronchitis A New Remedy in. In the Medical
and > Reporter j for November 17th, Dr. II. AVilson has
an article upon the treatment of chronic bronchitis. He
regards local medication as of the first importance, and
aiders in review most of the means, the use of which
has been recommended in this manner. Suggesting a new
remedy, lie For several years past I have been in
the habit oi using a remedy, which may not be new, but
which tar surpasses that of any other which I have tried in
relieving, and in many instances entirely eradicating, the
affection. I refer to the leaves of the common mullein,
(verbascum thapsus,) dried and smoked in a pipe. In that
form of the disease in which there is dryness of the trachea,
with a constant desire to clear the throat, attended with
little expectoration and eonsiderable pain in the part ailect-
ed. the mullein, smoked through a pipe, acts like a charm
and affords instant relief. It seems to act as an anodyne
in allaying irritation, while it promotes expectoration and
removes that glutinous mucus which gathers in the larynx:
and at the same time, by some unknown power, completely
changes the character of the disease, and, if persevered
in, will produce a radical cure/" He says the remedy
should be used as indicated abov< .
a day.
Ra I )f Obliqi lal Hernia. Or. 1). Ihi
Agnew has invented new instruments for the radical cure
blique inguinal hernia. The pri of cure does not
differ materially from that put in pi ers: the
instrume 1 may enhance the coir. of the ope-
ration. We have !. 'ption.
it to say, that the scrotum is in va linal
.!. and i- hold there, andthc canal rendei by
00 BeUadonna in Sore Throat [January,
an instrument not unlike a bivalve speculum. A long,
ar-pointed, curved needle is now armed with a wire, car-
1 up in the groove of the blades, and made to pierce the
integurn cning out through the walls of the abdomen.
Th< < '.id of the wire is now threaded, and the needle
is made to pierce again the | >ut a short distance from
the first insertion. The wire is now drawn down and fas-
tened ; the objed being to make a plug of integuments fill-
ingthe inguinal canal. Several stitches are now taken
nal.in front of the cord, the object of which is
bo aid tl in retaining the invaginated portion of the
1 thus forming a permanent tegumentary plug,
filling the canal, and thus preventing the descent of the
howel. We condense the above from an article in the
I Surgical Reporter, for Xovember 17th.
Bearing upon this point, we might remark, that Prof.
Tyme, of Edinburgh, says that all apparatus for this opera-
tion is unnecessarily complicated. "A piece of candle," he
, "with a little piece of twine through one end. will
i r all purpo-
adonna in Sore Throat. In the Medical and Surgical
Reporter, for Xovember 10th, Dr. J. W. Thompson has an
article upon belladonna. He has used belladonna in
inflammation of the breasts with good effect. He dissolves
&ij. in fj. of water, and applies to the inflamed brei
We use the fluid extract without dilution, and it has never
disappointed us, when used to prevent inflammation incases
of delivery of still-born children. Neither has it disap-
pointed us in tl, >f inflammation of the breast, where
suppuration had not already commenced. We ] i rre< I
to the paper of Dr- Thompson more for the purpose of giv-
ing his experience with belladonna in sore throat. He says.
"My experience with it in incipient sore throat would lead
me to rank it almo iifficiently early.
My plan is togive the sixtieth of agr. of atropii I rely
m it confidently if given within six hours of thefirstap-
of inflammatory symptoms. I have tried it
ionm; and have to
ilure." I influem
limited to th
ihrymal Duct. :
November L7th, Dr. -i. 1'.. Macdonal des-
ration. Ee done
il.] Dyspnm. 91
away entirely with the direotor, and only employ a blunt-
pointed, narrow, aim Blightly curved bisctoury, the blade of
which is only about three-quarters of an inch long, the heel
about three-sixteenths of an inch broad, and which tapers
to a fine blunted point, a very little probe-shaped. It is
sharp on its concave edge, cutting to the point, which is
very narrow: and to provide for its strength, the back is
somewhat stout, and delicately clubbed at its extremity."
Dyspnoea from Cardiac Disease relieved by the Inhalation of
Oxygen. In the American Medical Times, for November 17th.
Dr. J. C. Acheson, reports a case, in which a troublesome
dyspnoea was relieved by the inhalation of oxygen. In the
rase reported, the pulse was imperceptible, with other
symptoms corresponding. Pic says : "Within 15 minutes
after the patient began to inhale the oxygen, signs of relief
were apparent. The restlessness ceased; the breathing be-
came much easier: pulse became perceptible at wrist; -in-
telligence began to return ; and waking from his lethargy,
he complained of the coldness of his body, and desired more
clothing." The patient died, but the benefit resulting from
the inhalation of oxygen argued better results in more favor-
able En extreme dyspnoea, in the last stages of con-
sumption, we have resorted to the inhalation of small doses
of chloroform, with very decided benefit.
Diphtheria. In the Cincinnati Medical and Surgical JS<
for November, Prof. TV A. Iieamy has an article upon this
-non. He says he lias treated 250 cases, and remarks:
"I will here assert, that, in my humble judgment, any one
who will, at the very outset ot the attack, administer full
to i grs. to children 8 to 0 years old) of sulph. of
quinine, and continue its use, in connection with chlorate
of potash, and apply nit. silver in solid stick locally, avoid-
ing mercurials in any quantity or form, catharticizing as
little as possible, will find such su< cess attending his treat-
ment as will lead him, if he had doubts as to t\\o nature
and pathology of the disease, to settled and satisfactory
fusions. Id many cases, I deem it better to use nitric
I in connection with the quinine treatment, than chlor-
of potash."
Diphtheria. Jnth< al Re-
, for November, one of the editors, Dr.T.S. Case, has an
article upon diphtheria. We take pleasure in </i\inLr the
92 [January
treatment of those who have had experience with the dis-
. be that treatment what it may. In a typical case Dr.
( Jase's treatment is the following : "During thefebrile sta
it' there be any indication of an overloaded condition of the
stomach and bowels, i give an emeto-cathartic ; alter the
operation of which, I direct the i 'ill doses of Dover's
powder to quiet ai:v nervous excitement, to prevent the too
action of the cathartic, and to encourage perspiration.
In addition to this, 1 prescribe, to he taken until the kidn
are acted upon freely, the following* mixture:
R- Spts. etheris nit., ^ij.
Olei Terebinth., 'ry\).
Mucil. gum. Acaeiie, 5vj. M.
1 )ose for an adult desertspoonful every hour or hour and%
it half. For a child, this mixture might he rendered more
pleasant by the addition of sugar &c. After the subsidence
of the fever, I immediately commence upon the tonic and
stimulant treatment, consisting of beef tea. egg-nogg, &c,
bitum; and in addition, quinine, comp. tr. cinchonae,
muriatic acid diluted and sweetened, chloric ether, carbon-
ate of ammonia, chlorate of potash, &c. These various
remedies are to be applied, in quantity and time, as indi-
cated by the condition of the pulse and nervous system/'
Any person who will take the trouble to examine our
Summary" for the last year, will find the therapeutic ex-
perience of the most influential in the profession, whether
at home or abroad.
Lecture* on t) ses,
'ally of Epilepsy, 1 >y Charles Bland Radcliffe, M. D..
Kellow of the College, Physician to the Westminister
Hospital, etc.
Mr. President and Gentleman Of the three Lectures
which T haveHhe honor of delivering before you. I pro]
to devote that of to-day to the Physiology of Muscular Mo-
tion ; and this J do because 3 to be necessary to re-
id. T the whole of this subject, and to change our opin-
py important particulars, bef< an hope
to I ingthe theory and therapeutics
of convulsive di
I opinion r> g muscular action, I
! 1 1 ;
need scarcely say, is, that muscle is endowed with a vital
perty of contractility, and that the state of contraction is
brought about when this property is called into action.
When the muscle contracts, thai is to say, this vital proper-
ty of contractility is supposed to be roused or excited, or
stimulated into action, and the more the muscle contri
the more is this property supposed to be thus acted upon.
But this is not the only opinion which maybe held respect-
ing muscular action. On the contrary, it may be held that
;rue type of muscular contraction is to be found in rigor
mortis. It may be held, indeed, that muscle contracts, not
because a vital property of contracility has been roused into
action by a stimulus, but because some antagonizing influ-
ence has been withdrawn, which previously prevented the
free action o\' common muscular attraction in the muscular
tissue.
When, upwards of ten years ago,* I endeavored, for the
first time, to show that the latter view of muscular action
the correct one, I believed that I stood alone in this
ion. In point of fact, however, others had gone before
me, whose thoughts were, more or less, akin to mine.
Writing in 1832,fDr. West of Alford, in Lincolnshire, says:
pvous influence is imparted to muscular fibre for the
n of the will, and of all other deposers to contraction,
withdraw for a while this influence, so as to al-
pcrty of muscular Able (contractility) to
w itself/' And in support of this opinion he appeals,
amongst other arguments, to the fact of rigor mortis being
deferred until all traces of nervous action have disappeared,
and to the fact, not less certain, of spasmodic action taking-
place when we have evidence of co-existent nervous debil-
ity. It would appear as if this idea had been suggested by
a remark of Sir Charles Bell, for Dr. West refers to a lecture
at the Royal College of Surgeons of England, in which,
< saying that the question of the modus operandi of motor
nervous influence could never be settled, Sir Charles adds,
that he had been led to suppose that muscular relaxation
might be the act. and not contraction, and that physiologists,
:' Vital motion. 8vo. London : Churchill. ! -
er Muscular Contract] mIod
al Journal, edited by Michael Ryan, M. I >. Vol. 1.
04 tures on [January,
in studying the subject, had too much neglected the con-
sideration oi the mode by which relaxation is effected.
!n years later Dr. "West is followed b\
physiologist ofn name Professor Duges, ofMont-
pellier who maintains that all organic tissues are the seat
of two o movements expansion and contraction;
and that contraction, which is in no sense peculiar to muscle
thing more thau the cessation of expansion "in con-
tion musculaire ne consiste que dans i'annihilation de
expansion."' The muscle contracts, he thinks, in virtue of
its elasticity, just as a piece of caoutchouc might contract,
( fr< e from a previous state of extension ; and an analo-
gy is hinted at between the expanded state of the muscle
and the :lui 1 state of the fibrine of the blood, and between
rigor mortis and the coagulated state of the fibrine. Analo-
in its effects to electricity, the vital agent is supposed
to accumulate in the muscles and produce expansion by
causing the muscular molecules to repel each other; and
contraction is supposed to be brought about either by the
sudden discharge (as in ordinary contraction) or by the
gradual dying out (as in rigor mortis) of this vital agent. Ir
apposed further, that the rhythmical movements of
muscle are caused by successive discharges of the vital
at, which discharges arc brought about whenever this
at acquires a certain degree of tension; and that the
cramps of cholera, or the spasms of tetanus or hysteria, are
produced by the development of the vital agent being for
the time suspended. After Professor Dugesi' comes the
present distinguished occupier of the Chair of physics in
the I niversity of Pisa. Writing, in 1847, about nervous
influence. Professor Matteucci says: twCc fluide, developpe
principalement dans les mus repand. et, doue d'une
nave repulsive entre ses parties, comme la fluide electricque,
il tient les elements de la fibre musculaire, dans unetat de
i analogue a celui presente par les corps electrises.
Quand ce fluide nerveux cesse d'etre libre dans le muscle,
de la fibre musculaire s'attirent entre eux,
ime on le voit arriver dans la roideur cadaverique . . . .
Suivant la quantite de ce fluide quie cesse d'etre libre dans
e de Physiologic Comparee de V Homme el des Auimaux. s\<>.
March 17th, 1847.
loin atraction est plua ou moim
hypothesis appears to have beeD framed partly ii
quen< lerationswhi bow that
the | ntraction" wasowingto the
in the muscle in which the "induc-
ing contraction'1 anifested an idea originating with
M. Becquerel and partly in consequence of the analogy
which is found to exisl between the law of contraction in
muscle and the law of tl barge in electrical fishes;
but it is right to at Prof Matteucci does not
appear to have attached weight to his opinions upon
the subject.*
Xext in order, f and preceding myself by not more than
a month or two, is Professor Ennel, then of Zurich, now the
ipier of an important chair in the University of Vienna.
The action of nervous influence, according to this physiolo-
i antagonize muscular contraction, and this opinion
Hinds upon the fact that rigor mortis supervenes when
all signs of nervous action arc at an end, that the muscles
are more irritable when removed from the influ-
rhc ner. intres, and that cramps and other
rive muscular contraction are often seen to
happen spontaneously in paralysed parts. And later still,!
. the date of my first publication on the subject
a similar jpectingthe action of nervous influence
upon mi sd to Professor Stannius, of
[ have received several pamphlets,
Columbia. U. S. of Ann
in which i determines a state of ac-
and that contraction proceed- from the with-
The protrusion of the tenacles ol the snail and
;' the head and limbs of the
muscular
r. Mackall thinks, are unintelligible withoul
igaticn. And that contraction is the
al l]v-
. athor aims, for it i- die
a muse]
which
. K'oii. ( : sellsch. den
a and Todl
!. Heilkunde, Stuttgart. 1-
96 lures on [January,
Rostock, by bod oua experiments, in which lie has
>r mortis relaxing, and the losl irritability returning
to, the muscle under the injection of blood into the
vess<
I do no1 stand alone, then, then, in thinking that a great
change i iry in the theory of muscular action a
change amounting to no less than a complete revolution:
and i am glad that it is so, for, thus supported, I am more
b >ld to challenge attention to the arguments upon svhich I
opinion.
h is only within a comparatively recent period that it has
been possible to demonstrate the necessity of a fundamental
change in the theory of muscular action. When I wrote
first on the subject, I did not command the facts which are
ntial to such a demonstration, and I do not think that
the writers whose names I have mentioned were a whit
re fortunate in this respect. Now the ease is cntirely
erent, and the present difficulty is, not to find facts, hut
to make a selection, and to marshal those that aie chosen
in 1 1 10 short time at our disposal.
The true key to the interpretation of the phenomena of
muscular action, as it seems to me, is to he found in the
weries which have recently taken place respecting tin-
electrical condition of muscle and nerve; hut before at-
tempting to find and apply this key, it will he well to see
how muscle behaves under the action of blood and nervous
influence.
I. Arguing from the comparative anatomy of muscle it
would seem as if muscle were not most disposed to contract
when it is most liberally supplied with blood. It would
if the degree as well as the duration of contraction-
were inversely related to the supply of blood. Thus the
degree and duration of contraction) is greater in the volun-
tary museles of fishes and reptiles than in the voluntary
muscles of mammals and birds : greater in the muscles of
any given animal during tli pe of hybernation than
during the fever of summer Life.
The fact, moreover, that rigor mortis may he "relaxed,"
and the lost irritability restored to the muscle by the injec-
tion of blood into the vessels a fact which has been abun-
dantly demonstrated by Dr. Brown-Sequard* and Profes
Comptea Rendus, Jnhe 9th and 25th, L831
would appear to bo in direct contradiction
the idea that the muscle is in any way stimulal con-
; by the blood.
One of Dr. Brown-Sequard's experiments pon the
arm of a criminal who had been guilotined at 8 a. m., on
the 1-th of July. 1851. The experiment, whi<
in injecting and re-injecting a pound of defibrinated d
blood into the brachial arte
fourteen hours after decapitation. At tb
in a state, of perfect rigor morti
into the vessels, som sd in
different parts of tb rm, of the arm. and
more particularly of the wrist. Tb
larger, and the skin acquired tb has in rube-
ola. Soon afterwards the whole surface had. n reddish-vio-
let hue. A little later, and the skin natural
living color, elasticity, and softness, and the veins stood out
distinct and full as during life. Then the
in the fi ly in the shoulders, and on ex-
amination they were for.: Lave recovered their lost
irritabili uarter t muscles were i
irritable than they had been at five p. m., at which time
the as first exam and this incr
was kept up without abatement until 4 a. m., when fiiti
r to abandon
the experiment was commence
and that of the room 6
The of another experine n rab-
which I. ; killed by
[uard waited until ri hen
I the defil one
lie hind lim
m the body. Fifteen minut tnent
d re-
adily t Ivanic in
From this time, through the night, until
day, the blood intervals of
to 3d minute.-, and during tb time the ma
All this whi
>ther hind limb < limal, and
of the rest of t' mor-
>Op. cii.
98 iures on [January,
p. in. the injections were discontinued.
On resuming the experiment after this interval of an hour
and a half, the limb, with the exception of a few bundles of
fibres here and there, had again become rigid. The effect
of I tions was precisely as at first; and when, from
the of the evening, the experiment was again aban-
doned, the muscles were perfectly soft and irritable. On
the morning following, the limb upon which the injections
had been practiced was in a state of perfect cadveric rigid-
. while the muscles of the rest of the body, which had
1 left to themselves, were already beginning to pass out
his state. On the third morning, the rigor mortis of the
Limb was undiminished, and the other muscles of the
were soft and in an advanced state of putrifaction.
About the time Dr. Brown-Sequard was engaged in these
resting experiments, Professor Stannius, without the
knowledge of what was being done in Paris, was carrying
out an analogous series of inquiries in Rostock.
On the 21st of July, 1851, at 7.1 a. m., Professor Stannius
a ligature around the abdominal aorta and crural arter-
ies i ppy. About a quartea past ten, the muscles had
begun to stiffen in the parts from which the blood was ex-
cluded. At a quarter to eleven, both hinder limbs Avere
stretched out, and perfectly stiff and cool. At twenty
minutes past eleven, the ligatures were loosened, and the
blood was seen and felt to penetrate into" the empty vessels.
At a quarter to twelve, the natural warmth had returned in
some degree, and the right hinder limb was a little more
Hexible than the left. At noon, both the limbs had recover-
ed their flexibility, and it appeared once as if the left had
moved spontaneausly, but no sign of ] . caused by
pinching the toes. At half-past twelve, the muscles of the
paralyzed limbs cantracted everywhere upon the applica-
tion of the galvanic polos ; and at one point the galvanism
cause pain, for the animal, which was before quiet
gave a sudden plunge iorwards. Death happened unex-
; edly at twenty-( i nutes past twelve p. m.
A similar experiment was performed upon another pup-
arly in the morning of the following day. At noon,
. there was no evidence of stiffness in either of
hind limbs, but the muscles below the knee had ceased
e touch <-f lee electrodes. At a quarter-
limbs were stretched out and
nd all e Li'ritibility were at an end. At
1861.] wulsive Diseases.
twenty-five minutes to three, the ligitures were unti<
twenty-five minutes to four, the application of the eh
caused strong contraction in the muscles of both tl;i
and weaker contractions in the muscles of the lel'i
low the knee, while, at the same time nearly all tn
rigidity had disappeared from both limbs. At tw<
minutes to six, every trace of stiffness had disappeared, i
the muscles responded- perfectly to the prick of a h
well as to the touch of the electrodes. On the follov
morning the animal was found dead, and with the rigi<
of death fully established everywhere.
Now, that the stiffness of which mention is here made
is perfectly identical with rigor mortis will appear frefm the
following experiment. In this experiment, the aorta and
crural arteries of another puppy were all carefully tied.
Four hours afterwards, the muscles behind the ligature
were perfectly rigid, and all traces of irritability had cl:
peared in them. In the evening' of the day following, the
animal was still alive at least in its anterior half and,
upon the whole, it was comparatively fresh and quiet.
Twelve hours later, the animal was found dead, with the
parts before the ligature in a state of rigor mortis, and with
the parts behind the ligature, which had been rigid before
death, flaccid, moist and partially putrescent; in other words,
the parts behind the ligature were in the state which comes
on after rigor mortis, and hence it follows that the stiff]
which existed in these parts before the complete death of
the animal must have been identical with rigor mortis.
Here, then, are certain experiments which would seem
to show that the influence of the blood, be this what it may,
;ercised in counteracting the contraction of rigor mortis;
! this inference, which I had drawn from the experiments
of Dr. Brown-Sequard before my attention was directed to-
those of which Professor Stannius, is the same as that wl
the last-named physiologist has drawn from his own experi-
ments.
There are, however, certain facts* which
that muscle is affected differently by arterial and by venous
ive led Dr. Brown-Sequard to think
the omee of arterial blood is to minister to the n
tion of muscle and other til i of
'Compter Rendus, Xo. xvi,
J Oo [January,
of power, and that office of
apply a stimulus, by which the power
called "mto action a view
the function of the black Mood is no
conomy than that of
arteriai
guuient in favor of the idea that venous blood
adowed with these stimulating properties is based upon
well-known fact, that the muscles contract violently
en the wholi >:." blood becomes venous, as in as-
xia. Another argument is derived from the fact, also
fjui. the phenomena of asphyxia, that the left
ventricle of the heart appears to pulsate more violently dur-
moments of the process of suffocation; for at
.e pulse is firmer and fuller, and the mercury
higher point in the haemadynameter. Other
' asedupon some original experiments of Dr.
Brown-Sequard, in which it was seen that certain involun-
tary museles might be thrown into or out of a state of i
ion by injecting alternately black and red blood into
their ve these experiments, the uterus of a
pregnant rabbit parated from its connexions with the
spinal centres, and blood injected into the aorta.
On injecting black blood, the uterus contracted, and two or
thrc ere expelled; on injecting red blood, these
contn Lediately passed off.
But, it may be asked, is it not possible that these convul-
!(1 contractions may be due to the want of arterial
d rather than to the presence of venous blood ? And
iplanation the less difficult of the tw
It violently con-
ed when as when it is strangled to
th. Ct is certainly true, thai ay, that an animal is
ddenly emptied
they are all luddenly
d with blackbiood. AndtL mrely
the convi ttending upon heemorr-
of arterial blood seeing
h cases rather than to
of ven- eingthat this cause can only
L1 any rate, with the fact of convul-
: it is evident that
ntial to convulsion.
c allowed that the fuller pulse of the first
1.] Conmrts 101
moments of -Buff is due to increi mulation of
the left ventricle on the part of the venous blood, for this
phenomena may be the result Lifficulty which
nnarterialized blood experi< trough
>mis capillaries a difficulty by which the ordinan i
traction of the venti
in distending tin >f the intermediate arteries.
And it is certainly unn(
any stimulating properties in the venous blood to explain
the contraction of the uterus which by
injecting such blood into the aorta of a pregnant
for is it not a well-known fact that the uter ten < on-
tracted and expelled its contents \ regnant animals
have been bleeding to death in I
It would seem, also, that an argument in favor of the
idea that the contraction in these several cases is really due
be absence o al blood may be found in a recent
experiment, in which Dr. Ha r that stri
nia and brnsia act, in part at least, ]
alization of the blood. 1: scperiment,
measures two equal portion :alf into
and mi; - all quantity of strichnia with
portion. Then, after thoroughly saturating the blood
in ea c 1 1 I re p eatedl y shaking it wi tl l f re si i
quantity up with 100 air, and
A hours
the air within tl 1 by Bu
and. it of thi found I
whic in contact with
tains mo vnandi- mic acid than the air
which had b in contactwith the simple blood th
i position
ion of
Air after h
hav-
ing b<
Li in
Common Air
mtact w
'
Blc
i
'iOUl
a i n i n /
17.
. . . 79.
.71
100
.00
tares on [January,
[no chuia has prevented the blood
..t'ii and giving off carbonic acid. It has
say, from becoming arterial,
and for this reason the action ofthe poison may he said to
of blood. I be -aid, in-
i! to very copious loss of blood, for in
experimi suits are given in the accom-
panying ddition of a very minute portion ofpoi-
red as equivalent to a loss of two-thirds
of the whole amount of blood, inasmuch as this addition
- of the power which this blood had of
sygen, and of so becoming arterial. When
brucia is be only difference is one of degree.
The f the blood, then, be that what it may, would
: i to be exerted in counteracting, rather than in causing
muscular contraction. At any rate there would seem to be
bo far as we have seen, for supposing that blood
se a stimulous to muscular contraction.
II. It is very far from certain that muscular contraction
is produced by any stimulation derived from the nervous
em, * On the contrary, there are certain facts which seem
bher fatal to such an opinion.
One of these (acts is to be found in the extraordinary in-
muscular power in the hind legs of a frog after
. of the spinal cord. In illustrating this fact,
Dr. Brown-Sequard attaches a small hook to one of the hind
3 a little above the ankle, and tests the muscular power
the limb by hanging weights upon this hook. First of
all, he finds a weight which is just a little heavier than that
which the muscles of the Limb are able to lift, when they
thrown into contraction by pinching one of the toes.
This done, he then divides (he spinal cord immedi-
ihind the second pair of nerves, and goes on testing
the of the paralysed legs by changing the
upon the hook. The results are very strange. Im-
: yi : of the cord, the muscular pow-
er pul forth by the weighted leg when it.- to is pinched is
-7. but generally i1 is about a third or a fourth of]
was befo operation. Fifteen minutes later
idently rallying. In twenty or twenty-rive
had lost. At the end of an
r than it was before the operation- perhaps
An lion: Later still, it is certainly doubled
n bled: and from this time up to the twentv-fourth
A.
B.
60
10
60
80
GO
130
100
140
120
140
130
150
140
150
140
1851.] h uses.
hour, when the inert rally attains its maximum, il
i on slowly augmenting. The particulars of two experi-
ments with very fine frogs (A and B) were as follows,
(weights raised being expressed in grammes :
- experimented upon .
n of the spinal i
Immediately aft<
In five minutes .
In fifteen minutes .
Grammes raised after In twenty-five minutes .
the division of the^ In one hour ....
spinal cord. In two hours ....
In four hours . . .
In twenty-four hours
In forty-eight hours
At this la int the muscular power may remain
nearly stationary for six, ten, fifteen, or twenty days. In a
month, if the animal lives, the power in question will, in all
probability, have fallen to its original value before the ope-
>n. In six, seven or eight months it may not be more
than a third or a fourth of this v It is possible, how-
. that some part of this failure might have been pre-
vented if care had been taken to exercise the paralysed limbs
Ivanism.
other experiments, moreover, which show
plainly that the muscular power is similarly augmented
n the muscle has been altogether cut off from the spinal
thus contradict Dr. Mar [all's no
se of muscular power, after division of
al cord, is due to increa aulation on : of
the cord, which ;ed stimulation has come into' ]
controlling influence of the brain lias b
In one experiment, for example, Professor Engel clips out
whole of the cerebro-spinal system of a frog, bones
all, and, after five or ten minutes, lie finds that the mua
irritable as to be thrown into a state of
".on by a blow upon the table. lie finds, indeed,
under these circumstances are quite a
re in the case of a narcotized fr<
lit, Dr. Bro
. behind the roots of the brachial
r this he cuts through ;. res proceed-
f the hind . he
104 Lectures on [January,
th hinds limbs from the body, and on compar-
ing their irritability by pinching and galvanizing the nerves,
thai the "irritability is augmented*' in both limbs,
which had been previously cut oil" from
rd by the division of its nei
But what of this augmented irritability? There is, no
bt undue readiness to contract on the part of themuscles
undue readiness to bring about contraction of the part
but there are sundry difficulties, of a very
e character, which must be removed before it can be
allowed that this change is owing to augmented irritability.
Two such difficulties are presented by the two following
sriments in Dr. Harley's very valuable investigations
Biological action of strychnia and brucia.
In one of these experiments the hearts of two frogs arc
cut 3 in distilled water, the other in a
': solution of strychnia or brucia. Placed in distilled
water, the heart is found to go on pulsating for a longer
time. still, even for hours; placed in the poisoned solution,
heart is found to cease beating almost immediately, and
ate of rigor mortis before the other heart has
any of its power of contracting rhythmically.
In the other experiment, instead of the hearts of two frogs.
the two hind limbs of the same frog are placed, one in dis-
tilled water, and the other in a solution of strychnia or brucia
strength, and arrangements are made for test-
he irritability of the two limbs by galvanism. This is
experiment. The result, which is not less marked than
in thi .lie re the hearts are concerned, is that the limb
imni< n e 1 in plain water contracts strongly for some time
1 the limb is immersed in the solution of strychnia or
brucia Is d into the state of rigor mortis.
It would seem, indeed, as if the poisons acted upon the
irriti ues in the same way as that in which they have
bees i act upon the blood; for, as Dr. Harley points
if the irritability of the muscle may
I to imply the suspension of that process of ab-
onic acid the so-called
le whs inly most energetic
marked." But be the expla-
. tl mains, that the so-called ir-
rapidly when the irritability is said
ited tor in no the irritability
ntedthan : f rychnine poisoning:
1861.] Con
and thus, instead of ascribing the undue disposition to i
tract to augmented irritability, it. would seem more in ac-
cordance with the fact to BUppose that this undue disposition
ro contract ia dues to a change which is the very opposite
of augmentation. At any rate, after what has been said.
it is impossible to refer the phenomena of a so-called aug-
mented irritability to augmented innervation.
Nor docs the permanent contraction, which comes on
sooner or later in paralysed parts, appear to be in any way
dependent on the sitmulus of nervous influence. This per-
manent contraction comes on sooner or later in all paralysed
parts, and the fact may easily be verified experimentally.
Thus, after destroying the spinal cord in the lumbar region
of pigeon, the muscles of the paralysed parts are at first soft:
in a few days they become somewhat hard : after a few
- they pass into a state of permanent contraction con-
traction by which the legs are kept extended and divergent.
The muscles, indeed, would seem to become contracted,
because the action of the nervous system upon them was
suspended, and to remain contracted because this state of
things was permanent.
It would seem, also, as if the facts which still re
the background are equally unfavorable to the idea that
cular contraction is produced by any stimulation derived
from the nervous system. It is impossible, for instance, to
look upon the convulsions produced by haemorrhage, and
find a reason for believing that they arc connected with
undue stimulation on the part of the nervous system. For
if it be a law in physiology, as it undoubtedly is, that the
functional activity of an organ is proportion to the activity
of the circulation in that organ, then it follows that the ac-
tion of the nervous system must be at zero during the con-
vulsions of haemorrhage, seeing that at this time the vc
are alim ty of blood, and the heart is well-nigh still.
The inference, also, which maybe drawn from the general
fact of convulsion in haemorrhage is confirmed and rendered
more circumstantial by some re< erimental investiga-
tions of Dr. Kussmaul and Tenner/"1 of which the import-
ance cannot well be overral
In one of the experim hysiolo-
:. v.. Xatii chen. u. d. Thii
vol. ii. Frankfort. I
Ift!1) 5 on [January,
gists, Is are passed behind tL innominate
and rabbit,* and arrangements
which these thi be tied and untied in a
moment. On tyi the animal was violently
com ligatures about si onds
: at their he";
were instant] ight to an end. Convulsion is brought
on, thai of blood to the
brain, the medulla oblongata, the upper part of the spinal
I, and the cervi< al ganglia of the sympathetic nerve ; and
nvulsions are instantly suspended by allowing the
blood to return to those organs. In other words, the con-
vulsions would seem to be connected with a state ol inaction
of one or more of the nervous centres named ; for how can
there be any action where blood is wanting ? Xor can it
be said that there may be over-action in the rest of the
spinal cord and in the thoracic and abdominal ganglia of
Lpathetic system over-action in consequence of part
of the blood which cannot find its way to the head and neck
Ided to the blood which, under ordinary circum-
ices finds its way to these organs for there is another
experiment which furnishes conclusive evidence upon this
poi\
In this experiment the subclavian arteries of a rabbit are
tied at their origin, and a ligature is also placed around the
; of the aorta, a little beyond the opening of the left
subclavian artery. The ligatures, that is to say, are so
placed as to bring about a result which is the very opposite
of that which was secured in the last experiment. In that
blood was cut off from the head and neck, and the
circulation confined to the trunk and limbs; in I the
blood is cut off from the body and limbs, and the circulation
I to the head. In tl to say, I
of the brain, medulla oblongata, upper part of the
spinal cord, and the cervici Le sympathetic
nerve. p< than th< : for all
the blood of the body is diverted in this direction; while
the i abdominal
: at all.
tnmenco
inde-
1861.] Convulsive Diseases. 107
And what is the result? The result is paralysis of the
parts behind the ligatures, without convulsion. In one or
two instances the paralysis was preceded by trembling; but
in no instance was there convulsion, or anything approach-
ing to convulsion. It Was ascertained, also, that this ab-
sence of convulsion was not due to paralysis of the spinal
cord from want of blood, for on compressing the carotids so
as to prevent the flow of blood through these vessels the
animal was instantly seized with violent convulsion.
Here, then, are two experiments, the significance of which
cannot well be misunderstood. In the first, we see that
convulsion is instantly arrested by allowing the blood to re-
turn into the great vessels of the neck ; in the second, we
see that convulsion is not caused by cutting oil' the blood
from the body and limbs, and in that way increasing the
rush of blood to the head and neck. In the first we see,
further, that convulsion is instantly brought about by tying
the great vessels of the neck ; in the second we see that the
same result is brought about by compressing these vessels.
In other words, we see that convulsion is absent when the
presence of an undue quantity of blood may be supposed to
imply an over-active state of the cranial and cervical nervous
centres, and that convulsion is present, when, from com-
plete want of blood, these centres must be supposed to
be in the very lowest degree of activity compatible with
life.
In the second of these experiments, we may also find
proof that the convulsion is equally unconnected with an
over-active state of the spinal cord, and of the thoracic and
abdominal ganglia of the sympathetic system; for, after the
circulation lias been for some time at an end in these ner-
vous centres, and when, therefore, the functional activity of
these centres must be nil, convulsion is brought about by
compressing the carotids.
And lastly, an indirect argument in support of the infer-
ence arising out of these experiments that it is the absence
and not the presence, of blood in the cranio-cervical nervous
centres which ha3 to do with the convulsion may be de-
rived from the fact that drowsiness, and not convulsion, is
the consequence of that capiliary injection of these centres
arising from the division of the sympathetic nerve in the
neck, or of that venous engorgement brought about by ty-
ing the jugulars, or that double artcrio-venous eonjection
which happens when the sympathetic nerv< divided
[Janua
in the neck and lie jugular veins in the same
animal.
with blood, then, so with the "nervous influence," the
evidence throughout would seem to be altogether opp<
to the idea that the anion upon muscle isthatofa stimulus
to contraction : but upon this point it may be well to refrain
from forming an opinion until we have bad an opportunity
onsidering some facts which find a place more conveni-
ently in following sections.
[TO BE l ED.]
Rhus 71 idronin Paratysis. By Dr. Michalowe
Dr. Michalowski advises the use of fresb rhus toxicoden-
i in paralysis, and reports the following ease in support
of his recommendation :
A farmer, 35 years of ag<
years with violent rheumatic a tiie bones and joint.- of
the j olumn and of the lower extremeties. At last
-welling' of the joints supervened, and exostoses of the size
ben's egg appeared at many points of the vertebral
column, and two similar tumors, as large as a child's head,
on the transverse rami of the pubic bones. The lower ex-
mities of the patient were completely pa] ; his di-
Ld his urine was discharged by drop-.
many different ithout success, \h\
Micbalowski tried the extract of rhus toxidendroi .red
fron the plant, freshly gathered in botanical gardens. He
administered one grain of the extract, made into a pill, with
half a grain of the leaves. After t lie patient had ta]
ounces of the extract and one ounce of the leaves be was
npletely cured. During this treatment the swelling
the bones dimini ud of the cure
the patient had the t and in the sacral
were pricked by pins: be also had the
ing of a current going from the sacral region down into bis
Once only, the a< the medicine had to
be interrupt the patient complained of pain and a
burning sensation in his
1861.] 109
EDITORIAL AND MISCELLANEOUS.
OUR PRESENT NUMBER,
Our readers will observe that our present Dumber contains over one
hundred pages of reading matter. This issue opens with the valuable
investigation into the Marls of Georgia and the Adaptation of the various
Soils of this State to different kinds of Culture, by our colleague, Prof.
Joseph Jones, Chemist of the Cotton Planters' Convention. This valu-
able scries of papers is now concluded, its completion having been pre-
sented in the form of an extended Heport to the Association. As many
of our readers must have been deeply interested in Professor Jones' agri.
cultural researches, we refer them to the Book Stores of this city for the
volume containing this Report. It is the privilege of the country prac-
titioner of Medicine to relieve the tedium and drudgery of the daily round
^cultural pursuits, on a more or less extended scale, and we there-
fore, have no apology to offer for occupying a portion of our pages for
the several last numbers with matter bearing on Scientific Agriculture ;
but those who may have felt less interested in the-discussion, have still
no reason to complain, as, from an unusual press of original and selected
matter, t: number is nearly one-half larger than our usual
edition.
We call the attention of our rca l ming Lecture ot a
. on Outgrowths of the Cervix Uteri, by Dr. Joseph A. Eve, Pro-
r ot Obstetrics, etc., in the Medical College of Georgia. Dr. Eve's
vast experience and extended reputation in this department of his branch,
will certainly give great value to these Lectures and render them a most
contribution to the Literature of these important snbj
of this journal has been greatly delayed, but ju
requires that we should exonerate our indefatigable and liberal publisher
: any charge of delinquency. The delay was solely attributable to
r, a severe dissecting wound having incapacitated him for fur
Dishing editorial for the number, and even now, ehirography is performed,
without pain.
ill remember that this is the beginning of our
110 'f /((<>/(< . [January
volum > be filled with useful, practical matter,
doing credit to the Medical Literature of the .South and contributing its
to that of American Medicine. We invite their earnest
ith us, in keeping this journal what it has ever been, the
liberal exponent of true Medicine, a garner for the treasures of all parts
of the world1, and tfylTdispensor only of Medical doctrines wherever it
may bo read.
On Urc i^y Professor Jakscjii. Vierteljahrsrli riff fur die
ilkund, xvii. Jahrgaqg. 1860. The author of this pa-
per holds that these arc two varieties of uraemia which should be carefully
distinguished; one being caused by the decomposition of urine and ab-
;.iii df carbonate of ammonia into the blood (ammonaemia), the other
being the variety which accompanies Bright's disease of the kidneys.
lie has secu the former occur under the following circumstances :
1. In torpor and paralysis of the bladder.
2. [n dilatation of the pelvis and callices of thekidneyin consequence
of the ureter- being blocked up.
bscess, renal tuberculosis and sacculated kidneys.
The following are the main differences characterizing the two forms of
uraemir ; we shall, to save circumlocution, use the word ammonaemia as
:iic of the one, and Bright's uraemia as the name of the other :
;. In advanced ammonaemia the urine discharged from the bladder
man; 'ong ammoniacal odor, which Professor Jaksch has never
noticed in any sta^e of Bright's uraemia.
qs, either acute and febrile, or chronic and
afebrile, have not been observed in ammonsemia.
.'). Advanced ammonaemia is characterized by persistent dryness of the
mucous membrane covering the mouth and fauces, as if every particle of
moisture had been removed by blotting-paper; the membrane looks dry
and shining, and the dr\ . extends to the mucous membrane of
the nose, the conjunctiva, and even to the chorda? vocales; these syrup-'
il occur in Bright's uraemia.
4. The distinctly ammoniacal odor of the air exhaled, and of the cu-
taneous secretions of patients affected witli ammonaemia, does not occur
in Bright's di,-
5, Patients suffering from ammonaemia always show a marked dislike
to meat, and especially brown meats, even if their . have not
very far; a feature rarely seen in the other variety.
> r Jaksch bus never observed in Bright's disease the violent
intermittent rigors, stimulating intermittent fever, which occur in animo-
none of the < i r epilepti-
Qor oroupy or di exudations notl
8. Disturbed vision, a I in Bright's disease by exudation on
appear to tube place in ammonaemia.
nie ammonaemia is characterized by a uniformly pale and tal-
18GL] Mi ill
low complexion, and by gradually increasing emaciation ; very acute
and advanced aramonsemi I with very rapid wasting ol
turcs, and muscular debil to paralj
10. In all caj b ran a rapid course there
vomiting, with concurrent or consequent diarrhoea ; in chronic an
naeniia both phenomena were often entire! . or only occurred
temporarily.
11. In ammonsemla, whether acute or chronic r Jaksch has
always seen death occur after sopor, varying in duration from several
sf vend days.
The author d interesting paper gives numerous
illustrative of 1 and^enters very fully into the various
questions connected with diagnosis and treatment, fur which we are un-
able to make room.
0)i Glycosuria as an accompaniment of Marsh Fever. By Dr.
Bcrdel, Physician to the Vierzon Hospital. (L' Unioi Medicate, No.
lo9, 1859,) Dr. Burdel regards marsh poison as a myth, and looks
upon marsh fever as result of a perturbation of the cerebrospinal centre
and the sympathetic system, adopting very nearly the same phrase as
the " ich Bernard defines glycosuria. The author of the pre-
. in his researches into the nature of marsh fever, has con-
firmed the above view of its character by ascertaining in the majority of
of sugar in the urine.
Dr. Burdell employed the test with liquor potassae, Felling's liquids,
the test with bismuth and potash or carbonate of soda, and the yeast test,
ecially in the fi tencement of the attack that the quan-
tity of sugar was considerable ; it diminished gradually towards the ter-
mination of the paroxysm, and generally disappeared entirely during the
interval. The closer the attacks approach one another, the larger the
amount of sugar.
In 80 ca 11 marked intermittent fever the author uniformly-
found sugar; in CO other cases, in which the fever was at first in-
subsequcntly become remittent, the sugar was present,
but only in small quantity and for a brief space. In of inter-
mittent fever following- typhoid fever, a considerable quantity of sugar was
shown to be present.
In the cases presenting the 1 y of sugar, as much as 10
per 1000 was found.
TVoorara. Dr. Vella, the physician who applied this subscance in a
case of " itanus on the battle-field of Magenta, reports to the Academic
Sciences, a number of experim by him to establish its value
lie claims that woorara besides being a sovereign
dy in tetanus is almost an roia, to which conclu
Gonorrheal Treated with T . In an article in the
Medical Journal and. Review, by Dr. P. Poroher, I
11:2 Miscella
emetic is recommended in gonorrhoea. Tn regard to his method of using
it, he baa the following :
"In the formative stage of the di q after its appearance with-
in the first 1") to 36 hours, if possible and before the inflammation has
made any advance, order the recumbent posture to be preserved and the
use of warm mucilaginous drinks, with nitre and doses of tartar-emetic
sufficient to keep up constant nausea. The sedative circulates to the
remote parts of the system, the progress of the inflammation is thus
put an cud to, and in my experi snee, with hut one exception, tlie disease*
ipletelv arrested."
Hoffman's Anodyne in Dilirum Tremens In the same article
above referred to in the same journal. Dr. Porcher speaks highly of
Hoffman's anodyne in delirium tremens. He says he has used it- with
satisfactory results in eight cases "one drachm being administered,
diluted with water, repeatedly, until nervous tremor was allayed and
sleep induced." In the insomnia connected with this disease, he thinks
opium has better effect when combined with tartar-emetic, as follows :
"11. Tr. opii., gtt. xl ; T. emetic, peated every half hour till
sleep is induced."
Large Doses of Opium in Centric Convulsions in Children. In
the same paper above referred to, Dr. Porcher commends opium in full
doses, in cases of convulsions in young children, when not dependent upon
worms or errors in diet. An illustrative case is reported. Dr. Porcher
;ests that a combination of chloroform and laudanum would probably
be beneficial in these cases. For the last five years we have been in
the habit of trusting these cases to chloroform by inhalation, and the re-
sults have been so satisfactory that we have had ; to seek further
remedial aid.
Neuralgia. In the Charleston Medical Examiner for June, Or.
L. D. Ilobinson has an article upon neuralgia, in which his views of its
pathology are given, and also his plan of treatment. We subjoin only
the treatment. In a case reported, the treatment advised, which he says
was that usually advised by him, . lowing:
R. Chinoidine, l24 grs.
Pulv. Capsicum, 5 grs.
Strychnia, 1 gr.
M. flat. pil. No. 10. Dose a pill before each meal.
After using the above sufficiently long to break down the paroxy
and give the patient relief, we prescribe the following:
1\- Quevenne's iron, GO grs.
Quinine, 60 grs.
Ext. Hyosciami, 40 _
Pulvis Capsici, 20 grs.
wde into 40 pills. Dose, a pill after each meal and to bo continued
until completely relieved of debility."
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
(new series.)
U IV1I. AUGUSTA, GEIIICIA. FEBRUARY, 1861. KO. I
ORIGINAL AND ECLECTIC.
ARTICLE V.
The Diagnosis [Physical and Differential) of Phthisis Puhno-
nalis. A Clinical Lecture, delivered at the City Hospital,
leb. Qth, 1861, before the attending Class of the Medical Col-
lege of Georgia of 1860-61. By William Henry Doughty,
If. D., Hospital Physician.
Gentlemen : Perhaps, if I had canvassed the entire cata-
logue of diseases to which humanity is heir, no single one
of them could have brought greater claims for its consider-
ation, or have made stronger demands upon our patient and
earnest attention than the one that has been selected. The
history of our profession abounds in lengthened essays,
learned disquisitions, and numberless memoirs upon this
subject, all of which attest the profound interest that has
been felt in it. The annals of the past show that some of
the brightest intellects of the profession have been ardently
and scientifically devoted to the pursuit of a full establish-
ment and recognition of those features both signs and
symptoms which might be assuredly taken as indicative
of phthisis, distinct from all other diseases of the respiratory
organs. I remark again, tl^at profundity of thought, acute-
of observation, penetrating research, and logical acu-
men, together with most careful comparison, have been
114 Doughty. Clinical Lecture on February,
deeply exercised in order to its fall accomplishment. How
far they have succeeded, the doubtful response that rises
instantaneously in the mind of every practitioner will suf-
ficiently attest. This response, doubtful though it be, will
not be regarded as the negativing of the proposition, but
simply as expressive of the doubts and difficulties which
still hang around some of the cases submitted for examina-
tion. In a large majority of cases the land-marks, both
physical and rational, are so plain and distinct as to render
unequivocal the existence of the disease ; but the remain-
ing minority, often requiring of us a most positive opinion
are enveloped in doubt and encircled by the shades of ob-
scurity. The former, from their unmistakable characters
at once release our minds from farther consideration of
them except in a pathological and therapeutical view, whilst
the latter, from their indistinctness and subtle nature, be-
come anxiously interesting in a diagnostic view. Putting
out of mind the pathological interest of all cases, we do not
fear to assert that the latter the doubtful have been those
to awaken the energies of the profession, and to contribute
most largely to the present exactness of diagnosis of phthisis.
It is but common experience and observation in every de-
partment of life, that the grandest results are the fruits of
the hardest toil, whilst ease engenders superficiality. So
it has been in this instance, where openness of features and
distinctiveness of characters were well marked, it has, in a
measure, paralysed energy, but where evidences of disease
were obscure and pathological changes or manifestations
were ill-defined and mystic, all the powers of a nice dis-
crimination have been taxed, and the highest energies of
the system bent to the unravelling of its diagnostic phe-
nomena.
Thus the diagnosis of tuberculosis comes to us as second
to no other question that appertains to the subject, and per-
haps only equalled in importance by those of its pathology
and curability.
1 have selected this subject solely on account of its practical
1861.] Phthisis Ptdmonalis. 115
importance and because of the prominence which it assumes
in the case upon which I have twice endeavored to lecture.
Of its practical importance you cannot be too sensibly im-
jsed, for though it were rehearsed in your hearing daily
you would still have need of assiduous attention in order to
remain practically familiar with it. Of course, gentlemen, all
that I can do is to repeat to you the conclusions and deter-
minations of others whose time and labor have been almost
exclusively devoted to the study of diseases of the chest,
and whose ripened experience and enlarged observation,
therefore, entitle them to our willing acceptance and judici-
ous verification.
Prior to the discovery of auscultation by Launec, and of
percussion by Auenbrugger, in the early part of this century,
no just apprehensions of the phenomena which characterize
the various diseases of the respiratory organs could be form-
ed by reason of which the utmost confusion existed, both
in regard to their nature and their treatment. The dia-
nosis of these various affections was particularly obscured,
insomuch that bronchitis was often mistaken for more serious
pulmonary lesions, pleuritic changes were also mistaken for
disease of the lung structure itself, and every form of chronic
pulmonary disease confounded with phthisis pulmonalis.
It did not stop even here, for affections of the heart and its
membranes, as well as the larger blood-vessels, were fre-
quently regarded as pulmonary maladies. At this period
the profession was wholly dependent upon the rational
symptoms ot disease, and by reason of the community of
action existing between the respiratory organs and their vari-
ous parts, it became hardly possible for them to escape the
commission of errors of diagnosis. But since the inaugu-
ration of this superior method of examining these diseases,
viz : by physical exploration, a greater part of the obstruc-
tions to correct diagnosis has been removed, and the com.
munity of action to which we have referred, has been made
to illuminate, instead of darkening, the path of the explorer,
by developing the study of their correlative signs. Thus>
11(5 Doughty. Clinical Lecture on [February,
as it wore, the beclouding circumstances of former periods
have become, through scientific analysis, the instrument of
light, the lens by whose converging rays objects of vision
have been rendered bright and intelligible at this date.
But you are not to suppose that the results obtained by the
latter method are so grand and overshadowing as to render
useless or unworthy of attention the other mode. By no
means. These results, though grand, constitute but apart of
that brotherhood which must necessarily exist between the
signs and symptoms of disease. Were we to confine our-
selves to the signs educed by physical exploration alone, we
would be overtaken in numerous instances, by the most
palpable and egregious errors. Yea, more : should we ignore
the rational symptoms of diseases of the chest we wrould not
only be involved in error as were our ancient brethren, but,
and I am sure you will agree with me in the assertion,
we should be far less excusable than the latter.
From these remarks you will at once perceive that we
are not to cultivate or adopt either method of examining
disease to the exclusion of the other, but to associate them
together, and to interrogate both alike upon all the patho-
logical phenomena that you may be called to pass judgment
upon. Connected or related to each other in this manner,
each will become an assistant to the other, and in doubtful
ciises, either a correlative or a corrective. The latter obser-
vation also extends to the various methods of physi-
cal exploration, each having to the other a reciprocal rela-
tion which is as steadfast as the principles of physical science
themselves. Tn the absence of this proper correlation each
ulso becomes a corrective of the other.
Furnished, then, with these various methods for the
interpretation of diseases of the pulmonary organs, we are
prepared, fully prepared, in a vast majority of instances cor-
rectly to understand them and rightly to appreciate them.
Hence we can be no longer justified in the commission of
those errors of diagnosis, with their evil effects in practice,
which were formerly abundant. On the contrary, abun-
1861.] Phthisis Pubnonalis. 117
dant facilities for qualification being afforded us, we are
bound by duty and conscience to acquire a knowledge
them in order that we may discharge, satisfactorily, the ob-
ligations which our relations to society devolve upon us.
And I may bo allowed to remark in this connection, that,
under no other circumstances in professional life will you be
enabled to experience more gratification than flows from
the conscious discharge of your whole duty, than in the pre-
sent particular.
But, having made these general observations by way of
introduction, let us proceed now to a direct consideration
ot^ the subject. The power to diagnosticate tubercular con-
sumption presupposes a full acquaintance with the natural
history of the disease, as its hereditariness, as well as its ac-
cidental acquirement ; its relations to age and sex ; its mode
of commencement usually insidious and almost insensible ;
its almost universally slow progress and development ; its
pathological cause and changes, viz ; the tubercular deposit,
its character, its changes and its results ; the laws which the
latter seems to observe, both in the points of its earliest de-
posit and its mode of progress to other portions ; the re-
lations of hemoptysis to it as evidence of tubercular deposit
already taken place, and its frequency as a symptom; the
products of the changes wrought in the lungs as manifested
by the expectoration ; its constitutional sympathies, as in-
creased frequency of the pulse, hectic fever, dyspnoea, night-
sweats, diarrhoea, chronic laryngitis, and general marasmus.
Besides this, we must have a practical acquaintance with all
of the physical signs that are discoverable in diseases of the
respiratory organs, for, as you should not fail to remember,
there are "no special pathognomonic physical signs" which
belong to it. You need never expect to find a certain set
of physical signs present in all cases, incident alone to the
conditions of the pulmonary structure induced by this dis-
ease, for the tubercular deposit may and does vary greatly
its place of deposit, its extent, its character, as when in
an isolated, scattered manner or coniined to a single spot.
ain, these would vary with its location near the super-
118 .Doughty. Clinical Lecture on [February,
fices of the lung or deep within its structure. For instance,
let us suppose the existence of a deposit near the pleural
iring of the lung, under the progressive softening and
maturation there occurring, the pleura becomes ulcerated,
and an admission of air allowed into the pleural cavity, we
would then have the physical signs of pneumo-thorax su-
per-added, whereas if a similar deposit existed deep with-
in the structure of the organ, we should only have develop-
ed the ordinary signs by percussion and auscultation. Or if
it existed in the form of milliary tubercles scattered irregu-
larly throughout the organ, the physical signs would again
be found to vary from those evolved from a circumscribed
deposit in any portion of it.
Then again, there is nothing special in the sounds elicited
from pulmonary tissue hardened by tubercular deposit, for
the same or similar sounds would be produced if the solidi-
fication proceeded from any other cause, as inflammatory
adhesions, etc. The signs afforded by auscultation of a
tuberculous cavity wherever seated yield no distinctive dif-
ferences from those given forth from a similar cavity, the
result of any other species of diseased action: in otherwords,
the physical signs are the same whether it be a tuberculous
cavity or a local abscess resulting from pneumonitis. The
same remarks might be extended to any of the physical
signs for they represent morbid conditions whether the re-
sult of the tubercular cachexia or not. In the language of
Professor Flint, "the phenomena which it embraces belong
also to other affections. They represent morbid conditions
not peculiar to tuberculosis, but existing in other forms of
disease." He further remarks thus : " isolated from other
other signs, and dissevered from symptoms, pathological
laws, and associated circumstances, none of the physical
phenomena which have just been considered would possess
marked diagnostic importance. Nevertheless, from their
combinations, their conjunction with vital phenomona and
with facts pertaining to the natural history of the disease,
acquire a positive value, and are hardly less significant
than if they belonged to it exclusively."
1861.] Phthisis Pulmonale. ' L9
The physical signs produced by tubercles in the In
fer according to the stage or state of the deposit If the
chest be examined during their existence in a crude Btate
they will be observed to differ widely from those produced
during the stage of softening or after the formation of*
ities. This is very apparent, ami you must be prepared to
meet these differences in practice, otherwise you will often
be foiled in your efforts. It is common to divide tubercu-
lous disease into several stages, founded upon the condition
of the deposit itself as that of crude tubercle, of its soft-
ening, and of excavation. Connected with physical explor-
ation, this division is not so convenient as that suggested by
Professor Flint, because we are not always able to define
the exact state of this product, and very often these various
states are united. Some of the earlier deposit may be ma-
turating and breaking down the vesicular structure into ab-
jses, whilst at other points it may be in a crude con-
dition, and this Btate of things may exist, either in the differ-
ent lungs or in different parts of the same lung. Besides
this, the term crude tubercle simply expresses the state of
the deposit itself, without regard to the mode of it- di
bution through the lung, whether ag^ into mat
or disseminated in minute particles throughout it. It i>
more or less indefinite, and sugj of lew of the
signs incident to its presence. Professor Flint suggests the
following basis of division, viz: (1) "Small, disseminated
tuberculous deposits;" (2), "Abundant deposition, involving
considerable solidification ;" and(3), "Tuberculous dis<
inced to the formation of cavities." Size and mode of
distribution are the distinguishing feature.-: in the first two
divisions, and are, to a greater or less extent
various physical signs incident to them ; the third ie
cal with the corresponding one in the other division. \V
come to apply this in practical auscultation and perc
you will then find that it is not an unim]
matter, for it will require but a limited experience to
quaint you with the material differences whic
120 DOUGHTY- Clinical Lecture on [February.
tween the physical phenomena elicited from a lung or lobes
of a lung occupied in the one case by small disseminated
tubercles, and in the other by an abundant deposit. In the
former, the intervening portions of healthy vesicular struc-
ture, particularly if they assume a complcmental action,
will modify the percussion sounds to such an extent as to
render them, in some cases, almost inappreciable, certainly
doubtful, whilst the auscultatory signs may be so obscure
as to require the nicest tact for their detection. In the latter,
however, the aggregated mass, limitable and circumscribed,
affords the clearest evidences under both methods of physi-
cal examination. The correlative phenomena in the latter
instance, associated with the semeiological and historical fea-
tures of the case establish the diagnosis, whilst in the other,
doubts only become confirmed.
There is a law in tubercular consumption of which you
should, at an early period, be apprised, viz : that "the de-
posit, in the vast majority of cases, takes place at or
near the apex of the lung." This is not invariable, though
exceptions to it are rare. In examining then for tubercu-
lar deposits you will first direct your attention to this point
and any evidences, however slight, of solidification when
not owing to the natural disparity existing between the two
lungs becomes highly suspicious, and if accompanied with
increased vocal resonance, and with any of the elements of
broncho-vesicular respiration, may warrant a positive opin-
ion. If occurring in a patient liable to its inheritance and
accompanied with symptomatic manifestations, however
slight, it may be regarded as certain. Usually this deposit
occurs "at the summit of the lung on one side before the
other lung is attacked," though the other is subsequently
invaded. Hence it is observed that "in the bodies of per-
sons who have died with tuberculosis, the two lungs almost
invariably are found to be diseased, but the deposit is most
abundant or the ravages are more extensive on one side."
1 1 you remember, the case in connection with which these
remarki are mad presented this feature or rather conform-
1861.] Phthisis Pulmonalis. 121
ed to this law, and this fact becomes presumptive of tuber-
culosis. By reference to the notes of examination, I find
the following statement : Percussion over apex of left lung
anteriorly and posteriorly, gave appreciable dulness; of
right lung, over apex, marked dulness, extending in a
varying degree, over the entire upper third of the lung.
The correlatives o\' auscultation were, in the left lung,
broncho-vesicular respiration, and increased conduction of
sound; in the right, bronchial respiration, the expiratory
murmur being greatly prolonged, and much greater conduc-
tion of sound than was observed on left side.
Here, then, we have the evidences of structural disease at
the apices of these organs, more advanced and prominent
than in any other portion of them, and farther advanced on
one side than the other, thus, according to the law of
tuberculosis to which I have adverted, affording strong pre-
sumptive evidence of tuberculous solidification.
In regard to the normal disparity between the right and
left lungs, it is said that "distinct dulness, however slight,
on the left side, is highly significant, while on the right side,
if slight or moderate, it is to betaken as a morbid sign with
considerable reserve." And again, "distinct dulness at the
left summit, be it ever so slight, in connection witli the di-
agnostic symptoms of tuberculosis, may almost suffice to es-
tablish the fact of the existence of the disease, when, if
situated on the right side, other corroborative evidence is
requisite." In our patient above, unfortunately all of the
diagnostie symptoms of tuberculosis arc not present, not-
withstanding the evidence of extensive solidification in both
'ungs, so that the diagnosis is not in every particular con-
firmed. Hut few diagnostic symptoms arc present, and
they are not such as you would expect from the advanced
appearance of the case. They are pain in the chest rati
obtuse than lancinating, slightly increased respiration,
paroxsymal cough with mixed .ration, scanty and
tight, and general emaciation, with lose of muscular strength.
Those absent are hectic fever, niLrht-s\veats, diarrl
1 __
Doughty. CUniccU L
e on
[February
chronic laryngitis, and the thick suppurative expectoration
common to consumption. About thirty years ago he recol-
lects having "spit blood," but his subsequent history rather
militates against t\ic supposition that lie Jwas then tubercu-
lous. He is not hereditarily predisposed to the disease, and,
until thirteen months since, was as hearty and robust as any
one. At that time lie contracted a severe acute disease ot
the chest, probably pneumonia, and has been declining ever
since.
But let us return to the division which we have adopted
and pursue the course there marked out. What physical
signs may we expect to find when the tuberculous deposits
exist in a small, disseminated state ? Of course we can expect
little or no aid under this state of things from any of the
collateral methods of physical cxpploration, as inspection,
palpation and mensuration ; for the lung maintains, to a
great extent, its natural resiliency and elasticity, thereby
abolishing all evidences usually afforded by them. In this
condition of the deposit, our resources are limited chiefly to
the two modes, percussion and auscultation, and in order that
the signs elicited by these be diagnostic, they must establish
their proper correlation, and must be conjoined with the
symptomatic phenomena however obscure. Percussion usu-
ally affords what is termed appreciable dulness or simple
dulness, or technically diminished vesicular resonance. If
the deposit though small, be confined to the apex or a single
lobe of the lung, as the upper, this diminution of reso-
nance will extend only over that particulai region, or if it be
disseminated throughout the entire lung or lungs, as it oc-
casionally is, it will be found to embrace the entire super-
ficies of the chest. The dulness will correspond to the
degree of encroachment of the masses upon the vesicular
structure or the relative size of the m [f the encroach-
ment be small, the variation of the vesicular resonance will
' versa. But sometimes the vesicles im-
mediately surrounding these small deposits become em-
physematous or assume an increased action, and acquire an
1861.] Phthisis Pulmonalis. 128
increased capacity, in this case instead of appreciable dry-
ness on percussion, you wil or may have an increased sonor-
ousness, but not of the normal vesicular quality it is called
tympanitic resonance. This abnormal clearness need not
be confounded with the normal vesicular resonance, if at-
tention be paid to its quality and pitch. It is non-vesicular
and high in pitch. The normal vesicular resonance has a
certain timbre or tone, and is low, grave in its pitch, whilst
tympanitic sonorousness is always high in pitch and its
quality has a type in the sounds elicited by percussing over a
hollow organ. This sound is one of the characteristic signs
of emphysema of the lungs, and when evidence of tubercu-
lar disease is most apt to to be found over the left lung on
account of its anatomical relationship with the hollow ab-
dominal organs. Of this relation you should at all times be
mindful, since the gastric sounds are frequently transmitted
over its surface, and under numerous circumstances are
found modifying the percussion resonance.
Sometimes you will find instances in which the normal
vesicular resonance is not abolished, and yet there are some
of the indications of tympanitic resonance present. It is
neither strictl}^ vesicular nor non- vesicular, but a combina-
tion of the sounds of each. This modification is called
vesiculotympanitic resonance, and is entirely compatible
with certain relations of the solid deposits to the adjoining
pulmonary structure.
In the next place let us consider the signs elicited by aus-
cultation from a lung occupied by this species of deposit.
In a large majority of cases they consist in simple modifi-
cations of the healthy respiratory sounds. And yourability
to detect them necessarily depends upon the degree of your
familiarity with the latter. The chief of them, the most
important because most frequently met with, have types or
representatives in the healthy respiration to which they arc
referred and with which they are compared. Thus we have
a certain abnormal respiration charact* - bronchial
respiration a sign which is constantly present in extensive
124 Douc.hty. Clinical Lecfure 011 [February,
solidification of the lung whenever occurring because its
characters have a more or less exact resemblance to those
sounds produced by the rush of air to and fro through the
larger bronchial tubes in health. The normal vesicular res-
piration has certain distinguishing features, the absence or
modifications of which become the signs of disease. I would
impress you, gentlemen, with the importance of this great
truth as the first requisite to skilful and accurate ausculta-
tion, the absolute necessity of a knowledge of the charac-
ters oi' normal respiration in each and all of its branches.
Possessed of this knowledge, you will find physical auscul-
tation comparatively an easy task, whilst in its absence, you
will often be involved in error and darkness.
The most commonly observed modification of the healthy
respiration is that called broncho-vesicular respiration by
some called rude, and by others, harsh and dry respiration.
The former we adopt because it piesents the types with
which it must be compared, and also because it suggests
the particular place whence it must be evolved the smaller
bronchial tubes, and the vesicular portion of the lungs.
But what is the broncho-vesicular respiration, or how may
you recognize it ? In the language of Prof. Flint, who first
proposed it, if all of its characters are present, "we shall have
an inspiratory sound, neither purely tubular nor vesicular
in quality, but a mixture of both, (broncho-vesicular,) the
duration somewhat shortened, (unfinished) the pitch raised ;
a brief interval followed by an expiratory sound, prolonged,
frequently longer and more intense than the inspiration,
and higher in pitch." It includes, then, modifications both
of the inspiratory and expiratory sounds, and implies a sub-
stitution of certain features of bronchial respiration (normal)
in certain parts of the vesicular structure of the lungs
sometimes a few only of its features may be recognizable.
The normal features of the vesicular murmur, may not be ob-
literated, yet they are so far obscured by those which belong
to the other, as to have its low-toned, soft, expansive mur-
mur supplanted by a rude, harsh sound. This kind of (lis-
1861.] Phthisis Pulmonalis 125
ordered respiration is always heard when the encroachment
is but slight, or has not extended to a great degree of solidi-
fication ofthe parenchymatous structure ; when the latter is
accomplished well-marked bronchial respiration is pro-
duced.
Sometimes the expiratory murmur presents the very ear-
liest indication or becomes the earliest cognizable physical
sign of tuberculosis. In health, there is but a small propor-
tion of individuals one-third in whom a well-marked ex-
piratory sound may be heard, when, therefore, it exists in
an appreciable degree and possesses any of the characters
which pertain to broncho-vesicular respiration, it may be
taken in connection with associated symptoms as evidence
of disease. The most usual changes which it undergoes in
the early period of tuberculosis are a prolongation and ele-
vation of pitch, in these respects occasionally outstripping
the sound of inspiration. It is not difficult to understand
the reason of its prolongation, for the elastic recoil of the
lung is impeded by the presence of these deposits, conse-
quently the escape of air from it is retarded. The expira-
tory sound is, upon an average, only one-fifth the length of
the inspiratory, therefore, any material prolongation of it
becomes at least suspicious, and justifies us in attaching
great importance to it when other corroborative evidence
exists.
Another modified respiratory sound occasional!}- discover-
ed in this condition ofthe tubercular deposits is exagger-
ated vesicular respiration. It is rather significant of dis-
at neighboring points to the region over which it is
heard, and is not essentially abnormal. It is synonymous
with puerile respiration, and exemplifies what I have allud-
to as the coinplemental action of a part. This sound is not
so frequent an attendant upon disseminated tuberculous
deposits as upon abundant deposit of circumscribed dimen-
sions. In the former, it is obscured by the presence and
universality of the broncho-vesicular respiration.
A very important physical sign usually available also is
126- Doughty. Clinical Lecture on [February,
increased vocal resonance an increased conduction of the
sounds of the voice into the ear of the observer. In auscul-
tating the healthy chest over the vesicular pulmonary struc-
ture, the act of speaking is attended with a peculiar vibration
not, however, possessed of much intensity. It varies great-
ly with individuals, and in the two lungs, and in different
parts of the same lung. There seems to be no direct trans-
mission of the sound, but a widespread diffusion of it over
the porous structure. It is too extensively diffused to ob-
tain much intensity, but when, from any cause, the vesicu-
lar structure becomes solidified, it acquires an increased
conducting capacity, and this latter corresponds with the
degree of solidification. Therefore, increased vocal reso-
nance becomes an important physical sign of tubercular de-
posit, whether aggregated or disseminated; in the latter in-
stance, being the correlative of diminished vesicular reso-
nance and the broncho-vesicular respiration.
But, again, if these scattered deposits have becomes often-
ed and are being discharged by expectoration, you will
have superadded to these various signs, some of the adven-
titious rales, i. e., such as have no natural type in the healthy
chest. It may be, that in one part of the lung they are
being discharged, whilst in another they are still in a crude
state, under which circumstances some one or other of
the moist rhonchi will be heard, most probably the sub-
crepitant. You are aware that these rales are produced in
the bronchial tubes, and are most generally treated of in
connection with bronchitis. If the time and occasion war-
ranted I should be glad to digress at this point and make
further allusion to them.
Let us briny recapitulate : the percussion sounds are di-
minished vesicular resonance or dulness or ''tympanitic
dulness' ' or the vesiculotympanitic variety: the ausculta-
tory signs are broncho-vesicular respiration, increased vocal
nance, perhaps exaggerated vesicular murmur, and
some of the adventitious rales, as the subcrepitant.
There is a manifest tendency in such deposits as we have
1861.] Phthisis Putmonalis 127
considered, ultimately to become consolidated, both under
the usual progress in deposit and the resultant soitening of
the pulmonary structure. Hence the physical signs here
enumerated would become gradually intensified, and final-
ly merged into those of the second division of our subject
which I will now proceed to discuss.
In cases of abundant tubercular deposition, involving ex-
tensive solidification, most of the auxiliary methods of
physical examination become available, and the evidence
adduced by them is by no means unworthy of notice. If
you remove the patient's clothing and inspect the chest you
will very probably discover some depression either in the
post-clavicular or sub-clavicular regions, caused by the di-
minished expansion of the lung beneath, and also be able to
detect diminished respiratory movements on the diseased
side or at the diseased point. Palpation will reveal to
you an increased sense of resistance over the solidified por-
tion, abnormal vocal fremitus, and diminished elasticity of
the thoracic walls. Mensuration will also disclose deviations
from the natural dimensions, and thereby assist, although
this method is much less needed in this disease than in some
oth
Percussion over an abundant deposit yields much great-
er dulness than in the other division marked dulness is
the term used to express it. If the bronchial tubes includ-
ed in it remain open, especially if they be at all dilated or
enlarged, or if the surrounding vesicular structure be high-
ly emphysematous, it will partake, more or less of a tympa-
nitic sonorousness.
The signs commonly afforded by auscultation arc well
marked bronchial respiration occupying the seat of the de-
':. broncho-vesicular respiration, and some of the adven-
titious rales in the immediate vicinity of it ; exaggerated
vesicular respiration may also be present at some points.
The crepitant rhonchus may be heard, indicating circum-
scribed pneumonitis, or the sub-crepitant, indicating capil-
lary bronchitis or the presence of the softened tubercular
128 DoufliiTY. Clinical Lecture on [February,
materials in the smaller tubes, or any of the moist or dry
rales may be present The latter only become diagnostic
of phthisis when heard at the summit of the chest in the
vicinity of a tuberculous deposit. They are incidental and
depend in most instances upon the existence of circum-
scribed bronchitis or pneumonitis. "Their value is en-
hanced by association with other phenomena, physical aud
vital, pointing to tuberculous disease."
The correlatives of the voice are also well developed
there is well-marked bronchophony over the solidification,
and in many instances, pectoriloquy. In the latter there is
a transmission of the articulated voice it is " articu-
late through indistinct speaking/' There may be also
an abnormal transmission of the heart sounds in addition .
Another sign that frequently accompanies abundant tuber-
culous solidification is a bellows sound attendant upon whis-
d words. It is said that "this sign may be present in a
lotable degree, when the bronchial respiration, broncho-
phony, or exaggerated vocal resonance are not strongly
marked/'
"When the tuberculous deposit has advanced to the stage
of excavation it is exceedingly difficult to be able at all
times to diagnose it. Indeed it is not always possible be-
cause the varying size, position and relations of the cavi-
ties often prevent the evolution of those signs distinctive of
their existence. Repeated examinations are frequently
necessary to settle the question of their presence or absence.
More or less solidification always remains in connection
with these cavities, hence the most of the physical phenom-
ena which we have just considered still remain though
combined with those peculiar to cavities. Cavernous respira-
tion is the technical name for the latter. The features of
this sound are different both from those of bronchial respi-
ration and the vesicular. Thus Professor Flint describes
them as follows : "They consist of an inspiratory sound.
non-vesicular or blowing, but compared with the bronchial
inspiration, low in pitch, hollow, more slowly evolved; and
L] Phthim Putmonatis 129
of an expiratory sound if present, lower in pitch than the
sound of inspiration." (page 481.") All of these characters
may not be distinguishable ; von may have only the
inspiratory sounds present ; the distinguishing characteris-
tics are lowness of pitch and absence of the vesicular qual-
ity.
Bronchial respiration generally exists in the vicinity of
the cavity, with which you may compare it, and for which
you should not mistake it. Recollect that the chief ele-
ments of the latter are tubularity of sound and highness of
pitch. Cavernous respiration is a variable sign, and may be
present at one examination and absent at another. This
variableness depends, to a great extent, upon the amount of
tluid matter contained in it at different times, and also upon
the rigidity of its walls. Thus if it be filled of course it
will disappear, and with the discharge of its contents by ex-
pectoration will re-appear. Hence it is recommended in
the examination of patients for cavities in the lungs, not to
do so shortly after rising in the morning, but to wait some
hours so as to permit the discharge of the matter accumu-
lated during the night. This sign is much more available
when one large cavity exists than when a number of small
ones are scattered throughout the lungs. In the latter case,
their size prevents its perfect formation, and it is often or apt
to be, obscured by the co-existing bronchial sounds. Under
the act of coughing sometimes in a large cavity, a gurgling
may be detected. This is conclusive of the existence of a
cavity when heard ; they are rarely so large, however, as to
render it of much value.
Pectoriloquy is a vocal sign supposed by some to be in-
dicative of a cavity, but by others said not to be exclusively
so. It may accompany solidification of tisssue either with or
without an excavation. You will recollect that this sign
was quite prominent at the posterior angle of the scapula in
in our patient, on the right side: it may or may not be in-
dicative of a cavitv there. 1 was unable to detect the cav-
l30 Doughty. Clinical Lecture on [February,
it! 11 his respiration at that point. When associated with the
hitter in any ease it may be regarded as diagnostic.
Metallic tinkling is another incidental sign produced as
a vocal or tussive phenomenon, supposed to be produced
when a cavity of some size is partially filled with air and
fluid. I can only mention it and pass to the physical signs
educed by percussion. As in auscultation, those of solidifi-
cation still remain with modifications or superadditions.
Thus if the cavity be full of fluid it will be remarkably dull
on percussion, perhaps fiat; or, if empty and of some size,
it will give a circumscribed tympanitic resonance, or some-
times a modification called amphoric resonance (a metallic
sound) or a cracked metal sound (bruit de potfele.) The
first "maybe imitated by striking the cheek when the
jaws are moderately separated and the integument rendered
somewhat tense," and the second "by folding the palms of
the hands loosely and striking the dorsal surface on the
knee, in the manner frequently done to amuse children,
producing a sound as if pieces of money were placed be-
tween the palms." "The production of this sound is now
generally attributed to the air being suddenly and forcibly
expelled from a cavity communicating with the branchiae
by several free openings, precisely as the blow on the knee
expels the airbetwecn the palms in the experiment mentioned
by which the sound may be imitated." (Flint, page 120.)
Thus, gentlemen, I have viewed in detail the three di-
visions adopted, imperfectly, but I trust truthfully. And
wherever the combination of signs and sounds here men-
tioned occur, or whenever these various correlative physical
signs are present associated with the usual symptomatic
phenomnea which belong to tuberculosis, your diagnosis is
positive and complete. But in some cases, the symptomatic
evidences are few and dubitable, and then the importance
of the physical signs becomes greatly enhanced and demand
on your part a most skilful survey and judicious consider-
ation. Under these circumstances, the differential diag-
is of tuberculosis acquires almost exaggerated import-
1861.] Phthisis Pulmonalis. 131
ance because the same physical signs may he common to
other affections, as dilatation of the bronchial tubes the
ultimate result of bronchitis or chronic pneumonitis. The
latter is so rare as scarcely ever to give rise to discussion
but the other is not so infrequent. When the diagnosis
devolves mainly upon the physical signs it is exceedingly dif-
ficult, if not impossible, always to discriminate between tuber-
culosis and dilatation of the bronchial tubes. I confess my
inability in the patient up-stairs. The difficulty originates
in the fact that has already been mentioned, that there are
no physical signs peculiar to tuberculosis, but any or all
of them may be attendant upon the physical conditions giv-
ing rise to them, however produced, whether from tubercu-
lous changes or any other diseased action. It is onlv in
the exceptional cases, however, that such difficulties arise ;
for, as a general rule, the diagnosis is plain and satisfactory.
But you must be prepared to meet these exceptions, for
come they will in practice, and it may be that the only test
of your opinions will be found in the results of your prac-
tice.
AVhen I conceived this lecture, gentlemen, it was my inten-
tion to confine it to the differential diagnosis of tuberculosis,
and dilatation of the bronchial tubes. But upon reflection I
thought it would be of more interest to you to dwell upon
the simple diagnosis of the disease, without special refer-
ence to any other. If, however, you will indulge me I will
give a brief summary of the chief points involved in the dif-
ferential diagnosis.
Bronchophony, increased vocal fremitus, and bronchial
respiration are physical signs of dilatation of the bron-
chia?; and in its saccular variety, you may have superadded
cavernous respiration, gurgling, and "in some instances
pectoriloquy." If there be any degree of bronchitis present
as there usually is, more or less of the moist rales will be
found also. Bronchial dilatation usually affects the upper
lobes, though not especially the apex like tuberculosis. The
bronchial voice and respiration are due more to the enlarged
L32 Doughty. Lecture on Phthisis Pulmonalis. [Feb.,
calibre of the tubesthan to the solidification of tissue, and
hence are not bo intense as in tuberculous solification. Di-
latation of the bronchiee is not progressive, in the sense in
which that word may apply to tuberculosis, and usually exists
on one side. But, says Prof. Mini : "the point to which
most importance ia to be attached is the absence of the
rational evidence of phthisis derived from the history and
symptoms. In cases of dilatation, cough and expectoration
generally have existed for a long period. If the affection
he tuhcrculous. certain events are to he expected which, if
the affection he dilatation, the case will not be likely to pre-
sent. Among these events and results the most prominent
are progressive and marked emaciation, loss of muscular
strength, pallor of the countenance, hemoptysis, lancinating-
pains in the chest, diarrhoea, marked acceleration of the pulse,
hectic paroxysms, night perspirations, chronic laryngitis.
If all these are absent, the fact favors the supposition of di-
latation being the pathological change giving rise to physi-
cal phenomena which, associated with more or less of the
svmptomatic phenomena just enumerated, would devote un-
equivocally the existence of tuhcrculous disease. Occasion-
ally, however, it happens in cases of phthisis, that nearly
all these rational indications are wanting. Hence, under
these circumstances it is not safe to decide positively from
their ahsence that tuberculosis ma}' not be excluded." How
shall I determine that this is not one of those occasional
cases of tuberculosis, in which "nearly all these rational indi-
cations are wanting?" The most important ones wanting
acceleration of pulse and respiration, hectic fever, night
and chronic laryngitis. Thirty years ago he had hemop-
tysis, but never had a cough until thirteen months since, at
which time he contracted some acute disease of the chest,
probably pneumonia; he is not hereditarily predisposed
to consumption. The history of his cough and expector-
ation furnishes no light. Finally, gentlemen, following the
admonition of the learned professor to whom I have refer-
red, I consider it unsafe to declare that tuherculosis does not
exist.
1861.] Dugas. A Case of 133
rCLE VI.
Iremity }mly
orted by D. ;.\s.
M. D., &c, Professor of Surgery in the Medical Coll<
rgia.
On the 18th of January last Mr. James Gaines, of I);r.
boro', in this State, brought his man servant (Reed) to me
for j nal advice, and gave me the followingh istoryof
the ease : Reed is a negro about twenty years of age ;
fine constitution, and well developed muscular system. He
was out with some friends hunting at night about two month".
. when they utreed a coon." While Reed held up a torch
Tor his comrades to cut down the tree the blows of the axe
caused a large dead limb to fall, which prostrated him.
His friends ran to him and found him unconscious and ap-
parently insensible. They removed the branch which still
ed upon him : lifted him up, and in a short time he re-
red his consciousness and was carried home. His ma-
ter examined him and found that he had entirely lost the
>f the right arm, and that it was insensible to any de-
gree of pinching. Medical aid was obtained i as pos-
sible, and it was found that the blow had been sustained
alone by the right shoulder. This wag considerably bruised
and somewhat swollen; the: skin over tin- deltoid muscle
and just beyond tin- extremity of the acromion process was
abraeded : but the most careful examination could de-
tect neither fracture nor dislocation of any of the bonc<.
The pulse at the wristwas normal, the surface of the limb
was (.-old, the insensibility complete from the lingers to the
upper part of the arm. and the patient unable to move any
stele of the limb. There was no injury to the h< .
any other part of the body.
>re-arm was put in a sling, lotions applied to the
shoulder, and stimulating frictions made to the limb for A
month without a mendrnent. Electric shocks and cur-
rent >rted to for sometime, and it was found
that he conld feel th ks above the elbow' but not be.
134 Paralysis. [February,
low it. They did not seem, however, to excite any muscu-
lar contractions, and were discontinued.
It i nowjusi nine weeks since the accident. On strip-
ping the patienl and examining him in the erect posture no
inequality of height can ho detected in the shoulders, and
the only visible difference between them is the partial atro-
phy of the deltoidand scapular muscles on the affected side.
The entire right limb is smaller than the left; it is percept-
ibly cooler than the other; the pulse is normal; severe
pinching can he Blightly felt above the elbowr, but not at all
w this: he can move neither finger nor any muscle of the
limb and shoulder. I now proceeded to make a most care-
ful examination of the scapula, clavicle andhumerusandjoint
without being able to detect any fracture nor any displace-
ment whatever. The roughest manipulations werepainless
and not the least cripitation could be induced. Everything
was in its proper place andposition. The ulnar nerve was
insensible to pressure at the elbow. The limb dangled by
the side of the body as if dead.
Xow what could have occasioned this paralysis if not an
injury to the axillary plexus by being suddenly and violent-
ly jammed against the ribs by the shoulder joint? And yet
there arc some who deny that this is possible.
This case derives additional interest when taken in con-
nection with several others I have had occasion to report
within the last few years. (See Southern Med. $ Surg. Jour-
nal for 1857, p. 323^ and for 1859, p. 741.) It is worthy of
remark that in the two first two cases I published, and in
which the drooping of the shoulder consequent upon frac-
ture persisted, the patients continued to suffer much pain
in the limb ; whereas in the third and in this (the fourth I
have seen) they suffered none after the subsidence of the
immediate effects of contusion. In the former cases the
axillary nerves continued to be pressed upon and irritated
in the latter they suffered only at the time of the blow.
1861.] Convul D
/. By Charles Bland Radcliffe, M. D.,
>llege, Physician to the Westmini
Hospital, etc.
LECTURE I. CONCLUDED.
Iii the able hands of Prof, du Bois-Keymond,* the gal-
vanometer has recently brought to light certain facts which
appear to be essential to the full interpretation of the mode
in which muscle is affected by electricity.
Of these facts those which require to be mentioned first in
the present inquiry are these: that* there are electrical cur-
rents in living muscle and nerve ; that these currents die
out J ' with the irritability of the nerve and muscle :
and that they have finally disappeared before the occurrence
ot' vigor mortis.
The next fact to which I would prominently direct at-
tention is this, that the electrical currents of muscle and
nerve are weakened during ordinary muscular contrac-
tion.
In the beautiful experiment by which this weakening of
the muscular current during contraction is demonstrated
by Prof, du Bois-Reymond, use is made of the gastrocne-
mius of a frog, with a long portion of the sciatic nerve at-
tached to it. The muscle is placed upon the cushions of
the galvanometer, and the nerve is laid across the poles ot
an induction coil, which coil is not then in action. Onplacing
the relaxed muscle upon the cushions of the galvanometer,
muscular current transverse the coil, and the needle is
deflected to a considerable distance from zero. Passing a
series of alternating induction currents through the nerve,
and so producing a state of tetanus in the muscle, the needle
swings back, and for a moment or two passes to the other
side of zero. Under the current of the relaxed muscle,
that is to say, the needle passes from zero; when
contraction is produced, the needle passes towards zero.
How, then, is this : Is the needle acted upon by a
reverse current during contraction, or is it left free to <
late back to its point of rest in consequence of the cessation
of the current which had previously kept it away from this
point! To answer this question, the experiment just des-
cribed is modified in the following manner:
Having fin tained the point to which the needi
bnngenuto sche Eloctrioitat. 8vo. Berlin. !
136 Lectures on [February,
deflected by the current of the relaxed muscle, the current of
the coil is broken, and the needle allowed to return to rest
at zero. Then, throwing the muscle into a state of tetanus,
the circuit of the coil is closed. In other words, the experi-
ment is so conducted as to test the current of the contract-
ed muscle. And what is the result? It is this: that the
needle moves in the same direction as that in which it
moved under the current of the relaxed muscle, but not to
the same distance from zero. That is to say, the current of
the gastrocnemius is found to be weakened during the con-
traction, not. reversed. I have often verified this fact, and
I shall be happy to show the experiment after the lecture
to any who may be sufficiently interested in the subject to
remain.
In showing the corresponding weakening of the nerve-
current, the ischiatic nerve of a frog is divided in the ham,
and dissected out for a sufficient length towards the spine.
This being done, the divided end of the nerve is bridged
over the cushions of the galvanometer, so as to touch one
cushion with its end and the other with its side, and a note
is taken of the degree to which the needle is deflected by
the nerve-current. The frog is then poisoned by placing a
little strychnia under the skin, and when the tetanus occurs,
the needle is seen to recede three or four degrees nearer to
zero ; and this not only during the principal attacks, but
also during the more transitory shocks which are produced
on touching the animal. It is seen, further, that the needle
again diverges from zero when the spasms pass off. For
this fact also we are indebted to Professor du Bois-Rey-
mond.
And thus in ordinary muscular contraction as well as
rigor mortis, the phenomenon of contraction would seem
to be coincident with the absence rather than with the pre-
presence of the natural electrical currents of muscle and
nerve.
The influence of artificial electricity in muscular action is
a difficult problem ; but even here there are facts which
show that the full solution may be hoped for before long.
When the hind limb of a frog is attached by means of its
sciatic nerve to the conductor of an ordinary electrical ma-
chine, and the conductor is in turn charged and discharged^
the Limb js seen to be at rest in the former period and to be
convulsed in the latter. Xow, in this experiment, the limb
as part of the conductor, must participate in all the changes
1861.]
Convulsive Diseases.
137
X-,
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of charge or discharge which pass over the conductor; and in
thiscase therefore the muscular contraction would seem to he
related to the dis appearance of ordinary electricity from the
muscle, and not to the pre-
sence of ordinary electric-
ity in the muscle.
The muscular move-
ments resulting from the
action of a galvanic [cur-
rent are not a little com-
plicated, and their full in-
terpretation',! ^proportion-
ately difficult.
The muscular move-
ments, resulting from the
action of a galvanic cur-
rent upon a motor or
mixed nerve, provided
nerve "be divided and its
end lifted up are divisible
into periods of double,
alternate, and single con-
traction. In the first
period that of double
contraction there is con-
traction at the beginning
and end of the current,
and the only point to be
noticed is, that the con-
traction at the beginning
of the "direct" current*
is the strongest. In the
second period that of
alternate contraction
the contraction occurs al-
ternately at the beginning
of the "direct" and at the
end of the inverse current.
In the third period that
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The current is spoken of as "direct" when it passes towards the muscle,
s "inverse" when it passes from the music. In other words, the current
s ''direct'' when the positive pol is farthest from the muscje, and "in
when nearest to the muscle.
L38
Lectures on
[February
of single contraction there is, first of all, contraction at the
beginning of the direct current, and at this time only; and,
later still, there is apparent irregularity. Later still, that
is to say, contraction may attend upon the beginning of the
inverse current, after it has ceased to attend' upon the bc-
ginning of the direel current; and not only so, but it may
return to the beginning of the direct current after it has
ceased to attend upon the beginning of the inverse current.
Ney, these alternate revivals
of contraction, which are
known as "voltaic alterna-
tives," may occur several
times in succession upon
thus reversing the current.
The muscular movements
resulting from the action of
a galvanic current upon a
loop of nerve are found to
he divisible into the same
three periods of double, al-
ternate, and single contrac-
tion ; but the movements
themselves occurin very dif-
ferent order within these pe-
riods. In the period of double
contraction, the contraction
at first is strong at the begin-
ning of both currents direct
and inverse ; and then, a
moment or two later, it is
strong'only at the beginning
of the inverse current. In
the period of alternate con-
traction, the time of the
contraction is at the end of
the direct and at the begin-
ning of the inverse current.
In the period of single con-
traction, the contraction,
first of all, is at the begin-
ning of the inverse current;
and aftcrwa r d s, without
any a p pa rent regularity,
now at the b eginning
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l.] D 139
of i lie direct, and now at the beginning of the inv<
current. It is only, indeed, in this final of appar-
ent irregularity, or "voltaic alternatives," that the
movements correspond with those which result from the
n of a current upon a nerve which has been divided
and lifted up at its end. All this may he seen at a glance
mparing the ahove (able with one preceding it.?;
In commenting upon these phenomena, i( is convenient
insider them as belonging to the three groups in which
they have been arranged. And first, of the movements be-
longing to the first period that of double contraction.
In looking at the movements belonging to the first peri-
od, it is not difficult to find a reason which will, in some dc-
, explain how it is that contraction is confined to the
Beginning and end of the current, and to these times only.
It is not difficult to see that the beginning and ending of
the galvanic current in the nerve may involve certain
changes in the strength of the nerve-current, and that these
changes may in their turn give rise to momentary induced
currents in the nerve and in its neighborhood; for such
momentary currents are induced, not only when a current
begins to pass and when it ceases to pass, but also at the mo-
ments when it undergoes any change of strength. It is not
difficult to see, also, that the muscular fibres to which the
nerve is distributed may be the seat of some of the second-
ary currents thus induced, and that these fibres may on this
account be made to contract. Xor is it difficult to see if
the contraction be thus connected with the induced current
that there will be no contraction in the interval between
the besnnnins: and ending of the inducinc; galvanic current;
for if this latter current passes steadily there is no induced
current in this interval. It does not follow, however, that
the contractions are caused by the presence of the induced
hot Claude Bernard has recently stated that a period of si
Contraction precedes the three periods of which mention is made a |
od which i- distinctive of the undisturbed and perfectly unexhausted
and of which the el. iture ia contraction at the beginnii
the two currents, inverse as well as direct. On farther inquiry, however,
I think Prof, Bernard will per le phenomena a titled
to this pr< significance; for, d in a recent communi-
cation to the Royal Society, [find that they are producible at \ ill in the
the period of double contraction bj under particu-
lar circnm>tan
140 Lectures on [February,
currents which are thus developed. On the contrary, these
currents are no sooner communicated to the muscle than
they arc with drawn from the muscle, and it may be that
the contractions arc really due to this withdrawal. At any
rate, it is in connection with the induced currents of which
mention bas been made that we seem to have a reason which
will, in some degree, explain why it is that contraction is
confined to the beginning and end of the galvanic current,
and to these times only.
In considering the movements belonging to the second
period that of alternate contraction the first thing to be
done is to ascertain how it is that the order of contraction
as set down in the first table is reversed in the second table
and this thanks to Dr. Rousseau, of Vezy, is no very diffi-
cult matter.*
A\ lien the current acts upon a loop of nerve, it is not enough
appose that the only current is that whicb passes direct-
ly between the positive pole and the negative pole. On the
contrary, there is a more roundabout way a way which is
made up partly by the portions of nerve beyond the poles,
and partly by the intervening muscles of the thigh: and
along this more roundabout way another current will pass
in a contrary direction to that of the other current. In this
case, that is to say, in addition to the first current, which is
distinguished by the name of primitive current; there is a
second current, which is known as the derived current.
Where, on the contrary, the galvanic current acts upon a
nerve which has been divided and lifted up at its end, the
only current acting upon the nerve is the primitive current.
In this case, indeed, the circuit of the derived current is
broken, and for that reason there can be no derived cur-
rent.
2sow, it is in the action of the derived current that Dr.
Rousseau has found an explanation for that reversal in the
order of alternate contraction which takes place in the case
wbere the galvanic current is made to act upon a loop of
nerve through ordinary poles.
One proof of this is afforded by an experiment in whicb
the galvanic current is passed through a rheophorc bifurquc
a Vhcophore. that is to say, in which one of the poles (say
Logons sur La Physiologie et Pathologic du Systeme Serveux. P
latide Bernard. Tom i. Leoon 10. Paris. 1858.
1801 .] Diseases. 141
the negative) is forked and so arranged as to receive the
pther pole (the positive) between its prongs. It is Been, in the
first place,that the portion of nerve which lies across the p<
[od upon by two primitive currents, and that these cur-
rents pass in opposite directions from the central positive pole
to the outlying negative poles. It is seen. also, that there
no outer or derived current, and that there can he no such
cnrent in this case, inasmuch as the two out poles are both
of the same character both negative. It is obvious, more-
over that there will be no difference in the result where a
nerve which has been divided and lilted up at its end is laid
across the rheopliore bifurque ; for where there is no deriv-
ed current it cannot matter whether the circuit of this cur-
rent is interrupted or not. What, then, it may be asked, is
the result of using this arrangement of the poles? Will
the two primitive currents neutralize each other, and pro-
duce no action in the muscle ': Theoretically, such a con-
clusion is not improbable ; for it is a well-known fact that
opposite currents of equal value do neutralize each other.
Practically, however, the muscle is found to contract; and
not only so, but the order of contraction is found to be one
and the same in the case where a loop of nerve is acted
upon, and in the case where the nerve acted upon is divided
and lifted up at its end. It is found, also, that the muscle
responds to the current which passes in the portion of nerve
nearest to the muscle to which the nerve is distributed. In
other words, it is found that the reversal of the order of
alternate contraction which occurs where a loop of nerve is
acted upon by the ordinary poles of the galvanic apparatus
is due to the action of a derived current; for on excluding
this derived current by means of the rheophore bifurque,
this order of alternation is made to merge in that which
irs where a nerve divided and lifted up at its end is acted
upon, and where there can be no derived current.
or does Dr. Rousseau content himself with this negative
>f. On the contrary, he shows very clearly that the ac-
tion of the derived current will reverse the order of alter-
nate contraction in the case where a loop of nerve is acted
Q by ordinary poles.
Passing through ordinary poles, the inverse primitive cur
rent gives rise to contraction at the moment when the cir-
cuit d. It acts, that is to say, as the direct current
when there is no derived current to complicate its action.
v, if the order of alternate contraction is reversed bv the
142 Lectures on [February,
action of a derived current, and if two opposite currents (ah
n in tlic experiment with the rheophore bifurque,) it is
that which passes through the portion of nerve nearest to
to the muscles which acts upon the muscles. It may, also,
do this by because the current acting upon the muscles actr
ing upon the portion of nerve nearest to the muscles, is not
the primitive inverse current, but a portion of derived cur-
rent the course of which is diametrically opposite that is,
direct. In other words, the acting current, underthese cir-
cumstances, is one which ought to be attended by contrac-
tion at the closure of the circuit, for it is a direct current.
We arc now enabled to sec why the direct primitive cur-
rents acts like an inverse current, when this current is made
to act upon a loop of nerve through ordinary poles ; and
this it may do because it will show that the current acting
upon the muscles, by acting upon the portion of nerve near-
est to the muscles, is not the direct primitive current, but
an inverse portion of derived current. In a word, the act-
ing current is inverse, not direct ; and, therefore, we should
sxpect to have the result of the action of the inverse current
contraction at the end of the current.
In this period of alternate contraction, then, there would
;u to be one and the same law for the muscular move-
ments resulting from the action of the galvanic current upon
nerve a law by which the muscle is made to contract at
the beginning of the direct and at the end of the inverse
curent.
In the period of alternate contraction, then there would
seem to be one and the same rule for the muscular move-
ments resulting from the action of the galvanic current upon
nerve a rule by which the muscle is made to contract at
the beginning of the direct, and at the end of the inverse
currents.
How, then, is this ? Why is it that muscle contracts thus
alternately V It is, perhaps, too much to expect a full ans-
wer to this question at present ; but a partial answer, as it
seems to me, may lie found in the collation of the three
facts which follow.
The first fact is this that the direction of the nerve-cur-
rent in the sciatic nerve of a frog (except in those last mo-
ments in which the action of the galvanic current upon the
the uervegives rise to the "voltaic alternatives") is inverse or
centripetal. In these lasl moments the nerve-current may
ometimes inverse and sometimes direct; and this change
II.] Convulsive Diseases. 143
may take place more than once, but, except in these last
moments, the direction of this current is, as I have said, al-
ways Lnv<
The second fact is furnished by Professor dn Bois-Rey-
mond in an experiment in which the two ends of a Long
portion of nerve are placed upon the cushions of two gal-
vanometers and the middle of the same nerve is laid across
the poles of a galvanic apparatus. Looking at the needles
of the galvanometer before passing the galvanic current,
these needles are seen to diverge under the action of the
nerve-current, and from the direction of this divergence it
ident that this current sets from the end to the side of
the nerve : looking at these needles while the galvanic cur-
rent is passing, one needle is found to move still further
from zero, the other is found to return towards zero.
The third tact, which has been recently furnished by
Professor Eckhardt,* is to be found in an experiment which
may be illustrated as follows: In this experiment the nerve
of the leg of a frog, properly prepared for the purpose, is
placed, one portion (that nearest to the leg) across the poles
of an induction coil, another portion across the poles of a
galvanic apparatus. Having done this, the leg is first
thrown into a state of tetanus by passing a scries of induc-
tion currents, and then, the tetanizing influence still con-
tinuing in operation, the continuous current of the galvanic
apparatus is transmitted in turn to and from the leg. This
is the experiment. The result, which is not a little remark-
able, is : that the tetanus ceases when, the inverse current
passes, and continues when the direct current passes. Nor
is this result altered by inverting the order in which the
continuous and induction currents are made to act upon the
nerve. Thus applied after the direct current the induction
current produce contraction, but not so if they are applied
after the inverse current. Nay, it would even seem as if
the direct current is actually favorable to the production of
tetanus; or, with this current passing, a solution of salt,
which of itself is too weak to cause tetanus, will have this
effect In observing this fact, Professor Eckhardt proceeds
as follows First of all, he tetanizesthe limb by placing the
portion of nerve nearest to it in a strong Bolution of salt ;
on Medical Electricity, \>. 111. Bj Dr. Althaus. 8vo.
144 hires on [February,
after this, he adds water until the strength of the saline
solution is no longer sufficient to provoke this state of con-
traction in the muscles; and then, all things being- as they
were, lie passes the direct current. The result is that the
tetanus immediately returns.
Now, on comparing this last fact with the two previous
facta, we may have, as it seems to me, some insight into the
mode by which the galvanic current acts upon the nerve in
the period of alternate contraction. On the one hand,itisseen
that tetanus is prevented or arrested by the inverse current.
Tetanus is prevented or arrested, that is to say, when (as
the first and second facts show) the galvanic current coin-
cides in direction with, and imparts power to, the nerve-
current. On the other hand, it is seen that tetanus is not
prevented or arrested by the direct current. Tetanus is not
prevented or arrested, that is to say, when (as the first and
second facts still show) the galvanic current differs in direc-
tion from, and diminishes the power of the nerve current.
The one result, indeed, is in harmony with the other; for
if contraction is counteracted by imparting power to the
nerve-current, it is to be expected that contraction will be
favored by detracting power from the nerve-current' And
this result, moreover, is not at variance with the premises.
For has it not been seen that ordinary contraction is coinci-
dent with the discharge of ordinary electricity, and with
weakening of both nerve and muscular currents ? And has
it not been seen that rigor mortis is associated with abso-
lute and permanent annihilation of the two last named cur-
rents ?
And if this be so if in this manner the inverse current
antagonizes, and the direct current favors, contraction
then it seems to be possible to apprehend, in some degree,
why it is that contraction occurs alternately at the brgin-
ning of the direct, and at the end of the inverse current.
When the inverse current passes, the influence upon the
nerve current is one which antagonizes contraction, and
hence it is not to be wondered at that there should be no
contraction at the beginning of the current ; when the in-
verse current ceases to pass, there is an end of the influence
which antagonized contraction, and contraction may there-
fore follow as an equally natural consequence. When, on
the other hand, the direct -current passes, the influence upon
the nerve current being one which favors contraction, the
occurrence of contraction at the beginning of the current
18G1.] 145
may be accounted for : when the direct current ceases to
. the influence which flavored contraction is at an <
and therefore the absence of contraction at this time is not
to be wondered at.
In the third period that of single contraction the mus-
cular movements resulting from tl. d of a galvanic
current upon nerve i d somewhat perplexing,
hut with a little thought it may n that the key
will apply to their interpretation.
If. as ha.- just been seen, contraction attends upon the be-
ginning of the direct current because this current is found
to favor contraction, it is not difficult to find a reason which
will explain, not only why in the first period of double con-
traction the contraction at the beginning of the direct cur-
rect is strongest, but also why in the first part of the period
at present under consideration that of single contraction :
there should lie contraction at the beginning of the di
current, and at this time only. Xor arc the apparenl
ilarities in contraction the "volaic alternatives" which
ir in the latter part of this third period of single cont
tion entirely inexplicable ; for it may he that these apparent
irregularities this apparent shitting of contraction from
the beginning of the direct to the beginning of the inv<
current, and so backward and forward once may be
thing more than the natural conserpience of the chai
which at th'. and are taking place,
in the direction of the nerve-current.
Looking back, then, at the arguments which have been
advanced in the pr< ction, there would to be
littl i for su] - vital property of eon-
lility has been called in: >n during contraction by
ricity; for has it not appeared that
r mortis ident with the utter extinction of
nerve and muscular currents ': that ordinary contraction i-
mded by weak<
tion attends upon the d' of stntical electricity'.'
and that contraction i- favored when tl,
vanic current is to detract power from the nerve-curr*
is it not I that contraction is antagonized
when the action of I current is found to impart
power to the nerve-cui oking hack, indeed, i,
i as it muscular coincident with
id contraction with the.
10
146 Lectures on [February,
of this action. In a word, it would seem as if mus-
cular m< otliing more than a physical proci
it is quite in accordance with what we know of the physi-
cal action of electricity that should mark the impartation of
this action, nnd that contraction 3hould attend upon its ah-
ion.
Lt would seem, also, thai this view of muscular motion
under the action of electricity is one which tallies well with
what h;; 'ready said concerning muscle under the
ion of nervous influence and blood. Indeed, knowing
i we do of the action of electricity, and knowing also
that the nerve-current is a componant part of, and the only
intelligible idea in, nervous influence, is there not some dif-
ficulty in supposing that nervous influence can do other-
than counteract muscular contraction ? And with re-
t to the blood, is there not some ground for believingthat
- fluid must counteract contraction by keeping up those
mical changes in the muscle and nerve upon which the
electrical currents of muscle and nerve may be supposed to
be based : At any rate, the view of the action of electricity
upon muscle, which has been advanced in the present
don, is one which appears to support and explain the view
already arrived at respecting th< of blood and nerv-
ous influence upon muse
LY. In constructing a theory of muscular motion, there
are many facts which still remain to be considered, and
some of which must not be left unexplained. How is it for
mple, that muscle undergoes no change of volume in
contracting ; that contraction is brought about by "mechani-
cal irritation;/' that muscle contracts with diminished
power as it contracts upon itself; that the waste of muscle
is proportionate to its contraction ; and so on? An
- to be explained without the aid of a vital property of
contractility and a doctrine of stimulation ?
The fact that muscle contracts without undergoing any
change in volume the gain in breadth being precisely
loss in length has been often appealed to as
an argument that the process of contraction is beyond the
| >e of any physical explanation ; but, in point of fact, this
nge in muscle has its strict parallel in the change which
passes over a bar or iron under the action of magnetism.
The experiments of Mr. Joule* are quite conclushe upon
phical Magazine, February and April.
1SG1.] ' 1
the latter point. In 01 i be
magnetl in the ated
copper wire. One end of this bar was I
was attached to i of levers by which an}
length was multiplied 3
rectangular iron wire, one-fourth of an iuch
ith of a an inch thick ; the i
in length, and one-third of an inch in
_ the coil with a current c
bar to saturation, or nearly so, the index of the multiply
aratus sprang from its position, and vibral at a
point l-10th of an inch in advance a distance giving
L-oOOOOth of an inch for the actual elongation of the
After a short interval the index cei rate, and be-
to advance gradually in
of the bar under the heat radiating from the coil; and
continued to do until the ci bar
demagnetized, when it immediately vibrated abou
l-10th 01 an inch lower than that to which it .
pre\ attained. In order to show that the bar under-
went no change of volume in thus elongating, Mr. Joule
placed a bar of annealed ir< yard long and half an
inch square, in a gh y inches long, an inch and
a half in diameter, and surrounded by a coiled conductor
ipperwii l-20th of an inch in di-
amel 110 yards ii xtremity ot this
was closed ; the other v. as fitted with a stopper, the centre
of which was pierced with a graduated capilliary tube
whi division was equal 0000th part of
iron bar. This being done, the tube was filled with water,
the Btopper adjusted so as to force t r to a convenient
height in the capillary tube, and the coil alterternately con-
nected and disconnected with a Daniell's battery of live or
sixc . apparatus of sufficient power to m;
iron bar to the full. T ! he experiment. Th
atno perceptible occurred in th
fluid in the eapilliar i making or on breaking
with the battery, and this equally whet!
try, orwhel sing or falling any
inperature acco
bar. T riment, iud hich ail'-
moat conclusive proof that the bar und
volume on being magnetized or dei
tjon of the bar which tai on m : tiou
Lectures on [February.
had not been accompanied by a corresponding loss in breadth
water would have been forced through twenty divisions
of the capillary tube wheneverthe circuit of the battery was
plcted.
Under the influ< magnetism, therefore, there arc
a in a bar of iron which are strictly parallel to tbo.se
which take place in muscle ; and this parallelism extends
also to that point which is so characteristic of muscle, viz:
suddenness with which the contracted and elongated
state- may alternate one upon the other ; for, in Mr. Joule's
experiment, the bar was seen and heard and felt to
jam}) suddenly from the longer to the shorter form, or from
Bhorter back again to the longer, according as the elec-
tricity was communicated to, or withdrawn from, the coil.
is a vital property of contracility at all necessary to
iain the next fact the contraction which i- brought
about by what is called " mechanical irritation." ( >n the
contrary, it is very possible that this phenomenon may
nothing more than the natural consequence of the mechani-
cal interference with the electrical currents in nerve and
muscle. It may be supposed, as in a previously related
e, that a certain interruption in the nerve-current will
a result of the pressure which is implied when a nerve
is subjected to a ''mechanical irritation;"' and that, conse-
nt upon this interruption, momentary currents will be
induced in the nerve and in the neighborhood. It may be
-apposed, further, that the muscular fibres to which the
nerve is distributed are the scat of some of the secondary
currents thus induced, and that these fibres are thrown
f contraction by the disappearance of these currents.'
. also, when the muscular fibre is directly subjected
to mechanical irritation, it may be supposed that there has
:> some interruption of the muscular current in the part
I upon, that this interruption may give rise to mo-
atary induced eurrentsin the neighboring muscular fibre
and that the disappearance of these induced currents may
ilarly bring about contraction in the fibres included
within the circuit of the currents. And, surely, after what
id, it is easy to believe that the contractions rc-
mechanical irritation" arc thus due to definite
; intelligible changes in the nerve and muscular currents
cribe them to au unintelligible "irritation" of a
not very intelligible vital property of "irritability" in n<
and mm
1 i:"1
Nbristhe ' fca with diminished
power as the muscle conl elfan argument that
the law of muscular contraction is different fromany known
physical law paction. \i is no don M.
inted out that the force of muscular conti
the muj ipon itself; but
rgumen
mus< different from the law of
all physical attn Indeed, ela $, in
shrinkin Dgation, behave in ev
riment, and undoubtedly
coutracti< hysical proc
ipeal cannot be made to the fact that the
- proportionate to the amount ofmucular
>n, in order to show that muscular contraction is the
tional activity in the muscle ; ter what has
y that this waste has not been iucur-
:n restoring the- At any rate, i;
tain that the electrical condition of nerve and muscle which.
according to the prei is connected with the state
relax rid not with the state of contraction,
which cannot be kept up without a, correspondin nical
in the tissues concerned,
conclusion, (for thoug <-\i-
:d there is no time to bring it forward)
; argument? i- i
ion rather than contraction
h- it not this I
whirli are said to belong
ntractility which is called irritability .
lertain ag
that the nt contract:
referred to that form of contractility w
[eristic persiste:
which antagonized contraction during
lid ? And if so, what need is there
of the doctrine of stimu-
i which is founded thereon ?
> doubt, a difficult matter to abaudoi
d in the mind, [is that which
.ntractility to ;
itractility
ii when !i. 1
final purpose of
L50 L loses. [February,
traction, aud particularly thai form of contraction which is
of the will instead of being
brought about by the infusion of more life into the muscle,
ht about by the induction of a change which is re-
xtent in rifformortis. But this difficul-
tly which diminishes when it is steadily
looked in the face. Solar as the will is concerned, the
theory under consideration requires one to suppose that
voluntary muscular contraction is brought about, not by im-
parting something to the muscle, but by removing some-
thing from tl "lc which had previously antagonized
contraction. idea changes with reference to the
muscle, but nor with reference to the vital activity of the
will, for in either case and equally the will is a living act-
ing power. And as to the rest, it is surely as easy to sup-
pose that the willacts through the instrumentality of a force
ii must belong to muscle as a physical structure, as it
suppose that it requires the super-addition ot a vital
tractility, and a special provision for stimu-
ls, I repeat, a difficult matter to abandon old
views, ami, turning round completely, to regard muscular
contraction as a process which is most fully realized in rigor
mortis; but we have at least this advantage in so doing
that we gain an explanation which is physical and intelli-
gible an explanation, moreover, which applies to rigor
as well as to ordinary muscular contraction. For
what is the case with respect to rigor mortis? The case is
-imply this: that as long as there is any sign of " irritabil-
" or any trace of nerve-current or muscular current.
long is there is no rigor mortis. If these signs and traces
diiy, as in persons in whom the vitality of the
>een exhausted by long life, or by chronic disease.
as consumption, the muscles become speedily rigid ; if
and tra< -low in dying out, as in persons
en cut down suddenly in the full glow of health.
arc equally slow in passing into the state of ca-
rigidity. Once contracted, moreover, the muscles
remain contracted until the supervention of putrefaction
rent which mosl speedily in the casewhere the
. in their physical integrity least perfectly. The
d, which arc utterly unintelligible upon the hy-
that contraction depends upon the stimulation of
vital property of contractility, are precisely what they
lit to be according to the premises : for according to the
premises all I ' the commencement ofri
}uon dying out of that action in muscle and nei
of which the electrical current is one of the signs ; and all
t'TU | jsaryto its continuance is the absence of thia
.. and the physical integrity of the muscular structure.
- the premises, indeed, there is no difficulty in
explainii unexplained, and hitherto contradict
cnar. ihis form of muscular contraction; .
it would seem that rigor mortis ma;
type of muscular contraction in general, and
's in favor of the theory of muscular
tion of which I have had the honor of sketching the
broader outlines in the present lecture.
o modern da ns of the use
\e Treat) Syphilis. ByDr.ETHae
Grriefswald.
The contention concern];. admissibility of mercury
1U the treatn iilis (Die Xaehtheile der Murkurial-
kur. Vienna. 1859. 8) recently excited by Dr. Hermann
__:, ike that of the advantages resulting
lation and blood-letting, must be witnessed at
each generation, has virtually, in my opin-
io hings of Virchow and Waller
hr. 1859. 111.) The following lines
,1 onlv as a supplementary examination of the
rts adduced by the opposers of mercury to
-rain their opinions.
The very first li ireface prove tha
r happily belongs to that class who are fully con-
the glorious progress we have made." "The in-
lercurial treatment were but little known
uutil our times : indeed, ancient physicians scarcely ha<
indi isgivingthat mercury incorporated into
ns man in the organism, and may pro-
. various destructive and often incur-
igation of the present til
,r kiDd, are du-
ration of mercury. '
dof proof that what we designate a
.itional syphilis was well known to the earl- jrvera
152 Mercury in the [February,
of syphilis at the time of its general prevalence at the end
of the 15th and during the first decade of the 16th centuries.
Now Hermann asserts that this constitutional syphilis"
originated from the administration of mercury to cure the
hitherto far milder diseese. Hermann supposes that "consti-
tutional syphilis firsl occurred when mercury began to be
used, particularly about the middle of the 16th century, by
Francis 1.. and in the form of Barbarossa's pills."
Although these words do not place the historical know-
ledge of Hermann with his subjectina very favorable light,
yoi his immediately following explanation as to the method
by which those physicians arrived at self-deception concern-
ing the true nature of constitutional syphilis, does so in a
much less degree.
"The first physician," says Hermann, after asking the
reader to 'imagine" himself in their position, "treated
syphilis, doubtless both chancre and gonorrhoea, with mer-
curials." Notwithstanding the complete ignorance evinc-
ed by tb 'Is. in regard to the earliest periods of syph-
ilis, tiie recommendation is made to "suppose" one's selfin
the position of those physicians, when a recommendation to
study their writings, winch are accessible to every one in
the collection of Luisinus, Gruner, Fuchs, etc., would have
been more to the point. By such a proceeding the com-
piler would soon have made the discovery that "primary
syphilis" did not at all present itself "undoubtedly" to those
sicians as gonorrhoea and chancre, and that they least of
all treated gonorrhoea and chancre with mercurials.
The cardinal assertions of Hermann amount to this, that
-constitutional syphilis is the product of mercury," and
wthis fact which has been, for the first time, verified by the
exact investigation of the present time," might better be
road "by \h->. Hermann, Lorinserand Kletzinsky."
Lei us examine whether these assertions are founded in
tact.
The earliest observers of syphilis did not determine to
ly mercurial inunction until a long-continued opposition.
they feared the most injurious consequences from
Iness," particularly in cutaneous affections, which,
prominent sympl ped a very large share
ention. Besides, the powerful effect of mercury
upon the mouth was well known, as it had for a long
time been a common remedy in various cutaneous dis-
L861.] Treatment of Syphilis
eases.* The su Pits application observed in i'
diseases induced its use in this new malady also; soon be-
coming a remed leral use among physicians, but op-
.1 ly many, its abuse by the profesi ion, and the dangers
salivation being depicted in the most frightful colors.
Many writers also affirm that mercury was by no means a
certain remedy in syphilis; consequently, the use of guiac-
uin became for a time the pr ; mode.
li to understand that the mercurial treatment fre-
quently produced the worst consequences, and in); infre-
quently death, when we read in Torella, for example, that a
salve weighing 54 ounces contained 4 ounces of mercury,
and that inunction with this of the whole body was con-
tinued for nine days (Luisinus, p. o2T). Yet the assertion
that "constitutional syphilis" was produced by mercur
wot found in the writings of any of the early writers. They
had, as Hermann says, w- no idea " of this effect of the
metal.
Among i he most decided opp . mercury is Leoni.
His detestation of it is as great as could be desired. wiThere
is nothing more injurious to those affected with syphilis
than to use mercury externally or internally, under the form
<>i ointments or fumigations. From such applications per-
always suiter in important organs/' (Luisin. p. 904.)
"Important organs" arc the brain, from which was suppo
to flow the material of the saliva, the lungs, the heart, the
liver. Leoni likewise describes the gummata, the no
the pair nit he had "no idea that these mi
be artificial .
Yet even at that time such objections were not wanting.
y are most definitely discussed by Fallopia, the anato-
mist, during the late period of the guiacum method of cure.
Fallopn the gummata, tophi, etc., of the major-
ity of cai I of mercury, and puts the
riod of tb
>f syphilis, ai
earliest and most important: Mi mus^ a S in his
lime-wa1
"ad libiti
.
.rulara el ana, ed
L54 Mercury in the Treatment of Spyhilis. [Feb.,
stress upon this opinion. "The causes of the tumor
Fallopia, "originate in the affected viscera, but, in most
the inunction by mercury." (Luisin. p. 826.)
Accordingly, Fallopia asserts that gummata, etc., may be
produced by the disease itself, but occur most frequently
after the use of mercury which has not cured the disease.
He explains this pro follows : "When these parts arc
anointed tluy become enfeebled, and are thus then selected
by the di He believes, therefore, that gummata, etc..
arise because the mercury has weakened the particular part,
thus inviting the disease there." .Luisin. p. 827.) But.
irom the preceding words, it appears that evenFallopiafinds
a residue of cases in which gummata are not to be ascribed
to mercury. On the other hand, Fallopia attributes caries
of the bones in syphilitic patients entirely to the influence of
mercury. "The infection of the bones in syphilis is terrible
and the more so because they are infected in such parts as
do not permit of a cure, as the bones of the head which are
designed to inclose and protect the brain, and these I have
seen so much affected as to be all carious. I have many
examples. Some times the bones of the palate are so much
involved that the whole palate decays, and not these only,
but the usual bones also ; and it should be borne in mind
that it is not in every inveterate case of syphilis that this oc-
curs, but only in those in which mercurial inunction has
been enployed." (Luisin. p. 827.;
Notwithstanding, Fallopia had not the idea that mercury
produced only injurious effects under all circumstances, for
wit! i all these objections, he considered mercury capable of
overcoming the disease. (Luisin. p. 810.) We quote also
the following, from the same source : "A third most excel-
lent methodis with pure mercury, which being absor
overcomes the disease, expelling excrementa at the palate.
For me it does this admirably/' (Luisin. p. 782.
The principal reason for the distrust with which Fallopia
regarded mercury was his preference for the "cura regia,"
. by the use of cvacuants and the methodic employmenl
guiacum. "Why use mercury by which health is not
certainly nor If it does not cure, it
ravatesand the disease becomes more stubborn.'" Fal-
lopia does not therefore doubt the curative power of i
. . but considers it less certain than the cura re
Whether this opinion was well founded, we may learn from
what bur author says further; "I do not approve of this
StH.J Mer Treatment of &
licament, bu1
i by the curia r The cura regia, there-
bre, sometimes fail d, and then Fallopia had i - to
'ii ry, under what circumstances and with what suc<
e following quotation will show: "I have seeu a young
Dan lahorin g under syphilis in which (
led. An empiric cured him with mercury. Where!
[have made use of it in stubborn and desperate cases, and
ieularly where L have first tried all other methods.*'
And many others after him who ne
weary of declaiming* against mercury, had, like him,
recoui ibborn and desperate ca Every
died them, but unlike Fallopia, they did not
dways honorable let the world know the truth.
If the quotations hitherto given from the writing- of the
opponents of mercury are but little calculated to support the
opinion of Hermann, that constitutional syphilis first ap-
>eared after the employment of this metal, and that
sarher } 3 had "no idea" of such an effect produced
ertions of other physicians, who did not parti-
cipate in the opinions of those named in regard to mercury.
ire still less favorable to his vicv
Thai mplaints mentioned by Hermann were not
in the earlier periods of the general prevalence of
from the fact that several physicians de-
ny pointedly and fully against these objections.
mple, Leonardo Botallo, one of the most experienced
. syphilis in the lGth century, says : " *
the body become inflamed and uL
.en not being exempt, in patients who have
mercury? Why does their color become lead-
VThat produces, keeps up and increases other various
yraptoms before mercury has been used, ui
id hurno:
Then, as now, thoe :ury care-
fully, and by such use not only produced no constitutional
but, on tl . avoided tl
unfounded are such objectipns.
pie of tli
ired
ili turn membrorum do
rcula et nod
L56 Wasting Paraly, [Februa
Effects which remind mo of Sigmund's process followed
myself in many cas<
So much for a doctrine which, like its predecessors, \
in a short time, and it is to he hoped forever, he consigi
to oblivion, a place assigned to it by a. non-professio
write!* 3 I since, when, as at the present, the most
founded aspersions were heaped upon physicians who w<
at least our equals, and the "exact investigations" of t
present are boasted without the examination having be
made, as Waller has shown, as to whether mercury m
not be found even in the urine of persons who have
been syphilitic and have never been subjected to a mercur
treatment.
Wasting Paralysis. By William Roberts, M. D., Londo
Physician to the Manchester Royal Infirmary.
The next case, which has only recently come
care, is one of the best marked examples of wasting pal
that I have witnessed. The disease is presented simple ai
uncomplicated, without neuralgia or rheumatic pains, wit
out cramps or contractions of the muscles, and without tl
least trace of nervous paralysis. In the parts affected,
combines the two instances before related ; for the atropl
has seized upon the upper segments of both the upper an
lower extremities, leaving the lower segments umnjurd
and thereby occasioning a strange and curion aorij
The patient is a healthy-looking man of 38 years. B
was formerly a warehousemen, and subsequently he 1
a school. He thinks the muscular strength has been slow!
declining for 16 or 18 years, but during the last two or thr<
years the disease has made much more rapid progrei
When he is stripped, the nature of his ailment is at oil
aled, without the necessity of asking a question. Tl
two upper arms are like those of a child so small and thi:
while the shoulders above, and the forearms and hands b
low, are of the full proportions of a moderately muscul
man. The odd appearance of the shoulder-blades likewil
immediately strife beholder. Instead of being bona
s surface of the ribs in 1 JcapuJ
lie loosely beneath the shin. attempt i
moving the arms, their lower angles are thrust backwal
and upward above the level of the arm-pits; and they pn
fl.] Wat 1
1 1
t uuder I prominently as to look like a pair of
nt wings. This singular condition arises from the
lal destruction oi the muscles binding the shoulders to
trunk, namely: the serrati, the rhomboidei, thepector-
c trapezii, and the lav. dorsi. In the lower extremi-
atrophy has followed a corresponding course. The
Irhs are greatly emaciated, while the legs are stout and
muscular action is weakened in proportion to the
phy of the muscles. The hands and fore-arms pos
iction all their proper movements. The patienl
with facility, and grasps with force. The forearm
flexed and extended with readiness, but so feebly,
two-ounce weight in the right hand and a four-ounce
in the left, suffices to overcome the utmost resistance
[the biceps and brachialis anticus.
atient stands erect, the abdomen is protruded
d a corresponding dee}> concavity occupies the lumbar
behind. He walks slowly and with evident difficul-
accomplish considerable distances three or
n* miles if permitted to walk at hi iding
Irs is a painful labor to him.
right and left are affected almost exactly alike, and
onfined to four groups of muscles on each
in the upper limb, (a) those which unite the
:st, (b) those which move the elbow-joint ;
id in the lower limb, (c) those which move the hip, and (<1)
it.
igularity in the upper limb which is ab-
m the lower, that the scapulo-humcral muscles, com-
the deltoid, the supra and infra-spinatus, the sub-
;-is and the teres major and minors, continue vigor-
1 well-nourished, isolated betwecnthe group above and
up below, of which the muscles have degenerated
to the verge of annihilation.
baracteristic feature of wasting p
. is here represented. I allude to i1
irse the singling out of a muscle or a part of a musle
id the decay of the surrounding
scicuius in tolerab
lie of each trapezius is lil pared.
KVha ins of the wasted muscles is perfectly under
ic control of the will. The skin is acute! . anda
elim ly complained of.
[February
Concerning the determining' cause of this man's corn
plaint, then rching inquiry has failed to elicit an;
ig satisfactory. The most reasonable explanation is on'i
red by the patient himself who, I may remark, is a mar
musual intelligence that it has arisen from excess
exposure to cold. When occupied as a warehouseman, h<
lied to work in rooms di fire. The cold
y iclt by him at the time, and lie frequently
be benumbed. It is from this period that he
-t commencement of his ailment. -
By far the largest number of cases of wasting palsy are
produced by undue and too long continued strain on the
muscles ; accordingly artizans are found to be the most fre-
quent victims of partial atropy, and the disease Hills with
unerring certainty on the groups of muscles most tried,
same fact comes out with clearness when the frequency
of the disease in the right arm, and the left is considered.
On a comparison of a large number of cases, I found that
the right arm was more than three times more frequently
eked than the left : and in the two hands the proportion
was three to one in favor of the right.
Masons and mechanics, who wield heavy hammers, have
the muscles of the shoulders first attacked ; shoemakers,
tailors, and milliners are iirst seized in the hands.
A Middleton silk weaver lately under my care, exhibited
an example of wasting palsy, confined to a single muscle.
When he was employed at the loom the index linger of the
right hand was used to lift up a portion of the machinery
ach throw of the shuttle. This was effected by the con-
traction of the extensor indicis. Xow the power to elevate
the index with sufficient force to lift this weight had been
failing in this man for the last eighteen months, lie was
able to work for a time as usual, but in half an hour or so
the linger was thoroughly fatigued, and he was compelled
to repose. By alternate periods of work and repose he was
able to do about a quarter of a day's work.
The grasp of the hand was powerful, and there was no
alteration of sensation. On uncovering the forearms no
different perceived. No doubt this arose from the
small magnitude and deep position of the extensor indicis,
but the nature of the case was rendered clear by its perfect
analogy with corresponding ailments in writers, tailors, and
er artisans, m all whom the atrophy falls on the muscles
most used.
1.] Wasting Parol: L59
muscnlar atrophy froi rk,
well-marked group, easily recognized, and not
Their pathology and mode ot production ap-
3 plain. The fatigued muscles suffer in their nutriti
:,r o[' duerepose, and become a prey to fatty and
ular degeneration of their fibres. There is no tendency
.tension of the disorder to the muscles of the trunk
the exciting cause has only a local operation. IT
early, perfect rest of the injured n
will generally suffice to bring about restoration, but if
>phy have existed a twelvemonth or more the rase is well
i hopeless ; and even, if seen early, I have never been
to obtain success in treatment unless the patient has
particular work which had pro-
, fortunately it is seldom that an ar
n do this upport of his family depends upon
. and he persists in the labor that is slowly ; rely
lermining all his usefulness. The hest advice to give
a patient i - his occupation at once. The
Middleton weaver above-mentioned, acting under my
ion, became a gardener, and is now doing well in that
>ne of the tailors turned letter carrier, and he
dates himself on the change, which appears nbtun-
igresg he has since made continues, to lead
ration of his hand. A writer should be
immended to accustom his left hand to do the work ot
the ri that the latter may rest.
iderable number of cases of wasting palsy are pro-
duced by cold and wet. These also form a concise group,
ervers have wished to set apart under the
rion ot "rheumatic form of muscular atrophy." The
invasion of the complaint when thus caused is often some-
what sudden, and the v ccompanied by cramp.-.
rheumatic pains; but
eculiariti warrant a separation into a dis-
hat set in with the so-called
umatic complexion, subside soon after into the ordinary
story of the groom, whoe describ<
art oft:. , betrays much of the rheu-
tic natui ! from neuralgi< through-
- the whole of his illness, yet it does not appear that cold
iate .-hare in producing the atrophy
the thigh. On the other hand th miner, whose
Led, although the m<
ting Parab/ [February.
constantly immersed in water, never suffered pain during
the four years that his complaint had endured.
The frequency of excessive muscular exercise, and of ex-
; re to wet and cold as determining causes of partial
wasting palsy, explains why tt\e great majority of such cases
occur in the male sex. In ten eases of this sort that I have
i only two were women ; one a domestic servant and the
other a iactory hand.
palsy has sometimes been known to be conse-
cutive to other disorders. The boy whose case was related
first, had an attack of infantile paralysis previously to the
setting in of the wasting- palsy. An old pupil brought me
tild about three months ago, in which the left upper
arm was excessively wasted, with good preservation of the
forearm and hand. The history of the ease pointed un-
equivocally to the infantile paralysis of the whole limb as
the first disorder. The forearm and hand recovered in a
months, but the muscles of the upper arm underwent
a gradual atrophy until they had been completely de-
stroyed.
It is well known that acute diseases aie sometimes fol-
lowed in the course of convalescence by partial or total
a very inexplicable nature. Typhus and ty-
id fever, dysentery, cholera, and diptheria, the three
especially, have furnished frequent examples of such
paralysis.
Avery curious circumstance in the history of wasting palsy
s disposition to run in families. There has been pub-
lished an account of at least ten families in which the dis-
ease has appeared hereditary. In four of these it was con-
fined to two brothers in each. Another family, whose his-
tory has been supplied by Dr. Meryon, had four boys affect-
ed, and there were eight healthy sisters. In another family
mentioned by him all boys, namely: two, had wasting palsy
1st the two sisters were sound. A sea-captain mention-
u'an had lost two maternal uncles and a sister from
the disease, but two other Bisters and three brothers con-
tinued healthy. In a later instance recorded by the same
observer the patient's two aunts had died of general muscu-
lar atrophy. In a family known to Oppenheimer two
uncles and a cousin of the patient were already deceased,
while another cousin and two brothers still suffered from
ting palsy.
Altogether, these ten families included twenty-nine indi-
1861.] Wasting Paralysis. ltil
viduals struck with wasting palsy, and of these only lour were
females. This great preponderance of males is quite inex-
plicable. It cannot depend, as in the previous case, on the
greater exposure of one sex to the common exciting cause
cold, wet, and hard work because in the hereditary
rases the disease frequently appears in early youth or child-
hood, longbefore the sexes are unequally subjected to fatigue
and exposure.
Cases of hereditary origin have another peculiarity. In
nearly all of them the wasting spreads eventually to the en-
tire muscular system, consequently they tend to a fatal ter-
mination, and offer hut a small chance of recovery. Such
- are not, however, absolutely hopeless. I have recent
information that, in the family mentioned by Dr. Meryon,
although the three eldest sons have died, the fourth has
every prospect of surviving, and for more than four years
has exhibited a steady improvement.
AVasting palsy is essentially a chronic disorder. Wc
measure its advance by months and years. Some cases
complete their history in six or eight months, others linger
tor many years. I found the mean duration of a consider-
able number of cases to be a little over three years.
The disease may terminate in one of three ways, namely :
in recovery, permanent arrest, or death. The second mode
of termination occurs when the wasting of the muscles
ceases, and the limb continues tor an indefinite period in
its maimed condition, neither amending nor deteriorating:
the muscles, which are entirely destroyed, do not reappear,
and those which are only partly consumed continue to ex-
ercise their feeble powers under the control of the will, hut
do not regain their former bulk or vigor. This stationary
condition being once ushered in by the arrest of the atrophy
the disease may be said to have reached its ultimate term,
and the skeleton-like footprints it leaves behind are to be.
regarded not as the malady itself, but, like the scar of a
healed-up wound, only as the commemoration of a morbid
activity which has now altogther passed away.
Generally speaking, when the disease has fairly entered
on the stationary phase, and has continued so a year or two,
there is very little danger that it will resume its active ca-
reer. Individuals have lived twenty and even thirty years
with their crippled limbs unaltered. There are cases, how-
s', where the malady, after lying torpid lor years, ha-
awakened to new activity. Aran has related three info
11
162 Wasting Paraly* [February,
Lng examples. One was a woman who, when a child, had
atrophy of the muscles of the right hand, from which she
recovered completely in her twelfth year. When forty
years of age she was attacked again in the .same place. In
another instance, the right leg became the subject of wast-
ing palsy, but gradually recovered. Sixteen years after the
shoulders were seized, and the disease involved both upper
extremities, and several muscles of the trunk. In a third
case, the right leg was the seat of debility and atrophy.
Alter remaining quiescent for eight years, the disease start-
ed into fresh activity in the left leg and right arm.
On the question of the nature of wasting palsy and its
true pathology, opinions are divided under two suppositions.
Some suppose thalthe seat of the disease is in the nervous
centres, and that the muscles are affected through their
nerves, while others, and I reckon myself of the number,
consider the muscles as primarily affected. I will not
weary the reader with a discussion at length on this point,
but must refer those who are curious on the subject to my
essay, where the question is fully debated. I may, however,
shortly state the results of postmortem examinations where
the disease has proved fatal. The wasted muscles have
always, of course, been found diseased; usually there lias
been found fatty degeneration of the primitive fibres. In
other cases the fibres have simply withered away until
nothing remains but the empty sarcolemma, and, at length,
even this disappears. The two conditions maybe found to-
gether in the same subject. The muscles of the lower ex-
tremity appears more prone to the fatty change, while those
of the upper extremity more frequenty suffer simple atrophy.
Hence ilie wasting is a more conspicuous symptom in the
latter than in the former. The muscles in the calf have been
known to be completely changed to masses of fat, without,
any material change of shape or bulk.
The state ot the brain and medulla oblongata has invari-
ably been that of perfect health, hi nine out of thirteen
autopsies of cases of general wasting palsy the spinal cord
was sound, but in the remaining four there was softening or
degeneration. Cruveilhier found, in two eases, atrophy o\'
the anterior roots of the spinal nerves, and this has been
found since, in two instances. In live other eases, where
this pecularity was especially searched for, it was not found :
on the contrary, the anterior roots possessed their usual
. and showed no sign of degeneration.
1861.] Pathogenesis of (Morot L68
The nervous branches, which supply the wasted muscles,
have been examined in a few instances. Cruveilhier and
Virchow found the muscular branches much atrophied.
Dabonlbene, however, found no change in the peripheral
branches, and Mr. Partridge, who examined one of Dr.
Mervon's cases, states briefly that the tendons and nerves
were unchanged. Amid this conflict of evidence, it is im-
possible to come to a certain conclusion regarding the pa-
thology of the disease, but the weight of evidence inclines
very strongly to the belief that the muscles are primarily
affected, and that the morbid changes sometimes found in
the several parts of the nervous system are secondary.
Wasting palsy is especially liable to he confounded with
lead palsy and reflex paralysis, especially the essential par-
alysis of infancy and childhood. Lead pal sy is distinguish-
ed by its comparative sudden invasion. In a day or two,
or a fortnight at most, lead palsy has reached its height,
and the muscles assailed arc reduced to complete immobil-
ity, whereas, in wasting palsy, the waning strength keeps
pace with the gradually decreasing volume of the muscle,
aim the precursory symptoms of lead palsy are very
marked. These are colic, anaesthesia, tremblings of the
limbs, general dyscrasia, undue mobility of the emotions,
especially the depressing ones ; inline, all those anomalous
symptoms and conditions embraced by the term lead cach-
exy. It is also usually easy in such eases to trace wry dis-
tinctly the entrance of lead into the system. London Med.
U'.e Pathogenesis of ( nloro*
It is known that fewer colored blood-corpuscles are found
in chlorotic than in healthy blood : while in the latter, one
cubic millimetre contains from four and a half to five mil-
lions, the number in the former falls as low as to two and a
half millions in the Bame quantity. It is known, too, that
the colored blood-corpuscles contain iron, and chlorotic
blood is, therefore, deficient in iron: and, further, that the
deficiency of chlorotic blood in colored blood-corpuscle-,
and in iron, is the consequence of an impaired Btate of the
formative funct; tamorphosis), and not the resull of
increased waste (Eatamorpo >r the urine of chlorotic
patients is poor in solid materials. Lastly, it is known that
the small amount of iron which the healthy organism ap-
1 1>4 Pathogenesis of [February,
propriates to itself from the most varied diet as from flesh,
milk, eggs, water, etc., fully suffices for the needs of the
system : especially as in the healthy state the bile is the only
secretion that contains iron, and yet the ferruginous con-
tents of the bile are in great measure re-absorbed from
the alimentary canal. How, then, is the occurrence of
chlorosis in a healthy girl to be explained? She receives
still the same ferruginous articles of food; it cannot, then,
depend upon a want of iron, or upon a withdrawal of iron
from the system, for these conditions do not exist; and yet
I he girl, with a constant supply of the same amount of iron,
becomes chlorotic, i e., there is a failure in the formation
of red blood-corpuscles. What is this owing to? The vi-
talist, who ascribes to the sanative power of nature a Pro-
metheus-like contrivance and action in the preservation and
restoration of health, is compelled to have recourse to a sup-
posed error or caprice in regard to the direction that this
sanative power takes, in order to explain the occurrence of
chlorosis. But I am glad that the time is past in which
such phrases and terms are deemed satisfactory, and in
which it was fancied that an already obscure subject was to
1m- explained by something utterly unintelligible. Xow,
when we ask for a substantial reason as to why chlorosis
should occur with a sufficient supply of iron, the theory
hitherto held is at a loss for an answer. The theory, to be
sure, contains the truth, but it does not contain the whole
truth ; a link is wanting in the account of the origin of the
disease. The organism, in fact, lacks the power to apply
the iron furnished it to the formation of a hematine. Upon
what does this want of power depend? We find the an-
swer to this fpiestion in a discovery of Lehman n. Physio-
logical chemistry has, tip to this time, made various excre-
tions the objects of its researches, and especially the urine
Its results, therefore, at best, have been of interest only as
means of diagnosis. But where it has more thoroughly
investigated the changes of tissue, fruitful results are to be
found for practice, for pathology, and for therapeutics. I
may mention, for example, the value of that beautiful dis-
covery of Halwachs and Kuhne, that benzoic acid in its pas-
through the liver is converted into hippuric acid by the
decomposition of the glycocholic acid. From this, Falck
inferred that benzoic acid must be almost a specific against
the condition known as icterus ; and experience has proved
il t. I.,- so. In like manner, for the explanation of the ori
I.] CM 165
of chlorosis, I will show the value of Lehmann's discoi
ery, that hematine is a glucoside.
We know from Bernard that the liver is a sugar-secretipg
an : and, we know, also, that in disease the seer*'
of the different glands vary in amount, appearing at one
i iiu- Lvely increased, and. at another, diminished
even entirely suppressed. There is no conceivable reason
why this should not be the case with the seerction of si
in the liver; indeed, we know already that this secretioi
increased in many forms of diabetes mellitus, and that in
all febrile diseases it is entirely suspended. We will
supposo, for a moment, and the supposition does not stand
a! all in our way, that the sugar-secretion of the liver has for
some time been diminished : what will be the first co
quence of such diminution? Inasmuch as the hematine
requires sugar for its formation, (for, according to Leh-
mann's beautiful discovery, it is like saliein, phloridzin,
tannin, >mbination of sugar or a glucoside), there-
fore, when there is a failure in the supply of liver-sugar,
formation of the coloring* matter of the blood will not be
'inplished, even when the amount of iron is sufficient, a?
and, consequently, the construction of colored
blood-eorpusclcs will be stopped; or, in other words, the
chlorotic condition will originate. The essential cause, then,
of the occurrence of chlorosis is a deficiency or cessation of
the secretion of liver-sugar; the feet that the supply of iron
in forming hematine, is only a consequence of
the former circumstance, and it is not the real cause of the
If the supposition thus made be true, viz: that chlor
depends upon a defective secretion of sugar by the liver a
supposition, the corr of which has, we think, been
proved analytically and synthetically three inferences may
Irawn from it :
cured by means of sugar, which
supplies what is wanting through the failure of the liver.
2d. Chlor > be treated by every means which can
ire the sugar-making function of the liver to the norma!
condition.
3d. T\ the preparations of iron with whicli
chlo mpirically treated, effect the cure. not. as is
universally believed, by supplying the requisite iron to the
large doses operate by promoting
and Li tion of sugar in the lr
1<)<) Pathogenesis of Chlorosis. [February,
I. [f the deficiency of Liver-sugar is to be supplied by the
ingestion of sugar, it must be a sugar like that of the liver,
i.e., grape and not cane-sugar. For though the health or-
ganism may be able to convert the cane-sugar into grape-
sugar, yel the question is whether the impaired digestion of
chlorotic patients is equal to the task. l)oes grape-sugar,
then, cure chlorosis? In northern Schleswick, where I
practiced medicine for twelve years, and, as I have been
told, in many parts of Hanover, honey is a popular remedy
for chlorosis; and lean attest its efficacy from my own ex-
perience. Even though the honey may contain a small por-
tion of iron, yet this is not the curative agent, for other ar-
ticles of diet which contain just as much iron, are entirely
powerless. As honey, by long-continued use, in large
doses, may produce flatulence, acidity, colicky pains and
diarrhoea, it may be well to combine it with suitable correc-
tives, as the hitters, carminatives, etc., and to take it fasting
in the morning in the dose of a tablespoonful.
II. We are still entirely in the dark as to the means
which increase or diminish the secretion of liver-sugar.
There is here a wide field open for inquiry into the powers
of remedial agents. But, little as we know with regard to
this subject, we are yet acquainted with one agent which
promotes the secretion of sugar, and we find it efficacious
in the treatment of chlorosis; it is nothing else than cold
water. It was shown, some years ago, by Dr. Fetters, in
the "Prager Yierteljahrschrift," that the secretion of sugar
iii diabetes is increased by drinking cold water copiously;
and the experience of every hydropathic institution pioves
that chlorosis may be cured by the same means.
Many physicians regard the free use of cold water as a
means which acts only by powerfully increasing the waste
of tissues ; and, therefore, they give no credit to the assur-
ances of hydropathic physicians, that chlorosis is cured by
this means; for, according to their theoretic views, it must
aggravate the disease.
1 n chemical processes, water at one time plays the part of
an acid, at another that of a base ; it has, also, a twofold ac-
tion as a remedy. Acting in one way it greatly increases
the waste of tissue (Katamorphpsis) ; acting in another, it
promotes its formation (Anamorphosis). Indeed, a glance
at the development of the foetus throws light on the action
of water in the organism, and may remove some rusty pre-
judices. Schlossherger has shown that in the earliest con-
1861.] Chlorodyne. 167
dition of the foetal life, the blood is of all the parts poorest
in water, while alter birth it is richest. Since, then, the
vouncrer the foetus is, its vegetable life is the more energetic
^ .
and the formation of tissue is more active than its waste, ii
is evident that this formation is increased in activity by ;i
large amount o\' water.
ill. Whether the last of these three inferences will be
verified the future will show. What is chiefly needed in
the inquiry is an accurate method of investigation, in order
to measure exactly the variations observed in the secretions
of liver-sugar alter the employment of different agents.
When Buch a method is found, then the question as to the
effect of iron will he easily decided.
These remarks are not vet sufficient to prove beyond all
doubt that a failure in the secretion of liver-sugar is the im-
mediately cause (A' the disease; yet, I think I have shown
the insufficiency of the prevailing opinions on the subject
to explain the morbid process, and on the other hand tic
high probability of the new theory. The future may give
sentence in the matter. Should every doubt be finally re-
moved, it would then be shown that chlorosis and diabetes
mellitus are, in their essential nature, diametrically opposite
morbid processes ; and experimental pathology might one
day succeed in producing chlorosis artificially, as has been
done in the i diabetes, so that the means would thus
be found for the radical cure of diabetes. Maryland and
Virginia Med. J
Ghlorodj/m . V>y Dr. Edward Squibb, of Brooklyn.
This most extraordinary humbug does not deserve a mo-
me; onsideration ; and wTere it not for the cir-
cumstance that physicians occasionally resort to it by name
or by it* misrepresented, and without a due know-
its heterogenous composition and quackish charac-
be little else than waste of time and space to
allude to it. It claims English origin, or rather to have
n invented in the English East India service; and in
order to secure for it the magical power of mystery and
nam ;omposition was concealed, or indefinitely stated
as a u of perchloric acid and a new alkaloid.
i it was stated to have been analyzed by a Dr. Ogden :
latter i snted as having given the formula
L68 Chlorodync. [February,
by which it i.s prepared. As it nevcrcould have been either
invented or analyzed, it is not improbable that its whole
story and career are fictitious. It mainly consists of chloro-
form and muriate of morphia, but contains besides,perchloric
acid, oil of peppermint, hydrocyanic acid, tincture of capsi-
cum, molasses, and tincture of cannabis.
Such a villianous mixture could never by any possibility
have been invented, though it may have resulted from some
uncommon degree of empirical ignorance and stupidity;
and such a mixture, once made, would have defied the skill
and knowledge of any analyist whatever, chemical or logi-
cal. And yet an analysis is said to have been made, and
i he proportions are given in drachms, drops, and grains.
Then, of its properties. It is said to be twice as heavy as
water, which, from its composition, is impossible. It is said
lo be sedative, diaphoretic, astringent, antispasmodic,diuretic,
etc., and to improve the pulse in all imaginable respects,
including that of increasing it by decreasing the frequency
of the beats ; and finally, the sum of its impossibilities ac-
complished, lias the accustomed climax of such cases, viz:
that it cures consumption in about the usual proportion of
cases, viz : eight out of twelve, and all of the usual un-
doubted diagnosis and gravity. That any mixture not ab-
solutely antagonistic in its elements, containing two-thirds
of its weight of chloroform, and eight grains of muriate of
morphia in nine drachms, beside hydrocyanic acid and Indian
hemp, should be sedative in effect, is not suprisiug ; and
the molasses, capsicum, and peppermint are so many ad-
ditional shot to be fired into the bushes ; but the perchloric
acidis a novelty. Hitherto regarded chiefly as a chemical
curiosity, it now makes its appearance in the materia
medica, under circumstances most unfavorable for obtain-
ing any definite character or classification. In the small
quantity in which it enters the company of these power-
ful narcotics, its chance of effecting anything more than the
peppermint and molasses, is remarkably small. The whole
thing is, in effect, an absurd sarcasm upon the appetite for
novelty and complexity, which appetite, in a proportion of
the medical profession, is industriously catered to by the
crowd of nostrum or rather money makers, who are so
easily found in the rauks of all sciences and professions.
American Med. Time*.
1861.] Relapsing or E rr< ni /' L69
\rrent Fever. By Dr. Tweedie, Physi-
cian to the London Fever Eospital.
Relapsing or recurrent fever 1ms been thought by some
to resemblethese*Weor sweating fever of Normandy and by
others the yellow fever of the West Indies. Pr. Wardef]
say 8: "There were undoubtedly some considerations which
led to the supposition that the epidemic relapsing fe
bore resemblance to the suette, or sweating fever of Nor-
mandy. In a few instances, though these were of rare oc-
currence, the epidermoid tissue was raised into vesicular
eminence, varying from the size of a millet seed to the sec-
tion of a small pea, these vesicles containing a transparent
fluid, and quite unattended with any areolar blush. On the
third day they become shrivelled and opaque, and desqua-
mated in thin, furfuraceous scales. From the occasional
presence of these bullae with other more logical characters,
some degree of similarity certainly was manifest between il
and the suette. There were physicians who endeavored to
show its near alliance to the yellowfever of the West Indies
indeed gave it as their opinion that, in some respects,
there was a positive identity between the two, only that the
epidemic prevalent in this country had become greatly
modified by climate and other circumstances calculated to
alter its general features. When we take into consideration
the usual number of yellow eases, together with two or three
cases of less important correspondent symptoms, we are
compelled to admit thatthe assertion is not wholly unfound-
ed. Xo trace of its importation into Scotland, however,
could be found, which has generally been the ease where
yellow fever has been communicated from one country to
another."
Relapsing fever has always appeared to the author to be
a form intermediate between the continued and periodic,
but having a more close analogy to the latter. lie has been
led to this view by considering the suddenness of the inva-
sion, the abrupt termination of the symptoms after a defin-
ite period by copious and apparently critical sweat, the in-
terruption of the convalescence by a similar, though shorter
paroxysm, or it may be paroxysms of nearly certain dura-
tion, and a final abrupt cessauouof the disease generally af-
sweating. Even in the more sevej -. ii
which there was gastric disturbance with jaundi ! oc-
casionally cerebral symptoms, the resemblance to the ma-
lignant or pernicious periodic fevers, more particularly those
170 Relapsing or [February,
included under the bilious remittents of tropical climat*
striking.
Symptoms and 'progress. In relapsing fever the invasion
Is sudden. Thepatient, previously in good health, without
warning, is seized with a feeling of indisposition, complain-
ing of chilliness or shivering, acute headache, Languor and
lassitude, Bevere muscular aching and arthritic pains. The
appetite fails, the skin becomes hot and dry, the tongue
white, the desire for fluids cosntant, and the urine scanty
and high-colored. Towards evening the symptoms are ag-
gravated ; the night is passed either in restless agitation or
snatches of unrefreshing sleep. Occasionally the heat of
the skin is relieved by irregular Bweating,but still the other
symptoms suffer no diminution. Vomiting of bilious fluid,
often accompanied with pain at the epigastrium, is an early
and nearly constant symptom. It may occur in the first or
primary fever only, or it may come on in the relapse also.
A.s the disease progresses, the patient becomes more pros-
trate and disinclined for bodily or mental exertion, the
pulse more rapid and tense, the tongue more thickly coated.
the bowels constipated, the muscular and arthritic pains
more acute ; and the nights are passed in restlessness and
wakefulness, unless the nervous system be calmed by the
aid of opiates.
About the third day a marked remission of the symptoms
is often observed ; but whether there be a remission or not,
at a period varying from three to seven days more com-
monly on the fifth day a copious general sweat breaks out
and almost immediately afterwards the fever vanishes, leav-
ing the patient unexpectedly free from the painful Symp-
lon is with which a few hours previously he had been har-
assed. Dr. Cormack, who watched the phases of this sin-
gular disease, tells us that the change for the better was
often sudden and complete, thepatient one day moaning
and groaning in pain, and the next at his ease and cheerful.
complaining only of hunger and weakn<
This apparent convalescence, however, is not of long du-
ration, for when the patient and his medical attendant rea-
sonably conclude, from the favorable change that lias oc-
curred, that the fever is at an (Mid. and that time only is re-
quired for complete restoration to health, a sudden and un-
lo >ked for recurrence of the pre aptoms takes place
This relapse happens at Borne period between the twelfth
and the twentieth day (from the beginning <*\' the disease),
1861.] irrmtFi 171
oe on orabout the Beventh after thecrisis, and without appar-
ent cause or indiscretion on the part of the patient The
relapse is indicated by the same symptoms as the primary
fever rigors, headache, muscular aching, ho1 skin, thirst,
quickened pulse (the rapidity being o\' often disporportion-
ate to the other symptoms) coated tongue, and Loss of appe-
tite.
After a few daya two, three, lour or five this Becond
attack suddenly ceases after a profuse sweat, and the patient
becomes a second time convalescent. The return to health
is comparatively rapid and complete in the young and
and vigorous, but in the aged, and especially in those who
have been previously in indifferent health, the strength is
more slowly gained.
Nor does the mildness or severity of the relapse appear to
he influenced by the previous attack; for it has been ob-
served that the symptoms of the second are sometimes more
mild, and at other times more severe, than those of the
primary fever. In some instances, for example, in which
the first attack was by no means severe, the second has
been characterized by delirium, deep jaundice, violent purg-
ing, and other grave symptoms. Such cases are, however,
immon,
metimes. again, a second but mild relapse takes place,
generally about the twenty-first day: and I have already al-
luded to the circumstance, that patients have suffered thi
four, and even live separate and distinct attacks. Such
frequent relapsinu-s have been seldom noticed in the epi-
demics in England.
Other anomalies are/jn some instances, observed. Thus
the symptoms of the relapse, instead of appearing suddenly,
come on gradually and insidiously ; or, instead of the ordin-
ary well-marked progress of the symptoms, there may b<
only Blight acceleration pulse, and a little increased heat of
skin, to mark its occurrence ; occasionally, in place of the
abrupt termination of the attack by sweating, the crisis ha-'
apparently been connected with some other evacuation,
such as hemorrhage from the nose, diarrhoea, or the n
trual discharge. In some on the other hand, in
which the ordinary symptoms of the first attack have b
well marked, there has been no relapse, nor anything a] -
recurrence.
There appears, too, to be n greater tendency in relapsing
172 Relapsing or [February,
fever than in other acute diseases in pregnant women to
abortion or premature delivery. 80 invariably, indeed,
according to Dr. Wardell's experience, did this happen.
that throughout the whole duration of the Edinburgh epi-
demic a period extending over at least fourteen or fifteen
months ho never discovered even a solitary instance of the
impregnated uterus not expelling its contents; and the
statements of others, whose opportunities of observing this
fever were equally ample, confirm this statement. The same
tendency to abortion was observed in the patients received
into the London Fever Hospital.
The relapsing fever sometimes, however, assumes a more
severe character, the aspect of the symptoms from the com-
mencement indicating a much more serious disease. The
rigors are violent; the heat of the skin is intense; the
heart's action depressed, indicated by the softness and com-
pressibility of the pulse; the patient complains of extreme
prostration, and feelings of exhaustion or sinking; there is
often incessant vomiting of bilious fluid, accompanied with
a more or less deep-jaundiced appearance of the skin,
though the evacuations exhibit no deficiency of bilious ad-
mixture, but the urine is generally loaded with bile.
In some cases, sudden collapse takes place the pulse be-
comes rapid and feeble; the skin universally cold, more
especially the hands and feet; the face livid ; partial or com-
plete unconsciousness succeeds; the sphincter become re-
laxed, and death takes place after a few hours.
The diagnosis of relapsing fever may be given in a few-
words.
It differs from other forms of fever 1, by its sudden in-
vasion; 2, by the short duration of the primary fever, and
its termination by an evident crisis ; 3, by the almost uni-
form occurrence of a relapse occasionally a second or third :
4, by the unusual number of cases with more or less jaun-
dice or yellow color of the skin, accompanied often with
gastro-enteritic and gastro-splenic symptom ; and 5, by the
absence of characteristic rash.
The small mortality, or death-rate, of relapsing fever
shows its comparative mildness, being about one in twenty -
nve, or under 3.9 per cent.
Anatomical characters. This singular form of fever, if un-
complicated, seldom proves fatal. In examination of the
fatal cases, no special lesion, so invariably present as to in-
11.] Recurrent 1
dicate the anatomical character of the disease, has been dis-
covered.
The blood lias in some cases been found throughout the
body in a fluid state indicating a decrease in the normal
amount of fibrin. lam not aware that it has been subjected
to further chemical analysis.
The brain, with the exception of a moderate amount of
sub-arachnoid serosity, and perhaps an increased quantity
in the ventricles, shows no remarkable deviation from a
normal state.
The heart and lungs exhibit no evidence of disease.
The liver has been found enlarged from congestion, and
the gall-bladder more than usually distended with bile ; and
what may be considered worthy of being noted, no obstruc-
tion to the free escape of the bile through the ducts, even
in cases in which the jaundice had been well marked, can
be detected.
Xo disease in any portion of the alimentary canal is dis-
coverable.
The spleen exhibits the most marked and constant lesion,
more especially as to the size or volume. It was noticed
in a considerable number of cases in the Edinburgh epidem-
ic, in 1*43-4. Dr. Wardell saw several in which this or-
gan was three or four times larger than natural ; in one, it
weighed twenty ounces. This splenic enlargement was ob-
served by other physicians during the same epidemic;
tli us. in a fatal case examined at the London Fever Hospi-
tal, the spleen weighed thirty-eight ounces. It thus appears
that, this organ is occasionally larger in relapsing than in
cither typhus or enteric fever.
Urea has been found in the blood. In a fatal case re-
led by Dr. AVardell, in which the patient fell into a state
iipor twenty-four hours before death, crystals of nitrate
of urea were discovered in considerable abundance in tin-
blood taken by cupping, ordered for the relief of the cere-
bral symptoms.
It thus ap] >ears that, with the exception of splenic enlarge-
ment a lesion common to the other forms of fever, con-
tinued and periodic there is no special lesions found after
death in relapsing fever. If structural changes is discover-
ed, they are to be regarded as accidental, and due to some
ondarv or intercurrent affections. Laneet.
174: Cretinism. [February,
Cretinism.
In a former number oi the London Medical Review we ad-
verted to the increasing spread of one of the most hideous and
loathsome diseases which afflict mankind, viz : leprosy. It is
now our object to draw attention to another equally distressing
malady, which owing to its nature and close affinity to
scrofula, affords many points of interest for consideration, al-
though, fortunately we may claim an almost total exemption
from it in this country.
The most common continental seats of the affection are the
hern provinces of France, and certain districts in Switzer-
land, and in the north of Italy. The inhabitants of the two
great chains of mountains, the Pyrenees and the Alps, where
it has existed from a remote period, suffer most severely. In
addition to these European localities, China, Syria, Northern
India, the bleak shores of the Polar Seas, and some parts of
the continent of America, furnish frequent instances of cretin-
ism, and the kindred disorder, goitre.
The causes and treatment of cretinism are so amply discus-
sed in most systematic treatises on medicine, although the
etiology of the affection has not yet been clearly solved, that
we shall not dwell upon this portion of the subject further
than in making the consolatory remark that it is, to a large
extent, amenable to judicious treatment and removal from the
affected districts, a fact which is sufficiently evidenced by the
circumstance referred to by Dr. Watson, in his lectures, that,
ont of the total number of patients admitted into Dr. Guggen-
buhPs special hospital for cretin children, during twelve years,
one-third became perfectly restored to health and reason, while
the rest were improved in mind and in body.
The statements of most recent French and Italian writers
upon cretinism tend to show that it is upon the increase, and
we. therefore, in accordance with the sound principles enun-
ciated in the aphorism, Venienti succurrite morbo, and in the
hope of obtaining information upon the point from medical
gentlemen residing in those districts of this country in which
fcre may be said to be endemic, publish, at full length, the
iiication of cretinism, given in a recent memoir
\L Morel, avIio has paid considerable attention to the sub-
We need scarcely permise that numerous modifying
a dependent upon the climate, mode of living and cus-
tho locality, must determine, more or less, marked
diffi rences in the character of the disease.
First Division. Goitrous individuals with symptoms of
II.] Mm.
cachexia and of mental dulness. All the cduntries which con-
tain cretins, joitrous individuals, and no example can
be given in opposition to this fact. Nevertheless, goitrous
>ns do not necessarily become cretins, and goitre docs nor
form an indispensable accompaniment of cretinism. When I
have visited districts where goitre is endemic, such as certain
Localities in Meurthe and Moselle, people have not failed to
tell me that I should find no cretins there, but an attentive
rvation of tacts has proved to me that goitre is the start-
ing point of cretinism. In countries where goitre is endemic,
we may already distinguish the iirst lineaments of cretinism
in the appearance of individuals ; the lips arc thicker, the
nose is rounded and slightly flattened, and the zygomatic
arches are more prominent, hi other cases the respiration is
sibilant, difficult and sometimes stertorous ; the cretinous
cachexia begins to show itself. In these same countries when
there is a complication with malarious elements, the degene-
ration is displayed in an aspect which approaches still more
closely to cretinism ; we observe the lymphatic temperament,
hernias, tumid abdomen, mental dulness, &c.
There is a close connection between the goitrous and the
'ions epidemicity, the goitrous being only the iirst stage
of the cretinous, and it is very rare that we find actual cretins
where there are not also goitrous individuals.
;ond Division Cretins possessing the power of continuous
reproduction. The cretins in this second division are capable
of continuing their species, and many of them marry. They
have the ordinary appearance of the healthy individuals of
their country, but begin to be distinguished from them by a
more faulty conformation of the skull. They often have the
head flattened at the posterior and upper parts, whilst it is
considerably enlarged laterally. They present a greater de-
velopment of the zygomatic arches ; the nose is more flatten-
the lips are thicker, and the chin is square : the distance;
fmm the root of the nose to the commissure of the lip
. the bones are coarse and large, and the thickened
articular surface are unsymmetrical ; there is generally a dis-
proportion between the upper and lower extremities. Goitre
- a characteristic of the individuals in this division.
cretins never surpass a certain intellectual limit ; their
'i and embarrassed.
Third Division. The cretins in this division may be divided
into two The first is composed of those who can,
although only with difficulty, propagate their Bpecies ; the
nd. of those who are sterile.
i7<; ('/etinism. [February
First Seel ion Cretins limited in their fecundity. These
are remarkable on account of the Bmallness of their stature,
which makes them appear like stunted dwarfs, and by their
uncertain and wavering gait. Their hair is very dark and
bristly, their skin is black and rugged, and probably contains
more pigment than in the normal condition. The f imdamental
principles of cretinism are strongly shown in the superior and
posterior flattening of" the head, and in the exaggerated devel-
opment of the temporal portion and of the zygomatic arches.
The nose is small, rounded and crushed down at its upper
part, the lips are thick and coarse, the tongue is hypertrophi-
cal, the flesh is soft and flabby, and the chest is narrowed.
Menstruation is tardy and irregular, and is in proportion to
the limited fecundity of these degenerate beings, who produce
only an abortive offspring, or scarcely living children.
Second Section Sterile Cretins. The external appearance
is the same as in the preceding ; the stature and physical con-
stitution are also identical. In both sections the upper eyelid
is disproportionately elongated, void of contractility, and over-
Laps the eyeball in an ungraceful manner; the tongue is
thickened, and the speech cmbanasscd. The difference arises
in the internal characteristics. The organs of generation are
either atrophied, or only sparingly developed. Many of the
cretins in tnis class have no second dentition; their average
length of lie is limited, and at twenty-five or thirty years of
age they present symptoms of decay. Goitre is very rare in
this division.
Fourth Division. Cretins presenting complex degenera-
tions.-In all countries where cretins exist, we may observe
individuals who appear to deviate from the ordinary type of
inism by a grouping of frequently very variable peculiari-
ties. Amongst them we find all the varieties of misshaped
heads, from the prcternaturally small head up to the hydro-
cephalic, and also many goitrous persons, deaf-mutes, and in-
dividuals suffering from single or double hernia, or afflicted
with diseases of the hip, or congenital dislocations. The ano-
malies shown in the organs of generation are remarkable ; in
fact, in contradistinction to the sterility of some, we mayper-
ceive a development of the genital organs in other.-.
Fifth Division Deformed Cretins. These cannot walk.
bu1 drag themselves along, or remain fixed to the place where
!. They only present to the view a shapeless
j; their eye- are blear and lustreless, and the saliva drib-
between their thickened lips; their skin is black and
and their hair bristly ; sometimes they have enor-
18G1.] itment of Skin D 177
mous goitres. The speech, which is rudimentary and incom-
plete in the third and fourth division.-, is replaced in this by
inarticulate, wild cries; and the perceptive facilities are
obtu- \don Med-. ./* view.
On the Employment of Chloride of Zinc in the Treatment of
Skin 1>
After having for a considerable period employed the chlo-
ride of zinc, exclusively in its property of a caustic, in cs
of Lupus and some analogous cutaneous affections, Dr. Yeiej,
of Caustadt, has extended its use to the treatment of chronic
leers of the legs, of sycosis, of chronic eczema, &c.
He uses either an alcoholic solution (composed of equal
parts') or an aqueous solution, consisting of ten parts of chlo-
ride of zinc, and ten parts of hydrochloric acid to 500 parts; of
water, or the solid caustic moulded by fusion into cylindri
sticks.
In tins last form. Dr. Veiel propose-, like all other surgeons,
to produce an energetic caustic action. He has especially had
recourse to this methad of treatment in thirteen cases <f lupus
with most satisfactory result-. His method of applying it is
thus: When the epidermis roved and replaced by
more or less thick crusts, these are detached by mean.-, of
emollient poultices: in case the epidermis is intact, the chlo-
ride of zinc, is applied until the skin is previously denuded by
the use of a blister; by means of a pointed pencil of chloride
of zinc, he penetrates deeply into the hypertrophied tis-
those which are surmounted by tubercles, in such a
manner as to apply the caustic to all the affected parts, and
this application is continued beyond the diseased textures
to an extent of a few lines. All around the lesion the suri
which is riddled with holes, somewhat analogous to a hoi
comb, exudes, immediately after this operation, a sangnino-
lent blackish liquid, and subsequently a serosity of a fighter
color, which, at the end of some hours, harden- into a smooth
and firm crust. Towards the third and fourth day a &
purulent discharge raises up the (-di:^ of this crust, and
should be afforded to it by a few puncture-. A hour the sixth
or the eighth day the civ rated at its edges, ami can be
detached by the application of poultices continued daring
some days. It is rarely neco-sarv to renew the application of
17* Treatment of False Articulations. [February.
the caustic more than three times, except in cases where the
morbid tissue possesses unusual thickness. When the suppu-
rating surface which succeeds upon the fall of the eschar no
longer presents any granulations of a bad nature, aud becomes
raised to the level of the healthy parts, it is covered with
poultices during some days, and then lightly touched with the
alcoholic solution of chloride of zinc every three or four days.
When the edges begin to contract, the aqueous solution is
substituted lor the alcoholic, and continued occasionally until
the cure is completed. The time requisite for obtaining tlii^
result rarely exceeds three or four months.
Dr. Veiel employs the alcoholic solution of chloride of zinc
with advantage in the treatment of inveterate eczema of the
eyelids, of the lips, of the genital organs, and about the anus.
The aqueous solution sometimes cures cases of eczema solare,
or eczema impetignodes, which have resisted all the usual
remedies. The alcoholic solution readily removes the indura
tions which occasionally remain as a sequel of psoriasis on the
neck, the back and the thighs ; it is only necessary, in order
to apply it in these cases, to be careful in removing the scales
which cover the indurated parts.
There is a form of psoriasis palmaris accompanied by warty,
painful indurations, which only gives way to the solid chloride
of zinc, which is employed after having perfectly removed the
epitlermis by means of a blister.
The aqueous solution is very useful in cases of sycosis .
iavus. Zeitschrift der GeselUcJwft ckr Aerzte su W'
2 he Treatment of False Articulations li Periosteal Autopktshj.
The method by which M. Jourdan has given the name
Periosteal Autoplasty consists essentially in the oblique resec-
tion of the two fragments between which the false joint has
been formed, after having detached the periosteum, either
upon the two portions, or upon the upper fragment only ; one
or more clefts are then made in the periosteum, into which
-lips of the periosteum covering the other fragments of bone
are inserted, and the lips of the clefts are brought together by
sutures, or the delicately constructed forceps called serrefinc*.
edges of the wound in the soft parts are then incomplete-
ly brought together; and, finally, the limb is maintained in a
of perfect immobility, for as long a time as is necessarv,
in an appropriate apparatus.
1861.] Innalation of Chloroform, ITS
This operation has fully realized M. Jourdan's expectations
in the eases in which lie has tried it, a circumstance which
will be fully understood if we bear in mind the important part,
which is played by the periosteum in promoting the union of
a bone after its fracture.
7%. Chief Soura of the Danger Resulting from th* Inhala-
tion of Chloroform.
In a recent communication made to the Academy of Sci-
ences at Paris, M. Jeaucort stated that his observations and
researches had convinced him that upon every occasion when
the patients breathe freely during the inhalation of the chloro
form, ansethesia was produced readily and quickly, and that he
was also of opinion that if nothing offers any obstacle to the
regular and continued play of the respiratory current, not
only does the inhalation not present any danger, but in addi-
tion, it is exempt from what have been called the physiologi-
cal effects of the chloroform, or, at least, these are less marked.
Hut the respiration may easily become changed during the
inhalation, especially at its commencement, and it is in this,
change that the danger resides ; if any obstacle interferes with
the continuity of the respiratory action, the anaesthesia ccase^
to lie really producible, and the effort to produce it gives rise
; various accidents, more or less to be feared. The interrup-
tion to Yvqo respiration may arise from different causes de-
pending either upon the operator, as in cases where he admin-
isters the chloroform either too rapidly or in too great
abundance, or upon the patient himself, where he voluntarily
ceases to respire, and even resists the injunctions which are
made to him upon that, head ; the immediate result is the
modification of the quantity and quality of the air contained
in the lungs; the secondary result is variable, and may occa-
sion the production of a transient, slight sense of suffocation,
or of fatal asphyxia. The explanation of the latter phenome-
na may be found in the double source from which they arise,
viz : the sudden deprivation of respirable air, and the poison-
ing resulting from the gaseous mixture retained in the lung-.
M. Jeaueourt considers that we may thus account for the
occasional fatal effects which have attended the employ-
ment of anaesthetics, and which have; been doubtfully referred
yncope ; the default of inervation of the heart appearing !<
result from the complex character of the asphyxia itBelf.
An attentive examination into the causes of these accident-
180 Dysmenorrhea and Sterility. [February,
furnishes an indication of the means which it is necessary to
adopt for the purpose of obviating them, and the rules upon
this point may be comprised within the following general for-
mula : In order to avoid all chances of accident in the in-
ducement of anaesthesia, it is necessary to watch carefully that
there exists an unfailing renovation of the air contained in the
lungs until the invasion of sleep. If the respiration is carried
on up to this time in an equable and continuous manner, it
will not be interrupted afresh.
Elsewhere, M. Jeaucourt who recommends the employment
of chloroform in most cases of labour, and who considers that
it diminishes the frequency of puerperal complications, states
that the amethesia, under these circumstances, ought not to be
pushed further than the abolition of sensibility, and the relaxa-
tion of the upper extremities. The labour loses its ordinary
gravity, and is accomplished in a normal manner, without any
risk even of suspending or abating it, if we take the precaution
of commencing the administration of the vapor at the moment
when the os uteri is completely dilated.
Causes and Treatment of Dysmenorrhcea and Sterility. By
Beverly Cole, M. D., Professor of Obstetrics, &c, in the
"Medical Department of the University of the Paciiic, San
Francisco.
At a recent meeting of the San Francisco Medico-Chirurgi
cal Association, I made a verbal communication upon the
subject of Dysmenorrhea, (as met with in this country) in
which the causes and treatment were discussed. I took the
position that the immediate causes were, in a majority of
eases, of a mechanical character, and. consequently, require a
treatment essentially surgical.
1 now propose, briefly, 1st, To show the connection between
Dysmenorrhcea and the subject of this paper, viz: Sterility ;
and, 2dly, The identity of the treatment indicated in the two.
It must be borne in mind that Dysmenorrhcea is a vague
term, which obstetricians have applied to a symptom of vari-
ous conditions; that, indeed, by tin's term, is meant painful
no ftstr nation, arising from whatever cause it may, such, -for
instance, as a neuralgic diathesis, congestion of the womb, in-
flammation of its lining membrane, membraneous exfoliation*
and mechanical obstructions of the cervix. Excepting the
neuralgic diathesis ami inflammation, the others may all !>
L861J DywMnorrhaa and SteriUty. 18]
included under the general head of Mechanical Causes, and
those are, by tar, the most frequent in this country. Thai
congestion should be considered a mechanical cause, may, al
first appear Btrange, yet, upon reflection, it will be seen thai
its operation or influence upon the catamenial flow, attended.
is, with swelling o\' the cervix, at the expense of its canal,
thus oftering a barrier or obstruction, is essentially of a
chanical character.
The causes above enumerated will, at once, be recognized
by the observant practitioner, as operating, in the majority of
-. in the production of Dysmenorrhcea. Now, if eonges-
, membraneous exfoliations, and a narrowness (congenital
or acquired) of the canal of the cervix produces painful men-
struation, through the mechanical obstructions which the)
offer to the flow, the proposition is tenable that the same ob-
struction will pro-cut itself to the admission of the male mah
into the cavity of the uterus, and, hence, conception under
such circumstances, is a physical impossibility.
In either the one or the other of these conditions, namely,
Dysmenorrhcea or Sterility consequent upon the mechanical
can- umerated, the indications, in treatment, must be
same. No one would hope to cure a painful menstruation
ing from congestion, without directing bis treatment to
that cause, endeavoring to unload the turgescent vessels of the
lb, and thereby relieve the patient. This condition being
and the canal restored to its original capacity,
in tin- act of coitus the sperm is permitted to enter the uterus,
takes place.
The Bllbjectof this, condition may be either of the *anguin<'
i the nervous temperament. In the due case, the patieni
;- plethoric and robust in appearance, but usually indolent,
raking little exercise, subsisting upon a rich diet, rendered the
tnulating by the free use of the various condiment-,
and the drinking of wines, &c As the result of this modi
lite, the chylo-poietic viscera are kept in an over-excited state,
tiie venaportarum and liver are over-tasked, and a general
venous congestion of the whole abdominal viscera i- present,
including the rectum and uterus ; hence, in these cases, we are
also liable to encounter hemorrhoids.
The c :* treatment indicated in these cases is obvious-
Alteratives and purgatives are to be administered for several
days preceding the expected menstrual period, with the view''
ofexcitin tions and unloading the vessels, and thus
relieving the ted state of the womb. But, sometimes,
it occurs that (this condition having continued some til
132 Dysmenorrhea and Sterility. [February,
there will be a permanent construction of the cervical canal,
the same as would result from congestion or inflammation of
the urethra. In these cases, as in stricture of the urethral
anal, you should dilate the stricture at the same time that the
treatment above named is followed, and have the patient
placed upon a prescribed diet.
[t is proper that inflammations, when encountered, should
be treated as under other circumstances ; but often, when it is
chronic, and confined to the canal, the use of the bougie, in
dilntation, will be sufficient to excite a healthy action in the
part and cure the case, without any other specific interference.
In that form of Dysmenorrhcea, known as ''Membraneous
Dysmenorrhea," we usually meet with the same general and
local conditions as just described, with the exception that the
patient, during the "period," passes a membrane from the in-
terior of the uterus, some times entire, retaining the form of
the cavity of that organ at others, in shreds : in either case,
she suffers intensely, which is due to the transit of the exfoli-
ated membrane through the constricted cervical canal. The
treatment indicated in this case is the same as in the simple
form of Congestive Dysmenorrhcea.
Many cases of this character, in married women, have fallen
under my observation; iti the majority of which, the patients
have consulted their physicians on account of barrenness,
rather than for relief of their sufferings ; and in many of them
which had been considered hopeless, so far as possibility of
conception taking place was concerned, the women have, after
dilatation was effected, conceived and borne children at the
lull term of gestation.
But it is in that form of Dysmenorrhcea which authorities
denominate "Mechanical Dysmenorrhcea," or rather Dysmen-
orrhcea arising from mechanical causes, in which the treat-
si icut by dilatation should be expected to accomplish most.
Now, the immediate causes of this form of disease are vari-
ous, consisting, usually, of stricture at the external os, within
the canal, or at the internal os, and to these is added tumors.
occupying the canal.
In these cases, there may or may not be congestion pre-
sent, the patient complaining merely of excessive pain during
tin.- whole menstrual period, with bearing down, and sickness
a[ the stomach. She tells you that it is necessary for her to
take the bed. whenever she menstruates, her sufferings are so
exquisite. Upon examination with the speculum, it will be
discovered, possibly, that if an external os exists, it is difficult
to discern it, and that, in passing the uterine sound over the
I.] Dyt rhcea and Sterility. L83
cervix, aa presented through the speculum, a mere depression
or dimple marks the ^p<>t whore the month of the womb should
be. It' the sound is now pressed firmly upon this point, po
bly the instrument will enter the canal, or, as sometimes
occurs, you will timl it necessary to make a small incision be-
fore the instrument will pass.
In otlu in, there will he no unusual appearance
about the external os, hut, on passing the sound beyond, into
the canal, it will he suddenly arrested in its progress, by ;i
stricture, either in the eanal itself, or at the internal os.
When the instrument is arrested at the internal os, it may be
due to a simple stricture of that part, such as described of the
externa] a retroversion of the body and fundus of the
insider the shape of the uterus, its great Ha
bility to displacement, particularly backward, and the. effect
of this retroversion upon the shape and direction of the cervi-
cal canal, we can understand how this character of trouble
must be productive, more or less, of stricture at the point at
which the organ i> doubled upon itself; and, further, that bo
il continues, so long must the patient be the subject of
Dysmenorrhcea, and, if married, be disqualified for the per-
formance of that function upon the consummation of which
depends, in many instances, the happiness of both husband
and wife.
To illustrate tic- effect of Retroversion upon the shape and
direction of the cervical canal, it will be but necessary to take
11 of cylinder of paper, bend it on itself, and it. will bo
that the two sides of the cylinder will approach each
otht to narrow. \<:vy materially, the caliber of tin-
tube. The same effect, exactly, is produced on the cylindrical
the cervix, in backward displacement of the womb.
1 am . i viction, from an extended observation in
this cases, that no one cause of Sterility is so common
in women, otherwise healthy, as stricture of the cervix,
and, in a large proportion, this is dependent on Retroversion.
A- ha a ted, the treatment, in these ease-. ;
n'all al in its character, and consists in dilating the
strictured part, whether it be of the simple variety or due to
Ret] In the latter case, however, this treatment it-
indicated only after the ordinary means for righting the ut<
have failed.
I can:: propria * Me medical al\ i
-ion of this organ, dooming hi
pati- spair, by concluding that it will be im-
lier to ever become a mother ; or, at least, until
lS-i Dywrienorrhasa and Sterility. [February.
he has made every effort to overcome the constriction, and
thereby cure the case. Vet this is the daily practice of many,
and women are too frequently rendered, through these hasty
opinions on the pari of their physicians, the subjects of cruelty
or desertion ; when a well-directed course of treatment might,
in a very short time, overcome her difficulties, and bring
comfort and happiness both to herself and husband, when per-
haps hope had seemed to have faded.
In my remarks before the Medico-Chirurgical Association,
already referred to in this paper, and which will be found in
the report of the transactions of that body, the particulars of
treatment in these eases were given, and consists, 1st, in the
introduction of a piece of compressed sponge to the point of
stricture, previously guarding it with a ligature, by pulling
upon which it may, at any time, be removed. This is allowed
to remain intact for twenty-four or forty-eight hours, when it
may be removed and replaced by a fresh piece, which may
usually be carried higher than the first. When the dilatation,
through this means, has been carried sufficiently far, the
Knghsh elastic bougie is to be substituted. This should be
introduced at least once in forty-eight hours, and at each ope-
ration one a size larger than was used previously, should be
selected.
The daily or tri-weekly introduction of the bougie must be
continued some weeks, (as in the treatment of an urethral
stricture) or until the part ceases to contract (at least to any
extent) ; when, not unfrequently, to the satisfaction of patient,
friends and physician, the object of their solicitude is attained,
and the woman finds herself, in a short period, likely to be-
come a mother.
The foregoing lias been written rather with a view of call-
ing the attention of practitioners to the frequent causes of Ste-
rility in this country, and the importance of surgical interfer-
ence in the class of cases referred to, than to establish any
claim to originality in their treatment.
In conclusion, I would remark, that in many of the cases
which have fallen under my care, I have entirely failed in the
attempt to use the compressed cones of sponge kept in the
stores for sale, and made after the suggestion of Prof. Simp-
son, of Edinburgh. The difficulty has been that they were
much too large, and, therefore, I prepare my own tents, as
follows : Select a tine piece of cup or "surgeon's sponge," and
lui\ ing melted a quantity of blanched beeswax in an ordinary
1, the sponge is to be dipped into the liquid wax, and im-
mediately placed between two smooth surfaces (board or mar*
1861.] On Union of Fractv/rea in Syphilis. 185
ble) and a weight applied sufficient to compress the sp<
and free it from the surplus wax : in a few minutes it will \>^
ready tor use. By this process, a ilat cake of compressed
sponge is obtained, from which pieces may be out, of such
size and at such times as required. The piece to be intro-
duced should be well oiled and carried to the point of stric-
ture by means ot a long and Blender forcep.
Reports of cases, illustrative of this general plan of treat-
ment, will be furnished for the next number of the Medical
Pre..
On ttu Union of Fractures in Mercurio-SyphUitic P
By Prof. Sigimmd, of Vienna.
A young man in the Hospital of Vienna, while undergoing
treatment by means of mercurial inunctions, on account of
syphilitic ulcers of the skin and affection of the bones, met
with an injury : as the result of which, he sustained an oblique,
fracture of the humerus, about an inch below the tuberosities,
accompanied with considerable contusion of the soft parts, and
extravasation of blood. Cold applications were made use of,
and the arm was put in splints, in the usual way ; no unpleas-
ant symptom occurred, and consolidation of the fractured
bone was complete on the thirty-third day from the receipt of
the injury. Around the united ends of the bone there was ;i
very considerable bony swelling ; in other respects, the form
and direction of the limb were quite normal. On the day
when the fracture was sustained, the patient had undergone
the ninth of a series of fifty mercurial inunctions : this treat-
ment was not discontinued, but was carried on uninterrupted-
ly until the disappearance of the syphilitic symptoms.
Prof. Sigmuna has met with five case- where syphilitic pa-
tients have sustained fractures while undergoing mercurial
treatment. The bones broken in the were, the righl
radius (twice.) the left fibula, the left clavicle, and the
humerus. Complete union of the fractured bone had occurred
on the twenty-third, the twenty-sixth, the thirtieth, the twenty-
second and thirty-fourth day- respectively. In all the
the result- were satisfactory. In none of tin- was the
mercurial treatment discontinued, nor was any change mad-
in the diet of the patient
It is well known that in syphilitic patients no important
viation from the normal course occurs in the heal in
L86 Phagedenic Ulcers. [February,
of the soft parts. Prof. Sigmund has had occasion to perform
numerous and various operations in syphilis, and his observa-
tions entirely confirm the general opinion.
Prof. Sigmund does not believe that the bones of syphilitic
patients, whether or not they have been treated with mercury,
are more readily fractured than the bones of those who have
not had syphilis, and have riot taken mercury. Boston Med.
and Surg. Journal^
Phageden it Ulce rt .
Phagedenic, from the Greek word phago, I eat, is much
more expressive, of the literal meaning of the word whence it
is derived, than most ether medical terms derived from the
Latin or Greek.
The margins of a Phagedenic Ulcer have a strong resem-
blance to a worm-eaten substance, or the surface ot a sub
stance upon which a mouse has been gnawing.
What is a Phagedenic Ulcer? The Phagedena Gangreno-
sa, or Hospital Gangrene, so common in some of the European
cities, is never known on this coast. But there is a true
Phagedenic Ulcer often seen here, attacking the integument
and subcutaneous cellular tissue, generally about the face, and
is extremely difficult to cure. Sometimes it attacks the deeper-
seated structures of the face, as well as of other parts, even
the tendons themselves, resulting in a most alarming destruc-
tion of the tissues, without any assignable cause. The fingers,
for instance, are sometimes attacked, and the bones laid bare
by the ravages of the disease, in a few days.
The remedy we have found available, in such cases, is calo-
mel and morphine, in the following proportion- :
lv Morph. Sulph. - i
llvd. Sub. Mur. 5ii-
M.
Sigria. Apply to the ulcer every day twice. If the con-
stitutional effects of the morphine become manifest to an
undue extent, the preparation must be used very sparingly.
Thisis the only remedy upon which we repose confidence
in the treatment of the Phagedenic Ulcer of California. !
Francisco Medical Jyrcss.
I860.] Diphtk 1ST
7% f Diphtheria.
The Union Medicale has recently published two letters from
M. Loiseaa and Trousseau on the use of tannin and alum
locally in the treatment of pharyngo-laryngeal diphtheria.
M. Loiseau, considering the false membranes, in all cases, to
be but consequences of diphtheria, and, with the exception of
croup, rather useful than injurious, provided their putrefaction
be prevented, again lavs stress upon the beneficial action of
styptics, and especially tannin; these seem to convert the
morbid secretions into an imputrescible epidermis, which af-
fords protection to the denuded surfaces and promotes their
cicatrization. M. Loiseau performs insufflation of alum five or
bix times a day, and of pure tannin equally often ; he states
that a cure may thus be effected in three or four days, on the
>ame principle, which M. Trousseau adopted in his practice in
1S2S. A quotation from an articte published on the subject
in 1833, by M. Trousseau in the Dictionnaire Medical, has
elicited from the learned Professor a reply which we repro-
duce, as it explains the changes his views have undergone on
the efficacy of the medical treatment of diphtheria, and more
especially of croup.
"It i> perfectly true," says M. Trousseau, at the date
September 20th, "that in the epidemics of diphtheria, which
from 1S18 to 1^2S prevailed in the departments of Indre-et-
Loire, Loir-et-Cher, and Loiret, the disease of the lances readi-
ly yielded to frequent insufflation of alum, and to cauteriza-
tion with muriatic acid or nitrate of silver. It is equally true-
that, when the complain! was met in its early stages, foe;
tive days were sufficient to effect a cure, excepting, of course,
when diphtheria had invaded the larynx.
"For ten years past, however, diphtheria has acquired in
Paris and in the provinces a degree of gravity and of malig-
nancy which it did not, by any means possess thirty years
ago ; and I declare that it is now a long time since I have
had the good fortune to see genuine pharyngeal diphtheria
yield to treatment in four or live day-. Common pseudo-
membranous angina, or herpes of the fauces may be cured in
twenty-four or forty-eight hours, but not real diphtheria such
;i- we too frequently meet with.
I resort to the same d au and perform in-
sufflation into the throat every two hour-, and even e>
hour, if necessary, alternating the use of equal p mgar
and alum or tannin. From time to time I brush rather rougnrj
the uvula and tonsils, before restoring to insufflation, in oi
188 Treatment of Eruptions around the Anus. February,
that the medicinal agents may come into immediate contaet
with the mucous surface, and I consider myself very fortunate
when, after ten days' treatment, all trace of false membranes
lias disappeared.
"In live adults whom, within the last few months, 1 attend-
ed with my friends, Drs. Bernard, Patouillet and Blond eau,
the disease lasted nine days in one case, and more than a fort-
night in the others, and 1 repeat that it would have been
utterly impossible to use with more persevering energy the
remedies extolled by M. Loiseau, which I consider most use-
ful, namely: alum and tannin.
"Appealing to the testimony of my learned colleagues of
the Hospital for Infancy, JVI. M. Blache, Bouvies, Roger, Sec,
and of Dr. Barthez, Iiind their statements are perfectly simi-
lar to mine, and that they agree with me in thinking that the
singularly rapid, extraordinary and numerous cures effected
by M. Loiseau may perhnps be accounted for by his not hav-
ing allowed himself sufficient time to establish an incontrover-
tible diagnosis.
"It is difficult at first, and especially in children, to distin-
guish genuine diphtheria from pharyngeal herpes; and
although in doubt I prescribe the local application of alum
and tannin, I do not flatter myself that I have effected a cure
of tonsillary diphtheria when, after twenty-four hours, I cease
to detect in the throat any peculiar concretions.*'
We are happy to be confirmed by so competent an authori-
ty, in the remarks we have offered above on the importance
- >f diagnosis in the appreciation of the various remedies recom-
mended for a disease the gravity of which, far from subsiding,
seems rather on the increase, especially when observed in an
epidemic form.
Treatment of Eruptions Around the Anus. By J oseph Bell,
Ksq., Gateshead. Occasionally Ave see obstinate cutaiieou-
ulceration surrounding the anus in children. Considerable
tumefaction attends it betimes, and deep fissures are occa-
sionally seen. This disorder is probably herpetic, and al-
most always can be cured with yellow wash. The propor-
tions being from 1 to 1} grains of hydrarg, bicblorid, to 1
ounce aq. calcis. The part is to be frequently bathed with
it, and should the lotion produce pain, it is to be diluted
with water, and when at rest, a little lint, soaked in the
lotion is to be applied and left on the part; deobstruents
being at the same time administered. Med. Time* J- Gaz.
1861.] Editorial 180
EDITORIAL AND HISCELLANEOUS.
A COMPENDIUM OF HUMAN HISTOLOGY,
1 . 3Ior el, Professor Agrege a la Faculte de Medicine Je Stras-
bourg. Illustrated by Twenty-eight Plates. Translated and edited
by W. H. Van Buren, M. D., Professor of General and Descriptive
Anatomy in the University of New York, &c., &c. Bailliere
Brothers. New York : 1861. pp. li>7.
Dr. Van Buren and the Brothers Bailliere have certainly rendered
an important service to the profession iu the translation and publication
of this valuable work. Our readers must know that we cannot always
read thoroughly the works which it is our duty to notice as journalists.
This, however, is one of which we can speak witha personal knowledge
and we have found it both concise and comprehensive very interesting
and advanced to the last hour, of pathological investigation.
The author, after defining in his introduction the object and purpose
of the science of Histology, presents us with what we consider a wi\
convenient and simple division of the ultimate organic elements :
D the present state of Science, all of the simple elements of which
the body is composed may be reduced to one of the following typical
forms, viz: 1st, Structureless Material; 2d, Cells; 3d, Fibres; 4th,
Crystalline Substance."
In accordance with this brief and, at the same time, most philosophic
itication of the elements, our author proceeds to arrange them iutu
the several tissues which they arc found to compose, and, to systematize
Ilia labor, ho divides the work into ten convenient and rather brief
Chap-
Chapter I, Cells and Epithelial Membranes; Chapter II, Fibre-:
Connecting Tissue; Chapter III, Cartilage, Bone, Teeth: Chapter IV,
Muscular tissue ; Chapter Y, Elements of Nervous Tissue ; Chapter
VI, Vessels, Arteries, Yeins, Capillaries, and Lyphatics ; Chapter VII,
Glands : Chapter YHI, Skin and its Appendages ; Chapter IX, Intesti-
nal Mucous Membrane; Chapter X, Organs of Sen*
iu the treatment of these several departments, our author is clear,
. id happy in his illustrations With the description of each tissue,
190 31iscellaneous. [February
brief directions are given for the selection and preparation of specimens
for microscopic examination which is, in itself, a most valuable feature
of the work. The book is evidently preparedfor the elementary student
"11 as for the more advanced pathologist, and, on this very account,
must soon become generally popular.
Dr. Morel is very decidedly a follower of the celebrated Yirchow,
whose doctriue of ''Cellular Pathology" seems to have taken firm hold
upon his belief, and appears to enter as a necessary part into all his
reasoning. "The Plasmatic Cell" takes a place in the minds of these
pathologists, almost of every other element of nutrition as the very
cause, orgin, sole agent and pcrfecter of all organic processes self-
governed and uncontrolled by any other element in the entire organism.
Though to all this, we cannot, as yet, give our full assent, "still it can-
not be totally denied that some processes of nutrition are completed with
a certain degree of self-government in the system of organic cells ;'*
;iud both Yirchow and our author may be, in the main, correct, though
only out of time, being a little too much in advance of the general ideas
now dominant in the world* of Physiology and of Pothology.
The above work will be found in this city at the Book-store of Messrs.
T' Ttiehards & Son.
In addition to the above work we have received also from Messrs.
BaiJliere Brothers, the notice of work on the now all-important subject
of Diphtheria. The work itself has not yet come to hand, but doubt-
less will and shall receive due attention in our next issue. We refer
our Students at present in the city to Messrs. Richards k Son, where the
work may probably be purchased. Price, $1 50.
AN ELEMENTRY TREATISE ON HUMAN ANATOMY.
By Josi:rn Leidy, M. D., Professor of Anatomy in the University of
Pennsylvania, &c, &c, ao, &c Philadelphia. 1S61 J. B. Lip-
pincott & Co. pp. 663 octavo with three hundred and ninety-two
Illustrations. For sale by Messrs. T. Richards & Son.
As an elementary Treatise on Human Anatomy, Dr. Leidy's work \>
certainly a success. So long accustomed as we have been to the house-
hold words of Anatomical nomenclature, we arc scarcely abfe to do justice
in any attempt on the part of an author to simplify these terms, altering
; from Mr. Doubovitsky, of St. Petersburg. This letterwe maj
publish in a future number of this journal.
1.] MisceUanec 191
what, by dint of long use, has become, to us at least, familiar as the al-
phabet This impression, however, must not receive too much import-
ance in the mimls of teachers in recommending a work for beginners,
they must remember, if possible, as Dr. Lckly seems to have done, the
mountain in the way, which the nomenclature of anatomy present-
ed, and, knowing that simple terms are easier of acquisition than more
ot mplicated ones we should give full credit to the task accomplished
by our aathor.
The work is filled with clear and beautiful illustrations, the text open
and large, with each principal word or subject struck in large block type
to fix the attention of the student and the cream-colored paper on
which the print is executed is, by no means, an inconsiderable point c
value.
The authors descriptions are clear and concise, evidently from oil'
he is known to be, thoroughly familiar by daily and constant handling
with every portion of his subject.
Camphor as an Antidote to Strychnine Poisoning. In the
Pacific Medical and Surgical Journal, for June, Dr. M. T. Dodge
reports a case of poisoning with strychnine, entirely relieved by the ad-
ministration of camphor. According to the report, five grains of strych-
nine had been taken three hours previously. Ten grains of camphor
given in emulsion, and repeated every half hour or hour for seven
hours, when the spasms entirely ceased, and the patient rapidly recover-
ed. It would certainly be a fortunate discovery should camphor be
found to be a reliable antidote of strychnine. The case reported lacks at
least two essential points to make it available as proof upon this point.
thought by many that much of the strychnine in use is nearly inert
and if taken as claimed, there is no proof that the article was genuine.
More than this, there is no proof, but the patient's statement, that the
five grains of strychnine had been taken at all. There is certainly one
tuspicious fact in the case, that must in some measure detract from our
confidence in the antidotal power of camphor. Three hours had elapsed
from the taking of the poison before remedial aid was had, and yet the
patient was sitting up, and presented no very alarming symptoms. Prof.
Wood says that, in cases of poisoning from strychnine, the alarming
ims usually folkw the administration in from ten minutes to half an
hour. One of two things is evident : the five grains were not all taken
or the poison was not of standard strength ; either would effect the result
; as relate^ to the antidotal powers of camphor.
Ra medyfor Burns from Phosphorus. The skin should be wetted
with a solution of chloride of lime or of soda, or if these are not at hand
it should be dipped into a vessel with lead water.
1 92 Miscellaneous.
Glycerine in Skin Diseases. This substance has been justly recom-
mended in various affections of the skin, and especially in those attend-
nd with desquamation. In that troublesome affection pityriasis capitis,
in which the hairs become dry and fall off, during the abundant epidemic
exfoliation, undiluted glycerine may be applied with excellent and dura-
ble effect. In pityriasis rubra and pityriasis simplex, a mixture,
composed of equal parts of oil of almonds and glycerine, and one-half of
oxide of zinc, has proved very useful. Dublin Hospital Gazette, May
15, I860,;;. 158.
On the Therapeutic Methods of Preventing Pitting of the Face
in Confluent Small-Pox By Dr. Stokes, Dublin. During the last
five years Dr. Stokes has employed gutta percha and collodion in a con-
siderable number of cases of confluent small-pox, for the purpose of pre-
venting pitting of the face. In most of the cases the crust came off in
large flakes or patches, composed of the dried exudations and the cover-
ing material, leaving the skin uninjured. This kind of treatment was
most successful in cases of a typhoid character, but appeared to be not
so well adapted to those presenting a more sthenic type. Dr, Stokes
considers that the application of poultices over the face is the surest
method of preventing disfigurement in small-pox. Their use should be
commenced at the earliest period, and continued to an advanced stage of
the disease. In most cases they may be applied over the nose, so as
to cover the nostrils, This plan should fulfil three important indications
of treatment namely, to exclude air, to moderate the local irritation,
and to keep the parts in a permanently moist state, so as to prevent the
drying and hardening of the scabs. The best poultice is formed of lin-
seed meal, which should be spread on a soft material ; such as French
wadding, and covered with gutta percha paper or oiled silk. The con-
clusions to which Dr. Stukes arrives are the following . 1. That the
chances of marking are much greater in the sthenic or inflammatory than
in the asthenic or typhoid confluent small-pox. 2. That considering the
change in the character of disease observed during late years, we may
explain the greater frequency of marking in former times, 3. That, in
the typhoid forms of the disease the treatment of the surface by an arti-
ficial covering, such as gutta pcocha or glycerine, will often prove satis-
factory. 4. That in the more active or non-typhoid forms the use of
constant poulticing, and of every other method which will lessen local
inflammation, seems to be the best mode of preventing disfigurement of
the focc. British and Foreig?i Mcdico-Chirurgical Review.
Atropine. Strength of Solution Used. "When it is wished to
dilate the pupil for opthalmoscopic investigation, the strength of the
solution used should not be more than one-halt' a grain of the sulphate
i an ounce of water. This will suffice for the purpose, and the unpleas-
ant effects of a stronger solution will be avoided.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
(new sbru
[flL , AUGUSTA. (iEOMl. MAM, 1861.
ORIGINAL AND ECLECTIC.
ARTICLE VII.
-1 ( By A. AY". Bailey, M. D.,
Clinical Clerk of Jackson Btreet Hospital, Augusta, (
It is needless for me to endeavor to give a treatise on
this< all who may desire to acquaint themselves
fully with the subject can, by reading some Surgical work,
or Dr. Bozeman'a pamphlets, gain more knowi an!
would be able to impart.
It being my object merely to report a case, havin a
several successfully treated by Drs. Campbell during my
in their Hospital as a private student, and to add to the
already cured by the profession, and iour-
the attempts for the treatment of the disease, no matter
how formidable the case may appear.
Dr. Bozeman. of Montgomery, Ala., the pi :i. is
indebted for the mofi Lplanforthe f this af-
Aljout tw> man published his mam
lure, andth which he had met within the
the button suture and silverwire. I:. his
the sir
lighter and "less likely to yield un isure, admits
a higher polish, and allow- the wires drawn thro
the small holes without dragging :" but admitting all this.
1
194 Bailey. A Case of [March,
I lis experience has taught him that the button suture made
of lead is by far the most preferable for several reasons.
In using the silver button the Surgeon has to have a regular
smith, who may not understand' the nature of the parts,
and even if he did, there arc many little modifications in
shape required which he could not give unless the operator
was present to point them out; but with lead it is indiffer-
ent. The Surgeon can make his button while around the
operating. table, and beat it into any shape he may desire ;
for it is not until he has adjusted his sutures, that ho can
tell exactly the shape of button required. Lead is also
more flexible, and can be made to adjust itself to any sur-
face that may be presented to the operator, and hence more
likely to bring the parts in adj uxtation, and thereby cause
a more successful closure and adhesion of the fistulous open-
ing. I having assitsed in several operations performed by
Dr. Bozeman's plan with a leaden button suture, and hav-
ing taken great interest in taking notes on the cases from
the time of their entrauce until their departure, have select-
ed it as the subject of the present paper.
Vesico vaginal fistula generally occurs, as all are aware, by
the pressure of the child's head against the soft parts, or the
improper use of instruments during first labor, though it is
liable at any period during child-bearing when the labor
is such as to give rise to this dreadful complaint, for instance
in impeded labor when the head has descended low down
into the pelvis, and presses against the vagina and urethra
sufficient length of time to produce inflammation, gangrene,
and sloughing, or when the instruments have to be used to
effect delivery, which very often produces abrasions, and
also brings on sloughing of the parts. As to the position,
shape and space that the fistula may occupy, is altogether
owine to circumstances. Bozeman adds two more that the
operator may be enabled to classify all eases that may pre-
en1 themselves under its appropriate head.
Velpean's classifications are as follows : "The first class
eml I] those fistulas which cause a communication
1861.] Vest nal Fistula.
between the urethra and vagina; tin 1 class ie made
up of those which are established at the expense of the tri-
goone vesiealis ; the third class comprises all those situated
in th< 'id o( the bladder." Dr. Bozeman adds the
following two agreeing with Velpean so far as he
" The fourth class embraces all those fistulas formed at the
expense of a part, or the whole of the vesical trigone, and
the root of the urethra: of trigone and the bas-fonc1 of the
bladder: or, all three of the regions together. The fifth
class include all those complicating the cervix uteri, either
with or without injury."
The following is a case in which the posterior wall and
fundus have sloughed away to a considerable extent.
implicating the cervix uteri, and forming an opening in the
shape of a horse shoe, or segment of a circle, the point <>i
which severed the left ureter.
.lane, servant girl of Mr. X. J., of Fort Gaines, Georgia,
age eighteen, of robust constitution, ordinary height, well
proportioned and had always enjoyed good health. This
accident occurred, as 1 have formerly stated it does, in
ing birth to first child about twelve months previous to
entering the Infirmary. Ber labor was a very protracted
one and finally required the use of instruments to effect de-
livery. From the patient's weakened condition, and other
circumstances connected with her, not necessary to mention
here, an examination was delayed for nearly three weeks
after her entrance.
May 23d. An examination Was made byUrs. Campbell,
and "the opinion was that an operation would be attended
with but little success: a further opinion would be taken at
another time.
May 26th To-day a second examination was made, and
the opinion of the 23d strengthened, as the parts had slough-
ed to I greater extent than they had su die 1 ore
the operation with apparently SO little pain that it was
noted as an indication of gangrene having taken place.
May 81at A third examination was made to-day. and a
196 Bailey. A Case of [March,
prospect of a cure very unfavorable. It was, however, de-
termined that an attempt would be made as soon as all
things were more favorable. The patient did not complain
very much from excoriation or scalding, nor did the secre-
tion of calcarious matter take place to a great extent. In-
jections of warm water and castile soap were used several
times a day up to the day of the operation, the main object
being to strengthen and have the system in as good a con-
dition as possible. This was accomplished by nutritious
diet and tonics of iron and quinine in five grain doses three
times a day, in syrup.
July 29th. Gave an ounce of castor oil to put the bowgls
in a suitable condition.
.July 31th. To-day an operation was performed by Drs.
Campbell, assisted by myself. The patient being placed on
her breast and knees with a mirror situated so as to throw
the reflection of the light on the parts to be operated upon.
The edges of the fistula were thoroughly pared to their full
] '.; ilver wire were made with Simp-
3 needles ; the edges were then approximated as much
as practicable, and secured with shot over the leaden but-
ton ; the ends of the wires were partially twisted and lapped
with a piece of linen, and allowed to hang from the vulva.
This operation lasted nearly four hours, the delay being
chiefly occasioned by the irritable and nervous condition of
the patient, and the knife having wounded some small
blood-vessels at the farther end of the fistula, and caused
slow but troublesome hemorrhage, filling the vagina with
clots of blood and obscuring the veiw. Injections of acetate
of lead were used, vagina washed out, and the patient was
then put to bed, a catheter introduced and kept there con-
itantly, save for the purpose of cleansing, when it was re-
moved twice a day.
Recipe tine, of opium in twenty drop doses wTas given,
the purpose being to constirpate the bowels and secure rest
for the patient.
August 9th. The sutures were removed to-day, and (lis-
1861.] Vaginal Fistula. 197
covered that there is an opening :h end of the line of
adhesion, and the result of non-union was suspected the
entire length of the opening, from the fact that the bladder
was not relieved entirely by the catheter, hut that a portion
oi" the urine came away through some pari of the fistula
while the catheter in situ.
LUgustlOth. The patient is losing strength and flesh
from irritation and confinement to bed.
R. Tartrate iron, potash and quinine in live gr. d<>
three time a day ; diet, heef soup, bread, &c.
August 16th. Improving-, goes about the house and yard,
feels a little uneasiness, other than that caused by the un-
natural discharge of about half the urine, the other half re-
maining in the bladder, and passes off at intervals through
the urethra.
August 30th. General health improving, hut urine pass-
ed oft* as at last note.
October 14th. Up to this time the second, operation has
been put off from time to time for several unavoidable
causes. She has been subject to fevers occasionally : these
paroxysms have been successfully met with quinine, and
also her periods < ration are irregular and painful.
At this operation the edges of theoj
a button applied on one requiring two sutures, the
other one. The wires being well clamped, were cut off
to the shot, and the vagina plugged with lint to prevent
the recto vaginal septum from being wounded by the ends
of the wires, besides the protruded wires from the vulva are
liable to be jarred to some extent from the movements of
the patient, and may cause displacement of the button.
\v;is placed in bed, opiate- given, catheter introduced,
and removed occasionally as before. This time all the
urine was conveyed from the bladder by the catheter, as
none could be discovered coming from any other source.
v were not sanguine on this point, as the pi suf-
ficient to prevent its passage into the vagina.
O 24th. Removed the buttons and sutures, and
198 Ford. Report of a [March,
find only one of the openings partially united, the inferior
one at the neck of the bladder ; to this the application of
solid nitrate of silver was made, hut with little effect; the
other openings where the fistula crossed the ureter, there
was Little hope of union taking place from the impractibil-
ity ol' reaching the point sufficiently to insert the suture
carefully owing to its length and direction. The severed
end of the ureter, they were also unable to direct into the
bladder for the same cause.
A third operation was, however, determined upon which
succeeded only in partial closure of the fistulous openings,
still leaving two small holes, one the size of a small pin's
bead, and the. other a little larger. Repeated applications
of solid nitrate of silver at intervals of every ten or fifteen
days were again made, which succeeded in the cure
of the case, though at first seemed to be of but little or
no benefit.
The great obstacle in this case which made it of interest
to study and take notes upon, arc the following :
1st. The direction and extent of the fistula.
2nd. The great amount of sloughing and consequent loss
of tissue the greater and lesser curves of the opening were
so disproportionate that when the edges were pared and
drawn together there were formed on the edge of the greater
curve duplications or pouches, and this was really the cause
of non-union at each end.
3rd. The difficulty of directing and securing the bisected
ureter in its normal position.
ARTICLE VI I i.
.: Case hi which portions of a Foetus made their way from the
us through the Abdominal toalls by Ulcerative 7V
Patient R I. By DbSaussurb Ford, M. P., Demon-
of Anatomy, &c., in Medical College of Georgia.
Mrs. li , widow aged 35 years, stated she had been
delivered of three children one still living, the other died
1861.] // - 199
ismus nascentium with a third child had beeo preg-
nant, about five and a half months, up to January, L860,
when she aborted, the presentation a footling; the trunk.
superior and inferior Limbs protruding beyond the vulva.
the head remaining confined tightly by the contractions
which must have been anomalous of the 08 tinsse. f
ing detection, (for her pregnancy was the result oi criminal
she cut off that which was hanging from her,
when, to use her own language, the bead went hack. She
supposed the foetus to have been dead about nine days.
When questioned, she denied that there was any bleeding,
or other discharge at the time, and could give no account of
>rd, or placenta.
April 18th. Four months after this most strange and
unnatural occurrence. Mrs. H was admitted into the
Augusta City Hospital, with a fistulous opening immediate-
ly below the umbilicus, which was discharging, very freely,
a dark yellow and offensive matter, undoubtedly partly fecal
which could be accounted for after the extraction of the
bones. She continued in this state until July 25th, when
k charge of the Hospital, discovering the bones of a
,1 head protruding through this opening, then about two
inches in diameter. In receiving a report not a detailed
<>ne from the attendant physician before my service, I
gathered : that she was affected with chronic constipation,
which was at first relieved by enemas and cathartics, which
latter castor oil was generally used he thought could be
tected in the secretions from the fistulous open::
At first I this a case of extra-uterim
indeed the opinion was unsettled, until the examination had
. with th(
in a deplorable and emaciated -
prompt relief, b;
the 27th. It was ii' aary tor an i
of the abdomen, but bone after bone
rounding them having been disorganized was extra
by a rotary traction with a pair of strong for- hich
200 Ford. Report of a [March
bones were the following: two parietal ; two temporal,
without petrous portion attached ; one petrous portion ; one
malleus; one tympanic bone; sphenoid ; one malar ; occipi-
tal; frontal, in two pieces; one scapula; radius and ulnar,
with phalanges and metacarpal hones of one linger.
These bones arc, in development, as near the size of a six
months foetus as could be determined, which fact substanti-
ates her story. that she had been pregnant about six months.
After these bones were extracted, a digital examination dis-
closed a large cavity, answering to the internal form of the
uterus, which cavity, in the mesian line, had an outlet like
the form and position of the passage through the cervix. This
large cavity communicated, by an extensive opening, with
the ascending colon, the finger readily tracing the interior of
the intestine, above and below, as far as it could reach.
The 28th day after the operation, prescribed:
]}. Valet's Proto. Carb. Ferri, Sg5j
"Water gviii M.
Give a teaspoonful three times a day.
Apply to the wound, cloths wet with a solution of chlor-
ide soda. Had taken g castor oil this morning no effect
Fecal matter discharging through opening.
29th. This morning passed aliving worm, 4 inches long,
through fistulous opening, with large quantities of fecal mat-
ter. Had an action through rectum yesterday. Ordered an
ma of warm salt and water.
30th. Ordered daily enemas of warm water every morn-
in<>\ an hour after breakfast. Fecal matter dischanmia;.
31st. Fecal matter still discharging, though much di-
minished in quantity. Strength better.
August 2d. Passed a worm through the opening. Had
an action through rectum, after enema. Ordered, instead
of enema in the morning, castor oil 5g and spts. turpentine
gtls. v. '
A.ugus1 1th. Fecal matter still discharging. Continued
enemas. Strength much improved.
II.] // Case. 201
August 6th. Continue treatment Condition some bet-
ter. Left the city and record was not kept until
August 14th. la having natural operations through the
rectum, with very little discharge from opening. Strength
and general condition improved.
A.ugust L8th. Had an attack of ^astralgia. Ordered
. xxx tinct opii. and mustard over epigastrium. Con-
tinued to improve daily, havingnatural evacuations through
rectum, with fistulous opening very nearly healed, and no
inconveniences from discharges. Mrs. 11 left the
ptember 7th, two months and ten days after
the extraction of the bones.
Remarks. The fact that a foetus has escaped through the
abdominal walls, by ulceration, and the patient recovering,
indeed, impregnation existing, after such an accident, is by
no means novel. (See report of a very remarkable case
of Extra-Uterine Foetation in Keatino-'s edition of Rams-
botham's System of Obstetrics, page 580.) In this case
it will be noted that a fistulous opening was made, by ulcer-
ation, into some portion of the intestinal tube, and still the
patient survived, but exactly the counterpart of the case of
Mrs. II . I cannot find, in which the uterus itself re-
tained a part of a fioetus, that part ulcerating through its
wall _ extracted as detailed.
The fiendish criminality, and un naturalness of the act of
cutting off a foetus, on the part of the mother, and the ap-
parent discrepancy of her account, together with some of
the bones extracted, viz : a radius, ulnar, scapula, phalan
would seem to invalidate the opinion formed of the ca
. however, when we consider all the circumstan
cially the fri s Icitudeof the mother in any attempt,
however enormous, to avoid detection. The fact of t!
bones of the arm having been found will explain, in a m
. the difficulty of the delivery, in that a footling presenta-
>ne of the arms remains impacted with thehead,
could have I aily delivered, it' the head was not ab-
normally ment, the inferior and superior
202 Ford. Report of a Hospital Case. [March,
limbs and trunk hanging out, to the contrary notwithstanding.
The absence of the presence of a humerus ; a second malar
bone ; a second petrous portion of temporal bone ; a second
tympanic bone, &c, explains a statement she made, thatsomc
small"bones had come out of the fistulous orifice, from time to
time. Why, then, the number of these bones indefinite, might
not bones have escaped, which would show the case one of
extra-uterine foetation ? Because, by examination, after the
remaining bones had been extracted, neither the opening into
the colon, nor the passage through the cervix uteri, could
have been confounded with the openings through the fal-
lopian tubes, their size, form, position excluding the possi-
bility of such an error.
The time which elapsed after she aborted, before the first
appearance of the opening in the abdomen, could not be
determined, and the exact condition of Mrs. H from
the time she severed the body of the foetus from the head ,
to thetime she was admitted into the Hospital is unknown,
the probability, however, is that the detritus of the foetus
passed out per vaginam, and the uterus contracting down
upon the bones of the head caused them to ulcerate their
way through its walls. Adhesive inflammation was set up,
which prevented the escape of the discharge into the perito-
neal cavity, the exudation of plastic lymph, forming a distinct
cavity, by agglutinating the edges of the uterus with those
of the abdominal walls. The fistulous opening into the
colon was, most probably, formed by the bones cutting
through its walls. The exudations of plastic lymph, as in
the external opening, formed adhesions similar to artificial
annus. This internal opening, so to speak, had closed en-
tirely before Mrs. H left the Hospital, as evidenced
by the absence of any fecal discharge.
It is unfortunate the patient did not remain in the Hos-
pital until the perfect closure of the opening through the
abdominal walls had been effected; it was, however, granu-
lating healthily, then about J inch in diameter; this fact,
with her generally improved condition, warrants the opim
1861.] tures on Convulsive 1
ion of recovery, the principle difficulty (the opening into
the intestinal canal) having already been perfectly closed.
Mrs. I] was much agitated at the probability of
legal investigation, suggested by some of her female ene-
mies, who, hearing' the horrible enormity of her mode of
delivery, seemed determined to torture the unfortui
wretch, by exposure. With this anticipation hang-
ing over her, she left the city by stealth. Means were em-
ployed to follow her, but with no success.
hares on the Theory and Therapeutics of Convulsive Diseases,
especially of Epilepsy, By Charles Bland RadclifFe, M. D.,
Fellow of the College, Physician to the "Westminister
Hospital, etc.
LECTURE II.
In my last lecture I endeavored to show, as far as was
Bible in the time, that it is necessary to adopt a new
theory of muscular motion. I endeavored to show that a
fundamental change in this matter is absolutely demanded
by many of the facts which have come to light during the
past ten or twelve years, and chiefly by the messages which
may be said to have been telegraphed, along the three miles
of wire which enter into the coil of a galvanometer, such as
that which was then upon the table. For what are ti
One is, that there are electrical currents in liv-
ing muscle and nerve. Another is, that rigor mortis does
not occur until the final extinction of these currents. A
third is, that these currents are weakened in ordinary mus-
cular contraction. A fourth is, that contraction is produced
when the nerve-current is weakened by the action of a gal-
vanic current upon nerve. A fifth is, that contraction is not
produced when the nerve currentis strengthened by the action
a galvanic current upon nerve. In a word, the needle
of the gavanometer appears to show that muscle elongates
under the action of the muscular and nerve currents, and
that mm rhen this is weakened or
inted out also, keeping with these facts, that
inn- tion if connected with the T<>r-
dinary electricity, and not with the charging or charge,
204 Lectures on [March,
I endeavored to show, further, that there are no sound
reasons for supposing that "blood and nervous influence pro-
duce contraction by acting as a stimuli to a vital property
of contractility, and that there are many grounds for believ-
ing that these agents act upon muscle in the same way as
electricity, antagonizing contraction, not causing it an-
tagonizing contraction, possibly, by means of electricity
nervous influence by the nerve-currents blood, by keeping
up the muscular and nerve currents, for it is easy to suppose
that these currents may be kept up by the respiratory or
chemical changes which are produced by blood in muscle
and nerve.
As to the rest, I endeavored to show that there was no
need of a vital property of contractility, and of the doctrine
of stimulation founded thereon, to explain certain other
facts which must be accounted for by any true theory of
muscular motion. I endeavored to show, for instance, that
the fact of muscle undergoing no change of bulk in con-
tracting, the gain in breadth being precisely equal to the
loss in length, has its exact parallel in the change which a
bar of iron undergoes in passing out of the magnetic state
that contraction under "mechanical irritation" may be
nothing more than the natural effect of the discharge of
secondary currents, which currents are induced by mechani-
cally interrupting the nerve and muscular current that
muscular waste is proportionate to muscular action, not be-
cause contraction is the sign of functional activity, but be-
cause a given amount of waste is necessarily incurred in
that renewal of the muscular current which is necessary to
relax the muscle after each contraction that the will may
act in voluntary contraction by suspending the muscular
and nerve-currents ; that rigor mortis, which is utterly un-
intelligible on the accepted theory of muscular motion, may
be the natural result of the action of the common molecular
attraction of the muscular tissue upon the final dying out
of the muscular and nerve currents.
To briii"; forward all the arguments belonging to so com-
prehensive a subject within the space of one lecture was
manifestly impossible, even with the additional moments
which you, sir, so graciously placed at my disposal; and
thus I was obliged to leave much unsaid. I said nothing,
for instance, about the rhythmical movement of the heart
and other muscle, though 1. might have found in the theory
a key to their physical interpretation, and in them no small
1861.] Convulsive D 205
confirmation of the theory, I said nothing about the par-
turient contractions of the uterus, though in the theory I
may have hoped to have found the way of explaining how
it is that^ these contractions, begin at a certain time, and
continue until the completion of birth. Butthough obliged
to leave much unsaid, I hope I was able to say enough to
show that a fundamental change is necessary in the theory
of muscular motion, and to prepare the way for what 1 have
now to say upon the theory of convulsive diseases.
Epilepsy is at once the great type of convulsive diseases,
and the key to their interpretation. Epilepsy, however, is
a name which indicates much less than it did formerly.
Thus it does not indicate the epileptiform convulsion which
is connected withcertain positive diseases of the brain, with
fever, with uraemia and other retained excretions, with "ir-
ritation" in the gums and elsewhere, or with the moribund
state. And it is difficult to say precisely what it does indi-
cate ; for, as our diagnosis gains in exactness, epilepsy
changes from a special malady into a mere symptom, or
congeries of symptoms. At the same time, it is convenient
to take an ideal type of epilepsy, and regard it as a special
malady ; for there arc numberless cases, in which, in their
earlier >taLres at least, it is very difficult, if not impossible,
to recognise the disease of which the convulsion is merely a
symptom.
AVhat, then, I would begin by asking, is the theory of
simple epilepsy ? Upon which theory of muscular motion
is it to be based '." And, first, what are the facts?
An epileptic will often say never oftener than upon the
very eve of an attack "I am quite well," and many are
ready enough to echo what he says; but he and they have
little right to say so. Where the malady has not made
much progress, there may be a cheerful countenance, a
sharp digestion, a firm limb, and at the first glance it may
not I to say what is wrong; but, in this case, there
are always certain features which are incompatible with
true health and strength. In many instances there is a
want of tire in the countenance, and a dilated and sluggish
State of the pupil, which point to the brain as lacking in
energy: ami in keeping with these signs, it is found on
inquiry that the memory is more or less treacherous, the
ideas more or h-ss incapable, the imagination more or less
dull, the temper more or Less irritable, the will more or les<
200 Lectures on [March,
feeble, the character more or less undecided. It is, no
doubt, common enough to meet with epileptics, who, with-
out a i iv want of candor on their part, will maintain that
their minds are free from all infirmity; but if care he taken
to examine their history, it will always be found that their
friends have very different opinion upon this point.
In very many instances there is a marked disposition to
tremulousness and cramp; thus in upwards of seventy cases
which fell under the notice of my friend and colleague, Dr.
Reynolds, these symptoms occurred at one time or other
and in one form or other, in more than half of the whole
number.
In very many instances, again, if not in all, the hands
and feet are cool or cold, the pulse is weak and slow, and a
feeling of chilliness is almost habitual. Indeed, so far as
my own experience extends, the powers of the circulation
are always very defective in ordinary epilepsy.
In confirmed cases, these general features are so marked
as to be altogether unmistakable. Not only are the pupils
dilated and sluggish, but the under eyelids are puffy and
coarse. Often, moreover, the complexion has accpiired a
dull tinge a change which appears to depend in part upon
an habitually bloodshot state of the skin. At any rate,
this bloodshot condition is rarely absent, and where it is
most marked, as about the forehead and eyelids, it is often
accompanied by numerous spots of ecchymosis of about the
size of a pin's head. The torpid features are now rarely
lighted up with the fire of feeling or thought, the seme-
are duller than ever, the memory more treacherous, the
ideas more confused, the power of attention more distracted
the imagination more drowsy, the temper more uneven,
and the will more incapable. At this time, also, there is,
for the most part, little of that fine susceptibility of feeling
which is necessary to enable one to be miserable about any-
thing.
This change for the worse is particularly marked after
the fit. Indeed, at this time the senses may be so blunted
and the mind so clouded and confused, that the features of
the epileptic may become blended in those of the demented
person. Or symptoms of mental aberration may show
themselves, and transform the epileptic for the time into
the; lunatic. The fits, also, mayrecur so frequently, that the
mind may never have the chance of clearing up in the in-
terval, and in this way the general features of the convul-
1861.] Convulsive Di$eai J<<7
Bive malady may never cease to be confounded with thos
dementia or insanity. Xot unfrequently, also, there is the
gravest degree of mental infirmity from the very first, and
instead of ending in dementia the history of the epileptic
may begin in idiocy, hi deed, epilepsy is so frequent an
unpaniment of this saddest of all conditions, that it can
scarcely be said to be an accident.
The signs of the approaching paroxysm are very variable.
The patient himself will generally say, and say truly, that
the lit takes him by Burpise ; and certainly the signs of dan-
ger are not those which are likely to arrest his attention.
These signs also are very apt to vary in the same person.
As the time of danger approaches, the, patient may be-
come unusually fidgety, irritable, moody, forgetful, absent,
6r drowsy ; or he may sleep restlessly, grinding his teeth,
snoring or snorting, dreaming about things which distress
or terrify him, or even somnambulizing; or he may have a
disagreeable feeling of tightness about the throat, with
cramps or tingliugs in the limbs and elsewhere; or he may
be unusually "shaky,'' or may be annoyed with shudderings
of a very disagreeable and violent character.
Another sign of danger mav be giddiness or headache;
but, so far as the latter symptoms is concerned, I should not
be disposed to lay much stress upon it as a warning in simple
epilepsy.
Occasionally, the pupils may be more dilated and slug-
gish than usual, or one pupil may be more dilated and slug-
gish than the other ; or the eyes may be rotated in a pecu-
liar manner.
Usually, so tar as my experience goes, the pulse may be-
come feebler than it was before ; and not unfrequently the
patient will complain that nothing will warm him or k
him warm ; or he may sigh in a way which shows that he
is not breathing as freely as he ought to do : or, if as] rep,
the breathing may at times become imperceptible and in-
sufficient as to suggest the idea of death. The breathing
fails in this remarkable manner before the tit in a patient
at present under the joint care of a medical practioner in
the country and of myself, and we can both testifyas to the
Later still, there maybe certain vague and (indefinable
nations or movement varying in their eharaeter,
but all comprehended under the term aura sensation
pain, numbness, tingling, and a feeling as of cold vapor,
208 Lectures on [March
movements, of shuddering or spasms, beginning in a distant
part, as in the hand or foot, and travelling towards the
head. In other words, there maybe symptoms which, as
Dr. Watson thinks, are in some degree analogous to globus
in hysteria, or to the numb and tingling feelings which arc
the precursors of paralysis and appoplexv.
In some cases there may be special premonitions. In one
of my patients, the lit is invariably preceded by an intense
feeling <>1* hunger. In another patient, since insane, a little
blue imp made its appearance, and grinned and mocked at
him as he lost his consciousness. In a third, a guitar seem-
ed to be roughly grated close to the ear. But these signs
are of little value, for they arc only perceptible to the pati-
ent, and not even to him until he has ceased to be able to
bestir himself.
Last of all, there is a sign which is very difficult to catch
and this is the death-like pallor which overspreads the
countenance immediately before the fall. M. Trousseau
called attention to this sign five years ago as one which
is diagnostic of epilepsy ; and, since that time, I have seen
it in every instance in which I have seen the fit from the
very beginning. "II est une signe," says M. Trousseau,
"quie se produit du moment de la chute, et qui n'est inst-
able pourpersonne : e'est la paleur tres prononcee, cadaver-
ique, qui couvrc pour un instant la face l'epileptive. ]STous
ne le voyons pas, parceque nous arrivons toujours trop tard,
alors que la face est dija d'une rouge tres pronunce." M.
Delasiauve has also noticed the same phenomena in several
cases.
In the severest and most characteristic form of the parox-
ysm, the patient utters a peculiar choking noise, or a sudden
and startling cry, and at once falls down convulsed and in-
sensible. The convulsions are usually more marked on one
side of the body than the other. They drag the mouth to-
wards the side which is most affected, and twist the face in
the opposite direction until the chin may press upon the
shoulder. They push forward the tongue, and crush it be-
tween the teetln They clasp the thumb upon the palm,
and hold it down with the force of a giant. They seize the
walls of tin- chest and abdomen, and prevent the possibility
of breathing. They stiffen the limbs, so that the joints can-
not be bent without some risk of breaking the bones. In
sonic instances, they even take hold o\' the bladder, the
bowel, <>r the seminal vesicles, and expel the contents ; in
1861.] Omvulsi 209
others they may be bo violent as to bite ofl a large portion
of the tongue, to break the tooth, orto dislocate a limb. At
first, it seems as if the Bpasms would never relax; but after-
wards they are separated by intervals, which grow wider
and wider as the paroxysm draws to an end. The con-
vulsions, that is to Bay, are tetanoid at first clonic after-
wards.
At the instant of the fall, a corpse-like paleness over-
spreads the countenance ; a few instants later, and the livid,
black, and bloated head and neck, and the hissing, gurgling
choking sounds proceeding from the throat, BUggest the
idea of a person struggling undei the bowstring of some in-
visible exeeutioner. At times, however, the signs of suffo-
cation are absent, and the ghastly pallor of the beginning re-
mains throughout.
When the lit is at its height, a quantity of flrothy salvia
is usually blown or puffed from the mouth, and this is not
anfrequently reddened with blood, if the tongue or cheek
happens to have been bitten.
Jf the eyelids are open, the eye is seen to be projected
and distorted, with the pupil dilated to the utmost, and ab-
solutely insensible to light. As rule, however, the eye-
lids would seem to be closed: and well it is that they are
so, for it requires some nerve to meet the hideous stare of
the epileptic eye.
All this while, it is usual for the hands and feet to be
cool, and bedewed with clammy perspiration. Except the
head and nook, indeed, the whole body is cooler than na-
tural, and any little additional warmness of the head and
neck would seem to be simply due to the fact that their
are more distended with venous blood.
The other and less obvious features of the paroxysm are in
keeping with the
At first, it ma}- be difficult, perhaps impossible, to tool
the pulse, and the heart acts very feebly; but if the liin
of one hand kept upon the wrist, and the other hand Ik-
placed upon the bosom, it is found that the pulse rapidly
acquires a force and fullness which it never had in the in-
tervals between the fits, and that the heart beats more and
more tumultuously and violently as the pulse In
. instances, however, the pulse may remain almost
lent, and the action of the heart be extremely feeble from
the beginning to the end.
From the first all conscioui happily suspended
210 Lectures on [March,
lli is is our only consolation in so sad a spectacle ami the
most powerful stimulants fails to evoke any sign of action
in the dormant mind. The water which may be thrown
upon the face (with few exceptions) causes no blinking in
the eye if this be open and staring; the fire upon which the
patient may have fallen may char the flesh without causing
a single pang.
After continuing for two or three minutes, which seem
drawn out to hours, the convulsions cease, and the patient
is Left with all his muscles unstrung, like a person dead-
drunk, or struck down by appoplexy. The lungs, no long-
er restrained by the suffocating spasm of the earlier part of
the fit, resume their play with deep inspiration, and then
act with loud and strenuous breathings ; and as the respira-
tion rightss itelf, the veins of the head and neck become
unloaded, the natural color returns to the surface, and pre-
sently the patient wakes to an obscured and troubled con-
sciousness. "Je suis brise," Calmeil tells us were very of-
ten the first words of the returning epileptic at the Salt-
petriere or Charenton. The time during which the patient
lies in a fit before awaking is very variable, but (except in a
first attack) it is rarely more than half an hour, and it may
not be more than two or three minutes.
This is the usual, but by no means the invariable, course
of the fit. Often, indeed, the attempts at rallying may be
very imperfect, and fit after fit may recur for a long period
without any interval of waking; and occasionally all rally-
ing may be prevented by death.
"After waking, there are generally some symptoms of re-
action in the circulation, but in simple epilepsy these are
never marked. They may be enough to give a dull flush
to the cheek and a little fulness to the pulse for a short
time after the patient wakes ; but, as a rule, they cease
when the coma ceases, and coma is never much prolonged
in simple epilepsy. Usually the patient is headachy and
exhausted, listless and stunned, moody and iritable, until a
night's rest has enabled him to recover the balance of his
shaken nervous system. The jaded countenance also tells
plainly of the past struggle, even though it may present
none of those numerous and minute dots of ecchymosis
about the eyelids and upon the forehead which are such un-
equivocal signs of a severe attack of epilepsy.
- time goes on, the mental faculties recover more and
more imperfectly, and more and more tardily, and at last
1861.] Corv&aU - 211
their habitual state may bo one of pitiful fatuity from which
single ray of the Divine principle beams forth. Or the
moodiness and irritability which often follow attacks may
>me more and more marked, until at last they mi
into attacks of downright mania. Orsymp
may make their appearance. Or death may happen in a fit.
mortly afterwards. The natural tender. >ilepsy is
assuredly towards dementia: and dementia is the frequent
doom of the epileptic, if his disorder be uncheckd and life
prolonged sufficiently; but at the same time it is possible
for an epilectic to live many years, and to have many fits,
without losing- powers which are necessary to render him
an agreeable and serviceable member of society. When
death happens, it appears to be, most generally, from ex-
haustion in the period of prostration immediately following
the paroxysm.
But the symptoms of epilepsy are not always so startling
as have been represented, and in some instances they may
i softened down as to be recognised witli difficulty.
In the slightest form of the malady, the patient pauses
suddenly in the midst of anything he many happen to be
doing <>r saying at the time, Ins countenance becomes pale
and blank, his lungs cease to play, and, after a moment of
absence or giddiness, he is himself again. His memory has
kept no record of this sad passage in his history, and if it
had escaped the notice of others he might remain in happy
ignorance of it. Or in addition to those symptoms, a lurid
flush may succeed to the paleness of the countenance the
veins of the neck and forehead may start out in prominent
relief, the face may turn slightly towards one of the shoul-
ders, and there may be some convulsive twitching in tin-
. neck and arms, hi such a case there is no scream or
. no fall, no bitten tongue, no foam at the mouth, and at
st there is only some obscure gurgling in the tin
son, j rni> and some slight moistening of the lips
with salvia. In such a case the convulsive movements are
very partial, rarely extending beyond the face. neck. <-;
arms, but in some few instances the whole frame may be
agitated by one or two violent convulsive Bhocks. Tins
te of giddiness and al rad partial spasm may be
followed by fatigue, loss of memory, confusion of thought,
depression i irritability of temper, and at tu
it may end in drowsiness or actual sleep; but usually recov-
ery is almost instantaneous. At the same time there is rea-
212 Lectures on fMarch,
son to believe that dementia is a more likely as well as a
more Bpeedy consequence in this, le petit mat, than in ordin-
ary epilepsy, lc grand mat.
In some of these cases, moreover, it would seem not only
that the patient does not cry, or foil or suffer from general
convulsion, but that the state of intellectual eclipse the
; characteristic symptom of epilepsy is far from com-
plete. Esquirol says : uil est dcs acces dans lesquels on
n'obscrve pas la perte de connaisance ;" and M. Herpin di-
rects particular attention to these cases. Cases like these
are common enough in certain chronic diseases of the brain
as meningitis or tumor: but in simple epilepsy they are by
no means common, if other proof be wanting than the mere
rtion of the patient. I have met with tour such cases,
and have put them on record in various places.
The morbid appearances after death from simple epilepsy
arc necessarily very obscure, if the case have really been one
of simple epilepsy, and not one of epileptiform convulsion
connected with some special disease. In cases fatal during
the fit the brain has been found to be congested ; but this
appearance is clearly owing to the mode of death, and it is
allowed to be so.
In cases, again, where epilepsy has been complicated with
insanity, the brain or its membranes may present various
signs of inflammation, or of changes more or less akin to
inflammation ; but these signs are clearly referable to the
mental disorder, and for no other reason than this : that
they are as common, or more common, in insanity without
epilepsy.
In other cases there are signs of degeneracy, such as pallor
of the grey matter, softening, induration, atrophy, dropsi-
cal effusion ; but these are the very signs which belong to
the demented state. It is this very fact, however, which
furnishes some grounds for supposing that signs of this
character may have something to do with epilepsy. It
docs so, because the demented state is intimately connected
virh convulsive disorder for if a demented person be not
epileptic, he is almost sure to be affected with palsied shak-
ings, or cramps,* or spasms, in one form or another.
In other cases, again, theskull may be thicker and heavier
than usual, and several internal projections as the* clinoid
proc< m maybe considerably developed, or various parts
of the dura mater may be converted into bone. Indeed,
ther< are no constant changes in the brain proper or its
1S61.] Convulsive Diseases. 213
coverings not even that change in the pituitary boch
which bo mnch has been said by Wenzel ; forwritic
Rokintasky Bays that he lias "frequenly failed to discover
it in those who had notoriously suffered from epilepsy and
convulsions," and that he has "met with it in others who
were thoroughly healthy." It*is in the medulla oblongata,
indeed, that we alone meet with any appearances after
death which can be regarded as constant. In early cases of
epilepsy, it is true, we may fail to find anything' character-
istic even here ; but in confirmed cases Wm medulla oblon-
gata is often harder than natural, from the interstitial
lot' a minutely granular albuminous matter, or i
softened, swollen, and presenting evident signs of fatty de-
generation. Professor Van der Kolk, who was the first to
detect these appearances, has also detected some marked
changes in the bloodvessels, of the part, andto these changes
he directs particular attention. lie has examined fifteen
epileptics after death, and in them all the posterior half of
the medulla oblongata, on making a transveise section, was
found to be redder and more hyperaemic than it ought to
and this was the case whether death happened in an.
attack or not. On more minute examination, he found the
bloodvessels dilated to thrice their natural dimensions, and
their walls much thickened. And on comparing the me-
dulla oblongata of several epileptics who bit their tongue,
with the medulla oblongata of other epileptics who did not
bite their tongue, he found (what is a very curious fact) that
the capillaries were especially dilated in the course of the
hypoglossus and the corpus olivare in the former case
the tongue was bitten in the fit, and in the course of
roots of the vagus in the latter case, where the tongue
not bitten in the fit. These discoveries of Professor
der Kolk are the most recent as well as the most important
- in connection with the post-mortem appearances of epi-
lepsy.
What, then, is the theoretical purport of the foregoing
To which view of muscular motion do. dntV
And first for herein may be found the key to the whole
matter what is the theory of simple epilepsy to bo dedu
from the facts which concern the circulation and respiration
of the epileptic?
1. No very certain conclusion is to be drawn from a con-
ration of the state of* the circulation and respiration in
the interparoxysinal period, except this that plethora in
214 Lectures on [March,
the form so often exemplified in the butcher is never met
with, and that feverish activity, even as an accident, is of
rare occurrence. There are, indeed, cases of epilptiform
diseases which the circulation may exhibit at times some
signs of activity ; but these cases, as we shall sec in the next
lecture, present no objection to the conclusion which is
forced upon us by ilio, tacts that the pulse is rarely other-
wise than weak and slow in the interparoxysmal period of
simple epilepsy.
In the fit itself, the facts, when fairly read, admit of one
conclusion, and one only. At the instant of the fall, a
corpse-like pallor overspreads the countenance and the pulse
dies out at the wrist phenomena which seem to be only
intelligible on the supposition that the arteries are nearly
empty of red blood. A moment or two later, and the black
and bloated face, the choking sounds, and the absolute sus-
pension of all respiratory movements, show very plainly
that the formation of red blood is arrested for the time.
During the course of the convulsion, indeed the state is one
ofsuffocation. I hiring the convulsion, that is to say, the
supply of arterial blood is cut on at the fountain-head.
There is, however, one fact which, at first glance, might
o to show that there is an increased injection of arterial
blood during the convulsion. Such injection is manifestly
very imperfect at the onset of the fit,for upon no other suppos-
ition can we explain the corpse-like paleness of the counten-
ance and the feeble and imperceptible pulse. But if the fin-
ger be kept upon the wrist during the convulsion, it will be
found that the pulse will go on rising until it has acquired
a force and fullness which it never had in the interparoxys-
mal period ; and if the hand be placed on the breast, it will
he found also that this rising of the pulse is accompanied
by increased action of the heart. These facts arc evident
and unmistakable, but they do not show, as without reflec-
tion they might seem to do, and as they are often supposed
t'> do, that red blood is being injected in greater quantity
into the arteries during the convulsion.
W"hcn the proc< piration is arrested, the right side
of the hcaii and the venous By stem generally are soon gorg-
ncl distended with black blood. (Tnder these circum-
indeed, the gorged and distended state of the1 right
of the heart may reach a point in which the folds of
the tricupsid valve are forced widely apart, and an opening
1861.] Oonvulswe Diseases. 215
loft through which the beatings of tlio ventricle are made
to toll almost as much in driving the blood back through
the auricle into the veins. a> in sending it onward through
the pulmonary artery into the lungs. But it is not right to
suppose that the left Bide of the heart and the arterial trunks
are empty of blood; and this may he readily verified by
watching the changes which take place in the carotid and
jugular of a rabbit during the process of suffocation. On
exposing the 3, the artery is seen to bo filled with red
and the viens with black blood. On suffocating the animal
by tying a ligature around its windpipe, the color of the
blood in the artery darkens rapidly, and in about two
minutes and a half it is every whit as black as that of the
blood moving in the neighboring veins. Nor is the vein
CI O o m
_ed and distended and the artery comparatively empty.
On the contrary, the artery is felt to pulsate as strongly
under the rush of black blood as it did previously under the
rush of red blood. Nay, the pulse of the black blood is actu-
ally stronger than the pulse of the red blood ; for, on testing
with hsemadynometer, the late Professor John Reid (who
first directed attention to these facts, and who has investi-
1 the condition of the circulation in asphyxia more care-
fully than any other observer) found the mercury highest at
the moment when the blood in the artery had become
thoroughly venous and black.
A full pulse and a throbbing heart, therefore, must be
looked upon as natural accompaniments of asphyxia : ami
thus the full pulse and the throbbing heart of the epileptic
paroxysm, instead of showing that a larger quantity of red
blood is being injected into the arteries at the time, may
show that these vessels are then laboring under a load of
black blood, as they do in asphyxia. And that the full pulse
and the throbbing heart of the epileptic paroxysm must
have this Latter significance is evident, for the livid black,
and bloated head and neck, and the complete suspension of
all respiratory changes, show very clearly that black and
not red blond is coursing through the vessels at this time.
When the convulsion is over there is little to notice in the
the circulation and respiration. When the spasms
. the respiration is speedily re-established, and the re-
admission of arterial blood into the system may be attend-
ed with some transient and inconsiderable febrile reaction ;
but rion has nothing to do with the convulsion, for
when reaction is present convulsion is absent, and if con-
216 Lectures on [March,
vulsion returns, it is not until every trace of reaction has
taken its departure.
Regarding, therefore these facts the corpse-like paleness
and the comparative pulselessness at the onset of the parox-
ysm, and the signs of positive and unequivocal suffocation
by which this stage of paleness and pulseness is succeeded
and remembering the previous arguments, which show
that the convulsion is not to he ascribed to the presence of
the Btimulous of venous blood, there appears to be only one
conclusion, and this is, that the convulsion of epilepsy is
connected with the want of a due supply ot arterial blood
in the vessels.
Nor is it an objection to this view that the convulsions
cease when the blood has become thoroughly deprived, of
its arterial properties. In order to discharge their office of
conductors, it is certain that the nerves must be supplied
with a sufficient quantity of arterial blood. If, for example,
the principal vessels of a limb be tied, the nerves of that
limb, wanting their due supply of blood, are unable to carry
messages to the mind, or to transmit mandates from the
mind to the muscles, until the collateral circulation is suf-
ficiently established ; and. hence it is a fair inference that
there must be a point in the process of suffocation where,
wanting a due supply of arterial blood, the nerves must
cease to be conductors, and where, consequently, the con-
vulsions will come to an end ; for, upon an}' hypothesis, the
convulsions will come to an end when the nervous centres
cease to be in proper connection with muscles.
But, it may 'be asked, is there no change in the blood
itself? Is there not. some important truth in the "humoral
theory of epilepsy," as recently advanced in this place by
the late lamented Dr. Todd ? "I hold,*' said this distinguish-
ed physician, "that the peculiar features of an epileptic
seizure are due to the gradual accumulation of a morbid
material in the blood, until it reaches such an amount that
perates upon the brain, in, as it were, an explosive man-
ner; in other words, the influence of this morbid matter,
when in sufficient quantity, excites a highly poralized state
ol the brain, or of certain parts of it, and these discharge
their nervous power upon certain other parts ofthecerebro-
;il centre, in such a way as to give1 rise to the phenomena
of a m. A very analogous effect of that which results from
the administration of strychnia, which is best seen in a cold-
blooded animal, like the 1'vo^. You may administer the
18G1] Convulsive / 217
drug in very minute quantities for some time without pro-
ducing any sensible effecl ; bul when the poison has ac-
cumulated in the system up to a certain point, then the
smallest increase <^l' dose will immediately give rise to the
peculiar convulsive phenomena. This is the humoral theory
of epilepsy. It assumes that the essential derangement oi'
health consistsin the generation of a morbid matter, which
infects the blood : and it supposes that this morbid matter
has a special affinity for the spinal cord. The source of this
morbid matter is propablyin the nervous system, it may be
in the I) rain itself. It may owe its origin to a disturbed
nutrition an imperfect secondary assimilation of that organ
and in its turn will create additional disturbance in the
functions and in nutrition of the brain." And again :
Ling to the Immoral theory, the variety in the nature
and severity of the fits depends on the quantity of the poi-
sonous or morbid material, and on the part of the brain
which it chiefly or primarily affects. If it affect primarily
the hemispheres, and spend itself, as it were, on them alone,
you have only the epileptic vertigo. If it effect primarily
the region of the quadrigeminal bodies, or if the affection
of the hemispheres extend to that region, then you have
the epileptic tit fully developed."
This theory is based upon the well-known connection be-
tween the presence of urea in the blood, or carbonate of
ammonia resulting from the decomposition of urea the
i It of defective renal action and one form of epilepti-
form convulsion; and it might also have been based upon
the connection between convulsion and blood overloaded
with bile. But if there is any evidence in these facts in
favor of the existence of this hypothetical morbid material,
there is none in favor of the idea that the modus op< randi of
the material is in exciting a highly polarized state of the
brain, if by this state is meant anything like a condition of
excitement. On the contrary, it ia certain (as will be shown
in the next lecture) that the action of the brain and of the
em generally is reduced to the very lowest ebb
at the time when convulsion is brought aboul by the accu-
mulating i and bile in the blood; and it is not less
tain that strychnia, instead of actin , Todd e
iting a highly poraliz<
ing the
stimulating powers of the blood and by diminishing the
sfion of both nerve and muscle.
218 I ."lures on [Marcli,
There is little doubt, however, thai retained excretions
must play an important pari in the production of epilepsy
A free discharge in the office of excretion, not only in the
kidneys and liver, bul in every excretory organ, is essential
to the preservation of healthy blood ; and it may well be
believed thai an imperfect discharge of the office of excre-
tion, in oik' or other of the excretory organs, may lead to
the accumulation of eftete matter in the blood, and that this
accumulation ofeffete matter may be a not unimportant
cause, in bringing about an attack of epilepsy. Hut there
is no reason for supposing that \\w blood under these cir-
cumstances become stimulating. On the contrary, the con-
clusion which arises out of the history of the cases where the
area or bile is suppressed, is the natural conclusion, and
this is, that blood thus altered is less fit to discharge its
several offices ; in other words, less stimulating.
Nor does there appear to he any reason for supposing that
venous congestion has a more important part to play in the
production of epilepsy than that which has been assigned to
arterial injection. No doubt the veins of the brain and
head generally arc congested from a \cvy early moment,
butthere is a moment antecedent to this in which the death-
like pallor of the face is a sufficient proof that the veins
were emptier than usual before they became congested. At
any rate, the acknowledged anatomical difficulty must be
overcome before it can be supposed that Dr. Marshall Hall's
hypothesis of trachelismus or the prevention of the return
of Mood from the brain by the spasm of certain muscles in
the neck has anything to do with the causation of epi-
lepsy.
Et would seem, then, as if there was something utterly
uncongenial between epilepsy and arterial excitement. Jt
would seem, indeed, as if the spawns, as well as the loss of
consciousness and sensibility, were connected with want
of arterial blood empty vessels in the first instance, ves-
sels tilled with black blood afterwards. It is not imp
bable, also, that the blood may have been previously
rendered less stimulating by the retention of something
which ought to have been eliminated by one or other of
the organs of excretion. In a word, the phenomena are
entirely in harmony with the previous considerations re-
specting muscular motion ; for according to them, the ac-
tion of arterial blood is to antagonize construction, and
not i. it.
.
1861,] Convulsive Disecu 219
'1. Interrogating the nervous system, the facts are found
to have that theoretical significance which the state of Hie
circulation and respiration would lead us to expect.
These facts will scarcely warrant the idea that epilepsy
ifconnected with anything approaching to over-action of
the brain proper. On the contrary everything seems to
point to a state which is the very opposite of over-activity.
Thus, the comparative want of memory, intelligence, fancy,
and purpose, which marks the intcrparoxysmal condition;
the utter annihilation of everything mental in the fit itself;
and the gloom and prostration following the fit, are facts
which can have no double meaning.
Xor is a contrary opinion to he drawn from the morbid
appearances which are disclosed after death. If these
chance to indicate previous inflammation, it does not fol-
low that convulsion had any direct connection with the in-
flammation as inflammation ; on the contrary, the convul-
sion may have happened hefore or after the inflammation,
when the energies of the brain were prostrate or exhausted
an alternative which we shall see to be the correct one
when we come to speak of elcptiform disease connected
with special disease of the brain. And surely it is not pos-
sible to draw any but one conclusion from the appearances
which arc common to epilepsy and dementia pallor of the
grey substance, atrophy, chronic softening and induration,
dropsical cfl'usion and the rest?
But what of the state of the medulla oblongata V for, as
r Schrosder Van der Kolk has well shown, the seat
of the characteristic spasms, the bilateral character of the
spasms, and the appearancespresented after death, all point
to this organ as one which is specially concerned in bring-
ing about the epileptic paroxysm.
The spasms of epilepsy begin in muscles which receive
nerves from the medulla oblongata in muscles, that is to
. which are supplied by the facial, the accessory, the hy-
poglossal, and the portio minor trigemini; in slighter <;
they are limited to these muscles. The spasms of the walls
of the chest and abdomen, which are the most prominent
and marked features in the complete attack of epilepsy,
and which may be so fierce and unyielding as i fatal
suffo . also point to the same nervous centre; for a
similar state of things is brought about by the action of a
strong stimulus upon the great afferent nerve of tins centre
the pneumogastric.
220 Lectures on [March,
The bilateral character of the spasms is another argument
that the medulla oblongata [ally affectedin epilep-
sy. The lateral halves of this organ are connected in the
most intimate manner by transverse fibres and commissures
much more intimately than the lateral halves of the brain
and spinal cord ; and hence it is that the corresponding
nerves belonging to the two sides of the medulla oblongata
are under a stronger physical necessity to act together than
that which rides the corresponding nerves "belonging to the
two sides of the brain and spinal cord. In the ease of the
two latter centres, the nerves belonging to one side may be
paralysed or otherwise affected without any obvious injury
to the nerves of the other side; hut not so in the case oi
the latter centre. Indeed, it is evident that the actions
which eminate from the latter centre the play of the fea-
tures, the motion of the tongue, the vocal adjustments of
the larynx, the respiratory movements, kc must at once
come to an end unless there he the strictest sympathy and
concert in the action of the corresponding nerves of the
two sidi
Xow in epilepsy the spasms are always more or less bi-
lateral, and for this reason, therefore, it may he supposed
that they have some special connection with a nervous
centre of which one lateral half cannot act without the
other.
The appearance after death point also to the medulla ob-
longata as especially concerned in the production of epilepsy.
In an early stage of the disorder, we may fail to find any
characteristic changes; hut, in confirmed cases, the texture
is harder than natural, from the intestinal deposit or a
minutely-granular albuminous matter, or else softened,
swollen, and exhibiting signs of evident tatty degeneration.
The posterior half of the oblongata is redder and more
hypersemic than it oughttobe; and, on examining the hlood-
3els in this congested portion, they are found to be of
thrice their natural dimensions, and with their walls much
thickened and altered this dilatation and alteration being
chiefly in the corpus olivare and in the course <>f the hypo-
in the ease of epileptics who bite their tongues, and
in the course of the rool vagus in th< fepilep-
. who d<> qoI bite th< ir tong
It is evident, then, that the medulla oblongata is especial-
ly affected ii sy; but it does not follow, as Profee
Van dcr Kolk supposes, that the essential cause of the con-
1861.] 221
vulsive affection is to be found in an exalted sensibility and
activity of the ganglionic cells of this centre.
In favor of this view that epilepsy is dependent upon
exalted sensibility and activity of the ganglionic cells ap-
peal has been made to the fact of spasms, to the presence
of a full, bounding pulse, and to the freedom from attack
which is for some time the fruit of an attack, particularly if
this has been violent ; but the answer is not necessarily that
which Professor Van der Kolk supposes it to be. After
what lias been said about muscular motion in the first lec-
ture, it is not possible to allow that spasm in itself is an
argument in favor of exalted sensibility and activity in gang-
lionic cells. After what has just been said about the
phenomena of the circulation in epilepsy, it is impossible to
allow that the condition of the circulation favors spasms by
bringing about a more active state of the medulla oblongata,
'the functional activity of this, as of every other organ, be-
ing in direct proportion to the activity of the circulation of
red blood in the organ;) for it has been seen that the
bounding pulse to which reference is made, is- filled with
black blood, and not with red. Xor can the freedom from
attack, which is for some time the fruit of an attack, be ap-
pealed to as a certain proof that the attack is the sign of the
discharge of some overcharge of excitability previously pre-
sent. On the contrary, it maybe argued with some degree
of plausibility, from certain facts which have to be mention-
ed in the next lecture, that the attack was preceded by de-
pression of the circulation and innervation, that the convul-
sion supervened when the depression had reached a certain
point, and that the recurrence of the attack was prevented
tor a time by the state of reaction in the circulation and in-
nervation, which is a conserpience of the convulsion. The
may be one, indeed, of which the history of the rigors
of ague may serve as so inapt illustration ; for here we hi
first, the circulation failing more and more until the bathos
of the cold stage is reached; and, secondly, a state of re-
action which banishes the rigors most effectually so Ion .
it contin
It would even seem as if appeal might be made to the
appearances after death, and to the actual condition of the
circulation in the fit, for positive arguments against the idea
aything approaching of the medulla
obi-
Ti. of fatty degeneration can have but one signifi-
222 Lectures on [March,
cance under-action, not over-action. The interstitial de-
posit, also, implies an equivalent absence of healthy nerve-
structure, and so does the dilated condition of the blood-
vessels; and this absence of nerve-structure must necessitate
a corresponding absence of nervous action. The appearances
after death, indeed, ifthey show anything, show that the
medulla oblongata of the epileptic is damaged in structure,
and because damaged in structure, weaker in action, than it
ought to be.
The ureal argument against the idea of anything like
over-action of the medulla oblongata in epilepsy, however,
is to be found in the state of the circulation; for if, as may
safely be assumed, the activity of any organ is in direct re-
lation to the activity of the circulation of red blood in that
organ, how far from anything like over-action must be
the state of things in which as is the case in the epileptic
paroxysm, the vessels arc at first comparatively empty of
red, and afterwards completely filled with black blood ?
Nor can the curious discovery of Dr. Brown-Sequard, that
certain injuries of the spinal cord are followed by an epilep-
tiform affection, be construed into an argument that there
is anything like a state of exalted action of the spinal cord
in epilepsy. This curious result, which is brought about by
puncturing or dividing more or less completely almost any
part of the spinal cord, is developed, not immediately, but
in the course of three or four weeks after the injury. The
attacks, once developed, occur spontaneously at various in-
tervals, often several times a day ; they may also be brought
on by pinching or otherwise irritating the portion of the
skin which corresponds to the region of the whiskers in
man. This excitable spot is supplied by twigs belonging
to the suborbitary, the auriculo-temporalis, the second, and
perhaps the third, cervical nerves ; and it is a curious fart,
that the irritation which brings on a tit when applied to the
skin in which these twigs terminate, has no such effect
when applied to the twigs, themselves. Any other part of
the skin may be pinched or irritated with impunity, butthis
one spot can scarcely be touched without at once bringing
(Hi a lit.
These facts are very curious, and in the main, very un-
intelligible : but this much at least is evident, thatthey do
not countenance the idea of any over-action of the spinal
I in epilepsy. The fad thai the epileptiform affection
- doI make its appearance until four or live weeks after
] m;i.] Convulsive Jbiaeat 228
the injury would appear to show very clearly that the tits
have nothing to do with that local inflammation in the cord
which may be supposed to have been Bet up in the first in-
stance by the injury. After such a lapse of time, indeed,
is it not the natural conclusion, that any over-action of the
cord arising from the inflammation produced by the injury
must have died out, and left the cord damaged, weakened,
under-acting! Nor is a contrary conclusion to be drawn
from the excitable condition of the nerves proceeding from
the neighborhood of the cheeks ; for both sides of the face
are thus affected, if both sides of the spinal cord have been
injured. What the full significance of this curious fact may
be we may have yet to learn, but at any rate there is no
reason to suppose this excitable condition of the skin im-
plies an over-acting condition of the nerves or nervous
centres concerned in the phenomenon. The excitable por-
tion ot skin is not over-sensitive, for the animal manifests
no signs * f uneasiness when it is handled immediately after
a lit. Over-sensitiveness, moreover, would seem to have
nothing to do with the matter. At any rate, pain, and not
convulsion, is the consequence of handling those portions
of the skin of the animal which may have been rendered
highly hypersesthetic by the injury to the cord which
brought on the convulsions. It i^ certain, also, that a some-
what similar condition ol' excitability is brought on when,
in several experiments related in the first lecture ante.
June-July, the skin is cut off from the full influence of the
nervous -: and hence the natural inference would be,
that the action of the nervous centres in the epileptic guinea-
nus rather plus.
As in the former instances, however, so here; we turn to
the condition of the circulation ami respiration in order to
know what is the actual functional condition of the spinal
cord in epilepsy; and so turning, we see that the action of
the cord under these circumstances must be almost or alto-
gether nil. For what action can there be when little or no
arterial blood is injected into the vessels?
A similar argument will also dispose of the idea of over-
activity of the ganglia of the sympathetic system as a a
ible that the contracted state of
the arteries, which is implied by the death-like pallor of the
countenance and the comparative pulsel al the wrist,
may show that the coats of the vessels are in a state of
: and it ifl also possible that the cause of this spasm
22 1 Lectures on [March,
may have to be sought in the sympathetic system; hut it
docs not follow that over-action of this system is this cause.
On the contrary, the experiments of Drs. Kusmaul and
Tenner already referred to show most conclusively that
strong epileptiform convulsion is possible when the action
of the sympathetic ganglia is entirely suspended by arrest-
ing the supply of blood to these organs.
And certainly no opposite conclusion is to be drawn from
the vague and undefinable sensations or movements very
varying in character, but all comprehended under the term
sensations of pain, numbness, tingling, or a feeling
of cold vapor; movements of shuddering or spasm, begin-
ning in a distant part and travelling towards the head ; for
the most probable interpretation of these symptoms is that
of Dr. Watson that they arc in some degree analogous to
the numb and tingling feelings which are the frequent pre-
cursors of paralysis and apoplexy, or to the globus of hys-
teria phenomena which by the most perverse process of
reasoning can scarcely be supposed to indicate other than
a state of defective innervation somewhere.
But, it may he asked, is there nothing else ? Is there no
peculiar state of the nervous system in epilepsy? Is there
no morbid irritability.? In order to answer this question,
it is necessary to ask another What is morbid irritability ?
It is not inflammation; it is not fever; it is some indefin-
able and negative state which occurs frequently in teething,
in worm disease, in uterine derangement, and in many
other cases a state in which the patient is unusually de-
pressed by depressing influences, and unusually excited by
exciting influences. But what is this state ? Is it any-
thing more than lucre exhaustion? In difficult teething,
the strength is worn away by pain and want of sleep ; in
worm disease, the parasites help to starve and exhaust the
em; in uterine derangement, the health is undermined,
in all probability, by pain and by sanguineous or other dis-
charges. In each case there is unequivocal exhaustion of
body and mind, and the signs of morbid irritability appear
to be nothing more than the signs vf such exhaustion. A
weak person is more affected by the Beveral agencies which
upon the body from within and without, and he is so
because he is without some of that innate strength which
which belongs to the strong person : and the person who is
morbidly irritable, is in reality one who, \\yr want of this
principle of strength, responds impatiently to the several
1861.] True Ringworm.
stimuli, whose office it is to elicit his vital phenomena. Tn
a word, this undue morbid irritability may be nothing else
than the natural consequence of that general want of power
the signs of which are written so legibly upon the vascular
and nervous systems of the epileptic. There is no neec -
then, to look upon this morbid state of irritability as an
evidence of the existence of any peculiar condition in some
part of the nervous system ; for, thus interpreted, it only
shows that the state of muscular contraction is ill antagon-
ized by nervous influence. Thus interpreted, indeed, mor-
bid irritability only becomes another name for inefficient
innervation.
The theory of simple epilepsy, therefore, which may be
deduced from a consideration of the facts relating to the
nervous system is in harmony with that to which we have
been led by a review of the state of the circulation and res-
piration in the epileptic ; and this theory is one which tal-
lies as completely with the view of muscular motion set
forth in the first lecture, as it disagrees with that commonly
received opinion according to which the muscles are sup-
posed to contract convulsively because they are subjected
to excessive stimulation.
Clinical Report on True Ringworm (Tinea Ton
By Jonathan Hutchinson, Assistant-Surgeon to the London
Hospital, and Surgeon to the Metropolitan Free Hospital.
The diagnosis of ringworm to the practised eye is not usual-
ly difficult. Its patches differ from those of eczema, impetigo,
and common porrigo, in that they have no inflammatory crust,
only a thin branny desquamation being present, hi the latter,
the hairs are not destroyed, but simply matted together in
the crust, while in ringworm they are broken off short. The
roundness of its patches, and their abrupt definition; together
with the paucity of scales, distinguish it from all the forms of
psortasis ; and the latter are beside- veryrare on the scalps of
children. In alopecia circumscripta the patches are glabrous,
(piite destitute of hair, and free from even the Bmallest scales,
a in which ringworm departs from its usual type
for instance, if attended by inflammation its differential
diagi comes difficult. In all Buch cases the appeal is to
the microscope. To make a Satisfactory diagnosis with the
microscope the hairs from the patch should be carefully pulled
15
226 True Ringworm. [March,
out with tweezers, and some of the branny scales should also
be scraped off. Those should be put into a drop of glycerine
on the microscope-slide, and covered in the usual manner.
The addition of acetic acid renders the hair structure more
transparent, and the sporules, therefore, more conspicuous,
but glycerine is usually quite sufficient. After observing the
general size ot the hair-fragments, etc., with a half-inch ob-
ject-glass, a quarter-inch, or a fifth, should be employed^
Microscopic Diagnosis. The presence of sporules of a fun-
gus is an essential character. These are usually best seen in
groups on the outside of the hairs ; but a little practice will
o enable the observer to detect them in great numbers in
the interioi of the hair-shaft itself. It any hairs have been
pulled out with their bulbs the sporules may most probably
be Been very distinctly in the lower and less opaque part of the
latter structure. But. the peculiarities presented by the hairs
themselves (apart from the actual demonstration of parasitic
elements) are very marked. Instead of being round, of regu-
lar thickness, in long portions, and partial translucent, they
are black, in short broken fragments, swollen, bulging at
parts, and with their external layers split off in places. The
black tint (which is due, not to pigment, but to altered refrac-
tion from disturbed arrangement of the hair-fibres) is arranged
in longitudinal bars, giving the hair a fasciculated appearance.
If the extremity of a ringworm-hair is brought under view it
is seen to be broken and split up into fibres, resembling on a
small scale the stump of a worn besom. In, and on, the epi-
dermic scale sporules will also be found. It is consistent with
my own observation, that the younger the patient the more
likely is the disease to be restricted almost solely to the hairs
of the scalp, whilst in those beyond the age of about, ten years,
the epidermic scales are often attacked, the hairs being less
extensively affected. When the patches are situated on the
skin of the trunk, neck, or anus, t\io small hairs of the part are
almost always attacked, but they do not become infiltrated in
the manner so often seen on the scalp, nor do they usually
break off. In these regions the disease is primarily one of the
epidermis rather than of the hairs.
1- tine Ringworm Contagious? The popular#belief in the
extreme contagiousness of ringworm is of old landing, very
firm, and ver) widely spread. It i- also Bupported by the
experience of most dermatologists. ( me or two authors, how-
ever giving descriptions by which it is placed beyond
doubt that they were writing about the disease in question),
deny it- contagiousness. Thus, one authority writes: "Thia dis-
1861.] True Ringworm. 227
ease is not contagious ;" and adds, "that it is not communi-
cable by inoculation/' I am not aware that any evidence is
on record supporting the view that it is not inoculable, while
there are many tacts conclusively proving the opposite. The
experiment is one easily tried, and on such a mailer the anus
prubandl certainly rests with those who deny it.""' Mr. En-
nuis Wilson, after broaching the theory that the Buppi
cryptogamic sporules are in reality oil-globules, the result of
fatty degeneration of the hair-shafts, has the following extra-
ordinary passage :
w* Another consequence naturally follows the admission of the
explanation here given, which is, that this disease being in-
herent in the hair, and being due to an abnormal nutrition of
the system, is in nowise contagious. I need scarcely observe,
that this is a question of the utmost importance as affecting
the peace and happiness of families and the education of
youth. The disease occurs as commonly among the children
of the wealthy as among the poor ; and when the idea of its
being contagious is entertained the scourge is rendered doubly
severe."
Thus it would appear that a theoretic conjecture as to the
pathology of the affection is to decide this important question,
there being no need for clinical investigation as to what is
really the fact. Let me ask any one who has glanced ever so
cursorily over the cases I have cited whether he would to try
"secure the peace and happiness of a family,'' or "promote
the education of youth,'' by assuring an anxious mother, <>;
the head of a children's boarding-school, that the disease in
question cannot sj^read by contagion, and that no precautions
need be taken ( The clinical proof of the contagiousness of
true ringworm is as conclusive as is that of similar nature in
respect to scabies. When we see a disease in itself slight
and easily curable by local means, suddenly showing itself in
live or six individuals in the same family of different ages and
states of constitution, and none of whom were ever liable to it
before, it is surely futile to allege that constitutional causes are
sufficient to explain the occurrence. The case is yet stronger,
if possible, the affected children belong to different families;
and it culminates when we find that the disease has spread to
*It is <io.-irulk' that the ed in the microscopic examination of
ringworm products should be careful lest they innoculate themselves.
This occurred to myself, and [had a large, well-characterised
patch on one side the neck.
True lilngicoviii. [March
the neck and hands of the mother or nurse of the patient. To
rl that a disease is actively contagions under assisting
conditions is quite a different tiling from alleging that it wifl
inevitably affect every one who touches the patient. It is
not at all infrequent to witness scabies confined to a single in-
dividual in a family, although the exposure may apparently
have been considerable. In my report on favus I showed
that although undoubtedly capable of spreading by contagion
yet the fungus of that disease is difficult to transplant, and will
nol grow on a new soil unless precautions be taken to give it
a lair chance. The fungus of ringworm is much more easily
transferred from one to another, yet it also may well be sup-
posed to require certain conditions (i, <?., a soft skin or succu-
lent hairs and a fair opportunity of access) in order that it may
implant itself.
Is Ringworm a Constitutional Disease I With regard to the
question as to whether any constitutional predisposition exists
in cases of ringworm, it has already been answered by the
facts adduced as to contagion. These facts are of the same na-
ture in scabies and in ringworm. In both these, the invariable
presence of a parasite has been proved; both are curable
easily by local means, which destroy the vitality of the para-
site ; both are easily contagious ; both are constantly seen in
most healthy individuals. It is impossible to believe that
any form of dyscrasia can produce scabies, and it is equally
inconsistent with clinical evidence to hold that ringworm can
be produced by such causes. That scabies is a much more
severe disease in some individuals than others is well known,
and the same is no doubt equally true of ringworm. In the
n'rst place, early age, which involves softness and succulency
of the cutaneous structures, predisposes to both, or rather it
would be more correct to say, that advancing age pari pa
protects from both. Both are attended with a greater
amount ol* irritation in those of fair complexion, and probably
are more liable to occur in such. But to admit this is a
different matter to admitting that the strumous diathesis.
or any other form of general ill-health, predisposes to them.
:.nd in support of the latter suspicion there does not exist any
evidence whatever.
ntity of Ringworm on the Scalp with Ringworm on the
ral Surface. The great frequency with which ringworm
ire in the same individual, both on the seal}) and on other
of the surface, and the common occurrence of the dis-
different parts in different individuals of the same
ly, from mutual contagion set at rest all doubts which
1861.] True Ringworm. 229
might have been felt as to the identity of the affection. Every
now and then, even in young children, Ave see cases in which
the disease appears to avoid the scalp ; but this is probably
explained by some peculiarity of the hair in such individuals.
The hair of the scalp in adults appears to be proof against the
inroads of the fungus, and in them we always see the patches
on the skin of the chest or arms. It may easily be supposed
that the hair-structure in different children differ considerably
ns to the hardness of its cortex. When the patches occur on
the skin of other parts, the fungus usually attains a more lux-
uriant development than when on the scalp. The small hairs
of the chest on the affected parts, are usually attacked by the
fungus, but are rarely infiltrated extensively. The ravages
are much more superiicial than on the scalp, and for that rea-
son ihe cure is much more easily effected. Upon the ques-
tion of the identity between ringworm and some forms of sy-
: 3 1 shall not here enter.
Treatment. From time immemorial it has been customary
to employ various local irritants for the cure of ringworm.
Ink is the favorite application of mothers, and is a scientific
and frequently successful remedy. At the Hospital for Skin
diseases. Mr. Startin always blisters the patches with the veri-
cating fluid. A single blistering is usually sufficient for
patches on the skin, but those on the scalp often require two
or more. Many Burgeons employ nitrate of silver in solid
stick. M. Bazin insists strongly on epilation as a means of
cure, and there can be no doubt that it is an extremely impor-
tant one. By removal of the affected and adjacent hairs we
can reduce a ringworm patch on the scalp to the same con-
dition as one of the general surface, thus rendering it. much
more accessible to the influence of parasiticides. Of the lat-
ter it probably does not matter much which we select. The
ointment is a very good one, so also is the application
rong acetic acid. The great point in treatment is to keep
clearly in mind that the destruction of a vegetable parasite is
bject aimed at. It is needless to point out how strongly
fact that ringworm is curable by local means supports
the "pinions held in this report as as its purely local patholo-
gy.
-. 1. True ringworm, or tinea tonsurans, may
ffectmg either the scalp or the gener-
irface, in which circular patches are formed, on which the
haii-- break off short, and a short, and a slight, branny desqua-
;i, both hairs and epidermic scales exhiting under
the mi pe the sporules and thalli of a fun;
2:30 Irish Poisons. [March,
2. Ringworm in the scalp is rarely seen, excepting in
children ; but on the general surface is not very unfrequent
in young adults.
It is contagious, and spreads by contagion only.
4. It is not attended by any peculiar form of dyscrasia, but
on the contrary, often "attacks children in perfect health.
5. It is much more easily curable on the general surface
than on the scalp, owing to the circumstances, that in the lat-
ter situation the fungus has obtained access to the follicles of
the hair.
6. Being a purely local disease, ringworm does not require,
iy constitutional treatment.
7. A purely local treatment, if efficiently pursued, is always
and rapidly successful.
8. Epilation, and the use of one or other of the known parasi-
ticides, are the measures of treatment required.-
1). There is no real difference between ringworm on the
general surface.
10. Ringworm, although not unfrequently causing minute
vesicles, has no true analogy with herpes. Med, Times.
Remarks on Pish Poisons. By Dr. Reil.
The observations made by the author on this subject are,
ially, the following :
Fish may prove injurious to health either in the preserved
condition, that is salted, pickled, or dried, or in the fresh state.
Their poisonous properties in the simple or fresh state may be
to the following circumstances :
1. They may themselves under all circumstances be poison-
ous, as has been maintained in regard to several species of
fishes, although the fact requires further proofs.
2. They may under certain circumstances acquire poison-
properties, as for instance, by diseases peculiar to them,
or at certain seasons of the year, or, as is known of the Cyprius
harba and Cyprius carpio, at the spawning season.
3. Poisonous substances, such as Hydrocarpus incbrians,
mum occulum, Delphinium staphysagria, etc., may
been used in catching them, or they may have been
I in .-mother manner for instance, by acids and me-
talic salts, which contaminate the water in the neighborhood
; i - .
Their injurious properties may be owing to commencing
putrefaction.
1861.] /.<>. 231
The different modes of preserving fish give rise to chemical
processes which cause the formation ot poisonous mal
Injurious consequences from eating salted fish, particularly
salted sturgeon, are frequently observed in Russia. But also
codfish, and the smaller kinds of preserved fish, have given
rise to Byniptoms of poisoning. Cases of poisoning from her-
rings are perhaps the rarest, and this is probably owing to the
fact that the time f>r catching herring is limited to a certain
n, that they are salted without delay when still at
and that they are more rapidly consumed.
The character of the poison generated in preserved fish is
still doubtfnl : at the first the poisonous substance was thought
to he of cryptogainous growth, or a tatty acid ; more recently
Schlossberger advanced the view that the propylamin (tri-
methylamin) contained in the brine is the poison in question
but this opinion has been refuted by the experiments of Buch-
lieim.
Clinical Report on Epithelial Cancer of the Lip. By Jona-
than Hutchison, M. D.
This report embraces a statistical analysis of one hundred
ami twenty-seven cases of epithelions of the lip, occurring in
hospital practice, in allot' which operations for the removal
of the disease had been performed. The lower lip was air
ed in ninety per cent, of the cases, the upper in four per cent,
and the angle of the mouth in six per cent. From the series,
we rind that women are subjects of the disease in the propor-
tion offive t every hundred males, and when they are affect-
ed, it frequent in those who are in the habit of smoking.
of the patients was fifty-eight years, the
tremes being twenty-eight and eighty-two years. In all
cepting about twelve cases was the disease primary.
The results of the operations for the removal of cancer of
the lip in one hundred and twenty-seven cases may be
:ned up a- follow
tree patients died of erysipelas within ten days of the
operation : in seven, the cancer returned in the wound : nine
had a return of the disease in the cicatrix at different periods
r the operation; in five the lymphatic glands becami
ibsequently; three had the same ion the op-
posite part of the lip : and one hundred and five are reported
as having recovered from the operation, having left the hos-
232 Diagnosis of Apoplexy. [March,
pita! with sound cicatrixes. Inasmuch as most of the reports
were made within a few months of the operation, a sufficiently
long period had not elapsed to discover whether the disease
had returned in a larger proportion of cases than above indi-
cated.
Diagnosis of Apoplexy.
Mr. Foelman, the Professor of Physiology in the University
of Ghent, communicated to the Academy of Sciences at a re-
cent meeting, an account of some curious phenomena which he
had observed in a a dog, with some remarks upon an exami-
nation which he made of the animal after its death. During
several months, while attending a family as physician, he had
noticed a dog which appeared to be in perfectly good health,
and possessed of all his instinctive faculties, but which was
totally unable to co-ordinate his voluntary movements; fre-
quently, during the course of the day, he was observed to
whirl himself round, always in the same manner, and for
more than a quarter of an hour at a time. Upon making an
examination of the body, M. Poelman found nothing peculiar
in the thoracic and abdominal vicera, but in the cerebellum,
and especially in the middle cerebellar peduncles, there ex-
isted a considerable number of calcareous concretions which
gave a very firm consistence to these parts ; the scalpel, which
he employed for the purpose of cutting into this substance was
much notched; in short, the cerebellum, with the exception
of the vermiform process was, so to speak, petrified. M.
Flourens who brought the communication before the Academy
after commenting upon the exact relation which was shown in
this case between the pathological phenomena, and symptoms
and the functions of the disordered parts, said :
On this occasion, I request the Academy to permit me to
make some general remarks upon the diagnosis of apoplexy,
the feasibility of which appears entirely proved by my re-
searches upon the encephalon. By these researches I have
shown that the encephalon, considered as a whole, is com-
1 of three distinct parts essentially, that is to say, function-
ally.
1. The brain, properly so-called, consisting of the cerebral
or hemispheres, the seat of intelligence.
The cerebellum, the seat of the co-ordinating power.
:t keeps in equilibrium the movements of locomotion.
The prolongation of the spinal cord, or more exactly
at part of this prolongation which I have named
1861.] Delirium Iremens. 233
the vital protuberance or point, the seat of the principle of
life itself.
Hence, three classes of apoplexy may be arranged; the
cerebral apoplexy, the cerebellar apoplexy, and the bulbous
apoplexy. The symptoms of these are only deranged func-
tions ; the functions once known, nothing is more easy than to
trace the symptoms to the organ which is injured or diseased,
intelligence marks the seat of the apoplexy to be in the
brain properly so-called (the cerebral lobes or hemispheres) ;
the derangement of the balance of the movements of locomo-
tion denotes the seat of the apoplexy to be in the cerebellum ;
whilst sudden death would lead to the opinion that the seat of
the apoplexy (apoplexie foudroyante), was to be found usually
in the vital protuberance, although sudden death may depend,
of course, upon a certain degree of lesion in several other
parts of the encephalon.
I suppose, here, simple cases of apoplexy, because 1 speak
from a physiological point of view, the science of thh physiolo-
gist being to separate organs and their peculiarities, in order
to arrive at simple facts. In pathology, facts are almost al-
ways complicated ; it is seldom that a single organ only is dis-
ordered, and several organs are frequently, more or less, in
this condition. Hence, for the physician diagnosis is more dif-
ficult than fur the physiologist; but the plain laws, laid down
by physiology, may serve as guides, and lead to the unravell-
ing and analysis of complicated cases. London Medical Re-
Hoffman!* Anodyne in Delirium Tremens. F. 13. A. Lewis.
I was at Deer Island Hospital for a few months after my
graduation, and while there treated quite a number of cases
of delirium tremens, and of intemperance, the latter in-
cluding those who had irritation of the stomach, and the
"shakes," as some term the state, but not amounting to de-
cided delirium. I employed the various means presented
by the text books, and watched the success of students in the
same Institution, with variable success ; and atone time, think-
ing that Hoffman's anodyne might answer the indications, I
: it in 17 cases of delirium tremens and 14 cases of intem-
perance, in doses 5-s. every hour, and of the 31 cases I did not
'ne. Perhaps this will not in the least interest you, but
as I see the journals tilled with new treatments for this dis-
. and being a subscriber to the Journal, I thought it pos-
sible it might deserve a space in its pages. Huston Mea.dk
Surg. Journal.
234 Continued Fever. [March,
On the use cf stimuLents in the treatment of Continued Fever.
By I). Tweedie, Physician to the London Fever Hospital,
&c.
Speaking upon this subject in his recent Lumleian lectures
before the Royal College of Physicians, Dr. Tweedie says :
" It is always necessary to watch the effects of the h'rst few
doses of wine, and if the pulse abates in frequency, becomes
soft and fuller, the tongue moist, and the heat of the skin not
increased ; and, when there lias been delirium, if the- patient
becomes more calm, and has intervals of sleep, we may feel
Bure that the wine is doing good. On the other hand, if the
pulse increase in frequency and strength, the skin becomes
hotter, and the patient restless, flushed and excited, with
throbbing of the temporal and cartoid arteries, we may con-
clude either that wine is -not suited to the case, or has
been given too earh', and should therefore be withdrawn.
But, as a general rule, it is perhaps better to give wine a little
too early than a little too late, since, if it appears to disagree,
it is easy to suspend its use ; but it may be very difficult to
restore the vital powers if they have been allowed to remain
too long unsupported.
"Nor should the wine or brandy be discontinued until con-
valescence is fairly established ; but as the symptoms for
which the stimulants have been prescribed disappear, the quan-
tity should be gradually abridged by giving smaller portions
and at more distant intervals.
"In regard to the amount of wine and alcoholic stimulants
that may be administered in typhus, no precise rule can be
laid down, as the ever-varying circumstances presented by in-
dividual cases can alone determine this. It is prudent to be-
gin with half an ounce or an ounce, and to repeat this amount
at longer or shorter intervals, according to the effect produced,
from six to twelve ounces may be considered to be an aver-
age daily allowance, but sometimes it is necessary to give two
or three pints, or even more, in twenty-four hours, and, it is
surprising to observe, without the slightest intoxicating effect,
even when the patient has been previously unaccustomed to
stimulants. Indeed, in low lever-, the exhausted state of the
nervous system appears to be antidote to the effects of stimu-
lants in short, to create a tolerance of vine and diffusible
stimulants.
'The wine should always be conjoined with nourishment, in
onicr to assist its due assimilation, though in many cases the
digestive powers are so feeble that they are unable to elabor-
1861.] tinned Fever. 285
ate oven the Lighest articles of \'oo(\, and therefore the wine
or brandy may be given simply diluted with water.
"I have just alluded to the daily quantity of wine that it
may be necessary to prescribe in typhus, and stated th.it no
precise rules can be laid down, as the circumstances of each
must determine it. You are doubtless aware that there
is a great tendency in the present day to revive the Brownon-
ian Bystem, which flourished for a time in the latter part of
the last century, in all acute diseases, including fevers, without
regard to individual peculiarities. The doctrine inculcated
by some teachers with respect to inflammation is, that this
process being a deranged nutrition, involving supply and
waste, and the waste being considerable while the inflamma-
tory process lasts, there must be a compensating supply ; that
as the supplies for the formation of the abnormal products of
pus and lymph must be drawn from the blood, or from both,
the vital powers become exhausted, in proportion to the or-
ganic disintegration that takes place. Hence it is concluded,
that the more the inflammatory process drawn upon the blood
the greater will be the exhaustion of vital force, and the con-
sequent effect upon the whole frame.
"Upon this physiological theory of the phenomena of inflam-
mation is based the overthrow of established therapeutic prin-
ciples, on which the treatment has been for ages conducted.
But surely'even the abettors of this theoretical view must ad-
mit, that the object of treatment is to anticipate or prevent
those. so-called destructive processes : in other words, to pro-
mote resolution by all available means. Is this to be accom-
plished by extravagant doses of wine and brandy, regardless
of the ever-varying condition of the sufferer or period of the
disea-
"Similar reasoning is adduced in regard to the phenomena
- whatever be their type or special circumstances. It
gainst the indiscriminate employment of stimulants in fever
that we protest, being convinced that their proper adminis-
tration requires as much consideration as is generally bestow-
ed on other measures employed as curative agents.
"The enormous quantities of wine and brandy recommend-
ed in even the early stage of fevers, whatever be the form, the
individual circumstance.-, or whether there be local affections
present, have often surprised me, and inclined me to doubt
the accuracy of the statements. 1 have certainly Been inter-
current inflammations materially aggravated by the injudici-
ous stimulation adopted, and on more than on< n all the
ordinary characters of acute delirium tremens supervene
236 Acute Rheumatism. [March,
when the unlimited administration of brandy had been left to
(lie discretion of a nurse, who fancied that she was only obey-
ing instructions when she poured down dose after dose of pure
brandy. There is surely no practical philosophy in such in-
discriminate abuse of a really valuable remedy when given
on rational principles; and I deem it the duty of every physi-
cian who is convinced of the dangerous tendency of the
Brownonian doctrine applied indiscriminately in the treatment
of diseases, acute as well as chronic, to express his opinion
boldly and decidedly, that the young and inexperienced prac-
titioner may be warned of the dangerous consequences of this
recently revived doctrine. ":;" "':'
"Let me also allude to the importance of giving the wine
at stated intervals, and only when the excitement is moderate.
It is especially necessary to give it during the night, when there
is often great exhaustion. A dose of wine judiciously given
at this diurnal period is often followed by calm, refreshing
sleep; and hence the incalculable advantage of an interested,
experienced nurse, on whom so much responsibility indeed
the life of the patient often rests.'*
The conditions attending every attach of Acute Rheumatism .
By Dr. Wheelock, of Belfast, Maine.
An experience of twenty years, we are told, has convinced
the author that every access of acute articular rheumatism is
immediately preceded by a special condition of the nervous
system, induced by mental anxiety or by the action of the de-
pressing passions; and that if, when the body is in this con-
dition, a suppression of the sensible or insensible perspiration
have taken place, the result is invariably acute rheumatism.
"This truth," Dr. Wheelock natively adds, "though a simple
one, is to my mind, startling, and, without egotism, the most
important pathological discovery in the present century."
Reference is made to fifty cases of acute rheumatism as
supporting this view, and a dozen of these is given in illustra-
tion, which can scarcely be regarded as altogether conclusive,
seeing that few human beings suffering from any malady will
not present some traces of the action of mental anxiety or de-
ing passion, if such traces be sought after.
This view, according to Dr. Wheelock, suggests an addition-
al indication of treatment. "It is to bring into operation the
requisite normal influences. The patient is to be made to
1861.] Purpura Hemorrhagic*. 237
understand the true nature of the disease and its cause. Though
it cannot be expected that every individual shall exercise the
force necessary to the forgetting or ignoring mental agitation
in these cases, yet it may be presumable that a knowledge of
the real producing cause may not only prevent a recurrence
of it, but will greatly assist in fortifying the sufferer against
its protracted continuance. In my own experience, I have
found, when patients are informed that it has been brought
on themselves by a mental agitation that might seem to have
been avoided or was inexcusable and needless, the disease has
been shortened in its course or immediately stopped ; and
where there had been successive attacks, the patients
had thus been apparently spared these recurrences."
On the use of ScsquleJiloride of Iron in the treatment of Pur-
pura Ilemorrharjia. By M. Pize, of Montelimart la
Drome.
This paper, which was read before the Parisian Academy
of Medicine, is divided into two entirely distinct parts ; one
relating to the exposition of practical facts, the other to the
modus operandi of the remedy. M. Pize holds, without much
show of reason, that the drug has a sedative action upon the
heart ; and this opinion led to a prolonged and futile discussion
in the Paresian Academy of Medicine upon the action of
medicine in general. The practical facts are of considerable
interest.
In the tirst case, a girl, twelve years of age, presented for
six days all the symptoms of typhoid fever, and simultaneously
suffered from epistaxis, turgidity and sanguineous exudation
of the gums, expectoration, emesis, sanguinolent motions and
urine ; numerous ecchymoses were disseminated over the
surface of the limbs. This condition had persisted for a wholo
:. in spite of sulphuric acid, lemonade, extract of rhatany.
. mustard poultices, &c.
three and a half ounce mixture, containing fifteen grains
of liquid sesqui chloride of iron, was prescribed. In twenty-
four hours, the hemorrhagic tendency was checked, the urine
alone remaining sanguinolent. The pulse, which had been
very frequent, returned to 80 pulsations. On the following
day no blood was discharged, and the spots of purpura as-
sumed a dark hue. From that period, the disease proceeded
rapidly towards cure.
238 Purpura Hemorrhagla. [March,
The subject of the second case was a lad of sixteen, who,
after considerable growth and hard work, with insufficient
food, was seized with febrile symptoms, extreme prostration
of strength, and, on the fourth day, presented numerous spots
of purpura on the limbs, witli sanguinolent motions and epis-
taxis ; the pulse rising to 100 pulsations.
A four-ounce mixture, with fifteen grains of sesquichloride
arrested the hemorrhage in twenty-four hours, and reduced
the pulse to 90 pulsations. The p"btion was continued the
next day, and all the symptoms ceased. The Medicine was
then discontinued for two days. Epistaxis returned twice,
but with less violence than before. The pulse again rose to
100. The mixture was resumed ; on the ensueing day no
hemorrhage took place, and the pulse declined to 82. Con-
valescence was very rapid under the influence of the sesqui-
chloride, which was continued for several days; a small
quantity of substantial food and wine were also prescribed.
M. Pize's last case refers to an unmarried woman, twenty-
five years of age, who, two years before, had presented symp-
toms of chlorosis. After live or six days' indisposition, intesti-
tinal hemorrhage appeared, epistaxis and numerous spots of
purpura on the limbs. The pulse was weak, and rose to 119.
The day after the use of the chalybeate potion, hemorrhage
ceased, the pulse returned to S6, and fell two days later to 02.
The disease terminated as in the two preceding cases.
M. Pize then adverts to the analogous case, published sub-
sequently to his own, by Bourguignon, a case in which the
reporter deemed it expedient to add a fourth, recently publish-
ed in the "Gazette Medicale de Strasbourg,'' by Sir. Leroy,
de Saint-Ybars.
The following, in M. Pize's estimation are the obvious infer-
ences from these four eases, all relating to purpura hemorr-
agia.
1. Sesquichloride of iron is pre-eminently the agent for the
cure of the disease ; it arrests the hemorrhagic tentendeney
in the space of twenty-four or fourty-eight hours, and, con-
tinued, for a few days, rapidly brings about the convalescence
of the patient.
2. This medicine produces an immediate diminution in the
rapidity of the circulation, decreases the quickness of the
pulse; in twenty-four hours Irom 110 to SO pulsations, and may
therefore fairly be considered as a direct sedative of the ac-
tion of the heart.
1861.] Observations on Syphilis. 239
Observations on Syphilis.
In an essay read before the Rutherford County Medical
Society, May 3, 1860, Dr. L. M. Wasson, of Murfreesboro,
Term., attempted to prove syphilis to be the parent of
scrofula (Nashville Jour, of Med. and Surg. But this asser-
tion, although admitted in part by others, is loosely based
upon the impaired vitality, prostration and cachetic condi-
tion of the system, induced by syphilis, and resulting in the
"lymphatic temperament, which is the temperament of
scrofula." The system is thought to become inclined to
the scrofulous diathesis, because every fibre of the economy
cannot but be affected by "blood vitiated with ingredients
so incompatible with every tissue of the body," as the
venereal virus. Supposing that to be true, as far as it goes,
it does not follow as undeniable fact, "syphilis does pro-
duce, in every particular, the scrofulus diathesis," nor that
it is "a most powerful and frequent cause of scrofula."
In order to corroborate the assertion of Dr. Cullerier that
hereditary syphilis is always %due to maternal influence,
[Memoires de la Societe de "Chirurgie, torn, iv., p 230) Dr.
Xotta has published a memoir containing a number of ob-
servations which go to show, that the issue will be free
from the disease when at the time of conception the mother
was free from it, notwithstanding the father may have been
affected either at the time or previously, but that syphilitic
children will be the result where the mothers have been
subjected to the influence of the virus previous to concep-
tion, while the father was then suffering or had passed
through the disease. In registering these facts, we are not
prepared to admit the conclusions drawn from them, pre-
ferring to wait for the result of a more ample experience.
Arch. Gen, de Jlcdec.
Prof. Sigmund, of Vienna, finds the proto-iodide of mer-
cury only applicable to the papular and pustular forms of
syphilis, and even there it is slower in effect than other
mercurial preparations. Its reputed peculiarity of not in-
ducing salivation is groundless ; even when combined with
opium, it gives rise to diarrhoea, and in obstinate forms of
the disease, it is of little or no use, while in anemia it is
positively injurious. It by no means deserves the prefer-
ence given to it in the treatment of children, and admits
only of further trial in some obstinate" forms, combined with
iodide of potassium, but not in subjects disposed to catarrh
240 Observations on Syphilis. March,
of the longs, stomach or intestines. Wien Wochensehr.:
Mai Times and < <
Prof. Ik-bra has given, in one of the late meetings of the
Medical Society of Vienna his experience since 1858 of the
treatment of syphilis by syphilization. Taking the matter
from a simple chancre, he continues the inoculation as long
as pustules are formed, or until all the syphilitic symptoms
have entirely disappeared. Patients, upon whom no more
pustules arc produced, even by repeated inoculations from
different chancres, are pronounced "immune." The inocu-
lations were made three times a week, commencing with
four punctures in the side or upper arm and then in the
thighs. The aggregate number of punctures reached from
7 to G04. The earliest immunity ceased after the nineteenth
inoculation, or the forty-second day, with seventy-six punc-
tures; the latest by 219 punctures after 150 days. The pa-
tients, with the exception of two, received no medicine, not
even a warm bath, but were allowed nutritious food and
walking at pleasure. The artificial pustules were covered
with a piece of oiled linen : frequently it took from three
to six weeks to heal them up. A few patients, in whom
inoculation had not been pushed to immunity, were attack-
ed again with syphilis. Out of twenty-four (three with pri-
mary chancres, nineteen with secondary syphilis, two with
non-syphilitic lupus serpiginosus) fourteen had been dis-
missed, the rest remaining under treatment. The applica-
tion of mercurial ointment in two cases did not influence
the development and course of the artificial pustules. All
patients made perfectly immune are permanently cured.
They feel perfectly well during the inoculation, improve in
appearance and gain in weight; by and by all syphilitic
symptoms disappear. Parallel experiments, however, prove
the decided superiority of mercurial treatment. Wien
Wochensehr.: Oglethorpe Med. and Surg. Jour.
Against syphilitic chaps and fissures of the toes, an oint-
ment containing litharge, white precipitate and a few drops
of laudanum, has been used with marked success in many
of the hospitals of Germany. The same ointment is recom-
mended for the serpiginous and phagedenic ulcers which
asionally supervene upon vaccination in children of a
Bcrofulous or syphilitic- constitution. The process of cica-
trization is practiced by bathing the soivs with a decoction
of hemlock and marsh-mallows. Med. CJdr. li
1S61.] mors of the Breast 4J U
On (he Diagnosis of Tumors of (I '. By John Erich-
Ben, Professor of Surgery and of Clinical Surgery in Uni-
versity College, &c.
[In the present article Mr. Erichsen treats principal!
the diagnosis of cancer of the breast from cystic and adenoid
tumors of that organ.]
These cystic growths, though not so common as cancer
and the other solid tumors, are yet of by no means infre-
quent occurrence. They are of three distinct kinds :
1. Those in which the tumor consists of a singular unil-
ocular . 2. Those which consist of several independent
segregated together into one tumor multilocular
3. Those in which a series of small cysts are dif-
fused through a fibrous or hypertrophied mass; in fact, a
combination of cysts with a chronic mammary tumour.
Two theories are in vogue as to the origin of this form of
ic development. According to one set of pathologists,
it is produced by the obstruction and subsequent dilatation
of a lacteal duct. But this theory, I think, is weak : from
the fact of our not being able to trace one of these ducts
into the cyst ; from the fact that the fluid contained in these
cysts Bhowfc no trace of lacteal origin ; and from the fact
that such cysts are met with elsewhere, in places where no
lacteal duct previously existed. The other theory is, that
these cysts entirely new formations ; and this, partly for the
reasons before mentioned, and partly because tin-
closely resemble those met with in other secretory glaj
both as to structure and contents, appears to me to be t
more tenable of the two.
These tumors, I must premise, whether unilocular, mul-
tilocular, or consisting of cysts diffused in a mass of fibrous
or hypertrophied gland-tissue, are always composed of thin
Avails, formed of condensed cellular tissue, and containing
in their interior a fluid variable in amount and character ;
being in one serous, in another glairy, and in a third bloody ;
it is very commonly of a light straw color, not unfrequently
it is brown, and sometimes sanguineous, but these differ-
ences are accidental and of no importance.
We will now consider the diagnosis of tin
growths from cancerous and other solid tumors of the
breast. And, first, with regard to the unilocular cyst ; this
is the most common form, and occurs generally in women
at what one might call the "cancerous age," forty-five to
fifty ; it is frequently referred to pressure, or to a 'blow on
10
242 Tumors of the Breast. [March,
the part, or it may be connected with uterine disturbance
at the period of the cessation of the mensus. Thus so far
as the age and proximate cause are concerned, the history
throws comparatively little light on the subject, and the
diagnosis has therefore to be made entirely by palpitation
and examination of the tumor. Xow you can easily con-
that, depending only on manipulation to form a cor-
rect judgment of the nature of the tumor, the surgeon may
be exceedingly liable to form an erroneous opinion. I could
relate to you many cases in which error of diagnosis has
occurred, but I will confine myself to a few of the more
illustrative.
I was requested some time ago, by my friend, Mr Wal-
ter Wilson, to see a married lady, aged 45, who had in the
it breast a tumor oi about the size of an apple, hard and
painful on pressure. This, she said, had been diagnosed
as a fibrous tumor by a surgeon in the country, who had re-
commended her to come to London and have it removed.
On examining the tumor I suspected it to be a cyst. It had
not the stony hardness of a solid tumor, but felt obscurely
elastic on deep pressure. Acting on this supposition, I in-
troduced an exploring trocar and let out about two ounces
of dark serous fluid ; the cyst never refilled, and the patient
went borne perfectly cured.
I was requested one day to see an unmarried lady, aged
On going to the house I found her bathed in tears, and
Bisters in great distress around her. I was told she had
a tumor of the breast, which had been pronounced to be a
or. On examination I found a tumor in the right
nma, about as large as a pigeon's egg. It had been no-
ticed about fourteen months previously, and the patient had
been under both medical and surgical treatment for it. It
rounded, circumscribed, situated at the outer and upper
pari of the gland, hard but smooth, and not heavy to the
feel, On close manipulation, I felt some elasticity. I told
the patient that I did not think it was a cancer, but a cyst,
and that if I punctured it and drew off the fluid contained
in it she would probably have no further trouble. She
>rmed me that she had seen an eminent surgeon,
mii.) had pronounced it to be a cancer ; had explained that
ration was necessary ; that the whole of the breast
removed, and had fixed an early day for its perfor-
i requested to meet this gentleman, but this was
ed by the patient and her friends; and as our opinions
1861.] Tumors of the .Breast. 243
differed so widely, it was agreed that she should have the
benefit of Sir B. Brodie's opinion. That distinguished
geon saw the case with me the next day, and, lie haying
acquiesced in the opinion I had expressed, I tapped
. and let out about an ounce and a half of yellowish
serous fluid. The tumor collapsed, all idea of operation was
abandoned, and the patient has continued well up to the
present time.
I saw the other day a very similar case. It was that of
an unmarried lady, aged 48, who had had for about twelve,
months a tumor in the left breast, which had gradually in-
creased in size, until it had attained the magnitude of a
Tangerine orange. It was hard, circumscribed, situated at
the axilary border of the gland; it had also been pro-
nounced to be scirrhus. But, suspecting from its elasticity
that it was cystic, I punctured it with an exploring trocar,
and drew off about ten drachms of clear fluid, causing the
immediate subsidence of the tumor.
Xow here were three cases of simple cystic or fluid tumor
of the breast, which had erroneously been pronounced to
be solid, and which would have been submitted to amputa-
tion of the mamma if the mistake had not been discovered
in time. It is of very great consequence, therefore to be
cautious in these in pronouncing a definite opinion,
and to neglect no means in perfecting your diagn<
How is this to be don : As l have already stated, the
history very often throws no light on the nature of these
case*. Cysts occur at the same age and among the same
class of people as cancer of the breast, but there is one cir-
cumstance of great importance to which you must al .
attend, and that is the presence or absence of elasticity.
This last character may be said to be the great diagnostic
point between these tumors and cancer; and whenever you
feel, or even suspect, elasticity, you ought to introduce an
exploring trocar. If the tumor is c^ystic, the fluid escapes,
and you probably hear no more of the case. But if, on the
contrary, it is solid, a drop or two of blood only oozes out,
the puncture soon closes, and no harm is done. In making
tin* puncture, there is one little point to be attended to, and
that is, if you use an exploring needle, take care to posh it
aight in, and not to make the puncture in any way valvu-
lar: for if you do, the fluid may not escape, and rims ,
rious mistake may arise ; it is, however, far better, in all
cases, to use the exploring trocar in preference to the
grooved needle.
-44 Tumors of the Breast. [March,
If this little operation tapping does not procure the
closure of the cyst, you must resort to other measures, such
as injecting it with iodine, introducing a seton, or, if these
fail, excision of a piece of the cyst-wall. But you will gen-
rally find that tapping and the subsequent use of iodine lo-
tions will suffice to effect a cure.
The next kind of cyst the multiloeular is more difficult
to diagnose than the unilocular; firstly, because it is gene-
rally seated deeply in or beneath the gland, while the unil-
ocular occurs chiefly at the border or anterior surface, and
because there is not so much fluctuation, owing to the fluid
being divided among several cysts. But vet there is that
never-failing sign of cystic disease elasticity. You will
find, however, that there often exists a good deal of con-
densed fibrous matter round about these tumours, and hence
the removal of the whole gland may be required, the extir-
pation of the cystsalone being impossible. ( )ne reason why
cyst-tumors are often so difficult to diagnose as such., is that
they arc often associated with cancer. There great difficulty
exists, especially in the early stage ; and these eases are ex-
lingly liable to be confounded with cystic sarcoma, and
indeed in some cases you cannot make your diagnosis until
the tumor is removed, and then only by a careful micro-
scopic examination.
A woman, aged 45, was admitted into this hospital with
a tumor of the size of an orange, situated in the right mamma
deeply over the pectoral muscle. It had existed for about
five years, was not adherent to the skin, and there Were
several cysts of the size of plums. .At the upper part of the
mass, which could be felt through the lately mucuous co-
vering, the nipple was not retracted; there was only one
slightly enlarged gland in the axilla. Now here were all
the characters of a "cystic sarcoma" slow growth, no adhe-
sions, eysts, and no material glandular implication; and
yet. after the removal of the breast, the microscope reveal-
ed the tumor to be distinctly and decidedly cancerous.
?OU will sometimes find that tumors of a tixed, possibly
a semi-malignant character, occur with cyst.-, and give rise
to great difficulty in the diagnosis of their exact nature, and
render it Impossible for you to pronounce with certainty
whether tiny are benign or malignant. The following is a
of this kind.
An unmarried lady, 40 years of age, and in excellent
health, was sent up to me by my friend, Mr. Tuxford, of
1861.] Tumors of the Breast. 245
Boston, last November, with a tumor of the right breast,
which, without assignable cause, had commenced growing
about live years and a half ago : it increased slowly until it
had attained the size of an orange about two years since,
but afterwards much more rapidly, until at last it reached
the size of an adult's head. The skin covering it was not
reddened, and though thinned, was neither adherent nor in-
filtrated. There was no pain at night, or after handling it;
and no enlarged glands could be felt in its neighborhood.
The superficial veins were much enlarged over the tumor,
and a good sized artery was felt to pulsate over its upper
part. It was elastic, lobulated ; and a large mass, of a cvs-
tic character, projected from its anterior surface. There
were no adhesions between it and the pectorals, or to the
skin. The operation was performed on November 10th.
On removal, I found that the tumor weighed ninety-six
ounces, and consisted of large encapsuled masses, of a dull
grey or brown color. One section, it was solid in parts, and
infiltrated with a gelatinous fluid; in others, there were
large cysts, containing several ounces each of dark stringy
mucoid fluid. Dr. Harley, who examined it, pronounced
it to be colloid. There were also masses of fibroplastic
deposit in some par
Now her*1 was a case that approached closely to malig-
nancy in its local characteristics, without any constitutional
symptoms of cachexy ; and which presents an appearance
nn examination that renders it doubtful whether it may or
not yet recur.
The next class of cases to which 1 would direct your at-
tention are the chronic mammary or adenoid tumors. These
are uf exceedingly common occurrence ; and there are two
or three coeditions with which they are often ass<
the knowledge of which materially assists the surgeon in
his diagnosis. 1. With regard to the age, they generally
;r before the cancerous age, in early womanhood, be-
tween the ages of 18 and 25. 2, They are almost invaria-
bly slow in their progress. 3. They are lobulated, dist:
non-adherent to the skin or pectorals and eireumscrl
4. There is no cachexy or glandular enlargement: and, in
fact, they appear to be ^uite local and benign. T
usually I to which they can be assigned ; but I be-
lieve that they frequently occur in young women of nervous
temperament, and are commonly associated with uterine
disturbance kind. The chief diagnostic points are,
246 Tumors of Ike Breast. [March,
therefore, the age of the patient, the slowness of growth of
the tumor, and the perfect freedom from constitutional
symptoms ; but yet any one of these conditions may be
present in cases of undoubted cancer of the mamma.
Scirrhus very rarely occurs at the early period at which
the adenoid tumor is common ; but yet it is occasionally
met with in young women. Some years ago I removed in
this hospital a tumor from the right breast of an unmarried
female, aged 23. It was as large as a small flattened
orange, was hard, nodulated, but not adherent to the skin.
There was no retraction of the nipple, and it had been
growing for about eight months. No cause could be as-
signed for its appearance, and it was supposed to be adenoid.
However, on account of the large size of the tumor, as com-
pared with that of the somewhat atrophied mamma, I
removed the whole of the breast, together with the tumor ;
and it was well that I did so ; for, on microscopic examina-
tion, it was found to be scirrhus. The patient subsequently
married : and when I last heard of her, two years after the
operation, she was in good health. Now here is a case in
which cancer occurred within the period usually assigned
to chronic mammary tumor ; and hence you cannot rely
altogether on the age of the patient as a means of diagnosis.
Next, with regard to the slowness of growth ; although
it is an undeniable fact that benign tumors usually grow
slowly, and that rapidity of growth is generally a sign of
malignancy of action, yet this rule must also be taken with
exceptions, as in the following case :
Last June, I was requested to see an unmarried lady,
I 40, of a nervous sanguineous temperament, who had
been in bad health tor many years, suffering from uterine
disturbance, dyspepsia, and latterly from pulmonary symp-
toms. At the age of 18 that is, twenty-two years previous
to my advice being sought she noticed for the first time
a small tumor in her left breast. This continued perfectly
stationery, and about the size of a pigeon's egg, until last
February, when it for the first time became painful, and be-
rapidly to enlarge. Being at this time in Italy for the
(it of her health, this lady saw two distinguished
.an surgeons, who, after careful examination and ex-
ploratory punctures, pronounced the tumor to be a " mye-
." and recommended extirpation of the mamma. The
patient, however, preferred to return to England, and have
the operation performed here. On her way home she saw
1861.] Tumors of the Breast. 247
Velpeau in Paris, who with a great accuracy of diagu
pronounced the tumor to he benign, and gave her a written
statement to that effect. AVhen I saw her, on her return to
this country, in June last, I found a tumor of the left: mam-
perfectly mobile, firm, solid, inelastic; it had attained
the size of an adult's head, and was rapidly increas
There was no glandular enlargement in the axilla ; the skin
was thinned and reopened, but not adhered; the super:'
vessels were much enlarged, a tortuos network of veins and
one or two large arteries running over the tumor. There
was no constitutional cachexy : but the patient's health
and strength were at the lowest ebb, from general and J
standing constitutional derangement: and she could not
sleep at night, not so much from pain (which, however, was
constant, and at times very severe,) as from the constant
anxiety of mind which the presence of the growth pro-
duced. Sir B. Brodie and Dr. Walshe, who saw the case
in consultation with me, both agreed that it was probably
benign, but that no operation was practicable until the
patients state of health was improved. However, by atten-
tion to diet, and by being put on a proper plan of treatment
this was so much ameliorated that in July last, I was ena-
bled, with the assistance of Mr. Marshall and Dr. Cowan,
of Glasgow, to perform the operation for its removal. This
was attended by no difficulty, and by very little hemorrhage,
notwithstanding the size of the tumor, which weighed
rather more than live pounds. The patient made an excel-
lent recovery, and was able to leave town in less than three
weeks. On examination after removal, the tumor was found
to be lobulated on its surface. The section showed it to be
homogeneous, and of a uniform greyish color, with no soft
points or cysts, but distinctly and firmly encephalous. Dr.
Harley, who examined it microscopically, found it to be a
specimen of the chronic mammary tumor of Sir Astley
Cooper. In the plastic matter taken from different lobules,
examples of the glandular tissue were found. Some of the
blind tubes were remarkably distinct, and well filled with
cells. There was no trace of cancer.
Xow here was a tumor which, after remaining of sm;ill
size and stationary for more than twenty years, suddenly,
and without obvious cause, began rapidly to increase : so
much so that in less than six months, it had increased in
size from that of a pigeon's egg to the magnitude of a mas-
weighing more than four pounds. Here was extreme ra-
Tumors of the Breast. [March
pidity of growth without malignancy of character. In fact,
this extreme rapidity of growth resembled rather what is
not un frequently found in cncephaloid disease, than what
we exped to meet with in the chronic mammary tumor,
and rendered the diagnosis not a little difficult; the more
was possible that the chronic mammary tumor,
which had existed for so many years in a stationary and
ive condition, might have suddenly undergone malig-
nant degeneration, and thus taken on rapid increase of
bulk. This, however, was disproved by the careful micro-
pical examination made by Dr* Ilarley, who found that
tumor did riot present a trace of malignant structure.
It is, however, important to hear in mind that cystic and
told tumors may remain for a long time inahenign and
ive state, and then assume a malignant character. This
happened in the case of a woman, aged 48, who was sent to
the hospital by my friend, Mr. Adams, two years ago. At
the age of 27, she had first observed a tumor in the left
breast. This had slowly increased in size, until it had at-
tained, at the end of fifteen or sixteen years, the size of the
foetal head. When I first saw it, in January, 1858, one of
the cysts <>f which it was composed, had ulcerated, and a
thin sero-sanguineous discharge oozed out of the opening.
The general health was good. There was no glandular en-
largement iu the axilla, or adhesions of the skin, except,
around the ulcerated parts. It was freely moveable on the
pectorals. An operation for the removal of the tumor was
] >roposed, hut this the patient refused to consent to. At the
end of six months, she returned with a large ulcerated
cavity in the centre of the tumor, and fungati ng masses
sprouting from the bottom of it. There was still no cachexia
or enlarged glands in the axilla. The patient now consent-
ing to an operation, I extirpated the whole mass with the
ama. <>n examining the tumor after its removal, it was
found to he cystic. There were several large cysts, of the
size of pigeons' containing turbid hut light colored
us fluid. The central portion of the tumor, and that at
: the fungus were .-olid, grey, and rapidly under-
going softening and disintegration. (>n squeezing the por-
tion of the mas# (the base of the fungus) a milky juice
led; and Dr. Ilarley who examined the tumor, stated
n to be encephaloid. the sarcomatous structure heyond
this, constituting the general mass ^l' the tumor, appeared
1,. be adenoid. The Burface oi' the fungus, when exposed
and protruding heyond the cyst, was epitheliomatous.
1861.] On the Treatment of Favus. 249
Now here were cjt oma, cncephaloicl and epithe-
lioma, associated in one growth. The encephaloid was
staled by Dr. Ilarley to be cellular, without fibres, showing-
rapid development. The epithelioma was confined to the
surface of the fungus. The history of this case, the very
lengthened period (more than twenty years) that the tumor
had existed, the absence of all constitutional cachexy, ot
deep adhesions, or of glandular enlargement or other secon-
dary deposits, and its appearance only six months previous
to removal, all pointed to primary simple cystic disease of
the mamma, in which, as the result of secondary changes,
encephaloid had developed itself; being an instance of the
conversion of a simple into a cancerous tumor of the
breast. This patient died about a twelvemonth after the
operation, of gangrene of the foot and disease of the heart.
The cicatrix was quite sound ; but in the substance of one
of the ventricles a nodule was found, which was considered
by those who examined it to be of a cancerous nature.
MedicalJournal, April 14, I860,;;. 279.
On the Treatment of Favus. By Dr. W. T. Gairdner,
Physician to the Royal Infirmary of Ediuburgh, Lecturer
on Clinical Medicine and on Practice of Physic.
[In the case which forms the text of the following re-
marks, the head was at first covered with yellow crusts, of
long standing ; exactly four days afterwards, there was not
a vestige of a crust to be seen, nor even any broken sur-
face, though the patches of absolute baldness and the
stunted and diminished hairs in many places, showed clearly
the deep hold the disease had taken. The change was en-
tirely due to the successful poultices of linseed meal.]
tuch has been written about favus. and so many
perfi - have been recorded in periods varying from
six week veral months, [am almost afraid t<> state
my conviction ti result above mention
obtained in four days under linseed meal poultices, was
quite as much entitled to the name of a cure a- any that I
hav< -i or heard of either in the nature or in tic
cord with
<>PI ortunitn ion emending over less than a year
or two [fi idence of nothii than the
250 On the Treatment of Fat [March,
most entire ignorance of its habits. I do not, however,
doubt the cure of favus. Soap and hot water, with abun-
dant scrubbing, the hair being kept short, will commonly
keep the yellow crusts indefinitely in abeyance : as will
also, perhaps, more thoroughly and effectually, the simpl
oil inunction. There seems no reason, therefore, to beli<
(though hospital physicians can but seldom hope to witness
the result) that those simple means, long and perseveringly
usea\ will not erl'cct the cure of a disease which owes its
origin and perpetuation to nothing else than want of clean-
lin< -
Under ordinary circumstances, what takes place after an
apparent cure of favus, is this : So long as the hair is kept
shaved, and an alternation of oily applications with soap and
water is maintained, the disease does not reappear: but on
neglecting these precautions for a few weeks, yellow dots
begin to crop up. and these rapidly extend so as to become
distinct favus crusts, which in no long time, if uninterfered
with, will cover the whole head. I have repeatedly kept
eases under observation after the head had been completely
cleared, in order to observe the first beginnings of the erup-
tion after the suspension in the treatment ; and I have also
employed a great variety of medicated ointments and lo- .
tions, including sulphurous acid, iodine and sulphur oint-
ments, empyreumatic oils, mercurial ointments, and mixed
medications of various kinds. After most of these, I have
seen the disease reappear about as quickly as under the
simpler treatment b}T oil and soap. If there is any of them
in which I have faith more than another, it is in empyreu-
matic oils, as the juniper tar oil or common pitch ointment.
But the inveteracy of the disease evidently depends, not on
the difficulty of removing its visible traces, but on the com-
plete infiltration (so to speak) of the scalp with the sporules
of the fungus in all old standing eases ; and no treatment
will be of the slightest avail towards a radical cure that is
not deliberately and carefully pursued until a complete
growth of scarf skin has been obtained, perfectly tree from
all traces of the noxious germs. This must, of course, be
the work of a considerable time: just as it i^ a work of
time, and of unwearied attention to simple details, to rid a
virgin soil of ragweeds and whins, or even of stones. No
application of a specific can he expected to meet the one
any more than the other.
One point, not always Observed by those who have writ-
1S6L] Ulceration of the Rectum. 251
ten on this subject, is, that favus is often, perhaps even in
the majority of cases, implanted on the basis of a previous
eruption ; in other words, that the fungous crusts, or vege-
table mould, are sown on a soil already the seat of impetigo,
eczema, or some other variety of disease of the skin. Some-
times the original disease has died out when the favus first,
comes under treatment ; at other times, it still persists and
requires separate treatment. In the corirse of considerable
and varied experience of true favus, however, I have not
seen a single case that did not at once yield to local treat-
ment, to the extent I have indicated above ; and I am very
far from believing that any constitutional disorder has to
do with the production of the fungus, further than that
favus and other diseases may arise simultaneously, under
exposure to the same causes of filth, neglect and hygienic
errors of every kind, in every variety of boclilv constitution.
Edxn. Med. Journal, May, 1860. p. 1003.
On Ulceration of the Lower Extremity of the Rectum : its Va-
rieties. Diagnosis and Treatment. By James Rouse, Esq.,
Assistant Surgeon to the Westminster Ophthalmic
Hospital, kc.
Xotwithstanding the numerous works published on dis-
eases of the rectum during the last few years, there appears
still to be great difference of opinion as to the best mode of
treatment ; more particularly with regard to those ulcera-
tions situated on the mucous membrane lining the sphinc-
ter ani, and in the fossa immediately above that muscle.
There are three forms of ulceration of the lower extremity
of the rectum, which gave rise to very acute suffering ; and
although they vary considerably in position, have neverthe-
been described by most authors under the general head
of fissure. It is proposed, in the present paper to po'ntout
that three distinct forms of ulceration occur in this region,
which, by ordinary investigation may be distinguished from
each other, and which require different modifications of
treatment.
The most common form of ulcer found at the lower ex-
tremity of the rectum is that which is known i re of
the anus. This disease does not seem confined to any par-
ticular period of life, though it rarely or ever exists until
252 aeration of the Rectum. [March,
after puberty. It is more particularly common among per-
who lead a Bedentary life, and for the same reason it is
rather more frequent in women than men. The fissure ap-
pears to be by a tearing of the mucous membrane
lining the sphincter ani, by the passage either of hardened
> of a foreign body contained therein. The follow-
ing cases will, however, show that fissure of the anus may
lally be the result of external violence:
Case 1. A gentleman, aged 24, was riding a restive
horse, when it. suddenly bolted. He was thrown with some
violence, on the hind part of the saddle before he recovered
his seat. He felt some pain about the anus at the time,
and, on changing his shirt, he noticed a lew drops of blood.
For the next few 'lavs he experienced a slight burning pain
during the evacuation of the bowels, and in about a week
the characteristic pain of fissure was established. On an
examination being made, a small crack was perceived on
the posterior surface of the sphincter; it commenced about
two lines within the anus, and extended upwards for about
half an inch. Various local means were tried without
benefit, and an operation to he hereafter described, was had'
recourse to with perfect suet
Case 2. A captain in the navy fell off a ladder, and came
to the ground on his buttocks, with considerable force. He
did not observe any particular pain until he went to stool
the- following morning, when he experienced considerable
smarting, and noticed that he had passed a small amount
of florid blood. About a week alter the accident, he ap-
plied for advice, lie then, alter every evacuation of the
bowels, had pain, which lasted for several hours. On ex-
amination, an ulcer was found on the posterior surfac
the lining membrane of the sphincter : e not
indurated, and the surface was florid. An ointment, con-
taining mercury, was applied twice a day : and in the
course oi' a week a cure was effected.
Persons afflicted with this die describing the origin
of their Buffering, frequently state that while -training vio-
tly a1 stool, tlicy felt something give way, and on look-
heir evacuations, they n>lice<l a small quantity of
iod. h has more than oner occurred to mete be told by
with fissure thai the \\"r<>< were so bard that it was
from the an
This crack or fissure is almost invariably situated on the
! surface o\' the sphincter. 1 have seen upwards of
1861.] ration of the Rectum.
a hundred cases, and in only six did the position vary; in
three of these the fissure was situated on the perineal sur-
face of the muscle, and all occurred in women ; in two it
was Bituated on the leftside ; and in one on the right. It
commences about three lines from the margin of the anus,
and extends upwards in a straight line to the extent, usual-
ly, of half an inch, though sometimes as high as the supe-
rior margin of the sphincter. It the fissure he seen within
a week or ten days of its occurrence, it presents the appear-
ance of a bright red line with a sharply defined edge, and
does not appear to extend through the thickness of the
mucous membrane. A little later, if no treatment he
adopted, one or two florid granulations may frequently he
D protruding ahove the margin ; and it is during this
. v that a small amount of blood is voided on going to
stool. This appearance is very soon changed ; the edges
hecome everted, and more or less hard, and the surface of
the ulcer itself looks excavated and pale, like any other in-
dolent sore. The pain caused by this solution of continuity
is at first trifling, and only exists while the motion is pass-
ing ; hut it soon becomes most severe. It usually com-
mences about half an hour after the bowels are relieved
(the sensation up to that time being only uneasiness) and
continues for live or six hours. As the disease progresses,
the pain becomes more continuous and easily excited, and
even walking or sneezing will bring it on. At this stage,
the ulceration is found to have extended through the sub-
mucous cellular tissue into the fibres of the sphincter;
there is a constant desire to pass urine, a serious addition to
the other suffering, and this continues until relief is obtain-
ed by means of an operation.
This second form of ulceration is situated immediately in
front of the os cocygis, and was first described by Sir B.
Brodie, in a clinical lecture delivered at St. George's Hospi-
tal. This ulcer, which is almost invariably co-existent with
an enlarged and varicose state of the veins about the rec-
tum, does not, like the one just described, appear to be
Bed by a tearing of the mucous membrane. Mi". Quin
Btates, in his recent work 'On the Diseases of the Rectum '
that he has noticed a case in which, "the disease having
been of no long duration, and the suffering comparatively
slight, the membrane appeared to be thinned from beneath."
The ulcer, once formed, soon increases in size, and usually
remains quite superficial for a considerable time ; but at
254 Ulceration of the Rectum, [March,
-!h, from the continual irritation, the edges become
and hard. The surface, however, seldom becomes
so indolent as in cases of ordinary fissure ; and in this form
of the disease the ulceration seldom, if ever, implicates the
fibres of the sphincter ani. The pain which, as in fissure,
-used by the evacuation of the bowels is most intense;
there is usually very little spasm of the sphincter, but the
patient complains of severe lancinating pain, which gradu-
ally subsides into a sensation of burning, which continues
for three or four hours.
The third form of ulcer is situated in the fossa which ex-
ists between the external and internal sphincters; it is by
far the most painful and serious affection of the three. It
appears to be caused either by the lodgment of a small por-
tion of hardened freces, or by injury done to the mucuous
membrane in that situation by the passage of some foreign
body, such as a fish-bone. Two cases are known to me
where the presence of a polypus of the rectum (the extre-
mity of which was pressed into this fossa every time the
bowels were relieved) caused an ulcer in this position.
The ulcer, at first, is seldom more than the eighth of an
inch in diameter, and it is generally somewhat deeply exca-
vated. As the disease progresses, the ulceration extends
into the substance of the sphincter ani ; so that, when the
finger is passed into the rectum, the end of it sinks into a
small cup-like cavity, the inferior part of which is formed
at the expense of the superior margin of the sphincter.
Except in cases of long standing, the edges are not indura-
ted, and the surface almost invariably remains florid. In
this disease a certain amount of pus and blood is passed at
each relief of the bowels. If this ulcer be not cured by
means of an operation, it leads to a most troublesome form
of stricture of the bowels. The constant irritation set up
by the action of the bowels gives rise to inflammation of
the submucous cellular tissue ; this causes thickening and
hardening, by which means the calibre of the outlet is seri-
ously diminished.
The following case will illustrate this kind of termination :
Mrs. S., aged 23, complained of very severe
pain before, during, and after the relief of her bowels. She
had consulted a surgeon, who, on examination, found an
ulcer immediately above the external spincter. An inci-
sion was made through the ulcer into the tissue below ; but
this did not produce "the slightest relief. Six months after
1861.] Ulceration of (he Rectum,
the operation, she noticed that the discharge was much in-
creased in amount, and she found more difficulty in passing
her motions, which were small and flattened. A year sub-
sequently to the operation, I saw her, and, on examination,
discovered an ulcer of considerable size situated on the
posterior surface of the rectum, and involving the superior
margin of the sphincter, and such extensive thickening of
the submucous tissues that the finger could not be passed
through. Subsequently, by means of bougies, considera-
ble benefit was obtained.
In these cases, the pain complained of is most severe, and
there is more spasm of the sphincter than in simple fissure :
in some of these cases the amount of spasm is so great that
the muscle increases considerably in size. The pain ap-
pears to commence some little time before the bowels are
relieved, probably this is caused by the pressure of the load-
ed bowels upon the ulcer.
Diagnosis. The diagnosis of these cases is by no means
difficult. The peculiarity of the pain complained of, the
fact of its coming on either during, or soon after, the action
of the bowels, and the ease with which these ulcers may be
detected by the finger, when it can be introduced into the
bowel, render a mistake almost impossible. There exist
only two diseases with which these ulcers may be con-
founded : to wit, a syphilitic ulcer and spasmodic contrac-
tion of the sphincter. Neuralgia in the neighborhood of
the sphincter has such well-marked symptoms of its own,
that it can scarcely be mistaken. With regard to the syphi-
litic ulcer, its characteristic appearance, the class of persons
affected, the existence of syphilitic ulceration about the va-
gina, remove all doubts as to the nature of the complaint.
The diagnosis between spasmodic contraction of the sphinc-
ter and fissure is rather more difficult; in fact, it is only by
a most careful examination that the surgeon can determine
whether an ulcer exists or not. There arc, however, a few
points of difference which it would be well to remember.
In spasmodic contraction of the sphincter, the muscle very
rapidly increases in size ; the anal orifice becomes so con-
tracted that even a gum catheter cannot be introduced with-
out producing extreme suffering. This amount of spasm
is most rare in ulceration, and it is the pressure caused by
the finger on the ulcer itself that produces the pain.
rin, in ulceration, it matters little in which form, sooner
or later, there is always discharge of pus and blood : in
Ulcerations of the Rectum.
[March,
smodic contraction, this never occurs. Lastly, the pa-
tient having been placed under the influence of chloroform,
a careful examination of the bowel can he made (which it is
impossible to do without producing insensibility) and, as
in the following case, no ulcer is found to exist.
George , aged 45, a man of spare habit, sal-
low complexion and depressed vital powers, complained of
intense pain, which occured during the lime the bowels
ting, and for several hours after. The pain was not
Lnuous, but came on in paroxysms every few minutes.
The motions were very small and flattened ; but there was
no discharge or appearance of blood. On examination, the
Bphineter muscle appeared more developed than usual, and
the anus was so contracted that it was impossible to intro-
duce the finger. A speculum ani was employed, and the
most careful examination failed to discover any ulcer. Un-
der these circumstances, a small bougie, about six inches
long, was introduced every other night. At first the pain
caused was very great, and he was unable to retain it for
more than three or four minutes ; but he was soon able to
bear it for a longer time. The size of the bougie was grad-
ually increased, and he was ultimately cured.
Case 5. A gentleman, aged 35, of spare habit and ner-
vous temperament, had suffered with symptoms like those
just described, for six months, and the pain had become so
severe that he could not take exercise; he had tried various
means to obtain relief without success. The most careful
examination failed to discover any ulcer, but the sphincter
was immensely hypertrophied. Bougies were employed
for two weeks without producing the slightest relief, and
the patient was so worn out and irritated by the pain he
suffered, that he could not be induced to continue the use
of them. It was therefore decided to divide the sphincter,
and with the exception of the pain produced by the passage
of the fieces through the wound, this patient never suffered
any inconvenience afterwards.
I should not have insisted so strongly on the existence of
this disease, but one of the most recent writers on diseases
of the rectum doubts the existence of simple spasmodic
Dstriction of the sphincter.
There is one other precaution necessary in these cases;
and that is, to be quite certain that only one ulcer exists.
It is not very unfrequent to find two; they may be either
. above the other, or situated on opposite sides.
1861.] Ulceration of the Rectum. 257
The treatment required for the ulcer in front of the os
coccygis, and for fissure, varies according to the si
the disease. If it be treated before it has become indoli
local applications, and attention to the state of the bowels,
are all that is necessary. Grey oxide of mercury and s]
maceti ointment, (half a drachm to the ounce) or a scruple
of calomel to an ounce of lard, with ablutions night and
morning, and after each relict' of the bowels with yell
soap and water, will usually effect a cure. Great cure must
be taken in the choice of a laxative, the object being not to
purge, but to render the faeces soft, so that as little stretch-
ing as possible of the ulcer should take place. Confection
of senna or milk of sulphur generally produce the desired
effect. A very common medicine in these cases is confec-
tion of pepper : this, combined with confection of senna
very useful in cases of hemorrhoids, but it is apt in all cases
of ulceration to produce considerable aggravation of the
patient's suffering. When the ulcer has once become indo-
lent, the best and only treatment (likely to prove beneficial)
is by the knife. The operation is best performed in the
following manner. The patient being placed on the right
side, with the knees drawn up to the chin, the forefinger of
the left hand is to be introduced into the rectum, and the
knife passed up in front of it; the incision is then to be
made, commencing a few lines above the superior margin
of the ulcer, and to be carried through it down to the ex-
ternal skin, care being taken not to cut into the fibres
the sphincter, except in those cases where the disease has
already involved that muscle. After the incision has been
made, a small piece of oiled lint may be introduced into the
wound. It is better not to allow any action of the bowels
to take place for two or three days after the operation ;
this may be effected by giving a small dose of opium or n
milk diet.
The treatment required for the ulcer situated above the
sphincter is division ot the muscle. Local remedies never
appear to afford the slightest benefit, but only tend to wear
out the patience and spirits of the sufferer. The operation
is to be performed in the same way as for fissure : but, in-
stead of merely making an incision into the submucous
tissue, the sphincter must be divided by one cut, the wound
is then to be dressed in either with oiled lint or silk.
It is of course always prudent to try local means before
proceeding to an operation ; and the best application is the
17
268
Essential Nature of Asthma.
[March,
ointment of grey oxide of mercury, already mentioned.
most satisfactory method of applying the remedy is by
>fa suppository tube. The tube should first be lu-
bricated outside, and then filled with the ointment ; it is
then to be passed into the bowel to the extent of an inch or
an inch and a half, and the piston then pushed down; by
this means the entire surface of the mucous membrane
lining the sphincter is covered by the ointment.
Some surgeons recommend the application of nitrate of
silver for these forms of ulceration ; but it seldom proves
very beneficial, and the pain it causes is quite as severe as
that of the division. If it be attempted, a speculum should
be introduced into the bowel ; by this means, the ulcer is
brought into view, its surface should be dried by a piece of
sponge or list, and the caustic freely applied. British Med.
Journal, May 12, 1830, p. 358.
On the Essential Nature of Asthma. Bv Dr. II. Hyde
Salter, F. R. S.
There are two ways (which I have not mentioned in my
work) as indicated to be by my friend, Dr. Brown Sequard,
in which bronchial spasm, when once established, may be
kept up by the very conditions which it generates; one is,
the power which carbonic acid gas possesses of producing
contraction in smooth muscles. In asthma, the deficient
standard at which respiration is carried on, and the dimin-
ished interchange of the gases, produces an accumulation,
in the air locked up in the air passages, of carbonic acid to
an unusual degree. This, by the action to which I have
just referred, sets the bronchial muscles still further con-
tracting, and thus increases the very condition which at first
caused the accumulation of the effete gas. In this way,
asthma keeps up asthma. The other way is by the bronchial
3m stimulating the afferent or perceptive nervous fila-
ments, and thus giving rise to retlex muscular contraction ;
just as the stimulation of the sensitive roots of the spiral
nerves produces reflex muscular phenomena in the parts to
which the corresponding motor nerves are distributed. In
way, muscular spasm becomes a stimulus to muscular
But in both these, as in the other ways 1 have indicated
iu my book, the bronchial spasm is secondary to an antece-
dent nervous condition. British Medical Journal July 28,
18M, p. 589.
1861.] Gonorrheal Rheumatism. 259
Reasons for regarding Ghnorrhceal Rheumatism and Ophthalmia
as simply Urethral Rheumatism or Ophthalmia, fie. By Dr.
Elliotison.
u My first knowledge of the disease in question," says
Elliotson, "was obtained from Sir Astley Cooper's lectures,
which I attended at St. Thomas's Hospital in 1806-7, and
1807-8. How many years previous he had mentioned or
seen it, I cannot say. He pretended to no merit of discov-
ery, but related, in the most artless manner, the communi-
cation of the facts to him by a patient. 'An American
gentleman,' he said, 'came to me with the clap, and I told
him he might think himself well off to be so little affected.'
4Oh,' said he, 'a clap with me is a serious thing. When I
had it before, I was attacked a few days after the infection
with an obstinate inflammation of the eyes that was follow-
ed by rheumatism.'" "I thought," continued Sir Astley,
''that he might have caught cold while taking mercury; but
he said he had taken none. I therefore watched the disease,
and in a few days his eyes became inflamed, and after that
one of his knees swelled, and then the other became affect-
ed with chronic inflammation. He was attended by Dr.
Relp, of Guy's Hospital, and myself, for many months. He
left this country uncured; but I heard that he got well on
his voyage. Since this case I have seen a great many more
such."
"It was very natural to suppose, before our experience
became enlarged, that the disease was the result of gon-
orrhceal contagion, and that the appelation gonorrhoeal
rheumatism, given naturally to it from its alliance with
gonorrhoea, must have increased the tendency to this view.
We cannot, therefore, at Sir Astley Cooper believing that
the ophthalmia was produced, not indeed by the application
of gonorrhoeal secretion accidentally to the eye, as may
happen with any careless patient, but still by the absorp-
tion of it into the system, and that the proper treatment of
the rheumatism, produced to his view of course by the same
poison, was the same as of gonorrhoea half a drachm, ac-
cording to him, gradually increasd to a drachm, of copaiba,
with spirits of turpentine three times a day. We have no
ific remedy for gonorrhoea, any more than for measles,
latina, or small-pox ; and those drugs must in many
-Tavate gonorrhoea; and they would aggravate many
cases of the rheumatism. Copaiba, cubebs, and some analo-
260
Gonorrhoea! Rheumatism .
[March,
goua drugs, arc useful occasionally in gonorrhoea, but not
more so than in similar uncontagious affections of the geni-
tal passages, and possibly of some other mucous membranes.
If there is no reason to ascribe specific powers over gonorr-
hoea to them, neither is there any to conceive that they can
be remedies of the rheumatism bearing the distinction of
gonorrheal. Xor are the}'.
"The belief now generally prevalent, of the rheumatism
in question rheumatism with urethral discharge and in-
deed of the ophthalmia, being really the product of gonor-
rhoea! poison, is, I am satisfied, as unfounded as previous
generally prevalent disbelief that rheumatism and ophthal-
mia arc ever connected with gonorrhoea. It was long be-
fore this struck me; for I had always read of these forms of
disease, and heard them spoken of, with the epithet gonor-
rheal ; and had not seen them except in gonorrlicoal patients.
After a time I received the assurance of one or two patients
that the affection of their genitals could not have arisen
from infection ; but it made no impression upon me, be-
cause I am familiar with the untruths which arc often told
upon these subjects, and because patients do really some-
times fondly deceive themselves as to the character of those
with whom they intrigue. But, as years passed on, more
instances of the alleged impossibility of infection presented
themselves to me and some such patients, I felt certain,
could have no reason to deceive me, were too much endowed
with self-respect to stoop to an untruth, and were too acute
to be themselves in error. Some have told me this, long
afterwards, when they had ceased to incur the possibility of
catching any disease of the genital organs. I knew no one
inclined to this view till five years ago, when, accidentia
meeting with a surgeon, a married man and a father, who
had consulted Sir Astley Cooper and myself twenty years
at least previously for what we had all termed gonorrhecal
rheumatism, and since which time I had not heard of him,
I was told by him that, before he married, he had again
suffered a few attacks of rheumatism and urethral discharge,
"ii which occasion the idea of infection was altogether out
of the question, as he had not been exposed to the possi-
bility of risk. At this period he had no inducement to de-
ceive me as to his former lite; and formerly he had always
been candid when suffering for irregularities. He added,
that since his marriage he had occasionally suffered in the
Bame twofold manner as when he was irregular and single.
1861.] Gonorrhml Rheumatism. 261
I was much pleased, and I communicated to him that my
convictions of these affections being improperly termed
gonorrheal was as strong as his own.
Farther experience, up to the present moment, has set
the question completely at rest in my mind. Indeed, al-
though the circumstance is not noticed by the profession,
some writers clearly entertain this opinion, and state facts
which establish it, and yet lay no stress upon its difference
from the commonly received views. I have just found that
Sir Benjamin Brodie, in his Pathological and Surgical Ob-
servations on Disease of the Joints, published in London in
lsls. gives live cases of the disease witnessed by himself;
and remarks that in one the patient could not ascribe the
discharge to infection, and in another patient suffered from
strictures in the urethra, and, although rheumatism took
place twice with gonorrhoea, it took place twice also when
there was no gonorrhoea, but the urethra was in a state of
irritation and discharge through the mere introduction of
bougies employed on account of the strictures. He there-
- it may occur without infection. Brandes also con-
siders that the rheumatism may be re-excited after all gon-
orrhoea lias ceased, if the urethra is irritated by any common
cause; and speaks of this rheumatism as blenorrhaqique
(gonorrho&al) and trawrnatiqiie (such as from the introduction
ot a foreign body into the urethra.; Marechal gives a case
o{ rheumatism, that had followed an urethral discharge pro-
duced by nothing but the immoderate use of new beer, and
had never occurred in the man before.
"My own experience, extending through so many years,
renders it impossible for me to doubt that specific and con-
tagious nature i< unnecessary to the urethral irritation
which in certain persons gives rise to rheumatism and to
ophthalmia also in others that the mere irritation is suf-
ficient, and in fact La the cause, and that the gonorrhoea],
conts character is incidental only. The combination
<f ti <>f other writers with my own will, I hope, settle
stion. The single case of syphilitic infection of a
lady by secondary symptoms in the hand of her maid record-
ed by me in the Medical Times of September 4th, 1
removed all possibility of farther doubt respecting the
occurrence of infection from secondary sores. The d<
mination of the production of rheumatism by simple urethr-
al irritation is effected by the repeated experience of many
of us continued through a large number of years. The im-
262
Gonorrheal Rheumatism.
[March,
pedimenl to the perfect knowledge of what is known as
gonorrhoea! rheumatism was its extremely rare occurrence
among the instances of rheumatism at large on account of
comparatively small number of persons affected with
irritation of the urethra, and the still smaller number of
ons among these that have the unfortunate peculiarity
of liability to rheumatism from it. The impediment to the
knowledge of simple irritation of the urethra being the cause
was still greater on account both of the great rarity of simple
oared with gonorrhoeal irritation of the urethra, and of
few individuals indeed being the subjects of both
simple urethral irritation and liability to rheumatism from
irritation of the urethra. Those who, from habit, regard
this kind of rheumatism and ophthalmia when allied with
gonorrhoea as, therefore, gonorrheal, must remember that
very case of gonorhcea there are two circumstances
united the irritation of the urethra and the specific nature
and that the latter cannot exist without the former may
* without the latter. Consequently, no case of gonor-
rhoea! rheumatism or ophthalmia depends upon the specific
the gonorrhoea! nature of the urethral affection, and not
upon the irritation irrespective of specific nature.
V little experience of this rheumatism impressed me, as
it has done many others, with certain characteristics, audi
detailed them in clinical lectures above twenty years ago.
1. I saw and see it so frequently in the feet that when-
ever a rheumatic man has walked into my library lame
from rheumatism of his feet, I have startled him with the
question how long he had been suffering under gonorahoea.
It not unfrequently affects the hands, perhaps, as I once
saw, a single joint only; the wrists and elbows; but the
lower extremities most frequently, the knees as well as the
feet : the lips also. It may effect any joints, and several at
one time or in succession ; the loins also and back of the
neck. I saw it once in the joint of the jaw.
2. Its obstinacy and extreme duration are remarkable.
The longest ease 1 ever saw was the jaw, and after two or
three attacks imperfect rigidity, I believe, became promi-
nent.
3. I am not aware of ever bavins: seen it in a femal
e.
Bui gonorrhoea is comparatively rare in women, as one loose
t!<- contaminates Bcores of men, and, however great the
number of Loose women, the number oi'men who have been
1861.] Gonorrhce.al Rheumatism. 263
occasionally loose is almost equal to the number of all
men.
4. But the most important and perhaps an invariable
point in its character, is its inflammatory nature at first, and
for a very considerable time. This struck me before I had
seen many instances of the disease, and I did not find that
it had been noticed. But Sir Benjamin Brodie, whose book
upon diseases of the joints I had never seen, had possibly
made the same remark ; for previously, in fact above twelve
years before I was aware of witnessing the disease, he had
written that colchicum was the best remedy for it ; and the
great utility of this medicine against rheumatism I believe
to be in the inflammatory form. Not only is the disease,
but its inflammory nature, disposed to coutinue very long.
Yet at length, and after a long period, the time may arrive
when the iodide of potassium, tonics, and general and topi-
cal stimulants are the suitable means ; and forcible exten-
sion of the joint may be proper. Till that time arrives, the
treatment should consist of patient abstinence from ferment-
ed and distilled liquids and flesh food, the removal of exter-
nal stimulants, rest, and a position which favors the presence
of as little blood as possible in the affected part or parts, the
discreet use of colchicum and other purgatives, and the re-
peated application of leeches. The same kind of treatment
is suitable to the ophthalmia, which, however, is seldom so
obstinate. I believe that the rheumatism occurs in general
earlier than the ophthalmia; it often occurs alone, and
and there may be differences in these two particulars in the
same individual in different attacks.
5. These two affections bear no relation to the intensity
of the urethal. The smallest discharge will produce the
rheumatism, and perhaps the ophthalmia likewise, in the
predisposed ; nor is the intensity of duration of these in
proportion to the degree of the urethal ; and they, or one of
them may continue after the urethal.
[ have known several persons suffer from gonorrhoea
more than once without either of these consequences, and
then become subject to them ; but only one individual es-
cape an attack of rheumatism after every occurrence of
gonorrhoea when once rheumatism had followed the appear-
ance of urethal discharge. I have seen the predisposition
to this urethal rheumatism in several men of the same fami-
ly, whether the irritated state of the uretha was gonorrhoeal
or not.
2G4 GonorrhcBol Rheumatism. [March,
"The predisposition is a great misfortune, because, as
, as the urethal affection begin, the patient feels certain
of an attack of chronic rheumatism; and though it may
take place in a few days, it may not for a considerable time,
but is sure to come ; and the mildness of the urethal affec-
tion dors not foretell a mild attack.
UI will tinish by relating two cases one illustrating the
benfit <>f employing the living hand in treating urethal
rheumatism, the other the power of rigid abstinence in diet
to prevent it.
"Mr. C , set. 29, a married man with a young family,
living at 25, C G , got wet while affected with
gonorrhoea, and was seized suddenly out of doors with rheu-
matism. He became crippled, and could walk only with
;-.v- sticks, for the parts attacked were his hips, knees, and
soles of the feet. His eyes become inflamed. He took a
large quantity of medicine, and the medical attendant
honestly told him that drugs would do him no good. When
he had thus suffered for four months from rheumatism, the
having recovered, it was resolved to try the effect of
merely drawing a hand very lightly, slowly, and straight,
along the affected parts for half an hour daily. This treat-
ment was commenced on September 24th. In a fortnight
his pain was lessened ; in another fortnight so great was
the improvement that he could walk a considerable dis-
tance ; in another he declared himself nearly cured, and be-
fore the end of another he was well and able to work.
Without this treatment he, no doubt, would have been crip-
pled till at least the end of the year.
Although the disease was excited by cold and wet, yet,
as the man was laboring under gonorrhcea at the time, he
will henceforth probably be attacked with rheumatism
whenever he catches gonorrhcea. The case is interesting
ffording an example of urethal rheumatism originating
from ordinary exciting causes during the urethal affection,
for in general these have not been noticed in the first attack
ami certainly are not requisite for the production of subse-
quenl ones.
"The other case is mosl important. A married gentle-
q had labored under very obstinate rheumatism of the
m his last two contractions of gonorrhoea. T had no
btthat this would occur now as often as he caught a
rhoea, and i begged him to let me sec him as soon
he found he had contracted it again, lie did so a
1861.] Short-Sight. 265
year ago, and I immediately prevailed upon him to abstain
entirely from all fermented and distilled fluids and every
description of flesh food. Ho strictly obeyed my injunctions
for several months, and has perfectly escaped rheumatism,
although the urethal discharge continued slightly all the
time in spite of injections weak and strong and of all kinds,
for, although he lived low, it was not in his power to refrain
from walking."
Or the Surgical treatment of Short-Sight. By Mr. J. V. Solo-
mon, Surgeon to the Birmingham Eye Infirmary.
Mr. Solomon appears to have hit upon an operation by
which the focal range of short-sighted persons whose corner
are not conical, may be doubled in length. He has found
the plan especially successful, whether the eyes are promi-
nent or small, the aqueous chambers deep or shallow. He
has tested the operation on cases varying from the age of
twelve to fortv-five vears. A man of the latter aire, who
had worn double concave glasses of immense depth (Xo. 16)
for a great number of years, and, unaided by lenses, could
vith clearness the features of a person to know them at
a distance of nine feet only, obtained at once by the opera-
tion an increase of seven feet in his focal ranire. In a child
o
of twelve years of age, the operation increased the reading
distance from four to eight inches, and the power of identi-
fying persons' features from twenty to forty yards : and in
one sixteen vears of age, the effect was still more remark-
able.
These results have been obtained by dividing in a trans-
verse direction some fibres of the muscles of the lens the
ciliary muscle. Mr. Solomon does not consider it material
which part of the muscle is selected for division, but gener-
ally prefers either the upper or the lower part of the circle.
Supposing the latter situation to be selected, and the patient
to be seated in a chair, the operator stands behind, and
fixes the globe with the left fin.: in extraction, hold-
ing a cataract knife in his right hand, with the fiat of the
ie directed upwards, he pushes the point in succession
through the corneo-selerotic union, the pillars of the iris,
I the ciliary muscle. The direction given to -tru-
ment is obliquely downward and ontwai is taken
that the incision in the muscle is of the same Length as the
L2GQ Strangulated Hernia. [March,
puncture of entrance, namely, about two lines or two lines
and a half in diameter. In some cases Mr. Solomon has
found that the power of adapting the eye to distant objects
has been increased by practice and lapse of time.
In a young man who had been myopic from his child-
hood, and had suffered for the last three years from conges-
tion of the retina, the visual power and focus have been so
much increased that the outlines of large buildings at a dis-
tance of a mile and a half can now (six weeks after the
operation) be distinctly made out ; whereas before the cili-
ary muscles were divided they appeared as mist.
A new method for the reduction of Strangulated Hernia. By
Mr. Walter Jcssop, Surgeon to the General Hospital and
Dispensary, Cheltenham.
In May last, Mr. Jessop was called to a case of strangu-
lated hernia (left oblique inguinal), in a man aged fifty-two
years. The accident had occurred some thirty-six hours
previously. The taxis, opium, chloroform, hot baths in
short, all the ordinary modes of treatment, had been perse-
veringly applied, without success.
At the time of his visit, he found his patient in a partial
state of collapse, in a profuse cold perspiration, with great
tension of the abdomen, and symptoms of hiccough and
nausea coming on. The patient complained bitterly on his
lightly attempting an examination ; indeed, the part seem-
ed so exquisitely painful as at once to negative all hope of
success irom further direct efforts at reduction. An imme-
diate operation was proposed, but firmly declined by the
patient and his friends. Desiring them to seek further ad-
vice, Mr. Jessop left the room, but was immediately recalled
with a request that he would permit an hour's delay.
Agreeable to this, and while waiting in the house, a thought
struck him that it might occasionally be possible to relieve
a patient under such circumstances without having recourse
to the knife. On explaining this to the patient and his
friends, they at once consented to a trial of the means pro-
posed.
Calling a male attendant into the room, he directed his
patient, still lying on his hack, to the edge of the bed, and
with assistance, separated his legs, placing one over each
shoulder of the attendant, who, facing the bed, stooped to
receive them; and, in this position, by passing his hands
1861.] Strangulated Hernia. 267
round the fore part of the thighs, was enabled to obtain suf-
ficient purchase to permit of his raising him on to his head
and shoulders on the bed, thus throwingthe intestines baek
upon the diaphragm, and to some extent necessarily making
traction behind and directly from the scat of strangulation.
After two or three minutes' manipulation of the abdomin-
al parietes, he found the tumor become less tense, and
drawing forward the integuments round the point of rup-
ture, he made lateral upward, and downward movements
jerking as it were, occasionally, the parts immediately con-
tiguous to the structure. This seemed to excite but little
suffering ; in fact, the patient, so for from uttering complaint
declared himself, after the first two or three minutes, decid-
edly relieved that "the dead sickening weight that killed
his groin," as he termed it, was better. Continuing these
efforts, and varying them as they seemed to occasion dis-
tress, he presently felt a slight gurgling under his head, and
almost immediately had the satisfaction of finding the
hernia reduced, and his patient in a comparatively safe state.
The whole proceeding did not occupy ten minutes. Slight
peritoneal tenderness existed for some days, but the man
eventually did well.
The rationale of the proposed plan is simple. A mass,
large or small, of displaced intestine or omentum must as-
suredly be more readily withdrawn from its point of incar-
ceration or strangulation by traction from behind, than by
the best directed efforts of the taxis. Any one, for illustra-
tion, taking the trouble to put a fold or two of his handker-
chief in a ring formed by his finger and thumb, and lightly
strangulating it, will, on attempting to return it by pushing
or kneading from before backwards, find indefinitely great-
er difficulty in effecting his purpose than it he were to make
traction from behind. In short, the employment of the
taxis is at the best a clumsy and most uncertain mode of pro-
ceeding, and in future the author intends to make it mere-
ly supplementary to the plan he now advocates.
"One swallow fails to make a summer," and it may be
said that the practice of turning patients a posteriori up-
wards is opposed to all orthordox notions of propriety. Ad-
mit all this. Others, with greater opportunities, may hap-
pily be enabled to add to this single case; and granting
that the position of the patient may be dot positive
inelegance, it may, at any rate, contrast favorably with our
proceedings in lethotomv, and in many other operations on
the perineal region.
268 Phimc [March,
New operation for Phimosis. By M. Ridreau.
The well-known operation lor phimosis, practised by M.
Ricord, leaves scarcely anything to he desired under ordi-
circumstances, at least in the opinion of the majority.
Some, however, object to the permanent exposure of the
glans which asive a removal of the foreskin entails.
To meet the views of surgeons holding this opinion, we
quote the description of an operation, designed and success-
fully practised by M. Ridreau, a French military Surgeon.
'Stretch the prepuce by drawing the mucous membrane
forward, and the skin back, so as to lay bare the orifice of
the foreskin: introduce a slender cylindrico-conic wooden
rod into the aperture of the prepuce ; perform a circular
incision at about half aline from the mucous margin, di-
viding the skin only, which immediately shrinks backward
on the glands: maintain the mucous lining upon the wood-
en rod, and remove circularly a sufficient quantity of it to
give i'veo play to the glans in the aperture resulting from
the operation. Join the edges of the wound of the skin and
of the mucous membrane by a few small needles and twist-
ed suture. If a vessel bleeds, apply one of the sutures on
that spot."
The wounds heals in a few day.- with water dressing, and
then the condition of the organ is perfectly normal, the glans
being covered or exposed at will. Examination of the
anatomy of the parts explains the success of this operation.
The constrictionis seated in the mucous membrane, and this
is removed. Moreover, the skin of the penis unites with the
mucous membrane, not by a diminution of its substai
but by accommodating itself by numerous wrinkles (in the
usual manner of skin surrounding the sphincters) to the
destined aperture; accordingly, the moment it is divided
iilarly, it may, without difficulty, be drawn back upon
the penis. This operation p - peculiar io
'i; a very limited portion of the texture is removed, a
ring for the glans is retained ; no deformity results: the
. icatrix is Li: imperceptible as to be mistaken for the
natural junction of the skin and mucous membrane, and is
entirely concealed when the prepuce is drawn forward upon
the glans; the portion of mucous membrane removed be-
ing rephn-ed by integuments.
1861.] Editorial
EDITORIAL AND MISCELLANEOUS.
BOOKS FOR REVIEW.
We have received recently, from authors and publishers, quite a num-
ber valuable works ; some of which are the following : Researches upon
the VcDom of the Rattlesnake with an Investigation of the Anatomy
and Physiology of the Organs concerned, by S. Wier Mitchell, M. D.,
Lecturer on Physiology in the Philadelphia Medical Association. Tins
thorough and elaborate Essay is a publication of the Smithsonian Insti-
mtion, aud is presented in 145 pages 4to. When we can devote time
to its examination we feel assured that its condensation and review will
be of much interest to our readers.
From Messrs. J. B. Lippincott & Co., of Philadelphia, the two follow-
ing works, viz : Lectures on the Diagnosis and Treatment of the Prin-
ciple Forms of Paralysis of the Lower Extremities, by Dr. Brown-
Sequard, pp. 118, octavo. 18G1.
Also, by the same author, A Course of Lectures on the Physiology
and Pathology of the General Nervous System, delivered at the Royal
College of Surgeons of England, in May, 185S, published in this country
in i860, pp. 265, with beautiful illustrations.
From Messrs. Blanchard & Lea: Diseases Peculiar to Women, in-
cluding Displacements of the Uterus, by Hugh L. Hodge, M. D., Pro-
fessor of Obstetrics and Diseases of Women and Children in the University
of Pennsylvania, pp. 469, octavo, with numerous illustrations. Phila.
delphia. 18G0.
From same: Diphtheria, Its Nature and Treatment, with an account
of the history of its prevalence in various countries, by Daniel Denson
Slade, M. D., being the dissertation to which the Fisk Fund Prise wa.s
awarded July 11th, 1*60, pp. 85, octavo, with illustrations.
All of the above works have been trasnmitted to us through Me
Thomas Richards & Son, of this place, at whose store they will be found
by purchasers in this section.
Volume loth of the Transactions of the American Medical Associotion
has also come to hand, which, together with the other valuable works
above noticed, shall receive careful attention at our hands at a future
time.
270 Miscellaneous. [March,
Tartro-Ci/ric Lemonade Prof. J. Lawrence Smith expresses
(American Journal of Pharmacy, September, 18G0) his surprise that the
tartrate of Soda should have given place as a purgative to the citrate of
magnesia, a preparation which he very justly considers as obnoxious to
very many objections. Among these he enumerates "the not unfrequent
irregularity of its operation, sometimes not acting as promptly as de-
sired, at other times with too great and continued energy, requiring ano-
dynes to arrest its operation. Again, owing to the manner in which it is
made, and the want of uniformity in the composition of the commercial
carbonato and calcined magnesia, the amount of free acid in the solution
varies much when made at different times by different lots of materials.
There being sometimes two or three drachms of free acid present in a
bottle, and besides, under all circumstances, the mixture must be quite
acid in order to retain for any length of time the citrate of magnesia in so-
lution. Mitscherlich and Bcnce Jones has have both made experiments
on citrio acid, and they consider it a poison analogous to oxalic acid.
"Yet another objection to citrate of magnesia is the certainty of its
undergoing decomposition, resulting in the deposition of an insoluble
citrate of magnesia, a change that takes place very rapidly when the bot-
tle is opened.
"With these facts before me, I compounded a preparation of tartrate
of soda with lemon syrup and water (at first I introduced a small portion
of citric acid, calling the mixture tartro-citric acid lemonade.)
"It is free from the objections of the citrate of magnesia, is a prompt
and certain purgative, without excessive action, and uniform in compo-
sition, does not undergo decomposition even after the bottle is opened,
even more agreeable to the taste and less costly than citrate of mag-
nesia."
" Sal soda 21 lbs. 14 cz. avoirdupois.
Tartaric acid 15 " "
Sugar (white) 24 '
Water to make 25 gals.
"It is then put into strong twelve ounce bottles, and thirty-five grains
of bi-carbonate of soda added to each bottle, and immediately corked and
fastened with twine or wire.
"This preparation has been used in Louisville for about six years, and
is gradually extending over various parts of the west and south."
Banquet to M. Ricord. The banquet given to M. Ricord by his
confreres came off on Thursday evening. December, 20th, at the Hotel
du Louvre. The great dining room of this establishment, itself one of
the lions of Paris, afforded hospitality to about two hundred members of
the medical profession, who assembled for the double purpose of doing
homage to the great syphilograph and justice to a very copious and
recherche dinner. Great Britain, Germany, Sweeden, Ilussia, Greece,
Italy, the United States and South American Republics were all duly
represented on the occasion. London T^anrct.
1861.] Miscellaneous. 271
Strychnine in Typhoid Fever. In a clinical lecture, delivered at
the Mercy Hospital, and reported for and published in the Chicago
Medical Examiner, Prof. N. S. Davis remarks upon the treatment of a
bad case of typhoid fever. Quinin, alcohol, turpentine, &c, had been
used and yet the patient contiued to sink. At this juncture, in connec-
tion with the turpentine, a tea-spoonful of the following admixture was
givcu, and directed to be repeated every four hours :
R- S try chin, i. gr.
Nitric Acid, 5 j-
Tine. Op ii, 5 *!
Water, ij.
From this date the patieut improved rapidly. In reference to the
use of strychnin in continued fever, the doctor remarked, that in many
cases between the fifth and fifteenth days, the impulse of the heart be-
comes weak, the voluntary muscles unsteady, the capilary circulation
feeble, with an evident tendency to passive congestions in some of the
internal viscera ; and in such, he had seldom failed to find a remedy
strikingly beneficial.
In a review of Dr. Reeves' work on Enteric Fever, and published in
the Monthly for September, 13-39, we made use of the following lan-
guage :
"There is one agent that Dr. Reeves has not alluded to, which, be-
cause of its peculiar adaptation to certain conditions frequently present
in enteric fever, should not be passed over in silence. When there is
subsultustendinum, low muttering delirium, and the evacuations are in-
voluntarily discharged, all showing a complete prostration of the nervous
system, there is probably no combination of medicines equal to strychnin
which may be beneficially combined with small doses of opium."
S3 far as we know, we were the first to use and advise strychnin in
typhoid fever, and we are glad to see that so able an authority and ju-
dicious an observer as Prof. Davis should coincide with us in opinon.
Med. Monthly.
Deaths of Distinguished Physicians. We find noticed in the re-
ibreign journals the deaths of Dr. Edward Rigby, President of the
Obstetrical Society of London, at the age of Dtj ; Sir Henry Marsh, M
D , of Dublin ; Dr. Andrews, of Birmingham, Professor of Physiology
in Queen's College ; and Dr. Franci3 Broussais, last surviving son of the
celebrated Broussais, and himself an author of many valuable articles in
the medical journals.
We reget to record the decease of the distinguished Dr. John W
Francis, of New York, which took place last week. Dr. Franci.g has
been for a long time at the head of the profession in his adopted city,
and his death will be widely lamented.
262 Ifisccllaneous.
Sulphate of Quinia and Fcrrocyanurct of Iron in Rheumatic
Dysmenorrhea. Dr. J. B, Snelson states (St. Joseph Medical and
Surgical Journal, November, I860) that he has employed the sulphate
of quinia with the fcrrocyanurct of iron, for several years in rheumatic
dysmenorrhea, with very satisfactory results. lie commences the treat-
ment by emptying the alimentary canal by purgatives : during the men-
strual period he uses the warm bath, and gives opium combined with
camphor and ipecac to relieve the pain. After the period has passed, he
commences with a pill composed of two grains of sulphate of quinia and
an equal portion of fcrrocyanurct of iron, to be taken morning, noon and
night. These arc to be contiuuod during the intermenstrual period.
Frequency of Accidents or Irregularities during first Labour.
Dr. Richard McSherry states (Maryland and Virginia Medical Journal,
October 1860) that, in looking over his notes, he could not but observe,
with some surprise, to how great an extent primiparce are more liable
to accidents than multipara). In his own practice he has- had notable
irregularities or disturbances to contend with in more than 33 per cent,
ofhisprimiparac, while in multipara) this has happened in only 10 per
cent.
The Stereoscope. It is said that Sir David Brewster, in inquiring
into the history of the stereoscope, finds its fundamental principle was
well known even to Euclid ; that it was distinctly described by Galen
1500 years ago ; and that Gambatista Porta had in 1599 given such a
complete drawing of the two separate pictures as seen by each eye, and
of the combined picture placed between them, that we recognize in it not
only the principle, but the construction of the steoreoscope. Chemist
and Digest.
Ague. M. Eissen states that quinic ether, when inhaled during prr*
oxysm of ague, arrests the attack, and prevents the recurrence of future
attacks. This, however, is open to doubt, as the ether only oontains
kinic acid, which is known not to possess the tonic and antiperiodic
properties of quinine.
Homaipathic College. The Hahnemann Medical College, of Chicago,
has closed for want of support. The concern matriculated three students
on credit. Hahnemann taught, the smaller the dose the better the re-
sult, a statement singularly verified in this instance.
Spina Bifida treated by I?ije/tions of Iodine. Dr. Emil Fisher
reports (North American Medico-Chirurgical Review, Nov., 1860) two
cases of spina bifida treated by injections of iodine, by Prof. Gross, at the
surgical clinic of the Jefferson College. Both terminated fatally.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
(new series.)
< *
Vol. XVII. AUGUSTA, GEORGIA, APEIL, 1861. NO. 4
ORIGINAL AND ECLECTIC.
ARTICLE II.
(CONCLUDED FROM JANUARY NUMBER.)
Lectures on Tumors and Outgrowths of the Cervix Uteri By
Joseph A. Eve, M. D., Professor of Obstetrics and Dis-
eases of Women and Children in the Medical College of
Georgia.
Lecture Second .Treatment of Fibrous Polypi.
The only appropriate treatment for fibrous polypi is by
excision or ligation, although, when they have very small
pedicles, they may be twisted off or torn away and are
sometime detached, by traction intended to bring them
in proper position for excision, by the bistoury, scissors,
polyptome, or ecraseur.
Some authors and practitioners prefer the ligature from a
belief that it is safer. The correctness of this opinion is,
we believe, by no means established. The only danger to
be apprehended from excision is hemorrhage, which, it is
admitted, very rarely occurs, and then is easily arrested by
astringent injections, such as a strong solution of sulphate
of zinc, or of copper, or the persulphate of iron, or most
certainly by the tampon or colpeurytner.
In two hundred cases of polypi, removed by excision,
Dupuytren had hemorrhage only in two, and in these, it
was promptly arrested by proper means. Lisfranc had
18
274 JEve. Lectures on [Apri
hemorrhage to occur only twice in one hundred and sixt;
five cases, in which excision was performed. In both <
these it was stopped by the tampon. I have never know
hemorrhage after excision. The only instance in which
have witnessed hemorrhage, was one in which a very lar<;
polypus was detached by traction, without excision or lig;
ture. It ceased immediately on application of a tampon.
You thus perceive, the danger of hemorrhage is imagi]
ary. The advocates of the ligature assert that the polypi
is more effectually destroyed by ligation. This we consic
er a mere assertion unsupported by facts. It is as effectua
ly destroyed by one method as the other, for the remnant (
the pedicle always shrinks away or sloughs off. By exci
ion, the polypus is removed at once, and the tedious unce]
tain process of sloughing avoided. There is no danger c
local inflammation, constitutional irritation, or pyemia froi
the absorption of pus or putrilage into the blood. I hav
no hesitation myself in giving a decided preference to e^
cision over ligation, and this decision is supported by a larg
majority of tho most eminent authors who have written o
these subjects. When the stem is very large, or when a
artery can be felt pulsating in it, prudence might dictat
the application of a ligature previous to excision, whic
should be performed below it, the ligature being allowed t
remain a day or two as a security against hemorrhage. J3u
this precaution would, I think, rarely if ever be necessary
In such cases the ecraseur might be the most eligible in
strnment.
Dr. Churchill says "there are other cases in which excis
ion would be impossible or hazzardous, as for for instance
when the polypus has only just descended through the o
uteri. If doubtful, the ligature should be used." In thes<
very cases I consider excision most decideclly preferable, a
being more easily accomplished and much safer. But tin
difficulty of applying the ligature is not so great as the dan
ger to 1)0 apprehended from allowing a metalic instrumen
t<> remain in contact with the internal surface of the uterus
1861.] Tumors, fa
liable to irritate or pierce through its walls, and form a pu-
trid mass contained within it for several days.
No antiseptic vaginal or uterine injections could be re-
lied on to prevent absorption from the sloughing tumor.
It sometimes becomes necessary to tighten the ligature
repeatedly, or to apply a second ligature. The time neces-
sary for separation by ligature is indefinite. Days are al-
ways required and sometimes weeks ; during all of which
time the patient is confined to bed, kept in a state of anxiety,
and liable to fever or phlebitis from the absorption of putrid
matter.
If the polypus could not be drawn down low enough for
the pedicle to be divided, by a suitable pair of curved scis-
sors or the polyptome, I would infinitely prefer a method
proposed by Prof. Sympson, which is to crush the polypus,
and thus destroy it, by a properly constructed pair of for-
ceps, or to divide and bring it away piecemeal.
When a polypus is discovered, during pregnancy, or dur-
ing or soon after parturition, some authors advise to defer
its removal, unless delivery be obstructed by it, as the uterus
is more disposed to hemorrhage under such circumstances,
in consequence of its vascular system being so much more
developed. But as a polypus is itself a great determining
cause of hemorrhage, it would, I think, be the much safer
practice to remove it, if practicable.
J )r. West says : "the general rule, and one, concerning
the wisdom of which there can be no doubt, is not to meddle
with a uterine polypus, either in labor or after delivery."
It is always with regret and deference I differ from author-
ity I respect so highly. I would not willingly mislead you:
J give you my opinion with diffidence ; I may be wrong ;
I have had very little experience with polypi during
pregnancy orparturition. Dr. West's experience has doubt-
been much more extensive, and his judgment is reliable.
Numerous and various instruments and methods have been
devised for applying ligatures to polypi and polypoid tumors
time would fail were I to attempt a description of one-
half of them.
270
Eve. Lectures on
[Ap
The double Canula, invented by Dr. Gooch the inst
inn it I now exhibit to you is, perhaps, equal, if not super!
to any other. Various changes have been suggested ; bu
is doubtful whether it lias been improved. There may
an advantage in some cases to have the extremities curv
The instrument and its use cannot be better described tl
in Dr. Gooch's own words : "The instrument which I
for this purpose consists of two silver tubes, each eij
inches long, perfectly straight, separate from one anoth
and open at both ends. A long ligature, consisting
strong whip cord, is to be passed up one tube and down
other, and the two ends of the ligature hang out at
lower ends; the tubes are now to be placed side by s
and, guided by the finger, are to be passed up the vagi
along the polypus, till their upper ends reach that part
the stalk around which the ligature is to be applied; t
now the tubes are to be separated, and while one is fix
the other is to be passed quite around the polypus, til
arrives again at its fellow-tube and touches it. It is ol
ons that a loop of the ligature will thus encircle the sta
The two tubes are now to be joined, so as to make th
form one instrument; for this purpose two rings joined
their edges, and just large enough to slip over the tubes,
to be passed up till they reach the upper ends of the tu
immovably. Two similar rings, connected with the up;
by a long rod, are slipped over the lower ends of the tu
so as to bind them in alike manner; thus the tubes, wh
at the beginning of the operation were separate, are n
fixed together as one instrument. By drawing the end*
the ligatures out at the lower external ends of the tu
and then twisting and tying them on a part of the insl
ment which projects from the lower rings, the loop roi
the stalk is thereby tightened, and, like a silk thread rot
a wart, causes it to die and fall off."
Dr. Churchill says: "In many cases I found great
vantage from the cautious use of Musaux's forceps.
continued gentle traction, it is quite possible to draw 1
1861.] Tumors. 277
polypus within view; often to produce it externally, so as
to apply the ligature without any difficulty, after which the
forceps should be removed, and the polypus permitted to
return into the pelvis. It may doubtless, by gentle tractions,
In m 3, he drawn through the vulva ; hut T cannot
agree with Dr. Churchill that it should he permitted to
return : when once it makes its appearance externally, it
never returns with my consent ; it is too late then to think
of ligatures; it should he removed at once by the bistoury,
3ors or polyptome.
I have sometimes applied a ligature as a means by which
to draw down the polypus for the purpose of excision ; but
this could rarely be necessary, if supplied with suitahleYor-
ceps. unless the polypus were too soft to afford a sufficiently
firm hold to the forceps.
I was formerly much inclined to the application of a
igature before excision as a means of traction, from a belief
hat the hemorrhage was from the surface of the polypus;
but I now believe that is certainly not the principal source.
The removal of a polypus by excision is generally easily
effected. The patient may lie on her back or side, with her
knees drawn up ; the operator should then insert one or
two lingers, high up on the polypus if practicable on the
pedicle as directors for the forceps, which should be intro-
duced, one blade at a time, as obstetric forceps, and then
united at the lock, after their extremities are firmly fixed
on the polypus; gentle traction should then be made until
the polypus, if practicable, is brought out of the pelvis, when
it should be cut off, as near the os tincae as possible. Some,
I am aware, advise to divide it far from the os tincrc ; but
I cannot perceive that there can be any advantage in this
pours -poets excision; it may be proper sometii
even necessary in applying a ligature, as the pedicle is in
pome ositive near the uterus, in - nee
of an extension of the uterine tissue. There is so much pain
sometimes that it becomes necessary to remove the ligature;
but excision of the sensitive portion could be attended with
278 Eve. Lectures on [April,
no bad effect, beyond a slight momentary pain. The
patient' B suffering may be partially or entirely relieved, if
necessary, by chloroform. When the pedicle cannot be
drawn beyond the vulva, it may be divided in the vagina
by a pair of curved, blunt-pointed scissors, or by the polyp-
tome. The pedicle may sometimes be divided by the polyp-
tome without traction, and afterwards removed by the for-
ceps or the lingers. The polyptome resembles a small,
blunt hook with the inner or concave edge sharp. It is a
very convenient and valuable instrument which I have found
very satisfactory in practice.
One pair of forceps or hooks may sometimes prove not suf-
ficient for drawing the polypus down, and two or three
pairs may be required. It may even occasionally be neces-
sary to have recourse to obstetric forceps to deliver a large
polypus from the vagina. I employed obstetric forceps in
one case, but I believe serrated polypus forceps and hooks
would always answer a better purpose.
It is advised to plug the vagina in every case after excision;
but in a large majority of cases it is certainly unnecessary ;
it is time enough when a disposition to hemorrhage is
evinced. Although not so essentially necessary, as after
ligature, it is advisable that the patient should remain in
bed a few days, and not be neglected by her medical at-
tendant, that hemorrhage or any other unpleasent symptom,
may be detected in its incipiency and promptly treated.
A Large Internal Polyus Mistaken for an Ovarian
Tumor.
The 15th of August, 1846, Mary, a negress about thirty-
five years of age, the property of Mr. Wm. Jones of Colum-
bia county, was sent to this city for treatment, on account
of a large tumor which had existed, a considerable time, in
her right side. On examination I supposed it to be an
ovarian tumor. Although she had not borne a child, dur-
ing the last seventeen years, notwithstanding she had en-
joyed comparatively good health most of that time, to my
great surprise I discovered that she was pregnant. As it
1861.] Tumors, $c. 279
was apprehended that she might have a difficult, if not a dan-
gerous delivery, she was allowed to remain in this city until
after her confinement. After a protracted and difficult labor,
she gave birth, on the 19th, Jan., 1847, to a large healthy
female child. She had a favorable convalescence and was
able in a month or six weeks to return to Columbia county,
the hard tumor still in her right side uninfluenced by treat-
ment.
About August, 1851, four years and a half after this la-
bor, my friend, Dr. John T. Smith, of Columbia count}',
attended her in another accouchment, in which she was
soon delivered of a fine girl ; but in this case the placenta
was retained so long, and its delivery attended with so
much difficulty, that Dr. Smith sent to Augusta for a con-
sultation. Dr. II. F. Campbell delivered the after-birth
after a retention of twenty-four hours. It was detached
and extruded from the uterus into the vagina, so that Dr.
Campbell had not an opportunity to introduce his hand into
the uterus, where he would probably have discovered the
true nature of the case.
At my request, Dr. Smith very kindly furnished the fol-
lowing succinct history of this patient subsequent to the
placental delivery by Dr. Campbell: "Her recovery was
rapid. About six months after delivery, I was called to see
Mary ; found her suite ring with prolapsus uteri ; replaced
the womb, and after removing inflammation, used a glass
globe pessary to keep it up. At her monthly periods, she
suffered with menorrhagia and in the intervals with leucor-
rhea ; I was called to see her on the night of January 24th,
1853 ; found her laboring under considerable mental ex-
citement suffering some pain ; on examination discovered
a large tumor protruding through the vulva ; being at night
I could not inspect it satisfactorily ; directed cold astringent
applications, and an opiate for the night ; called early next
morning ; the opiate produced a pretty good night's rest.
On examining it carefully I found, instead of an inverted
uterus, a large polypus. After you removed the tumor she
280 Eve. Lectures on [April,
complained only from a little soreness ; the stalk soon
sloughed off, and she has been perfectly well ever since, a
period now of several years."
On the night of the 25th January, 1853, 1 saw this patient
with Dr. Smith and Dr. Thomas. The patient was suffer-
ing very much ; her pulse very feeble and frequent. There
was a large tumor protruding five or six inches beyond the
the vulva. It was perfectly insensible when touched or
pricked with a pin; but when moved, it caused severe pain
at the connection with the uterus. Having put the patient
under the influence of chloroform, we made gentle traction
on the tumor, until we brought the os tincae in view, after
which we divided the pedicle very near to it. This tumor
was pyriform ; about six inches long and about four in
width. It was redder and softer than most of the fibrous
polypi I have seen, not much firmer than muscular tissue.
From the length of time it had been retained in the uterus,
I would have supposed it to have been a fibrous tumor that
had been slowly enucleated from the parietes of the uterus
into its cavity, thence expelled into the vagina, and finally
from the vagina through the vulva ; but its pyriform shape
and thick pedicle clearly identify it as an original polypus.
Had it been primarily a fibrous tumor, embedded in the
walls of the uterus, it would most probably have assumed a
move globular shape, and certainly would have had no fibrous
pedicle connecting it to the uterus, its only connection with
the uterus could have been by mucous membrane with
the addition perhaps of some cellular tissue. From the
larsre size this tumor had attained, at the time of her
pregnancy, in 1846, it must have existed some years before,
during all which time, during the interval between her two
gestations, and during the time Dr. Smith treated her for
inflammation of the womb and prolapsus, it must have been
internal. It is impossible to determine precisely at what
time it was expelled from the uterus into the vagina; but
from all I have been able to ascertain of the history of the
case, she was certainly not subject to hemorrhages, at least
1861.] Tumors, #c. 281
the greater part of the time that the polypus was unques-
tionably internal : whereas she was subject to monorrhagia,
when it is fair to conclude the polypus must have been in
the vagina.
It is a very singular feet that, although living with the
same husband, she was sixteen or seventeen years sterile,
had two children while the polypsus was in the womb, and
has had none since, notwithstanding she has enjoyed good
health.
Ir is to be regretted that we have not a more particular
history of this most remarkable case ; but Dr. Smith's notes
were unfortuately lost, and the account furnished was prin-
cipally from memory.
The next case I will describe was a large enucleated
fibrous tumor. The subject of this tumor was a lady of first
respectability, about forty-three years of age. She had been
in bad health for twenty years. During several years pre-
vious to the time I saw her, she had been reduced by hemor-
rhage to the last extremity. This patient was brought to
me in May. 1853, by my friend, Dr. Pinkerton, of Hancock
county. She was at that time very feeble and anemic from
frequent hemorrhages. On examination I found an insen-
sible tumor, filling the whole pelvis, as large as the foetal
head at terms; the pedicle could not be reached; ligation
appeared to be impracticable, if deemed expedient. Dr.
Pinkerton and myself requested the counsel and assistance
of our friends, Drs. L. D. Ford and R. Campbell. In con-
sultation it was determined to deliver the tumor by a deli-
cate pair of obstetric forceps and divide the pedicle. TTith
difficulty we introduced the forceps and produced the tumor
partially through the external parts, at which juncture the
forceps losing its hold, we seized the tumor with two crotch-
ets and brought it through the vulva. To our surprise it
came away detached, no vestige of a pedicle remaining; the
only sign of attachment to the uterus was indicated by a
small portion being denuded of mucous membrane.
During the passage of this tumor through the external parts
282 Dugas. Lecture on [April,
there was a slight laceration of the perineum which I think
was attributable to the slipping of the forceps ; with the in-
struments now presented to you (a strong pair of plain poly-
pus forceps, and another pair with strong hooks, both
separable from each other like obstetric forceps) this
accident might possibly have been avoided; but it was
most probably inevitable under the circumstances, as the
tumor was very large and hard, and the patient had never
borne a child. It was, however, not extensive and the
patient recovered from it without any unpleasant conse-
quence.
This was the only case in which I have known removal
of a polypus followed by any material hemorrhage ; and this
was only alarming on account of the very feeble and
anemic state of the patient ; it was promptly arrested by a
sponge tampon.
This patient convalesced rapidly and was soon restored to
Ood health.
b
[Other oases related in the lecture are here omitted.]
ARTICLE IX.
A Clinical Lecture upon Rheumatism, delivered at the City
Hospital. By L. A. Dugas, M.D., &c.
Gentlemen : As we have here several cases of Rheuma-
tism to which I desire especially to direct your attention
hereafter, I beg leave to read to you the following paper
which I published in one of the early numbers of the Medi-
cal Journal of this city, and which contains a brief history
of some of the views I have long entertained upon the sub-
ject. I will then add some of the results of subsequent ex-
perience :
Rheumatism is a disease of which we find no satisfactory
account prior to the sixteenth century, towards the close of
which the attention of the Profession was called to it by the
justly celebrated Ballonius, under the singular appellation
it still retains. Subsequently, the able pen of Sydenham
delineated its characteristics in bold relief, and made it a
prominent feature in Nosology.
1861.] Rheumatism. 288
The term Rheumatism, according to Villencuve, (Diet.
des Sciences Med. torn. 48) is now applied to "a dis<
classed amongst the Phlegmasia, located in the muscular
and fibrous tissues of animal life, and attended with the
following symptoms: pain; more or less intense, either con-
tinued or intermitting, fixed or wandering, and with or
without heat, tumefaction, redness, and pyrexia. It usually
terminates by resolution, sometimes suddenly, followed or
not hy metastasis, rarely by suppuration, and still more sel-
dom by gangrene. Lastly its course is extremely irregular,
and its recurrence very frequent."
Scudamore defines rheumatism to be: "Pain of a peculiar
kind, usually attended with inflammatory action, affecting
the white fibrous textures belonging to joints, such as ten-
dons, aponeuroses, and ligaments, the synovial membranes
of the bursas and tendons ; and nerves ; occasioned by the
influence of variable temperature, or by direct cold, or by
moisture." It is called either acute or chronic, according
to the intensity and combination of the above symptoms.
The causes of this disease are extremely obscure, although
they have, by universal consent, been referred principally
to atmospheric vicissitudes. Exposure to a cold and humid
air is peculiarly favorable to its development. Whether the
low temperature and hygroscopic condition of the atmos-
phere, alone concur in such cases to give rise to rheumatism,
is extremely questionable. I believe it by no means im-
probable that the electric state of this medium is highly in-
fluential in the production of rheumatic pain, as well as of
many other phenomena connected with nervous affections.
It is not my design on the present occasion to inflict on the
reader even a recapitulation of the numerous predisposing
and proximate can- ied to this disease. The pro-
rioo is happily becoming satiated with speculations on
causes which must ever escape ourprcsent means of investi-
D ; and we are now disposed to cultivate a more fruit-
ful field that of effects. Let us, therefore, hasten to the
nature or pathology of rheumatism.
284 Dug as. Lecture on [April,
V,rc have already said that it is now generally regarded as
an inflammation of the muscular and fibrous tissues. This
is, indeed, the doctrine which has prevailed, more or less,
from the earliest notice of this disease. It is true that
many have considered this inflammation as of a peculiar
kind. Sarcone and other believers in the agency of animal-
culsa, &c, in the causation of disease, explained this pecu-
liarity by referring it to the action of those diminutive be-
ings on the white humors of joints, &c. Quarin viewed it
as a constriction of the vessels, from cold. Boerhaave call-
ed it an inflammation not sufficient to cause suppuration.
Cullen admits the inflammation, but adds that the muscu-
lar fibres are in a state of rigidity, which impedes and ren-
ders painful any movement. "It is," according to this dis-
tinguished pathologist, "an affection of these fibres which
gives an opportunity to the propagation of pains from one
joint to another, along the course of the muscles ; and
which pains are more severely felt in the extremities of
the muscles terminating in joints, because, beyond these,
the oscillations are not propagated." (Cullen's 1st lines.)
Bichat and Scudamore insist that it is a peculiar inflam-
mation, but do not attempt to define its nature. Villeneuve
states that "several authors, without determining whether
the proximate cause of rheumatism be spasm, irritation, or
debility, affirmed in general terms, some that rheumatism
was a peculiar affection of the nerves, others that it was a
lesion of sensibility, and a third class that it was a special
modification of the vital powers." (loc. cit. p. 462.) Villen-
euve admits that the nerves of animal life may be the seat
and even the primary seat of rheumatism, but does not think
those of organic life ever invaded by it. Scudamore, in his
definition of rheumatism, enumerates very specially the
nerves among the tissues affected by this peculiar inflamma-
tion. Sciatica is accordingly considered by him a rheu-
matic affection of the nervous trunk itself; whether of
the nervous matter or of the neurilemma, he does not de-
termine.
1861.] Rheumatism. 285
It is- evident that all the writers above cited looked upon
rheumatism as located alone at the seat of pain. Of late
vears, however, attention has been called to a peculiar con-
dition of the spinal marrow as intimately connected with
lesions of sensibility, as well as with many of those affec-
tions classed among the Xeuroses.
It appears that as far back as 1821, Mr. Player, in a letter
to the editor of the Quarterly Journal of Science, stated
that "the occurrence of pain in distant parts (from the spine)
forcibly attracted my attention, and induced frequent ex-
amination of the spinal column ; and after some years' at.
tention, I considered myself enabled to state, that in a great
number of diseases, morbid symptoms may be discovered
about the origins of the nerves which proceed to the affect-
ed parts, or to those spinal branches which unite them ; and
that if the spine be examined, more or less pain will com-
monly be felt by the patient on the application of pressure
about or between those vertebrae from which such nerves
emerge."
In May, 1828, Dr. Thomas Brown published in the Glas-
gow Medical Journal a very interesting article "on Irrita-
tion of the spinal nerves," the substance of which he asserts
he read before the Medical Society of that city in 1823. In
this paper he refers the morbid phenomena of the spinal
nerves to a state of increased irritability of their origin,
which he terms "spinal irritation." This affection of the
spinal marrow is attended with more or less pain on pres-
sure of the vertebrae at the diseased point. Some of his
cases were evidently rheumatic, and indeed had been treat-
ed as such by the previous attendant. His treatment con-
sisted principally of applications to the spine.
Dr. Darwall, early in 1829, inserted in the Midland Medi-
cal and Surgical Reporter, his "Observations on some
forms of Spinal and Cerebral Irritation." He would estab-
lish the principle "that disorders attacking the origins of
nerves, or their attachment to the central mass, whether
280
1)U(JAS. Lecture on
[April,
this be the brain or spinal chord, always disturb the func-
tions of the organs to which such nerves are destined."
"A treatise on neuralgic diseases, dependent upon irrita-
tion of the spinal marrow and ganglia of the sympathetic
nerve," by Thomas Pridgin Teale, was issued from the
London press in 1829. This invaluable publication has
opened to our researches one of the most fertile fields ever
explored by the profession ; one from which have already
been elicited some of the most important truths in the do-
main of pathology. The observations of Teale not only
confirm the views of those who wrote before him on Spinal
Irritation, but are also extended to lesions of the sympa-
thetic ganglia. I would, however, at present, refer only
to that portion of his work which relates to our subject. It
contains a number of cases illustrative of his doctrines, some
of which, like those reported by Brown, had been consider-
ed as rheumatic by other physicians, and indeed presented
symptoms such as are usually said to characterize some
forms of this disease. It is not a little remarkable that
with such facts before them, neither Brown nor Teale
should have thought of treating the more acute forms of
rheumatism in the same manner. They make no reference
to it, and the merit of introducing a new and rational mode
of treatment of rheumatism, was reserved for our country-
man Dr. J. K. Mitchell, of Philadelphia, who, in May,
1831, published in the American Journal of Medical Sci-
ences, his first article on the subject. In addition to the
eight cases then reported, Dr. M. inserted five and thirty
more in the same Journal, August, 1833 ; all of which con-
cur in confirming the spinal orgin of rhematism, whether
acute or chronic.
I must confess that neither of the transatlantic publica-
tions to which I have referred, had led me to reflect on the
nature of rheumatism; nor was my attention drawn to it
until the appearance of Dr. Mitchell's first paper. On read-
ing this, however, and comparing his doctrine with the pre-
vailing theories of the Pathology of this malady, I became
1861.] Rheumatism.
at once convinced that it was Impossible to reconcile the
various symptoms of this disease, on any other principle
than that of spinal irritation, and that with this view of the
subject, the treatment would be perfectly simple and effica-
cious.
From the definitions usually given of rheumatism, the
pain is manifestly considered as dependent on the inflam-
mation of the parts in which it is seated. That simple in-
flammation of the muscular or fihrous tissues should be the
sole cause of the pain, I cannot admit. It is true that the
patient's sufferings are generally proportioned to the de-
gree of the apparent inflammation, and consequently that
acute is more distressing than chronic rheumatism. But, I
would ask, why are not other inflammatory affections of the
same tissues equally painful ? It is impossible not to per-
ceive, on a close examination of the phenomena of rheumatic
inflammation, that they present several peculiarities, which
evidently distinguish it from ordinary inflammations ; and
indeed they are so strong as to have led some eminent pa-
thologists to deny that they constituted a whole, entitled to
the denomination of inflammation. Inflammation is usual-
ly said to be characterized by redness, heat, tumefaction,
and pain, all of which we find united in the most violent
forms of rheumatism. But there are sequela? or tcmina-
tions enumerated as belonging to inflammation, which never
follow rheumatism. Inflammation terminates by resolu-
tion, suppuration, or mortification. Its rise, progress, and
termination, are more or less gradual ; subject to certain
laws, and it is in most cat vptible of removal by
antiphlogistics. Rheumatism obeys no such laws of develop-
ment, progress and declension ; but, not [infrequently mani-
If and disappears with a degree of suddenness ut-
terly at variance with the course of ordinary inflammations.
\x< mode of termination is invariably the same (by resolu-
tion) never proceeding to suppuration, nor to mortification;
ami finally, it rarely, if ever yields to the antiphlogistic
288
Duu as. Lecture on
[April
treatment directed to the seat of pain.* The theory of
spinal irritation is that alone by which all these peculiarities
can be explained. If the point from which, a given nerve
arises be diseased, the functions of this nerve must neces-
sarily be vitiated; and if its functions be vitiated, the con-
dition of those parts to which said nerve is distributed must
also be morbid. In the case of rheumatism, the morbid
condition of the parts deriving nerves from a diseased por-
tion of the spinal chord, consists of inflammation of a pe-
culiar character, increased sensibility of the nervous ex-
tremities, amounting usually to pain more or less acute,
and, in many instances, diminished motility. All admit
lesions of motility to depend on an affection of the motor
system of nerves, and, inasmuch as the motor cannot be
separated or distinguished from the sensitive fibres after
their union in a common nerve, such lesions are referred to
the spinal chord. Why, then, should we not also regard
all lesions of sensibility not the result of local injury, f as at-
tributable to a morbid state of that chord which presides
over this function ?
Again, we see that not only the onset of rhematic inflam-
mation, but also its termination or cessation, is in many
instances extremely sudden, and indeed that sudden me-
tastasis is by no means unfrequent. These circumstances
are most satisfactorily accounted for by the fact that nerves
arising very near each other may be distributed to parts
very remote. For instance, the nerves of the right hand,
though very distant at their termination from those of the
left, arc nevertheless very near them at their origin in the
*I am aware that there arc eases on record, of suppuration and even of
mortification having occurred in parts affected with rheumatism, but they
arc so few that we may be permitted to doubt their authenticity, or rather
to look upon them as mere coincidences, dependent on complications or
peculiarities of habit. The success of the antiphlogistic treatment direct-
ed to tin1 scat of pain, is equally doubtful, especially when we bear in mind
the strong tendency of rheumatism to translation or sudden cessation
without appreciable cause.
I (lout, rheumatism and neuralgia.
1861.] Rheumatism, 289
medulla spinalis ; and hence a slight affection of the medulla
might for a time exist in one column, and subsequently ex-
tend or remove to that adjoining it; thus producing at first
a derangement of function on one side of the bodv, and then
on the other. My opportunities have not as yet been suf-
ficient to cnable]mc assert, from observation, that metastases
of rheumatism are limited to the periphery of nerves arising
in the proximity of each other. This, however, I am
strongly inclined to think, will most frequently he found to
be the ease. Whenever an upper and a lower extremity are
simultaneously affected, they most frequently belong to the
same side of the bod}\ It will probably also be observed
that the justly dreaded translation of rheumatism to the.
heart, is a much more common sequel of an affection of the
upper than of the inferior extremities.
The difficulty attending post mortem examinations of the
medulla spinalis, has very much retarded our knowledge of
the pathological anatomy of this organ. Its condition in
fatal cases of rheumatism has never been systematically in-
vestigated. We find, however, on record, a few eases which
I think calculated to throw much light on our subject. One
of these is reported in Johnson's Medico-Chirurgical Re-
view, (Oct, 1*27, p. 4G4) under the title of "Inflammation
of the Spinal Marrow." A youth, some time after bathing
in the Seine, experienced wandering pains, which subse-
quently extended to the whole surface of the body, and be-
came so intense that the least touch would occasion loud
cries. The pains continued unabated, delirium and diar-
rhoea ensued, and he died on the ninth day. On opening
the spine, the medulla was, from the 7th cervical to the 8th
dorsal vertebffi, evidently softened and infiltrated with pus.
In the same periodical (Jan., 1828, p. 184) is contained
another ease, in which the patient had suffered severely
from rheumatic pains in the upper part of the back, shoul-
ders, and arm-, and finally became paralyzed in his arms.
Dissection evinced that from the 5th cervical to the 11th
dorsal vertebrae, the membranes of the spinal canal were in
1"
290 Dug as. Lecture on [April,
flamed, thickened, and covered with a bloody effusion. The
marrow itself, for the same space, was similarly inflamed
and softened.
Dr. Mitchell gives the history of two cases of spinal dis-
s, as corroborative of his views of rheumatism. The
first* was one of caries of the lumbar vertebrae, in which
one ankle, and the knee of the opposite side were tumefied,
red, hot, and painful, afforded a fair specimen of acute rheu-
matism. Relief promptly followed leeching and a blister
to the affected spine, although the ordinary treatment for
rheumatism had been previously resorted to without effect.
The second case was that of a physician who, after receiv-
ing an injury of the cervical vertebrae, experienced an at-
tack oi acute rheumatism ot the hands and wrists, which
"was always relieved by remedies applied to the affected
part of the spine, and aggravated by pressure or rough fric-
tion there."
These four cases conclusively establish the fact, that irri-
tation of the spinal contents is attended with the train of
Bymptoms known to characterise rheumatism. May we not,
then, by legitimate deduction, infer that there is a spinal
disease whenever we encounter this train of symptons ? If
further evidence be requisite, it is abundantly furnished by
the numerous instances in which genuine, uncomplicated
rheumatism has been speedily cured by medication applied
exclusively to the spine. Dr. Mitchell, reports 41 ca
successfully treated on the new principles.
Pressure over the vertebrae corresponding to the origin of
the nerves supplying the seat of suffering, though in many
instances attended with more or less pain, is not uniformly
In some, not the slightest uneasiness is produced by it.
I cannot, however, coincide with Dr. Mitchell, in consider-
ing the tenderness, merely a proof of an irritated condition
"American Journal of the Medical Sciences, M.-i\. 1831, p. 56.
American Journal of the Medical Sciences, Aug., L833, p. 880.
1861.] Rheumatism. 291
of the "spinal braces ;" for, whenever this tenderness does
exist, it almost invariably corresponds to the origin of the
affected nerves. The degree of sensitiveness may perhaps
be indicative of the condition of the membranes alone of
the medulla.
In the case before us, we have a happy illustration of the
importance of localizing, and properly localizing diseases ;
for so lone; as rheumatism was thought to be an affection
of the whole system, manifesting itself indifferently in one
joint or another, all remedial agents were directed to the
general system. How many poor wretches have we not
seen subjected to the cruel inflictions of a regular mercurial
salivation, a systematic course of sudorifics, antimonials,
guaiacum, sarsaparilla, &c, the ordeals of steaming, vapor-
izing, sweating, &c., and after all, the patient doomed to
limp the remainder of his days ! But I say that it must be
properly localized; for those who view the disease as con-
lined to the seat of pain, will torture their patients with fric-
tions, fomentations, vesications, &c., with as little success
as those who endeavored to drive out or neutralize the con-
stitutional impurity.
We have now, I trust, traced rheumatism to its true
source, and every remedy based on this belief, gives ad-
ditional evidence of its correctness. Regarding the disease
as seated in the spinal marrow, and believing its nature to
be irritation or sub-inflammation, the treatment to be insti-
tuted is perfectly obvious. The local abstraction of blood,
by leeching or cupping the surface over the affected medul-
la, followed by the more permanent revulsive action of vesi-
catories, constitutes the most efficient treatment of rheuma-
tism. In many slight cases, the mere application of a sina-
pism will readily allay the pain; in others a blister will
be required and may be, or not, preceded by cupping, ac-
cording to the tenderness of the spine, the constitution of
the individual, &c. AVhen the local affection is 80 intense
as to induce high febrile excitement, it may be prudent to
take blood from the arm, though this should not be carried
292 Ls. Lecture on [April,
to excess. The opiates will occasionally be found useful
adjuvants. In obstinate chronic cases, the counter-irritation
will be most advantageously kept up by the ointment of
tartarized antimony, and should be persevered in, as long
iis the (1: a tendency to return. With this
plan of treatment, I repeat, the disease will be found almost
uniformly to yield in a few days, and without any internal
remedies, or applications to the seat of pain.
Yon perceive that I have, in the paper just read, used the
term Rheumatism in a general sense, and without discrimi-
minating between the different forms assumed by the dis-
ease. 1 will, therefore, add a few remarks in order to pre-
vent any misconception as to the pathology advocated, and
which 1 still regard as entirely applicable to every form of
rheumatism, with the exception, perhaps, of the acute
arthritic variety, in which other elements are added to the
spinal.
There is a form of rheumatism usually designated by
authors as acute articular rheumatism, the peculiar character-
istics of which are a fixed inflammatory action in one of
the joints, attended with intense pain, more or less tume-
faction, and high general febrile action ; all of which symp-
toms will continue, in spite of our endeavors, a certain
length of time, usually varying from four to eight week-.
This is, therefore, a self-limited disease, the intensity of
which we may abate, but whose duration we can rarely
shorten, fn this form of rheumatism we never find more
than one joint affected at a time, and this is usually one of
the larger joints, as the knee, ankle, elbow, or wrist. It is
in this form of the disease that we observe the heart so of-
ten implicated. According to my observation the cardiac
affection very rarely supervenes as a complication of any
other form of rheumatic disease. Again, acute articular
rheumatism differs radically from all other forms of rheu-
matism in the circumstance that one attack usually secures
complete immunity from any subsequent attack of the same
affection.
II.] Rheumatism. 293
That this form of rheumatism is, like the oilier varieties
to be hereafter noticed, dependant, to a certain extent, upon
a lesion of the spinal marrow, I firmly believe ; bul ii i i
also evident that this docs not constitute its whole patholo
gfVi for it is attended with a degree of constitutional disturb
ancc that cannot be accounted for either by the spinal
lesion or by the local inflammation. \\re moreover find that
a radical change is effected in the composition of the blood
in such cases, and that these obey many of the laws which
govern the diseases said to beoi the blood. It is, therefore,
no! surprising that the treatment which is applied directly
and exclusively to the spinal lesion, should only mitigate
and never arrest the disease. I know of no treatment en-
titled to much confidence in the curation of this form of
the disease. Yet, I must acknowledge that [ have some-
times thought that I derived advantage from the use of
opiates, quinine, antimonial emetics, lemon juice, &c.
But there is another form of rheumatism also called acute,
in which there are usually several joints implicated simul-
taneously, and in which there may be considerable febrile
excitement. This form of the disease is usually the effect of
exposure in inclement weather, and the patient will gener-
ally state that he has caught cold in all his limbs. AVc not
unfrequently see violent cases of this kind in which the
morbid sensibility invades most of the joints, as well as the
muscles and even the cutaneous surface; all of which are
exceedingly painful tothetoueh or upon the slightest motion,
so that the patient can neither move nor turn over in bed
without excrutiating pain. It is in this form of rheumatism
that we find revulsives, applied over the origin of the nerves
affected, most signally beneficial ; for without any other
treatment the disease will yield usually in a few days to
cupping and blistering over the affected region of the spine.
This variety I would, therefore, designate as acute neuralgic
rheumatism, in contradistinction to the former which I
would term acute arthritic rheumatism.
You will perceive that there can he no difficulty in cs-
294 Dugas. Lecture on [April,
tablishing the diagnosis as well as the prognosis of these
two forms of disease, [n the former the attack comes on
without any evident cause, affects but one joint, and that a
largo one, is attended with high febrile excitement and
yields t no remedy, but goes on steadily increasing in
intensity until it has reached its acme in three or four weeks,
and then gradually declines in about the same length of
time. The latter is, on the contrary, usually induced by
exposure, affects more than one joint, is not attended with so
much febrile excitement, and yields very readily to treat-
ment. I should also add that whereas the former usually
attacks the young and the robust, the latter affects all ages
indiscriminately, and one attack so far from securing im-
munity from others, rather predisposes the patient to them
in after life. It is in this neuralgic form of the disease that
quinine acts most advantageously and may sometimes be
substituted for the more painful spinal revulsives.
There is finally a third form of rheumatism, very general-
ly denominated chronic rheumatism. This variety usually
affects one or more joints, is not so painful as the two we
have just considered, occurs most frequently after the
meridian of life in the temperate, and is very common
with drunkards of all ages. This, like the last described
variety has also its origin in the spinal marrow, is amen-
able to the same treatment, but is apt to recur more or less
frequently in subsequent life, especially with the intemper-
ate, in whom I have never known it to be permanently
eradicated. The tendency to relapse may, however, be en-
tirely overcome in persons of good habits, by a faithful per-
severance in the use of revulsives to the spine.
While I place no reliance in the use of liniments, nor in
frictions of any kind, in this and the other forms of rheu-
matism, there are yet cases in which the joints, after re-
peated attacks, become so much involved that their
tea will not return wvy speedily to the normal con-
dition. In these cases frictions with neat's foot oil, opo-
deldoc, "i- even stimulating linaments, at the same time that
1861.] Rheumatism*
gentle motion is imparted to the joints, are advantageous.
I have derived derided benefit from the application to them
of the tincture of iodine once or twice daily as long as it
could be tolerated. I have also used advantageously a so-
lution of shellac. This may be made by dropping bits of
shellac in alcohol, successively, until the solution acquire
the consistency of mucilage. This, when applied with a soil
brush or mop, once or twice a day, will form a thick and
adherent pellicle which should he reproduced as fast as it.
may he disposed to scale off.
L will now read to you, from my note hook, a lew cases to
illustrate and impress upon your minds the several forms of
the disease I have just endeavored to define :
Acute Articular Rheumatism.
January 31st. Mr. A. L., aged 25 years, of robust con-
stitution and of full plethoric habit, was, last night, without
any evident cause, taken with pain in the right knee, which
to-day confines him to his bed. Is rubbing the knee with
with liniment. Ordered cream of tartar as a laxative, and
allowed the frictions to he continued.
22d. Pain increased: has some fever; knee a little
tumefied : very little tenderness at the lower end of the
si tine, which is ordered to he freely cupped.
27th. lias heen gradually getting worse under the use.
of tincture opium applied to the knee, morphine taken in-
ternally, and cooling beverages. Has refused to be blister-
but is now willing to submit to the application of tartar
emetic ointment to the spine. Morphine continued, pro re
. and a tahlespoonful of tine, guaiac. to he taken three
times a day.
29th. Pains increased ; fever high ; unable to move his
limbs in the slightest degree without intense pain ; tume-
faction increasing. Took 24 ounces blood from the arm.
Ordered the knee to he poulticed with flaxseed and laudan-
um.
31 st 1 '-ease still progressing. Ordered the spine to be
2&6 Dugas. Jjcctureon [April,
freely cupped to-day and to-morrow, and then blistered, pulv.
dov., at bed time.
February 8th. Xo amendment. He-apply the blister
and lake denarcotized opium as freely as may be necessary
to relieve pain.
L3th, Still suffers dreadfully ; fever still high and con-
tinuous. The blistered surface has healed. Ordered
another blister and the anodynes to be continued as hereto-
fore.
18th. Febrile symptoms less intense, and pains not so
excruciating. Thinks his knee would feel better if rubbed.
Ordered a liniment consisting of oil, tinct. opii. and sp.
tereb., also tinct. guaiac. and morphine internally.
28th. Is gradually improving; same prescription con-
tinued.
March 10th. Has improved very little since last date,
with the exception of a considerable diminution of the fever.
Ordered a blister to the knee. Continued the guaiacum
and anodynes. Bowels kept open with laxatives.
16th. All symptoms subsiding rapidly ; knee blistered
again; ung. ant. applied to the spine.
26th. Still improving ; knee blistered again.
April 5th. Case discharged, although the knee is so stiff
as to allow but little motion. The patient ordered to con-
tinue frictions with neat's foot oil, and to exercise the limb
as much as possible until he regain its free use.
Remarks. We have here the details of a case such as we
have denominated acute arthritic rheumatism, which occur-
red without evident cause in an individual in the full vigor
of life; which alfccted but one joint; which ran its course
uninterruptedly and without being modified in the least by
any remedy prescribed, whether directed to the spine or to
the general system ; and which continued upwards of 70
days, attended with a degree of febrile excitement entirely
dispr portionedto the local affection. This gentleman had
neve suffered from rheumatism before, nor did he experi-
any subsequent attack for fifteen years afterwards,
[861.] Rheumatism. 297
when he died of a dropsical affection which may have been
occasioned by some disease of the heart, consequent upon
the above attack of rheumatism. I did not sec him in his
last illness. His exemption from subsequent attacks of
rheumatism is the more remarkable from the fact that he
became very intemperate a number of years before hisdeath,
ami that intemperance is a very common cause of one of the
other forms of rheumatism.
Acute Neuralgic Rheumatism.
January 20th. Thomas Bernard, a native of Ire-
land, about 30 years of age, and of sanguineous tempera-
was taken about the first of this month with rheumatism
when working on the railroad; was subjected to a variety
of treatment by a country physician, the details of which
are unknown. I found him stretched upon his back, with-
out the power to move either of his limbs, and complaining
of the most excruciating pain in the loins knees, ankles,
shoulders, elbows and wrists. Fever high, pulse full and
strong, great thirst, no appetite, and costive. Ordered free
blood-letting from the arm. 01. ric, and diluent drinks.
January 21. Fever still high; cathartic operated well;
passed a wretched night, without a moment's rest. Upon
examination found the spine extremely painful on the least
pressure over the origin of the nerves of the lower extremi-
ties. Tenderness also existed, though to a much less de-
gree, in the upper portion of the dorsal vertebrae. Pre-
scription To be cupped freely over the origin of the nerves
of the superior and inferior extremities ; pulv. dov. at night;
light diet ; diluent drinks.
January 22. Pains much less intense ; can draw up his
3. Cups repeated; pulv. dov. at night.
January 23. Can turn over in the bed, and feels pain only
when he move-; swelling at the joints reduced, blisterover
lower end of spine.
January 24. Legs entirely relieved with the exception
208 Dug as. Lecture on [April,
of a little weakness. Fever entirely subsided. Cups to
the upper portion of the spine.
January 25. Arms much better. Cups repeated.
January 26. Can rise and move about the room, though
stiit' and weak. Ung. tart. ant. to be applied at each ex-
tremity of the spine.
January 28. Has improved so rapidly that he now walks
about the streets, and the case is discharged.
February 4. Exposed himself considerably, and has
again taken his bed, with great pain in the upper and lower
extremities. Blister to the lower end of the spine, and ung.
ant. to the upper.
February 5. Much better. Fulv. do v. at night.
February 6. Walks about the room. Saline carthartic ;
pulv. dov.
Februaiy 11. Feels quite well in every respect.
Chronic Neuralgic Rheumatism.
February 17. Resumed his work on the railroad.
Case 1. March 21. Mr. J. Gr., aged 25 years, had syphi-
lis abont eighteen months ago, for which he was treated
successfully with mercurials, but was seized with rheumatic
pains about six months afterwards in various parts of the
body, which he says have returned repeatedly under ex-
posure to bad weather. He has now been suffering severe-
ly several days with pains in the knee and wrist of the left
side, both of which joints are swollen and very sensitive to
the touch; has slight fever; pressure upon the spinal
column reveals great tenderness over the two lower lumbar
vertebrae alone. Freely cupped over these vertebrae, and
also over the uppermost dorsal and the cervical vertebne.
March 22. Feels no pain whatever; swelling consider-
ably diminished; feels a little stilt'. Ung. tart. ant. to be
rubbed over scarified surfaces, and a plaster of the same
kept on all night.
March 23. Js apparently well, and complains of nothing
but the soreness of the scarified parts. Case discharged.
1861.] Rheumatism. 200
April 4. Has had qo return of pain and continues well.
ise 2. February 3. Mrs. C. P., aged about 20 years,
of* robust constitution, experienced, about a week ago, pains
in her limbs, which, in a few days, were locatedinthe knee
and wrist ot' the right side, whichare now very much swollen
and painful. Liniments have been used freely without the
least relief. Pressure on the spine causes slight pain only
in the upper dorso- cervical region ; no fever. Ordered sina-
pisms t<> the upper and lower portions of the spine.
Februry2. Pains much alleviated; sinapisms repeated.
February 8. Swelling rapidly diminishing, particularly
in the knee ; no pain of consequence.
February 7. Walks about tlie house, and complains of
nothing but a little stiffness. Case discharged.
Case 3. January 31. Mr. G. F. P., about 30 years of
age, has been suffering excruciating pain from rheumatism
of the head for three weeks, during which time he has been
subjected to venesection, cathartics, a low diet, frictions,
void affusions, to the head, &c, without relief. Pressure
over the last cervical and first dorsal vertebra) produces
considerable pain. The hair had been shaved from the
upper part of the neck and a small blister applied, but this
did not extend as low as the sensitive part and it produced
no diminution of pain. I now ordered the application of
another blister of sufficient length to extend from the upper
cervical to the second dorsal vertebra?.
February 1. Blister has drawn very well, but still suf-
n much as ever. Ordered simple dressing.
February 2. Pain rather less severe ; ung. tart. ant. to be
spread over the blistered surface.
binary 3. Much relieved. Same prescription.
February 4. Quite well and gone to work.
This case illustrates the importance of making the revul-
sive application immediately over the seat of irritation, or,
in other words, over the painful vertebra in order to insure
success.
300 Dugas. Lecture on Rheumatism. [April
Bub- Acute Neuba^lgki Rheumatiim.
April 1. Mr. S. W., about twenty-five years of age, s
circus rider, 1ms just arrived from a country tour wit!
severe pain in the right shoulder and right hip, which In
says he has had nearly a week. He can neither stand upoi
the a Heeled leg, nor remove the arm from the side of the
body. The aftected joints are tender to the touch, and sc
are the vertebrae at the origins of the nerves of the nppei
and lower extremities. He has some fever, and is confined
to his bed. lie begged to be relieved as speedily as pos-
sible, without regard to the severity of the treatment, as h(
was an important member of the company to which hewai
attached. I accordingly ordered him to be cupped freeb
over the tender vertebrae at each end of the spine, and t(
have the scarified surfaces immediately covered with blister
ing plasters.
April 2. Patient much relieved, and states that he wa
enabled to move his limbs with but little pain immediately
after the cupping. Ordered simple cerate to the blisters.
April 3. Entirely relieved.
April 4. Resumed his performances at the circus.
Symptomatic Lumbar Pain.
March 26th. Mr. II. J., affected with orchitis for
several days, complained of pain in the lumbar region tc
such a degree as to prevent any rest at night. On exami-
nation found that he could not bear the least pressure ovei
the vertebrae of that region. Ordered a large sinapism tc
be dept on as long as he could bear it.
March 27. Relief complete.
March 30. The sinapism was re-applied and he has since
had no more pain in the back.
In this case the pain in the loins was probably symptom-
atic and not rheumatic. Yet it was very promptly relievec
by the same treatment.
1861.] / won Convulsiv I 301
ores on the Theory and Therapeutics of Convulsive Diseases,
'>/ of Epilepsy. By Charles Bland Radcliffe, M. I >.,
Fellow of the College, Physician to the Westminster
Hospital, etc.
LECTURE III. (CONTINUED PROM MARCH NUMBER.)
Iii the last lecture I spoke of simple epilepsy, and en-
deavored to show that the facts are more in accordance with
the theory oi' muscular motion propounded in the first lec-
ture than with that ordinarily received theory which would
ascribe the convulsion to over-stimulation on the part of one
or other of the nervous centres. In doing this, I insisted
particularly upon the asphyxial state of the circulation and
respiration, and argued that the want of red blood during
convulsion must necessitate at that time a corresponding
want of action in every one of the nervous centres. In the
present lecture I propose to continue the inquiry, and see
whether the same theory is applicable to convulsive diseases
generally. I also propose to add a few words upon the thera-
peutics of these maladies.
I. The Theory of Convulsive Diseases Generally. In pro-
ceeding to a cursory examination of convulsive diseases
generally, I shall divide these diseases into three catego-
. of which the distinctive signs respectively are tremor,
convulsion and spasm. In the examination itself, I shall do
as I did when speaking of simple epilepsy, and consider
first the condition of the circulation and respiration, and
afterwards review the several nervous phenomena, other
than tremor,jconvulsion, or spasm, which must not be pass-
ed by in silence.
/. Tlu Theory of Tremor. The category of convulsive
diseases of which the distinctive mark is tremor, includes
the tremblings of delicate and aged persons, of paralysis
aiis, of delirium tremens, the rigors and subsultus of
ers, and the shakings of slow mercurial poisoning.
1. The state of the circulation and respiration in these
ral conditions is sufficiently obvious. There is no
doubt that both these functions are much depressed during
common trembling ; for this is evident as well in the paleness
and chilliness of the person trembling as in the decided relief
afforded by wine. In delirium tremens, the perspiring
skin, the cold hand, the quick compressible, fluttering pulse
302 Lectures on [April,
arc all significant and unmistakable facts. It is evident,
also, that the trembling is connected with this state ofthings;
for if the dry skin and excited pulse of true meningitis
make their appearance, the trembling is at an end. On the
other hand, an argument to the same effect is to be found
in the fact that tremor is exaggerated into subsultus, or even
into convulsion, as the heart and pulse fail in the downward
course of the disorder. Rigor, moreover, is coincident with
a sense of coldness, a feeble pulse, a sunken countenance,
a corrugated skin, and subsultus, with a pulse faltering in
itsfinal throes; and that this coincidence is not accidental,
is seen in the fact that rigor disappears as the pulse and
warmth return, and that subsultus may be checked for the
time by the use of wine. And in mercurial tremor, an in-
ference as to the real state of the circulation may be drawn
from the general practice prevailing amongst the subjects
of this disorder of resorting to gin and other stimulants to
make themselves steady.
2. The nervous phenomena, other than tremor, arc
in accordance with the foregoing facts. In a bout of ordinary
trembling the mental faculties are all unstrung ; and in the
permanent and extremest form of this trouble, as in paraly-
sis, they have altogether succumbed before the inroads of
age or disease, <ind the sufferer lives only to sleep and eat.
In delirium tremens the mental state is passive in every
point of view. The patient lies unmanned, as it were be-
fore some dim phantom of evil ; or if not if, that is to say,
active delirium takes the place of the delirium tremens, and
other symptoms betoken the existence of active inflamma-
tion then the affection ceases to be delirium tremens, for
the trembling has disappeared. In the initial rigors of
fever, the mental state is one of dejection, languor, stupor:
in subsultus, it is one of vague dreaminess, or of drowsiness
not removed from mortal sleep. In slow mercurial poison-
ing, the failure ot the mental powers keeps pace with the
decay of the bodily strength, and the condition is one of
premature old age.
In the different forms of tremor, therefore, the state of
the nervous system, as reflected in the condition of the
mind, is one of comparative inactivity. Xor is it easy to
suppose that the condition of the brain is different from that
of any other part of the nervous system ; for if a due sup-
ply of blood be necessary to the due exercise of the differ-
ent nervous functions, as it undoubtedly is, then it follows
1861.] Con 303
the medulla, oblongata, the spinal cord, and every other
nervous centre, must he in a similar state of comparative in-
action during trembling.
II. The Theory of Convulsion. The second category, in
which convulsion is the distinctive feature of the muscular
disturbance, is divided naturally into two sections by the
absence orpresence of consciousness during the convulsion.
Where the consciousness is preserved the convulsion maybe
called simple ; where consciousness is in abeyance, the con-
vulsion is epileptiform. Simple convulsion occurs in hys-
teria, in chorea, and in those strange affections which take
an intermediate position between the two, as the dance of
St. Vitus and St. John, tarantism, and other affections of
the kind. Epileptiform convulsion includes the convulsion
connected with certain diseases of the brain chronic soften-
ing, chronic meningitis, tumor, induration, hypertrophy,
atrophy, congestion, apoplexy, inflammation with fever,
with uraemia and other suppressed secretions, with "irri-
tation" in the gums and elsewhere, and with death from
haemorrhage and other causes.
A. The Ihcorj of Convulsion. 1. The pulse of persons who
Buffer from hysteric convulsion is generally soft, quick, and
variable. The skin is frequently pale, and the hands and
feet are often subject to chilblains, even whem the weather
is not very cold. Xor is there any real excitement of the
circulation during the paroxysm. Indeed, the mode of
breathing which is slow, embarrassed, and accompanied by
deep sobs and hiccough, is altogether incompatible with any-*
thing like excitement in the circulation. There is, more-
over, some reason to believe that unncessary stress has been
laid upon a disposition to inflammation as one of the
characters of hysterical subjects ; but, be this as it may,
there \< no reason for supposing that any inflammatory dis-
turbance of the circulation in any organ has anything to do
with the symptom with which we are here concerned the
convulsion.
As in hysteria, so in chorea, the circulation is subject to
considerable fluctuations, but the habitual state is one of
marked depression. The pulse most generally is quick and
weak, and the heart Lb readily thrown in a state of palpita-
tion. In many cases, also, as additional evidences of a
feeble circulation the face, lips, gums, and tongue are pale,
the skin La pasty, and in extreme cases the serous cavities
are more or less water-logged. In some instances there
304 Lectures on [April,
may be all the signs of actual chlorosis; in other instances
there may be predisposition to rheumatic fever, but this pre-
disposition cannot be urged as an objection to the idea, now
very generally admitted, that chorea is essentially a fever-
less malady; for it is certain that chorea is never coincident
with rheumatic fever.
2. The habitually feeble state of the brain in persons sub-
ject to hysteric convulsion is shown in a variety of ways
indecision, irresoluteness, fickleness, pliability, over-sensi-
tiveness, fidgetiness, and so on. And in the fit the will is
altogether in abeyance, and the mental state is one approach-
ing very closely to unconsciousness. The condition of the
circulation at the time of the convulsion is also incompatible
with any but a very low degree of action in any one of the
nervous centres. ]STor is it necessary to suppose that the
uterus has anything to do with hysteric convulsion beyond
this that many common and important causes of weak-
ness and exhaustion refer more or less directly to this
organ.
The subjects of chorea present the same evidences of
mental feebleness as those which are met with in hysteria
the same vacillation, irrationality, inordinate sensitive-
ness, timidity, fretfulness, irritability. It is to be supposed,
also, that the mental state reflects the state of all the ner-
vous centres* for the circulation is manifestly unequal to
maintain the action of these centres at the normal pitch.
Nor is any contrary evidence presented after death. In a
certain number of cases, no doubt, traces of inflammatory
action have been found in or on the brain or spinal cord ;
but as such traces are notYound in the majority of cases, it is
evident that inflammation of the brain or cord cannot be re-
garded as essential to chorea. What the occasional traces
of inflammation may signify is another matter. It may be
that the inflammation preceded the chorea, and left the
nervous centres damaged, and to that extent weakened ;
and this opinion would not seem to be improbable where the
signs of mischief were evidcntl}' of no very recent date. It-
may be that the inflammation has been a consequence rather
than a cause of the chorea the nervous centres in con-
nexion with the muscles, like the muscles themselves, break-
ing up, as it were, from sheer fatigue. At all events, it
may be seen now, and will be seen more distinctly presently,
that inflammation of the brain or cord is not to be regarded
as a direct cause of any kind of choreic movement.
1861.] Convulsi 305
1>. leptiform Convulsion, 1. Cn a case
oi general epileptiform convulsion, the state of the circula-
tion is as Ear removed from anything like excitement as it is
in simple epilepsy. There is, indeed, the same failure of the
pulse at the commencement of the lit, and the same state
of positive BnfTocation during the fit. In the case of partial
epileptiform convulsion, the only difference is one of degree.
In any ease, the pulse is scarcely to be felt at the beginning
of the paroxysm, and everything shows that the circulation
is at a very low ebb ; and if the pulse acquires any sem-
blance of power as the paroxysm proceeds, the dusky and
livid color of the face, the interrupted breathings, and other
unequivocal signs of suffocation, afford sufficient proof that
this phenomenon is due, not to the increased injection of
red blood into the arteries, but to the impeded circulation
of black blood, as explained in the last lecture.
Xor is there any evidence of a contrary character, in the
antecedent history of epileptiform convulsion, for in those
cases in which the malady is of an inflammatory or febrile
character, it will be seen that the lit occurs either in the period
oi prostration which precedes the development, or else in the
period of collapse which comes on after the dying out of the
fever or inflammation.
In chronic softening of the brain, the habitual coldness of
the hands and feet, the weakened and perhaps degenerated
heart, the atheromatous or calcareous deposits in the arterial
coats, are amongst the many signs which show the innate weak-
- of circulation a weakness to which fever and inanima-
tion are alike uncongenial.
In chronic meningitis, as might be expected from the un-
mistakable evidences of a scrofulous, habit, and from the state
of weakness and exhaustion which are so generally present,
the pulse, for the most part is quick, weak, and much affected
by changes of posture. There may be some hectic excitement
in the evening, the cheeks flushing, the eyes shining, and the
aching head becoming a little hotter than it was before ; but
this faint excitement is not sufficient to raise the pulse to a
normal pitch of activity. In no case, indeed, is this reaction
of the circulation a marked and conspicuous phenomenon, and
in the majority of instances it is scarcely sufficient to impart
even a semblance of power to the weak and feverless pulse.
And if there is little vascular excitement in ordinary chronic
meningitis, there is. if possible, less in that form of the dis<
which is known as chronic hydrocephalus.
20
300 Lectures on [April,
In tumor of the brain the pulse is quick, weak, irritable,
fluctuating, or if not, it will be so as soon as pain, want of
sleep, and despondency common symptoms of tumor have
had time to bear their natural fruit of weakness and exhaus-
tion.
In induration of the brain, such as met with in lead-poison-
ing, &c., the phenomena presented by the circulation differ
very little, if at all, from those which occur in advanced
stages of ordinary epilepsy, and any difference there may be,
is one which indicates a state still more fully removed from
fever.
In atrophy of the brain, as in simple epilepsy, there is no
evidence of anything like excitement in the circulation.
In congestion of the brain, the head and face are congested
and dusky, the lips purplish, the jugular, full, the pulse and
respiration slow and labored, the hands and feet habitually
colder than the head. There are, indeed, many evident
signs which show that the circulation is not carried on with
proper vigor, and which appear to point to imperfect arteri-
alization of the blood as one cause, of this defect.
In apoplexy the convulsion is most apt to happen at the end
rather than at the beginning of the period of coma, when the
purpled lips and the inadequate breathings show the respira-
tory changes are rapidly failing. Or, if it happens at the be-
ginning, it is in those forms of apoplexy in which the con-
dition of the circulation at the time is more akin to collapse
than anything else, and not in those forms in which there is
an excited pulse, and strong determination of blood to the
bead.
In inflammation of the brain, the condition of the circula-
tion may vary a good deal with respect to the inflammation,
but little with respect to the convulsion.
Simple meningitis begins with paleness of the skin, a feeble
depressed pulse, cutis anserina, vomiting, rigor, perhaps con-
vulsion. Then follow rapidly the symptoms of high febrile
reaction and cerebral inflammation, the pulse becoming hard
and frequent, the breathing irregular and oppressed, the skin
particularly the skin of the head hot and burning. After
continuing for two or three days, these symptoms of high fe-
brile reaction give place to an opposite state of things, in which
the |>ulse loses its force, and becomes weak, small, irregular,
and the breathings are interrupted by frequent sighs and
pauses. ( )r, if at this time the pulse retains any degree of re-
sistance, it is evident, from the dusky color of the skin and the
Buspirious and labored respiration, that the whole of this re-
1861.] Con* i 307
sis
stance is not due to the injection of arterial blood into the
artery. Now, it is in this stage of collapse, or semi-suffoca-
tion, which follows, or else, in the cold stage which precedes,
the febrile and inflammatory excitement, and never during the
period of excitement, that the convulsion happens. And this
rule is constant. Indeed, the history of Simple meningitis
shows most conclusively that vascular excitement is as in-
compatible with convulsion as it is with rigor and subsul-
tus.
In tubercular meningitis, the pulse is weak and variable
from the first, now quick, now comparatively slow, rising in
frequency when the head is raised from the pillow, and falling
when it is laid down again ; and from the very first the respira-
tion is irregular, unequal, and interrupted with frequent sighs
and pauses. For some time there may be little disturbance
of a hectic character, particularly in the evening, but this soon
conies to an end, and the prostrate pulse forgets to put on
even this taint semblance of fever. In some cases, there may,
indeed, be a short stage of fever, and something like active
cerebral inflammation, especially in young children; but as a
rule the symptoms are altogether of a passive, non-febrile,
non-inflammatory character. In any case, however, the con-
vulsion is connected with a depressed state of the circulation,
and never with febrile and inflammatory excitement, if such
state there be.
In rheumatic meningitis, also, there is little or no febrile ex-
citement fr<>m the beginning, and the pulse has become
powerless and utterly weak before the convulsion happens.
In general cerebritis, the pulse, at first Blow, soon becomes
variable and readily affected by change of posture; the respi-
ration, also, is very variable and suspirious. From the first,
indeed, there is scarcely any fever, and little heat of head, ex-
the phenomena of cerebritis are mixed up with those of
simple meningitis ; but if such symptoms are present, they
. pass off, and give place to Bymptomsof slow .-inking a
in which, hour by hour, the breathing is more interrupt-
ed with sighs and pauses, %and the pulse more powerless, un-
'.- may have a fictitious power, from the presence of more
or less black blood in the artery, in which case the dusky
countenance and the purple lips will show very clearly that
any increased injection of red blood is at this time out of
the question.
In partial cerebritis there is even less febrile disturbance
than in general cerebritis, ami at no stage of the malady is
there anything like increased vascular action.
LectUTi [April,
The immediate antecedents of the epileptiform convulsion
which may attend upon the onset of fever arc paleness of the
face, coldness of the hands and feet, a feeble, soft, and fluctu-
ating pulse, a respiration that is short, accelerated, and inter-
rupted by frequent sighs. The immediate antecedents of the
convulsion which may attend upon the: end of the fever are, a
weak and thready pulse, a frigid hand, and lungs too much
gorged with blood to allow oi any proper respiration a state
in which, febrile reaction having long since died out, the hand
of death is already upon the heart or brain. The convulsion
which may attend upon fever, indeed may take the place
either of rigor or subsultus, and like these forms of muscular
disturbance, it is associated, not with the state of depression,
which is as much below the natural standard as any febrile
excitement is above that standard.
In the convulsion connected with dentition, there may have
been little or no previous fever, and by quick degrees the
pulse may have become excesssively weak, or there may have
been symptoms of cerebral inflammation with high fever, and
afterwards a state bordering very closely upon collapse. In
any case, the immediate antecedents of the lit are indicative
of great vascular depression great vascular depression
brought on slowly without any very obvious fever or deter-
mination of blood to the head, or else that which precedes or
succeeds active fever and determination. And so likewise
with the convulsion which is connected with worms or other
sources of irritation in the alimentary canal; for if there has
been any febrile disturbance, this has passed off, and left the
patient not only feverless, but pale and chilly. Nor is it
otherwise with those forms of convulsion which are referred
to uterine irritation. In the convulsion connected with men-
struation, the circulation is in the state in which it is in ordin-
ary epilepsy or in ordinary hysteria ; and a similar remark
a] iplies to several of the convulsions which may happen in the
course of pregnancy. In the convulsion of flooding, the face
and even the tongue is blanched, the hand frigid, the body
bathed in cold sweat, the pulse fluttering and well-nigh imper-
ceptible, the breathing a continuous sigh or gasp. In the
convulsion occurring in labour without flooding, the head is
often greatly congested, and the aeration of the blood seri-
ously interfered with, partly in consequence of the way in
which the lungs sympathize with the semi- comatose brain, and
partly because the regular expansions of the chest are inter-
fered with by the constant efforts at straining. In such a case
the pulse may be full; bnl if bo, the venous color of the lips
L861.] Ckmrnd* 309
will show that this fullness is due to the circulation of black
blood rather than to the circulation of red blood in the ves-
sels. \\\ the convulsion. which may happen daring puerperal
r, the vascular antecedents are the same as those which
may happen towards the end of every fever. And lastly, the
condition of the circulation before the convulsion which is re-
ferred t> "irritation" of a sexual character, it' it differs at all
from that which is met with in ordinary epilepsy, differs only
in being one of still deeper depression.
Nor is there any trace of vascular excitement before the
convulsion which may happen in the moribund state. In the
convulsion attending death by haemorrhage ov asthenia, the
blanched face and tongue, the frigid hand, the sighing or
gasping respiration, the faltering pulse, art signs which re-
quire no comment; and in the convulsion attending death by
idy or gradual suffocation, the state of things is equally
opposed to the idea of vascular excitement ; for how to ask
this question once more can vascular excitement and a state
of suffocation be compatible conditions i
In a word, there is no instance in which epileptiform con-
vulsion can be supposed to have any connection with an ex-
cited state of the vascular system, and there are many instan-
ces in which the circulation is as far as possible removed from
such a state : and the only conclusion which can be drawn
from these facts is one which seems to harmonize with the
physiological premises, and with the previous conclusions re-
specting simple epilepsy.
'2. In a case of general epileptiform convulsion, the mental
faculties are as completely suspended as they are in epilepsy.
The dilated pupil remains immovable under the brightest
light ; the ear is deaf to the loudest noise ; and when the
patient recovers if he do recover his memory is absolutely
blank as to everything which happened during the lit. In
partial epileptiform convulsion, such as occurs not unfrequent-
lv in chronic softening or tumor of the brain, as in partial
epileptic convulsion, the mental faculties may not be altogether
ended, and the memory is occasionally able to recall some
of the circumstances attending the fit. In the case of general
epileptiform convulsion, therefore, the condition of the mind is
evidently one of inaction. Of this there is no doubt. Nor
can there be any doubt that the state of the mind is one of
parative inaction in partial epileptiform convulsion : for
the utter bewilderment, the inability to collect and control
the thoughts, the trepidation, and the want of power over the
muscles, are all signs which cannot be mistaken.
310 Lectures on [April,
It would seem, also, that the brain is not less inactive than
every other centre of nervous action, for (to repeat the
argnmenl already u>v<\ so often) none but the very lowest
degree of action is compatible with the circulation of unarteri-
alized blood in the vessels. Nor isthere anything contradictory
in this conclusion in the tacts which remain to be mentioned.
In chronic softening of the brain the fits are preceded by
unquestionable, and often very marked, impairment of the
mental faculties, and in some cases the mind may be a total
wreck. Fire and energy are dyingoutand dulness and drowsi-
ness point to the coming coma, ofwhicb they are the forecast
shadows. The brain, also, is blighted, not inflamed. Jt is
pallid, whiter than it ought to be, deficient in red spots, and
in parts, softer than natural : and, on microscopic examination
the softened substance is found to consist of broken-down
brain tissue, with a greater or less number of cells containing
oil, and sometimes reddened with blood corpuscles, (for
haemorrhage is a common consequence of softening) but with-
out any of the products of true inflammation exudation and
pus-corpuscles.
Impairment of the mental faculties, progressively increas-
ing, is also a prominent symptom of chronic meningitis im-
pairment which would seem to be more marked by peevish-
ness, impatience, fidgetiness, and not unfrequently this wan-
dering may settle down into insanity. Or there may be no
positive symptoms of any kind. After death the principal
sign of disorder is effusion of serum beneath the arachnoid or
into the ventricles, and this is often the only sign. In some
instances there may be congestion of the pia mater, or evi-
dences of tubercular degeneration in this membrane and in
the contiguous parts of the brain ; but, ajs a rule, the appear-
ances are altogether negative. Indeed, in some instances,
where the quantity of effused fluid is large, as in chronic hy-
drocipalus, the brain has a blanched, bloodless appearance,
and the effused fluid is much less rich in solid constituents
than the serum of the blood a fact which is somewhat calcula-
ted to show that inflammation has no share in its production.
In the majority of cases of tumor, the intelligence does not
appear to suffer in any very marked manner, and when it is
otherwise, it is owing, in some degree at least, to the presence
of chronic meningitis. The pain, however, the want of sleep,
the depression of spirits, all combine to exhaust the brain, and
this exhaustion is generally shown by vagueness in the ideas,
by inability to fix the thoughts, or in some other manner.
Nor is the pain, which is usually so very prominent and dis-
1861.] Convulsive J) 311
3ing a symptom, an objection to the idea, that the brain is
acting inefficiently in these eases, indeed, pain in the head is
a sign that the brain is insufficiently supplied with arterial
blood, ir ceases, and gives place to delirium, when the arterial
injection increases. Nay, in some instances there is reason to
believe that the nervous energy is lessened during pain, and
that pain may be as much a sign of want of action in a senti-
ent nerve as spasm is a sign of want of action in a motor nerve.
At any rate Professor dn Bois-Raymond has shown that the
nerve-current in the nerve of a frog fails when the cutaneous
ramifications of the nerve are subjected to a treatment which
must give rise to pain. But be this as it may in other instan-
ces, in tumor of the brain it must be difficult to regard pain
as a sign of over-action, for the companion symptoms during
life, and appearances after death, are alike opposed to such a
conclusion.
In induration of the brain, there is as little evidence of any
excitement in the mental faculties as in any of the previous
cases, probably less ; and the condition of the brain after death
affords no countenance to the idea of inflammation, for the
brain is harder, darker in color, drier, more bloodless than it
ought to be.
In cases of atrophy of the brain, where the condition is con-
genital, the probability is that the patient is idiotic as well as
epileptic. In cases of hypertrophy of the brain, which cases
are occasionally met with in children, while the bones are suf-
ficiently yielding to allow expansion in the enclosed organ,
the patients have not had any other inconvenience beyond
the deformity a taint argument, possibly, that want of brain
and therefore want of cerebral action, had really to do with
the convulsion which would seem to be a constant phenomenon
in atrophy of the brain.
A person suffering from congestion of the brain is less
"bright" than he was, his conceptions are wanting in clear-
ness, he is deficient in the power of attention and spplication,
his sight is dim, his hearing dull and perplexed with ringing
or rumbling sounds, he is drowsy, and feelings of weight in
the head and pain arc familiar .troubles. Everything, indeed,
indicates an oppressed and inactive brain.
In apoplexy, the mental antecedents are those of congestion
ir softening, not of inflammation as such. There would, in-
deed, appear to be a strange absence of inflammatory tendency
in the brain in apoplexy; and if there are any evidences of
inflammatory action around the clot, it will generally be found
that this action was anterior to the hemorrhage in point of
! 1 1 2 Lee lures mi f Apri ] ,
time that, in fact, the blood had escaped in consequence of a
previously softened state of brain. It is possible, also, that an
argumenl in favor of a tendency directly opposed to the idea
of inflammation may be found in the fact pointed out by
M. M. Andral and Gavarral, that the blood in apoplexy is
deficient in fibrine ; for if the effect of inflammation be to
increase the amounl of fibrine contained in the blood, it may
be supposed that a deficiency of fibrine indicates a state of
things which is the reverse of inflammatory.
Nor is there the least reason to believe that any over-action
of the brain is concerned in bringing about the convulsion
which is connected with inflammation of the brain.
In simple meningitis, convulsion may attend upon the very
onset of the disorder. In this case, it coincides with the cold
stage which ushers in the true inflammatory reaction, a stage
of which the mental signs are, depression, confusion, perhaps
drowsiness. Or convulsion may attend upon the period of
final prostration which follows the true inflammatory reaction,
a period in which the mind is rapidly sinking towards a state
of coma. Convulsion may occur at one or other of these times
but it never occurs in the true inflammatory stage, when the
pupil is contracted to the size of a pin's head, when the im-
patient sensitiveness of the eye and ear is scarcely to be quiet-
ed by absolute darkness or silence, and while there is agoniz-
ing pain in the head or fierce delirium.
hi tubercular meningitis the acute pain, the wild delirium,
the intolerance of light or sound, which mark the outburst of
simple meningitis, are wanting, and the course of the disease
is insidious. Inordinary cases, "where the symptom set in
thus stealthily, the usual period for the convulsion is after the
brain and the system generally have given many unequivocal
signs of exhaustion. In other cases, where there may be more
marked febrile disturbance, the convulsion may happen in the
initial cold stage, or after the febrile symptoms have calmed
down and Left the system in a jaded and exhausted state. As
a rule, however, the idea of inflammation has as little to do
with this affection as with phthisis pulmonalis ; for when the
diseased products are examined microscopically, they are
found to consist, not of products of inflammation, but of the
well-known elements of ordinary tubercle.
In rheumatic meningitis the convulsion observes the same
rule, occurring either in the initial cold stage of the fever, and
preceding the accession of the violent pain and delirium, or
else waiting until the excitement has passed off, and. the patient
18 left drowsy and semi-comatose.
L861.] Cbnv '' i 313
In general cerebritis anything like wild delirinm or acute
pain in the head is absent, unless the affection is complicated
with meningitis; and the characteristic state is dulness and
drowsiness, rapidly progressing into typhoid prostration.
In partial cerebritis the course of the disease is less rapid,
and the downward progress may be interrupted by pauses of
longer or shorter duration, but in other respects its characters
are the same. From beginning to end, in either case, there
are no evidences of an excited condition of brain to be gather-
ed from an analysis of the mental phenomena, or at any rate
there are no such evidences at the time the convulsions make
their appearance.
In fever, convulsion may precede the establishment of the
febrile excitement, in which case the mental state is one of
great depression, oppression, prostration, stupefaction. In
other words, it may occur in the initial period of collapse or
rigor the cold stage ; or it may occur in the final period of
prostration, when a few incoherent mutterings are the only
traces of the previous delirium when the last traces of men-
tal action are rapidly succumbing to the drowsiness of ap-
proaching death. It may occur at one or other of these times,
but not during the active period of fever.
In epileptiform convulsion depending upon retention of
urine, the patient before the attack is drowsy, stupid, listless,
despondent, his eyesight dim, his hearing dull, his speech
drawling ; and in convulsion depending upon retention of bile,
delirinm is at an end, and drowsiness has beceme well-nigh
comatose before the time for the attack has arrived.
In difficult dentition the brain is exhausted by pain and
want of sleep, and drowsiness is taking the place of fretful-
a and wakefulness before the occurrence of the fit ; or if
there be any cerebral inflammation, the tit follows the rule
which has been already laid down.
In worms, and in other forms of irritation in the alimentary
canal, the mind as well as the body is not braced up to the
proper pitch of health, and the patient is jaded, irritable, and
drov.
In convulsion arising from ''uterine irritation" the mental
state is that which belongs to either epilepsy or hysteria.
In the convulsion of flooding the pupil is dilated, the thoughts
are undefined and incoherent, and before the tossingg change
into convulsion the last trace of mental action has died out."
In the other convulsion occurring during labour the brain
is exhaut pain and straining, and upon the point of
lapsing into a Btate of coma when the convulsion happens.
314 ProstatorrhcBa. [April,
In the convulsion of true puerperal lever the mental con-
dition is the same as in the convulsion of ordinary fever.
And, lastly, the epileptiform convulsion referred to "sexual
irritation" has the same mental accompaniments as ordinary
epileptic or hysteric convulsion, one or other.
Nor can there be any doubt as to the condition of the
brain connected with the moribund state. In death haemor-
rhage or asthenia, mental action fails pari passu with the
flowing of the blood out of the vessels, and the sufferer has
become altogether insensible to pain and trouble before he is
seized by the convulsion. And when death is brought about
by suffocation, whether slowly or rapidly, it is no less certain
that all mental action fails pari passu with the failure in the
respiration, and that the last spark of mind has vanished be-
fore the time for the convulsion has arrived.
Whenever epileptiform convulsion makes its appearance,
therefore, the attack is preceded by some evident failure in
mental energy, and in several instances this failure is almost
or altogether complete. Nor is it possible to suppose that this
state of inaction is confined to that part of the nervous system
which is the scene of mental life ; for the depressed or op-
pressed state of the circulation which precedes the attack in-
volves a corresponding degree of inaction in the complete
chain of nervous centres.
In a word, there is nothing in the history of epileptiform
convulsion which is not in perfect accordance with the history
of simple epilepsy, or which may not be interrupted in the
same manner.
(to be continued.)
On the nature and treatment of Prostatorrhra. By Professor
Gross, of Philadelphia.
J Vostatorhoea is denned to be a discharge from the prostate
gland, generally of a thin mucous character, dependent upon
irritation, if not actual inflammation, of the component tis-
sues of that organ. It has generally been confounded with
other lesions, as gleet, or chronic urethritis, seminal losses,
and cystorrhcea, or chronic inflammation of the mucous
membrane of the bladder. It does not often occur among
children or old people, but is most common during the ac-
1861.] Prostaiorrhasa. 315
tivity of the sexual organs, and is most frequently met with
in those whoso sexual propensities are the strongest. The
exciting causes are not always evident, but the disease lias
generally been traceable, either directly or indirectly, to
venerea! -, chronic inflammation of the neck of the
Madder, stricture o{ the urethra, or some affection of this
canal ; it may have its origin in diseases of the rectum, and
the me ot internal remedies, as cantharides; turpentine,
may excite a temporary prostatorhoea ; a common cause in
young men is masturbation. The symptoms are a discharge
of mucus, generally perfectly clear, ropy, varying from a
drachm upwards in twenty-four hours ; in efforts at defeca-
tion the flow is greatest. It is attended, also, with a
pleasurable, tickling sensation sometimes. Prostatorrhoca
may be distinguished from urethritis by the gradual super-
vention of symptoms, the transparency of the discharge, the
absence of charges in the urine, or difficulty in micturition.
The pathology of this affection consists in a disorder of
the follicular apparatus, leading to an inordinate secretion
oi its peculiar fluid. This may be due to inflammation, but
in some instances the organ appears to be entirely healthy,
in which case it is supposed to be due to a heightened func-
tional activity. The prognosis is generally favorable, as
this affection is not a disease, but a symptom of disease,
usually slight, and easily removed ; it is often, however,
very obstinate, and when the mind deeply sympathizes with
the local affection is very difficult of management.
The treatment should be directed to the removal of the
cause, and to this end there should be a thorough exploration
of the genito-urinary apparatus, the anus, and the rectum,
and a careful inquiry as to the habits of the patient. If he
is weak, gentle exercise, nutritious diet, wine and tonics arc
indicated. The tincture of the chloride of iron in union
with tincture of mix vomica is especially recommended ; if
he is plethoric, the antimonial and saline mixture is useful;
the most useful topical applications are cooling and anodyne
injection* ulard's extract with wine of opium in the
proportion of one or two drachms each in ten ounces of
er, three times daily; in obstinate cases, cauterization
i a week may be necessary; the cold hip bath is also
important, and if the symptoms do not yield, leeches should
be applied around the anus and to the perinreum.
3 16 Goitre, [April,
On the treatment of GoUreby the external application of Biniodide
of Mercury. I>v Dr. Frodsham, Physician to the Farring-
don < General Dispensary.
Dr. Frodsham reports veryfavorably respecting this plan
oftreatmenl :i plan to which we have already directed at-
tention ("Abstract," XXVI, 150), as having been carried
out with marked benefit in India, by (/apt. Cunningham, of
the 11th Irregular Cavalry.
"I have myself," says our author, "had considerable op-
portunity of testing its efficacy, and always with a most for-
tunate result. A certain amount of difficulty is, however,
experienced in its application, as the influence of the solar
rays appears to he absolutely essential to its curative action,
and therefore in this country it can only be adopted with
perfect success during a few of the summer months. The
following is the plan I have invariably pursued with the
patients under my care: .
"An ointment of the biniodide (biniodide of mercury, six-
teen grains ; lard, one ounce) has been first rubbed into the
swelling for several days. Then seizing the opportunity of
a powerful mid-day sun, the patient has been exposed to its
influence, the throat being thoroughly smeared with the
same application, and the head well elevated. It is gener-
ally borne for upwards of an hour, when a severe sensation
only of blistering is produced. The patient should then
be allowed to return home, and cautioned not to rub off the
ointment.
"Dr. Moreal suggested the application of artificial heat; and
thinking it possibly might have a similar influence, though
in a modified degree, I made several experiments, though,
I regret to say, with but little success. In one case I caused
the patient to sit before a large fire; in another, I held a
hot flat-iron a short distance oft* the swelling. In the latter
case, the pain was so great as to demand immediate discon-
tinuance.
"Some of the cases in which this treatment was most
eminently successful had been of long standing, and all the
usual remedies, both internal and external had been tried
in vain. One woman had Buffered from the swelling for
tour years, and for upwards of one year had been taking the
iodide of potassium internally, and applying the iodide of
potassium ointment externally, but without deriving the
Blightest apparent benefit. The biniodide was only applied
e ; and before the expiration of a month a diminution of
186L] Delirium Trent* 317
two inches, by measurement, in the Bize of the tumor had
taken place. At the end of six months no Bign of the form-
er disease was perceptible,
"The superiority of this mode of treatment consists in its
great cleanliness, its not discoloring the skin, and causing
no external breach of surface, together with its speedy
remedial action (one application generally sufficing). As
to the modus operandi, whether it is due to rapid absorption
or to chemical changes, is, I believe, as yet undecided."
On Delirium Tremens. By Dr. Jeffrey A. Marston, Assist-
ant Surgeon, Royal Artillery, Maine.
[The following paper by Dr. Marston is a most sensible
one, and they wrho are now treating all cases of delirium
tremens without alcohol will do well to consider it. Few
are more strenuous advocates of total abstinence from all
stimulants than ourselves in cases of health, but in certain
diseases we have found it indispensable to carry the patient
over certain periods of exhaustion. Dr. Marston says :
First of all, let us see that our terms are precise and clear.
I would say that there are three separate and distinct forms
of the disease in (question ; that if any one plan of treat-
ment be pursued in all, and if, without reference to their
distinctive features, they be individually and severally
heaped together under one head, we can obtain no reliable
data. Xot a little misconception, it seems to me, has arisen
from this very source:
I. Delirium e potu, or Delirium Ebrictatis properly so
called.
II. Delirium Ebriosorum.
penal
III. Delirium Hepatic
complicated < Gastro-Enteric > Diseases,
with Cardiac
^Central J
1'rofessor Todd, in one of his clinical lectures, has some
admirable remarks upon the two first forms, and their dis-
tinctions. The first I would illustrate thus : It happens in
the younger and more acute drunkards (if I may so term
them.) The disease follows quickly after a debauch
within 21 or 48 hours. The symptoms are the tongue
318 Delirium Tremens. [April,
very foul and tremulous; great headache; face rather
flushed : tenderness often upon pressure of the epigastrium;
nausea; sometimes vomiting ; perfect anorexia ; sleepless-
ness; tremors; hallucinations; illusions; restlessness; an
excited manner; a quick, sort, and tolerably full pulse;
and often t lie re is present a smell of spirit. Now, these
- are by far the most frequent. The disease occurs in
a man whose means prevent a regular steady soaking, but
in one who drinks very hard whenever his pocket allows it.
I [owever frequently this may be, there is always a good and
distinct interval weeks or months. The subject of the
disease goes in for a heavy night or so at a time his
money is exhausted he does or does not go to prison, but
at any rate he does not drink again for some period, for the
best of all reasons want of means. Here is the ordinary
form of the disorder : An acute alcoholism the drink
being in the man. An emetic purgative, with quiet and
repose for two or three days, sets him all right again.
The second form is a delirium of drunkards, in contra-
distinction to a delirium from drink. The illustration of
this form will be : The subjects of it arc older have the
outward and visible signs, and bring the history of a habit
of drinking; hard drinking indeed, if the aggregate be
looked to the steady weekly consumption of spirits, to
wit but less hard than the first variety in a given space of
time. Those men who have kept out of the guard-room,
and are shrewd enough to keep aloof from their officers ;
bear a good regimental character; arc seldom, if ever, in
hospital ; and although long suspected in the regiment of
being secret drunkards, yet are only proved so by some ac-
cident as turning out at night to a tire or admission into
hospital lor some trivial disease. At last he is caught, and
lodged in the guard-room ; or by some means or other he
is with all suddenness deprived of his drink ; and delirium
tremens sets in, appearing from the second to the seventh
day after confinement, while perchance the man is awaiting
his court-martial.
In short, you get the history of a man who has drank for
years and years ; during which time he has performed his
duty under sharp supervision, and has not suffered from
any disease, lie is deprived suddenly of his stimulus, and
takes delirium tremens.
Complicated Form. This variety will take in the various
symptoms of any organic disease present, and complicating
1861.] Delirium Tremens. 319
the case. It would be impossible and needless to enume-
rate the various complications, further than to remark that
that their recognition and diagnosis is all important ; the
difficulty of their treatment very great ; and that the mor-
tality tar exceeds that of the other and simpler forms of the
disease.
The visceral or glandular derangements become evident
for the first time during the attack of delirium tremens
the man never having been before in hospital and are then
only arrived at, from the fact that some unusual symptoms,
as convulsions, jaundice, oedema, persistence and peculiarity
of the delirinm, or albuminous urine, make them apparent.
The treatment of such cases must necessarily be modified
according to the diseased state and its indications.
Having premised this much, let us turn to the points in
dispute, which appear to be : That the theory of the causa-
tion or etiology of the disease hitherto propounded is
wrong, its pathology wrongly stated, the indications for its
treatment misunderstood, and the special modes of treat-
ment themselves (particularly that by opium and stimulants)
have been erroneously and injuriously pursued.
It is often better to watch than correct, and I would ask
how many cases classed under the first form have be
enumerated with the second and third varieties ? I fane
that by far the larger number of the so-called statistics con-
sists of individual cases of the first form, and if so, the
generalization from them cannot fail to be vitiated, when
applied to the whole disease.
Dr. Watson expressly says, that some cases occur after a
long debauch, and others in which the patient has not ab-
stained, but is continually fuddled ; and here the disease
arises because the man goes from his ordinary positive to
the comparative degree.
There is no doubt that those cases are numerous, and
their plain inference is "poisoning;" but so much has been
made of them, as virtually to exclude the occurrence of
other forms.
FMology. Taking the objections seriatim, the etiology ;
Watson says, the predisposing cause is drink; the exciting
cause, the privation of it. Against this view there is urged
the frequency of the disease following a debauch, &c, with-
out any privation ; in short, the frequency of the first form.
Such frequency it is argued, proves the disease to be the
result of poisoning, and the sufficiency of the poison alco-
320 Delirium Tremens. [April,
no! to form at once the exciting and predisposing cause.
The occurrence of some disease, such as catarrh, influenza,
gastric disturbance, in a drunkard, may he also an exciting
cause. Lastly, the statistics of prisons are against the
theory, it is said, of privation. The first objection is shortly
this, that we have proof of one cause (toxaemia from alcohol)
being sufficient, and hence it is unphilosophical to seek a
second. I can only meet this by stating, that there are dif-
ferent forms of the disease, which may have different
causes, nay, a plurality of causes. Besides, I shall adduce
positive evidence of the disease following the withdrawal
of alcohol. With regard to prisons, I can only speak of
military ones. No cases occur in them, I am aware, and
am not suprised at the fact; hut they occur antecedently,
coming on in the guard-room, where, if a man be tried, he
awaits his court-martial, probably for many days ; and I
state as a fact, that, cases of delirium tremens commonly
occur from the first even to the seventh day after the priva-
tion of liquor. The guard-room statistics would hence be
every bit as strong the other way. I am aware that statis-
tics do not settle the fact, they do not prove cause and
effect, viz : deprivation of accustomed stimuli as a cause of
delirium tremens ; but they cannot certainly be urged
against it, for they support at least the view of this priva-
tion being frequently an antecepent to the appearance of
the disease. Is it a necessary antecedent ? I believe it is
in some cases. Take the following :
Sergeant D., ?et. 39 years in daily expectation of a good-
conduct medal. Admitted April 13, suffering from a small
boil upon the lobular appendage of the right ear ; in per-
fect health apparently. Upon the afternoon of the 14th, I
noticed that he was very tremulous and nervous, and asked
him privately about his habits. lie denied m the most
positive and awful terms, that he drank hard, and refused
my offer of a glass of brandy. Upon the morning of the
15th, I learnt that he had slept badly, and found him suf-
fering from a decided attack of delirium tremens. He
talked incessantly, was bathed in perspiration, had illusions,
and fancied he saw strange animals, and heard strange
noises. His tongue was coated, and very tremulous ; the
eves ferrety, the pupils moderately contracted. lie was or-
dered a sharp purgative, and cold douche to the head, fol-
lowed by a basin of beef-tea. At 12 noon he took 33 of
Laudanum, but was sick, vomiting nearly it all ; at 2 p. m.
18G1.] / >> It'rium Tremens. 321
lie had some warm brandy and water, with 5js of lauda-
num, which he kept down ; about 3 p. m. lie had more
-tea, and said he thought he should sleep, lying down
for that purpose ; I happened to be in the ward at the mo-
ment, and my attention was arrested by his livid face and
heavy breathing. In about a quarter of an hour he had an
epileptiform convulsion ; two or three followed after a short
interval, and in about three quarters of an hour he died
with symptoms of apneea. Besides cold douche, artificial
respiration by Marshall Hall's method, and enemata of
brandy, were tried without avail. The post-mortem. wras
made most carefully by myself, and I could detect no
organic disease to account for his death. The left ventri-
cle of the heart, however, was in an advanced degree of
fatty degeneration ; and, besides some venous congestion
of the membranes of the brain, there were a few drachms
of fluid in the cerebral ventricles.
Xow, I would remark how strong is the tendency of the
evidence, negative and positive, of the facts here. A man
is entitled to a good-conduct medal which presupposes
eighteen years' absence from the defaulters' book as regards
courts-martial. I learnt from his wife, subsequently, that
for six or eight years he had drank very hard, and that, al-
though she had never seen him drunk, yet she could not
say that he was ever perfectly sober any night ; that she
did not remember his ever having been in hospital, or suf-
fering from any disease. He comes into hospital, is de-
prived of his liquor directly, and in fifty-six hours is dead.
This appears to me a strong case, but it is not by any means
an isolated one ; and others, equally positive, will be cited,
tar more than sufficient to meet the logical requirements
of one grain of positive against a bushel of negative evidence.
Pathology. Dr. AVatson's views may be epitomised thus :
The disease is "Exhaustion with nervous irritation ;" the
remedy, "sleep." Against this is urged the toxemic view,
and the positive chemical evidence of the presence of alco-
hol in the cerebral ventricles, and that sleep is an effect and
siirn of the improvement in the disease, and not the cause
ofit
Dr. Watson uses his terms advisedly. He does not pass
them for more than they are worth. Are there not certain
acquired physiological conditions or states of system which
produce uncontrollable cravings and desires ? and are not
se eravincrs instinctive desires of a need felt by such an
21
322 Delirium Tremens. [April,
abnormal system ? and supposing them unyielded to, do we
hot get nervous exhaustion and depression ? Is it true that
horses fed upon arsenic fall into a had state of health when
its exhibition is discontinued ? The facts related of the
Styrian and Hungarian peasantry relative to their frequent
sc of arsenic, and the evils which almost invariably arise
om its discontinuance ; the almost universally spread in-
stinct in man to the use of narcotics, stimulants, &c, (such
as opium, betel nut, tobacco, cocoa, with the rest); the
growth of the custom into a habit, and the way in which
men are impelled to the continuance of that habit, from the
fear of the chain of morbid phenomena which follow the
cessation of it ; do not these run very parallel to the facts
we observe from the use and abuse of alcohol ? Chossat's
experiments upon the effect of starvation on animals would
indicate that the nervous tissues undergo remarkably little
relative loss compared with the other tissues, in spite of the
great quantity of fat they contain, and their almost fluid
consistence. This has been held to explain the cause of the
curious psychical phenomena preceding death by starvation.
Restlessness, delirium and prolonged sleeplessness, are
common precursors of death in such cases. Xow it will be
said, that no analogy can be established between such cases
and the same phenomena following the withdrawal of alco-
hol. But I am not convinced of that. The whole doctrine
of diets, however satisfactorilyjit maybe settled on a chemi-
cal basis, is decidedly not settled upon equally certain phy-
siological data. We have facts in abundance to prove that
the chemical value of food is not the physiological one, and
that both man and animals live and grow upon substances,
and in proportions, perfectly different from what a chemical
view would indicate or conceive possible. When we ob-
serve how spirit is meat and drink to a drunkard ; how his
Bystem affords the proof of an altered and abnormal nutri-
tion ; how, in short, he has a special physiology of his own,
ins to me a natural and rational consequence that the
poison to him is no poison, but, on the contrary, a
special fuel lor his nutrition and development albeit, dis-
eased. Liebig has shown how the chemico-physioiogieal
theory oi the action of stimulants upon the human system,
is in accord with the actual experience of landlords and
others, viz : that a far larger amount ^[' food is consumed
by the abstainer from alcoholic fluids, than by one who par-
takes a moderate quantity of them. It seems to be a well-
1861.] Delirium Tremens. 323
ertained fact, that alcohol economises the food and tis-
sues, by arresting the amount of secondary metamorphosis.
Then Ave have the influence of the custom producing a
habit, and its known effects upon the body. Can any habit
be suddenly discontinued and broken without some, nay,
even a grave effect upon the nervous system ?
There seems to me to be no end of evidence to prove that
the sudden curtailment or withdrawal of any habit may
produce nervous exhaustion ; and if so, why, irritability is
a necessary concomitant and index of that condition !
In regard to sleep. A drunken sailor knows very well
that if he can "sleep it off," it is the best and most natural
way of terminating his fit. Xo doubt the tendency to sleep
is a sign of improvement in a case of delirium tremens.
Dr. Watson and others urge that sleep is the necessary pre-
cursor of improvement ; but if I understand the objection
raised to this view aright, it amounts to this, that before a
patient recovers from delirium tremens, and as a sign and
effect of his improvement, he sleeps very probable ; but I
am sure the jwst hoc is often a propter hoc, viz., not that he
sleeps after he improves, but he improves because he has
slept.
'se. G. S., aged 30, admitted June 8, 1858, from the
guardroom, where he had been confined two days. Had
been for years a hard drinker. It was stated (but not upon
reliable evidence), that prior to enlistment he had been con-
fined for a few months in a lunatic asylum. Upon inquiry
it was found that he had been drinking very hard for some
days, and that the debauch terminated about three days
prior to his admission into hospital. He was laboring un-
der all the symptoms of unmistakeable delirium tremens.
After the administration of a purgative and a saline anti-
monial mixture for twenty-four hours, without any amend-
ment, opium in grain doses was commenced, and continued
until his pupils became somewhat contracted, when it was
omitted, itc was allowed milk diet, with a basin of soup
at bed-time. Forty-eight hours having elapsed in hospital
without any sleep, and his delirium, tremor, and symptoms
of exhaustion augmenting, it was determined to give him
chloroform, for which purpose another assistant surgeon
with myself, alternately, sat at his bedside all night ; and
he was kept, at intervals, under its influence for eight
hours, during the greater part of which time lie slept
soundly. At the expiration of this period he awoke, and
.".-I Delirium Tremens. [April,
i-i
partook of some broth. lie appeared far less tremulous,
had lost his rapid delirious conversation, but retained his
suspicious manner, and was evidently haunted by illusions.
After some interval he was again put under the influence
of chloroform, and slept for four hours deeply. Awaking, Jem
he was still more rational and restored ; and after drinking
two bottles of porter, he spontaneously fell asleep. In this
state lie continued six hours, and awoke rational and well,
lie was retained in the hospital for some period, on account
of some dyspeptic symptoms and boils, and with the view
to invaliding on account of his uncontrollable habit of
drinking. This man was a dipsomaniac indeed. I think I
never beheld features so expressive of a true drunkard in
my life. During his fits he seemed to have labored under
certain dominating passions, and these had left such im-
pressions upon the facial muscles as to have permanently
altered his whole physiognomy.
Xow, here we have a case of delirium occurring in a chro-
nic drunkard, who had been deprived of his stimulus for
two days. lie is admitted into hospital, and does not sleep,
his symptoms becoming worse ; by the aid of chloroform
he slept for six or eight hours improves and by the ad-
ministration of more chloroform with the aid of porter, he
sleeps again, and is cured.
A. B., a mess sergeant in a line regiment, had always
been suspected of drunken habits. One day he absconded
with some money, was caught, and confined to the guard-
room. Whilst there, he became the subject of delirium
tremens, and was brought to hospital, with the history of
having endeavored to poison himself with arsenic. This
case was a very severe one, for the patient had an ever-pre-
sent sense of his crime, a fear of punishment, and was,
moreover, suffering from all the symptoms of the disease.
Numerous means were used (including opium) without any
benefit, and a fatal prognosis was formed of his ease. The
regimental surgeon administered chloroform by inhalation,
and procured artificial sleep for many hours. The man
awoke so much improved, that its administration was re-
commenced, and he was quite restored by its aid.
Here we have the symptoms continuing for a certain pe-
riod without any improvement, while induced artificial
( or narcotism was attended with such marked improve-
ment as to have impressed the medical attendant with the
belief that his patient owed his life to the chloroform.
161.] Delirium Tremens. 325
It would be tedious to cite other cases proving the same
ing. I conclude from them, that to procure sleep is
and, excellent advice, the i:ood effects of which arc borne
t by actual experience.
Treatment. The use of stimulants (alcoholic) in cases oi
tlirium tremens with the view of removing the exhaustion,
laying the morbid irritation, and procuring- sleep, would
1 looked upon as even more wrongly directed. If the
iology usually propounded be radically and totally erro-
^ous, then Ave are guilty of adding more poison to an al-
ady poisoned blood, to procure what is not needed, and
hat the presence of alcohol in the system is preventing
sep.
G. M., aged 45, but grey, and looking much older, was
Imitted into hospital for some gastric disorder. This man
is, and had for years been, a very hard drinker, and his
itures, particularly the nose, indicated "potations deep."
:ie morning (after he had been in hospital for some days)
vas called to him. He appeared insensible, was breath-
very heavily, the face and lips dark and turgid, the
ipils contracted. "Whilst examining him he had a coll-
ision of a tetanic character, the body being arched in the
isition of opisthotonos. The muscles of the fore-arm
3re so tense that the radial pulse could not be felt. The
sarts' impulse was scarcely perceptible. Having thrown
bucket of cold water over the head, I took advantage of
few moments of apparent consciousness to pour a glass of
)t brandy and water into his stomach; and he recovered
most immediately, so much so, that the medical officer,
hose patient he was, could scarcely credit the state in
Inch I found him.
G. P., aged 3G, admitted April 14, 1858, from the guard-
om, where he had been confined two days. His disease
is unequivocally delirium tremens, and no remedial mea-
res seemed to benefit him. He was tremulous, restless,
lirious, and did not sleep even with the aid of the fresh ad-
pistration of opiates. Two bottles of porter were given him
bed-time, and he was observed to smoke during the day
lie strong tobacco. His hands were so tremulous that the
:lerly had to hold the pipe in his mouth. By these means
slept and slept well, and made a good recovery, after hav-
been dosed unavailingly for four days previously to pro-
re that result.
At this moment I have a soldier in hospital who has always
326 Delirium Tremens. [April*
drank freely. He lias been under treatment upwards of eight
days for trivial bronchitis, and symptoms of incipient delirium
tremens appearing now, necessitate the use of alcohol and
opium with manifest advantage to the man, as regards sleep,
appetite and the disease itself.
These cases illustrate two points : the actual occurrence of
delirium tremens, after and during the privation of liquor;
and the speedy removal of the symptoms by the re-establish-
ment of the custom, when other means failed.
I have purposely selected these cases, because they illus-
trate also the fact, that whilst the men were taking their ac-
customed stimuli, they continued well, for they were men
who never appeared at hospital at all.
I shall not give cases of apparent cure by the adminis-
tration of opium, as they can be found in any work ; and,
after all, they are no proof that your patient recovered by the
treatment, but, perhaps it will be urged in spite of it.
The most curious cases are those in which the delirium con-
tinues for a long period, but in a modified degree ; the patient
sleeping tolerably every night, eating and drinking, and per-
forming all his functions well. It is well to look out here for
some complication (particularly renal or hepatic disease) for it
is surprising how small an amount of urea circulating in the
system may give rise to a persistence of anomalous symptoms.
Besides the ursemic, we have a peculiar and difficultly treated
form of the disease when jaundice is present, whether arising
from fatty degeneration, cirrhosis, or other hepatic disease.
These cases, of course, are more frequently fatal ; but I find
that, after local depletion, purging, or diuresis, stimulants,
more particularly gin, are not only not contra-indicated, but
are decidedly useful, more particularly if the patient be an
old chronic drunkard.
The most fatal form by far is that in which we have deli-
rium tremens occurring in a person already the subject of ty-
phoid fever cases by no means uncommon in this climate.
Having separated, however, these cases, there will remain
many in which a chronic derangement of the nervous system
is manifested, the patient sleeping night after night, for longer
or shorter intervals, and performing all his functions well.
In a few cases, opium given in full doses at bed time will
secure a deep sleep and manifest improvement. In others, a
liberal but regulated allowance of stimulants will prove ad-
vantageous, when everything else has been tried in vain. In
some, do plan .of treatment will succeed, although the patients
frequently reaocrer gfibei a Jong fnteryaj, while others lapse
1861.] Delirium T 327
into chronic mania, melancholia, or some form of Insanity,
ending their days in a lunatic asylum.
With reference to that singular phase of our mental life-
sleep, Sir Henry Holland advances views which my observa-
tion of the sleep of delirium tremens patients lias led me to
think perfectly truthful.
He is of opinion that sleep is not a unity of state, but a
Beries and succession of states, ever varying from moment t<
moment These variations having every degree of diversity,
from complete wakefulness to the most perfect -hep of which
we hove cognisance. It has long occurred to me that the
p of drunkards, and in delirium tremens, differs much
from the normal standard of intensity. Every one must have
experienced in his own person, whenhe was anxious to awake
at a certain hour, how he awakes at that time with a feeling
that he has not slept well, or at all, although he may he as-
sured that he has slept very soundly.
Sir \\. Holland's observations are so good upon sleep and
dreaming, in relation to delirium and insanity, that I shall
quote his words : "I know of no principle so capable of afford-
ing a guide, as that which views all the forms ot' insanity, in-
cluding delirium, in their relation to corresponding healthy
states of mind, tracing this connection through those interme-
diate grades, which are so numerously exposed to us in the
various conditions of human existence. The diversities of
mind in what is accounted its healthy state, the effect of pas-
sions in suddenly altering its whole condition, of slighter
emotions in gradually changing it, and of other incidents of
life in affecting one or more particular faculties ; its subjection
periodically to sleep, and casually to the states of intoxication,
somnambulism and reverie; its gradual transition in fever
from a state where there is consciousness of vague and wan-
dering ideas to the state of perfect delirium ; all these furnish
so many passages through which we may follow sanity into
insanity, and connect the different forms of disordered intel-
lect as well with each other as with the more natural and
healthy functions of the mind."
To sum up, I would say that the first and most frequent
form an i liers of this disease requires rarely indeed
opium, particularly at the commencement of the attack ; in
short, no specific treatment is necessary. In the second
variety, J would give it cautiously in moderate doses, after free
purgation, provided I did not find my patient improving by
and tranquility. The opium had better be given at any rate
in a full fore the accustomed hour of sleep. Should it
328 Opening the Joints. [April,
not succeed, my experience would indicate a "hair of the dog
that bit him," in the shape of porter or hot brandy and water,
spite of what has been urged to the contrary. If the surgeon
avoid both opium and stimulants, and his patient goes on badly,
depend upon it the chances are in favor of another doctor ad-
vising one or both these noxious agents, with much advantage
to the patient, to the no little chagrin of the first medical at-
tendant. Where great irritability of the stomach is present
there is nothing better than a sedative dose of calomel (gr.
vj.), with or without opium, and a large enema.
Supposing the physiological effects of opium upon the system
to be manifested, without sleep, or improvement following, I
should omit its use for some hours, give my patient some good
broth, flavored with brandy or wine, and induce artificial
sleep at night by the aid of chloroform.
I trust it will be seen that the use of opium is advocated as
a measure requiring discrimination and caution, but as a re-
liable one in many instances.
Of course the complicated forms require that the greatest
discretion should be exercised in its administration. Where
an embarrassed circulation exists, marked by venous conges-
tion of the mucous membranes and duskiness of the face, it is
better avoided altogether. Pulmonary emphysema, if exten-
sive, cardiac disease, or indeed any thoracic complication, will
require also great care, if they do not indeed prohibit opium
in any form. Edinburgh Monthly Journal.
On Opening the Joints. On Opening freely the large Joints
for the purpose of Discharging Purulent Matter, as well
as for the Better Treatment or Ulcerations of the Articu-
lar Surfaces. Remarks upon the Inocuousness of Atmos-
phere admitted into the Joints, &c, &c. By E. S. Cooper,
A. M., M. D., Professor of Anatomy and Surgery in the
Medical Department of the University of the Pacific, San
Francisco.
This is the first of a series of articles I design publishing
on purpose to show truths which, for the most part, are in
direct opposition to all established authority upon the sub-
ject, and are as follows :
1st. That admosphere admitted into the joints or other
tissues is not a source of irritation or injury, excepting
where it acts mechanically ; as when admitted into a vein
1861.] Opening the Joints. 329
by producing asphyxia, into the thoracic cavity "by its pres-
sure producing collapsion of the lungs, or when, by the
long-continued exposure of a large amount of surface of
any of the internal organs whose normal temperature is
much above that of the atmosphere, it reduces it so as to pro-
duce a morbid action.
2d. That the division of entire ligaments about the joints,
is not only no impediment to their ultimate strength but
facilitate the cure by enabling the surgeon to open the af-
fected part fully, for the purpose of applying medical sub-
stances to the articular surfaces when these are ulcerated or
otherwise diseased.
3d. That the only true mode of treating ulceration of
bone, however slight, within a joint, is to lay it open freely
and apply remedial agents directly to the part affected.
4th. That opening the joints early in cases of matter bur-
rowing in them is far more imperiously demanded than the
opening of other parts thus affected, and the operation pro-
duces no further pain or inconvenience to the patient, in
any respect, than when performed upon parts remote from
the joints.
5th. That after opening a large joint, the knee, for in-
stance, by an incision several inches long, the wound should
be kept open by the introduction of lint or other similar
substance until the parts within the articulation become
healthy, and in all cases it should be made to heal by granu-
lation.
6th. That extensive wounds opening freely the large
joints, such as the knee, (even when lascerated as by a saw,
which must necessarily heal by granulation) do not as often
give rise to violent symptoms as very small wounds, such
as are made by the corner of a hatchet, an adz, or a pen-
knife, which heal on the outside by first intention.
7th. That there are no known limits beyond which a ten-
don or ligament will not be reproduced after division, pro-
vided the parts are made to heal by granulation, and that
the present acknowledged rule of two inches being the
maximus, distance in which the divided ends of a ligament
to tendon can safely be separated, has not the least founda-
tion in fact. Each of the above propositions has been fully
tested by experience in numerous cases, which, during the
course of this series of articles, shall be drawn upon a3
largely as brevity will admit.
Case 1st. Mr. A. J., set. 29, received a penknife wound
330 Opening the Joints. [April,,
in the knee joint, immediately on the outer edge of the pa-
tella, which being small and causing little inconvenience,
gave him no concern whatever.
The wound healed by first intention on the surface, and
he continued his work as drayman as usual for two weeks,
having nol the least suspicion that mischief was brewing.
At the end of that time, however, the joint began to in-
flame, and shortly after attended with the most excruciat-
ing pain. The inflammatory action rapidly extending, the
tissues of the whole joint were soon involved, and in a week
more, when I was called, extensive fluctuation could be dis-
tinctly fell not only about the articulation, but in the lower
part of the thigh. Chloroform and morphine had been used
extensively, affording only temporary relief from the in-
tense pain.
The case being a common one, I at once opened the joint
freely by two incisions, eight inches long each, just back of
the patella, on the internal and external side of the leg,
which gave exit to nearly a quart of purulent matter, which
was burrowing in the joint and lower part of the thigh.
The smarting of the incisions had hardly subsided before
the patient pronounced himself relieved, and the following
night slept as well as if nothing had been the matter. The
incisions were filled with lint, wet in an evaporating lotion
composed of one part of alcohol and ten of water ; a roller
wet in the same was applied all over the limb as tightly as
the patient could conveniently bear, commencing at the
foot. About 24 oz. of spr. mindereri were given every 24
hours for the first three days, and an opiate administered
occasionally.
On the fifth day, the wound being in a state of suppura-
tion, the cold lotion was discontinued and poultices applied
instead.
The roller was still continued upon the limb from the
foot to the upper third of the thigh, a small opening simply
being left at the most dependent portion of each incision.
The poultices were applied outside of the roller.
The lint was permitted to remain in the wound for about
two weeks, when it was removed. Tincture of iodine was
applied every day all over the joint after suspending the
use of the evaporating lotion.
A gentle motion was instituted about the tenth day, and
kept up through the major part of convalescence, which
lasted about nine weeks, when the patient was able to walk
1801.] Opening the Joints.
comparatively well. He improved rapidly after that until
very was complete, though the wound was not entirely
cicatrized for over five months. Not the least immobility
followed in this ease, and the patient recovered completely
in every respect.
Remarks, In this case a single incision would doubtless
have answered the purpose, though not so well as two. The
true plan of operation in these cases is not only to discharge
every drop of purulent matter that may he collected, hut
likewise prevent any more collecting; and free incisions
kept well open until the parts inside become healthy, to-
gether with a roller tightly applied to the limb, are the
means of securing this object. The operation is not a
severe one when well performed, as it may be done safely
with great rapidity.
The knee-joint is surrounded by a large number of ten-
dons covered with sheaths lined by bursre mucosa, which
on being wounded are liable to cause the burrowing of pur-
ulent matter among the surrounding parts, and may there-
by give rise to symptoms almost as violent as when the mat-
ter forms in the joint itself; and though not so apt to gene-
rate a disorganizing disease of the joint, still, if neglected,
this often would occur, and it is difficult to ascertain before
an operation whether matter has formed internal or external
to the capsular ligament. In the treatment, however, it
makes but little difference whether the capsular ligament
contains the pus or not, so far as the operative procedure
is concerned, because it is nearly the same in both cases.
The surgeon should be sure that he opens the parts to a
sufficient extent to admit of the discharge of all the puru-
lent matter that may be accumulated, and it is immaterial
whether he involves the joint or not in the operation. It
is necessary to keep the incisions well open, other matter
might burrow still after the operation, and the worst con-
sequences ensue.
To sum up, it is the accumulation of purulent matter
that is to be prevented or removed in the treatment of injuries
about the joints ; and without this, all remedial measures
will be abortive, and local, and constitutional symptoms of
the highest grade will crime on. jeopardizing the limb, if not
the life of the patient.
When matter forms between the d< ed facia and
capsular ligament, involving the bursa* mucosa lining the
332 Opening the Joints. [April,
Bheaths of tendon about the knee, the pain is almost as
great as when within the capsular Ligament
The bursffi mucoso being tin- same instructure as mucous
membranes, are disposed to suppurate under slight inflam-
mation ; and being extensive here, pus is rapidly formed as
soon as the parts are lighted up by inflammation.
Case 2d. M. R. set. -!4, received a wound on the outer
side of the knee by the corner of a sharp new hatchet, which
gave exit to a drop or two of blood. The external wound
was about half an inch in length, and. as it gave him no
pain, was not the source of the least anxiety, and the patient
continued his employment of day laborer as usual for a
week. At the end of that time the knee became painful,
which induced him to go to bed. From this time on, for
live days, when I was called, the pain he suffered was most
agonizing. Finding fluctuation all over the knee, I at once
made an incision seven inches long, which gave exit to
more than a pint of purulent matter, and with it perfect
relief. After the pus had been discharged it was found
that the capsular ligament had not been opened, but that
the pus had. collected between it and the deep-seated fascia,
which had not been freely opened by the knife.
After Treatment. The after treatment was the same as in
case first, excepting that the tincture of iodine was not used.
Gentle motion was instituted, in about one week from the
time of the operation, and continued more or less every day,
until the patient recovered sufficiently to walk, which was
seven weeks. He has since recovered perfectly, without
the least weakness or immobility of the joints.
Remarks. The incision was made on the outer side of
the knee, which is the point of election in all cases where
one incision only is made, for the better discharge of puru-
lent matter in or about this joint, seeing that the patient
nearly always wishes to take a position on his back, with
the knees separated, and the diseased limb flexed, which
brings the wound on the outside of the knee, in the most
dependent position. Without giving this matter due con-
sideration, I have occasionally operated differently, but
seldom with entirely satisfactory results. In the next two
articles I shall give cases ot division and reproduction of the
ligamentum patell. American Medical Gazette,
18G1.J Origin of Cow-Pox. 333
Ni to Experiment Regarding the Origin of CowPox.
The opinion of Jenner regarding the origin of vaccinia,
alternately supported and contradicted by various observa-
tions, is at present, at Toulouse, being tested by new experi-
ments, of which, Dr. A. Fontan has given the following ac-
count, dated Toulouse, May 24th, 1860 :
"A happy accident occasioned my passing through Tou-
louse at a time when a question of the highest importance
waa being submitted to experiment, I mean the question of
the origin of vaceinia. The following is an abstract of the
principal facts: Some weeks ago, M. Sarans, of Rieumes,
observes that several mares brought back to his establish-
ment for the second or third time, were affected with the
grease (eaitx-aux jambes.) There was a sort of epidemic of
the affection, for nearly a hundred horses were found to be
suffering from it. The variety of grease was the pustular
form.
"One of these mares was taken to Toulouse to the veter-
inary school, where the learned Professor M. Lafosse recog-
nised the true character of the epidemic. He inocculated
with some of the matter of these pustules the teat of a cow,
in the presence of his assistant and numerous pupils. Soon
afterwards, fine pustules made their appearance on the ud-
der of the cow. One of the most distinguished physicians
of Toulouse, Dr. Cayrel, the official vaccinator of Toulouse,
vaccinated with matter from the pustules of the cow, several
infants who had never been vaccinated. Well character-
ized vaceine vesicles followed, presenting their pearly as-
pect, central depression, and rose-colored areola, increasing
m size from day to day without any trace of erysipelatous
inflammation.
A second cow was vaccinated with matter from the first
cow, and infants were vaccinated with the matter from the
second cow; the results were equally satisfactory as in the
former case. At present they have arrived at the fourth
vaccination from the first cow, and at the third from the
second cow. I was present at this vaccination ; the
Lclee were very fine. One was photographed in my pre-
sence, with a tolerable satisfactory result. The vesicle pre-
ted the most characteristic appearance of vaceinia.
When pricked, no purulent matter escaped, but gradually
rous fluid oozed out in great abundance, with which
several infants were vaccinated.
334 Chronal Laic of [April,
"The new matter is very active, and succeeded in the
case of a pupil of the veterinary school, vaccinated in infan-
cy, and in whom all attempts at re-vaccination had failed.
I saw a vesicle in an infant produced by the virus of this
pupil, finer and more developed than three other vesicles
produced by an ordinary vaccination in the same infant.
(Xo doubt the two vaccinations were performed simultane-
ously.)
-Already thirty infants have been vaccinated at Toulouse.
Xo unpleasant symptoms have manifested themselves in
any ease ; and in all, the result has been most satisfactory."
"Dr. Izarie, formerly vaccinator in Paris, considered the
vesicles so good, that he had his son vaccinated this morn-
ing with virus from one of the infants."
"An official commission has been named by the Prefect
to carry out these experiments. A report will be drawn up
and communicated in due time. Edin. Med. Jour.
A Treatise on a Chronal Law of the Pulse. By Alex. Mc-
Bride, M. D., Beria, 0.
In 1850, I treated more cases of bilious fever than any pre-
vious year. The cases were mostly in and about a marshy
district. In the course of the season I observed that dur-
ing the principal part of the fever the pulse was, in the men
patients, at 96 per minute; in the women generally higher.
This was so uniformly so as to attract my attention ; and
further observation through the season confirmed the fact '
that 90 in man and 108 in woman was the standard pulse of
the season. In cases where there was gastro-enteria, or
gastro-cntcric irritation or inflammation, or other special
irritation, superadded to the ordinary fever, the pulse rose
to a higher point. I further observed, during the same sea-
son, that quinine would not interrupt the fever in man, un-
less the pulse was at or below 72, nor in woman till at or
below 84. My observations this season, 1860, have con-
firmed, accurately, the above, having treated numerous
- of miasmatic fever.
Recently I was struck with the remarkable fact that
those numbers which the pulse usually indicated were exact
multiplies of 12, and that the stages of increase and dimi-
nution were 12; from which I conceived that there must
be some exact law of gradation. I began, therefore, a
1861.] the r 335
Belies of careful observations on the pulse of individuals in
all conditions, both of health and disease, which resulted in
a remarkable confirmation of the conception, and from
which observations I deduce the following ehronal law :
1st. The number of pulsations per minute in the adult
man, in a state of health and repose of body and mind, arc
00; of the adult woman, 72. There arc a few exceptions,
in which they will be found respectively 48 and 60. Both
in sickness and health, the corresponding grade of woman's
pulse is twelve above man's.
'2nd. Uneasy attitudes, and various disturbing causes,
vary these numbers. The pulse of men, generally, during
business hours, and also of women, is often found from 12
to 36 above these numbers ; hut it is seldom found to re-
main long on any other point than one of the multiplies.
3d. The accidental variations from the multiplies of 12
are more common in ordinary health than in fever.
4th. In fever the pulse will always be found, when regu-
lar, at 72, 84, 108, 132,144, 156 ; above which last point the
patient will die, if a woman, and when above 144, if a man.
In some exceptional cases the patient will die with pulse
not above 108 up to the time of death, or until it is lost. In
other cases the pulse will arise to 144 or 156, near the time
of death, and then descend with some regularity till lost a
short time before death.
5th. The pulse will be found at intermediate points for a
brief period during the transit from one point to another,
and while thepateint is under temporary excitement, either
mental or physical ; but under permanent or continued ex-
citement it will settle on a regular point.
6th. The lowest grade of febrile pulse in man is 72, in
women generally 84, except in some peculiar typhoid states,
when it falls actually below standard. But it is questionable
whether fever really exists in such a state.
7th. The pulse of children obeys the same law of grada-
tion by 12, though it is often difficult to keep a child quiet
long enough to make an accurate observation.
8th. There are some apparent and probably some real ex-
ceptions to these laws ; but in by far the most cases, when a
pulse is found to vary from these numbers it will settle to
the grade above or below in a few minutes except regular
sub-grades, which frequently continue longer.
9th. In person- iu ordinury health there will be found
more variation when hungry, when greatly fatigued, and
Chronal Law of [April,
after a full meal, than at ordinary times. Excessive use of
tobacco, and other causes which weaken or derange the
nervous force, cause irregularity.
10th. A pulse of 84 or 96 is not of rare occurrence in per-
sons of ordinary health, during business hours; 72 and 84
arc the most common numbers during the day.
11th. In many cases, hotli in health and disease, the
pulse will rapidly increase or diminish in frequency when
first manipulated, and in some persons this irritability will
continue several minutes, so that it will be found at any ir-
regular point between the true point and the grade next
above and below; but unless there is some peculiar state or
disease, it will generally soon settle on a regular grade or
sub-grade. The regular differences of number between ly-
ing, sitting and standing, are by grades and sub-grades de-
pending upon the nerve force of the individual.
12th. There is a regular sub-gradation by six found in
persons of ordinary health, while standing, sitting, etc., and
in convalescents: these pulses of 54, 66, 78, 90, etc., but in
most cases of short duration. There is also a more tran-
sient under sub-gradation sixths and thirds of 12, which
gives pulses of 58, 62, 64, 68, 70, etc., as high as 154 ; these
are all more transient than the regular sub-gradation by 6.
Uneven numbers are of exceedingly rare occurrence.
Pulses of the under sub-grades and uneven numbers may
all properly be called transition pulses.
Remarks. I think the reason we often have pulses re-
ported at irregular numbers is, that they are not care-
fully counted long enough. Example : An error of count-
ing of one in a quarter, or two in the half minute, gives an
error of four in the minute ; hence we get 64, 68, 76, 80,
etc. An error of one in the minute gives 61, 70, 73, 83,
etc., which must generally be erroneous. Another fruitful
cause of error is the omission to notice the irregularity of
the first ten or fifteen seconds.
Since discovering the facts of the above laws I have not
seen much of continued fever ; but what cases I have seen
were confirmatory. Phthisis, and diseases of the heart, are
obedient to the same laws, but for obvious reasons are more
subject than fever to transient variation in time.
I think any one who has carefully observed in continued
fever can call to mind particular cases in which the pulse
remained tor days at some of the numbers given above. The
following observations will suggest some reasons why this
1861.] the Pulse. 387
t gradation has not been noted by many : Most pi
eians examine the pulse without counting by a watch: I
many of those who do use a watch count only a minute,
or a part ot' a minute, by which means it is impossible to
arrive at accuracy. The other qualities of the pulse than its
lency convey different notions of frequency through the
je of touch, to wit: A very round and tolerably soft
pulse, without jerk, bound or vibration, conveys the notion
of unfrequeney : a hard, jerking, bounding, or vibrating
pulse conveys the notion of frequency. The particular men-
tal or physical condition of the observer varies his percep-
tion of time, viz.: when one examines a pulse when drowsy,
or just after rising from sleep, the pulse seem to him more
frequent ; when one is in a hurry it will seem slow, and
the like. There is only one way to arrive at accuracy, and
that is to carefully and for a length of time count by a
watch.
The subject is so new that it would be premature for me
to attempt many deductions at this time ; but if these are
found to be the real time laws of the pulse, the conclusion is
obvious that important hints can be taken from them in
diagnosis, prognosis, and treatment. I shall only venture
the following:
L) . I have already intimated that quinine oper-
n antiperiodical when the pulse in the two sexes is at
or below 12 and 84, which are the lirst fever grades ; but I
suppose if the pulse, during an intermission, were, in conse-
quence of special excitement, at or above these numbers,
the medicine would operate nevertheless. Let it be borne
in mind that quinine is an anti-intermittent, and not an anti-
Littent, and then it will be apparent why it operates with
1st- below the lirst four grades ; itifl simply because it is
an intermission. Then, if this be true, we gain some light
on the question of administering quinine in the various
forms of continued fever, viz : we need not give quinine in
continu with a view to terminate directly the fever,
because it is not intermittent. It is continued by some
cause over which quinine has no direct control ; and 1 1 1 i
may know by observing the grade of pulse; and many will
ing the rale, a I; rant of the medi<
When we visit our fever patient, and
I the pulse averaging below the grade on which it was
stationary the previ . we may rest ; that the
fever is about abating on grade, at least ; if we find it above
338 Chronal Law of [April,
we are sure the fever is increasing by a regular amount. If
our woman patient has a pulse of 108, we know that she is
not more sick than the man witli a pulse of 96. If the wo-
man's pulse arises to 144, we do not conclude that she will
certainly die ; but if the man's pulse arises to that point,
and above, we announce to his friends that they have no
grounds of hope in the case. This at least is the general
rule, and the exceptions are few.
I give below numerical statistics of observations with tin-
prominent peculiarities of each case briny noted. I give
the particulars of such a large number of observations, so
that it may be seen that I have not formed my conclusions
from a partial or hasty view. While engaged in the obser-
vations, I have been careful to note all the cases carefully
observed, as well as those which give regular grades and
even numbers, as irregular and uneven numbers; and it
will be seen, in nearly every case where there is an irregu-
lar number, that tnere was some reason for it. I have not
noted the pulse of all the patients visited during the time,
because I could not always have time and opportunity to
carefully count the pulse long enough to get its true num-
ber. Those persons who were examined in ordinary health
were sitting, unless otherwise noted ; others were in bed, or
sitting, as noted. My method of examination is to continue
the observation in each case till the temporary excitement,
if any exists, abates, and then count the beats from one to
live or more minutes, and then immediately note down the
result and the particulars of the case. In some cases the
Note. T do not court controversy with those who talk of curing bilious
fevers with quinine, or of breaking up terrible western fevers by giving
the quinine in the high febrile stage: I merely say I cannot do it. I
know very well that quinine may sometimes, during theparoxysm of an
intermittent, and if he does not happen to vomit it up, take good effect
during the intermission ; hut 1 never found it profitable to either the patient
or mysclfto give it in that way. During one Beason J made numerous
attempts to break up remitting bilious lever with the medieine, given
both during the paroxysm and the remission : the result was that a good
many doses were wasted by vomiting. I concluded that ipecac
cheaper and better emetic than quinine, and so hit off that kind of prac-
tice. However, in some cases ox bilious fever, where the patient is ooma-
witli thick, yellow, hrown, or black coat on the tongue, quinine w ill
aid in changing the action.
1861.] 339
minutes gives as true an indication as longer time ; but
frequently it requires several minutes.
As it is the chronal law that I am aiming to demonstrate
no attention has been paid in my notations to any other
qualities of the pulse than its cnronal oualities. In my note
book the learly all more fully described than in
the synapsis; but I deemed it more important to present a
large number oi ban to present a few more fully des-
cribed; for it is the numerical character aimed at solely,
and the larger the number of op 'lited the more near-
ly we approach the truth.
- my numbers and facts appear tome conclusive, it only
remains for the reader to consider whether my observations
have been carefully made and faithfully recorded and pub-
lished; in proof of which I have nothing to offer but the
here stated, and leave it for each person interested to
prove by his own observations, which he can do in a very
lays, by careful observation.
There will be found a larger proportion of irregular pulses
in the city than country, for very obvious reasons.
[Dr. McBride here adds a tabular statement of more than
100 observations of the pulse, giving in detail t\ic occupa-
tion, mdition of health or, disease, etc., etc., of each
individual. This table is of considerable length, and we
take the liberty, with our press of matter, to crowd It out:
remarking, however, that these observations in a remark-
able degree confirm and justify the deductions of the essay.
Eds.]
There are carried out in the table 120 actual observa-
tions, which give : Regular multiples, '.til; sub-grades, 8;
irregular, 31. Total, !-!!>. Proportion: 2^ regular, \o 1
Bub-grade and irregular.
With a view to further confirm or refute the principles
declared in the chronal laws, I recently, in November, 1800,
carefully made and noted 4o observations, not one of which
a regular fever ; 5 were on a woman who had nearly
died of monorrhagia, : 3 on a boy with atonic hydrocepha-
lus; several were upon persons drinking and smoking,
te of whose pulses would oi course be irregular; several
upon p> bo had come in from hard labor, riding,
.. in cold, windy weather; some hysterical, etc., etc. In
nearly every irregular case there was some very obvious
causes apparent. They resulted thus: Regular multiples
from 00 to 132, b-grades from 54 to 114; 31,
340 Popliteal Aneurism. [April,
irregular and under sub-grades from 56 to 98, 9 the multi-
ples in this medley of cases being one more than half, and
the irregular cases one-fifth of the whole. It will also be
seen hereby that there are more irregular pulses at this
season of the year than in the fever season. Cincinnati Lancet
Sf Observer.
Popliteal Aneurism Cured by Digital Compression. By George
C. Blackman, M. D., Professer of Surgery in the Medical
College of Ohio, Surgeon to the Commercial, St. John's,
And St. Mary's Hospitals.
In June, 1859, I was consulted by Joseph Humbrick in
reference to a large pulsating tumor in the left popliteal
space. He was an American, and was 27 years of age. For
some years he had been engaged in carting lumber, and
consequently was often compelled to sustain heavy weights.
He was not aware, however, that he had ever received any
injury upon the part affected. About thirteen months be-
fore I saw him he suffered excrutiating pain, which extend-
ed along the inner part of the thigh and calf of the leg as far
as the heel. About three days afterwards he noticed a small
pulsating tumor, about the size of a pigeon's egg, in the
middle of the popliteal space. His case was regarded as
acute rheumatism, and he was treated accordingly. The
swelling continued to increase ; and when I first saw him,
on the 5th of June, it measured about four and a half inches
in the axis of the limb, and five and a half in its transverse
direction. It had a pyriform shape, the apex being above.
For two months the pain had been severe ; and at the time
of his visit he was unable to extend his limbs completely.
Having noticed the favorable reports of cases which had
been treated by the London surgeons by flexion, I deter-
mined to unite this to the combined method of compression,
manipulation, and the internal administration of veratrum
viride, which I had successfully employed in a case of
femoral aneurism of large size. On the 7th of June, after
having given four drops of Norwood's tincture, I broke up
and dislodged sonic of the layers of fibrin in the sac, by means
of pressure with my thumbs and fingers ( Fergusson's mani-
pulation); after this I applied a bandage, as recommended
by Prof. Dudley of Lexington, in 1818. The foot and leg
were bandaged from the toes to the inferior margin of the
1861.] Popliteal Aneuri 341
aneurism, over which a compress was placed, and a still
firmer one along the coarse of the femoral artery reaching
to Poorpart's ligament These were covered by the ban-
dage which extended to the groin. The leg was strongly
flexed upon the thigh, and secured in that position. The
only effect of the veratrum was to cause an intermission of
the* heart's action every thirteenth heat. For an hour alter
the manipulation the pain was intense ; but morphia, freely
administered enabled him to pass a comfortable night. On
the following day, however, the patient became exceedingly
restless, and the compressor and bandage became deraged.
After a week's trial. Dudley's dressing was abandoned and
Petit* s tourniquet substituted. At the expiration of another
week this was changed for Skey's. At this time the tumor
had diminished somewhat, but still pulsated strongly.
Under the use of digitalis the patient's pulse rose from 85
to 110, and it was discontinued. Compression was continued
for another week, by the alternate use of the tourniquets
above mentioned. The patient now left for his home in
Xewport, Ky., the tumor having diminished about one-
third in size, but the pulsation being quite distinct.
On the 1st of July I requested my pupil, Mr. John Bil-
lings, and Mr. Charles Greenleaf, then a medical student,
to go to the patient's house and try digital compression at
the goin. This was employed for three hours, when the
pulsation entirely ceased.
On Monday last (February 4th, 1861,) the patient came
before the class of the Medical College of Ohio, and declar-
ed that his left leg was as good as the right. The contracted
and indurated aneurismal tumor can still be felt, by pulsa-
tion has never returned. It is a question whether this in-
durated mass will ever disappear ; for M. Paget has report-
ed an examination of a case fifty years after the cure by
ligature John Hunter's fourth patient and even after this
long period a hard, olive-shaped mass still occupied the pop-
liteal space.
Shortly after the treatment of the above case, a patient
came under our care having an aneurism of the innominata
of small size. Instead of ligating the subclavian and caro-
tid on the distal side, I applied Bourgery's tourniquet, or
compressor, for the subclavian, while a truss was adjusted
to the neck to compress the carotid. Veratrum in this case
had a happy effect in moderating the force of the circula-
tion ; and with compression above mentioned, I succeeded
842 Post Partum Detachment of th Placenta. [April,
in producing a temporary consolidation of the aneurism. In
a few hoars, however, pulsation returned, and in the course
of fl few days it became again consolidated.
Thus alternating, matters progressed for several weeks,
when, after trying digital compression for some hours, at
era! trials, it became evident that all our efforts were in
vain. The patient left the country, the tumor constantly
increasing; and in a few weeks more, after reaching and
enormous size, it hurst internally and suffocated the patient.
A post mortem revealed an aneurism of the innominata ;
and the opening communicating with the sac was of large
size. Cincinnati Lancet Obsert
A New sign of Post Partum Detachment oft) By
John Ctay, M.R.S.C., of Birmingham.
From investigations, with a view of improving upon the
old plan of management of the delivery of the placenta, Dr.
Clay ascertained that a very simple sign existed, by which
its separation, after the birth of the child, might he indicat-
ed, having tested it in upwards of nine hundred cases. Be-
fore dividing the umbilical cord he applies two ligatures.
If tin; maternal part is now examined, it will he found in a
flaccid condition, and almost live from blood ; hut after an
interval of from om4 to three minutes, it will he found to
have acquired specific weight, and that the vessels are more
or less tilled with blood. The one fact may he ascertained
by poising the cord on the fingers; t]\v other by slightly
grasping the cord near the vagina, with the thumb and fore-
finger of the left hand, and, with the right hand, suddenly
compressing it, when a well-marked sense of fluctuation is
perceived, a kind of resilience like that felt when an elastic
tuhe filled with fluid is suddenly compressed. "When the
placenta is detached the cord loses its increased specific
weight and the hydrostatic property just mentioned. This
is so invariable, that the loss of the previously acquired hy-
drostatic properties of the cord after the birth of the child
constitutes the sign of detachment.
The whole <>t the phenomena are manifested in three
stages flaccidity, repletion, flaccidity.
It' the cord be tightly grasped by a spasm of the os, or
by irregular contractions of the atertts, the loss of the hy-
1861.] The Nervous System. 343
drostatic properties may lor a short time be delayed. These
signs are not, of course, equally marked in every case.
When the uterus is tlaecid. they are but slightly manifest-
ed, though perfectly reliable. When, on the other hand,
the contraction is firm, the most inexperienced may detect
them. In eases of partially adherent placenta, the disap-
earance of the hydrostatic properties, and the failure to de-
liver the placenta by the usual manipulations indicate the
necessity for artificial detachment by introducing the hand.
In twin cases, the signs persist till after the birth of the
nd child, except where the two placentas are present.
It sometimes occurs that the placenta is separated simul-
taneously with the birth of the child. Here the first series
of phenomena are absent, and it may be be generally effect-
ed with safety.
The practical value of these facts is obvious, as the pla-
centa, when thus known to be separated, may be at once
extracted. The prompt delivery of the placenta is very im-
portant, as the uterus then contracts more effectually, the
risk of hemorrhage is not so great, and it may be fairly as-
sumed that the convalescence is less protracted.
To inexperienced practitioners it might be a safe instruc-
tion to impart, not to interfere in the extraction of the pla-
centa, so long as the hydrostatic properties herein defined
nt Dub. Quar. Jdur.
action of Alcohol, Anaesthetics and the Carbonic Gases upon
the Cer >>l Nervous System.
M. Lallemand read the following memoir containing his
own views and those of MM. Pemn and Duroy upon the
comparative action of alcohol, anesthetics, and the carbonie
: the cerebrospinal nervous sytcm :
"When etherization was first discovered Flourens demon-
strated that there are successive stages in the action of sul-
phuric ether and of chloroform upon the nervous centres,
and that the sensibility and motive power of the spinal mar-
row are abolished by both of these4 agents- In repeating the
experiments of Flourens we have studied the action of these
in the same manner, and we have ascertained
that while alcohol andamylene, like ether and chloroform,
abolish the sensibility and motive power of the spinal
cord, the inhalation of carbonic acid and carbonic oxide al-
344 The Nervous [April,
lows those properties to be retained up to the moment of
death in animals subjected to the influence of the two
gas<
Action of Alcohol ami Anaesthetic Agents. Into the
stomach of a C\o^ of middle size we introduced 100 grammes
ofalqoliol, at 21 degrees, dihfited with an equal quantity of
water, in three doses at intervale of fifteen minutes. One
minute after the administration of the first dose the animal
was in a state of complete Intoxication. The limbs were
flaccid, the skin had lost its sensitiveness, as had also the
ball of the eyes ; the pupils were dilated, the pulsations of
the erural artery were 120, and the acts of respiration 22 in
a minute. The posterior arches of the last three dorsal
viriebne were then elevated, and the spinal marrow WW
laid bare to the extent of about twenty-five centimetres.
The posterior and anterior columns were pierced, and the
posterior and anterior roots of a spinal nerve were seized
and drawn out with the forceps. Xo sign of sensibility was
elicited, and not the slightest muscular action. Four hours
after the operation this lethargic condition gradually passed
off; the tongue and jaws of the animal began to move, and
the eyelids closed when the balls of the eyes were touched.
Upon piercing the cord again the animal uttered mo
and the hinder limbs were convulsed. The dog was then
strangled."
Experiments with cloroform, sulphuric ether and amylene,
from which analogous results were obtained, are described,
after which the authors of the memoir continued as fol-
lows :
"Thus the action of alcohol, chloroform, ether and amy-
lene completely interrupts the sensibility and motive power
of the spinal cord and nerves. We have also ascertained
that by passing an electric current through the spinal mar-
row, when its action is thus suspended, its excitability may
be aroused, and may be manifested by muscular action.
^\*e would add that the interrupted properties of the
cord and nerves will reappear upon the cessation of the
disturbing influence of the agents that have been adminis-
tered.
Action of the Carbonic Gases Carbonic Acid. The
erior arches of the last two dorsal vertebrae of a la
were removed, and the cord exposed to the extent of
ul three decimeters. The animal was then made to in-
carbonic acid mixed with a very small quantity of
1861.] \ S stem. 846
water. Ai the end oflO minutes it was entirety insensible and
motionless, and the arterial blood had assumed the dark
venous hue. The posterior columns 01 the cord and the
posterior root of one of the nerves were then pierced with
a pointed instrument, without producing any manifestation
of feeling : bu1 by puncturing the anterior root and the an-
terior columns, violent agitation of the hinder limbs was oc-
casioned. The sciatic nerve being exposed and irritated,
convulsive motions were excited in the muscles of the limb
to which it was distributed. The muscular contractions
produced by irritating the cord and nerves grew more and
more feeble, but did not entirely cease until the animal ex-
pired.
Another experiment in which the oxide of carbon was
used, gave results similar to those just described.
The preceding facts allow a very distinct line of demarka-
tion to be drawn between alcohol and the anaesthetic agents
chloroform, ether and amylene on the one side, and the
carbonic gases on the other with respect to their physio-
logical action.
I. Alcohol, chloroform, ether and amylene act primarily
and directly on the nervous centres, in the substances of
which they may accumulate.
II. The carbonic gases exert their primary and special in-
fluence on the blood; carbonic acid imparting the venous
hue to the arterial blood, and carbonic oxide altering the
condition and physiological properties of the blood corpus-
cles.
It seems difficult not to admit that the insensibility pro-
duced by inhalation of these gases is merely the secondary
and consecutive effect of an alteration of theblood. It is
known, in fact, that innervation is accomplished only under
the physiological condition of the excitement of the nervous
em by blood ; and it is also known that when the blood
cannot obtain a due supply of oxygen as in asphyxia pro-
duced by a mechanical obstacle to respiration, or in cronp
an anaesthetic condition supervenes betokening imminent
danger, and, indeed, the speedy extinction of life.
Amesthetic agents, then, depress the factions of the nerv-
ous system, and by their progressive action suspend the
respiration ; which is under the control of the medulla ob-
longata. They produce anaesthesia primarily, and asphyxia
secondarily or indirectly.
Carbonic acid and carbonic oxide, on the other hand,
S46 Epilepsy. [April,
modify the properties of the blood disqualify it for sus-
taining innervation, and thus produce asphyxia primarily,
and anaesthesia secondarily or indirectly.
Conclusions. 1. Alcohol, chloroform, ether and amylene
art immediately upon the nervous system.
2. Carbonic acid and carbonic oxide act immediately upon
the blood by modifying its properties ; and it is by means
of this modification of the blood that they produce insensi-
bility. These substances then are only pscudo-ances the lies.
Jour, des Connaissanccs Medicates.
Woorara in Epilepsy. By M. Thicrcclin.
M. Thiercelin, struck by the counteraction of artificially-
produced convulsions by woorara, has been led to adminis-
ter the drug in the treatment of several convulsive disc;
more especially epilepsy, and with most marked effect.
Particulars of two cases of epilepsy, which had resisted a
variety of previous treatment, were laid before1 the mem-
bers of the Academy of Sciences at their last Bitting. One
of the subjects treated by woorara was a young man, aged
23. In him the disease was hereditary and congenital.
The patient had passed 4 years at Charenton, and was ac-
counted incurable. The number of attacks during the
month amounted to 20, whereof the greater part was most
re. The second case was that of a girl of 17, a suffer-
er from epilepsy for 8 years past, and during the last 12
months subject to daily tits. Under the influence of the
woorara, treatment, (the drug being applied daily in d<
varying from #ialf a grain to a grain to the suppurating sur-
face of a blister,) the attacks dimished in frequency so con-
siderably that in the first case they tell in number from 20
to 5 per month, and in the second, from 29 or 30 to S.
only did the frequency of the fits decrease, but a striking
general improvement occurred in the health of both patients,
and a marked diminution of the nervous irritability always
accompanying epilepsy was also noticed. Unfortunately,
the treatment could only be persisted in for 8 weeks, as the
stock ot woorara ran short; nevertheless, the results ob-
tained were decidedly of a nature to encourage other prac-
titioners jn following in the footsteps of* M. Thiercehn.
Lan
iV) Editorial. 347
EDITORIAL AND MISCELLANEOUS.
THE MEDICAL PROFESSIONITS GRATUITIES.
Th following paper has boon in our hands for sonic time ; but has es-
caped our notice till this late period. We deem the subject of culling
the attention of the public to the unjust draft made ou the Profession, of
BO much importance, and also for the able manner in which the grievance
is presented, that we here make room in our editorial department for the
Memorial of the Committee appointed by the Medical Association of
rgia :
To the Senate and House of Representatives of the State of
Georgia :
MEMORIAL.
At the Annual Meeting of the Medical Association of the State of
iblcd at Rome, April 11th, 1860, the following Resolu
wore adapted, viz :
Resolved^ That this AfiBOOiation Memorialise the Legislature of
>lish the Professional Tax upon Physicians, and to urge
the passage of an Act requiring the Inferior Court or each county to set
apart such portion of the county tax as the (J rand Jury shall recommend
to poi ngsfor the use of the poor.
Th gned were appointed a Committee to bring this matter bc-
r honorable body.
In performing this duty wv, beg respectfully to submit a few reas
f'u- this appeal to the Laic Making Power .
It is a fact, apparent to every observing mind, that Medical men, far
more than any other class of citizens, contribute gratuitously, their time,
and money, to the relief of the indigent. And as it i s the duty of
State authorities, and not of a particular class to bear the burden,
gratuitous services can ; 1 in no other light than centri-
ng to the State.
per centagc of population requiring those crviecfl is by no means
inconsiderable. Taking thecomr 1 as an average county, obser-
vations have been made by which we arc enabled, confidently, to 8
348 Miscellaneous. [April,
that the amount thus donated by medical men in Georgia, in the single
article of quinine can scarcely fall short of Thirty Thousand Dollars
per annum, with a strong probability that it largely exceeds that amount.
Tf, in connection, with this startling fact we consider the value of the
time and labor and other Medicines contributed, it is evident that the
amount of this gratuitous outlay of physicians to the State is enormous.
It is remarkable that the public, and especially the Legislature, has so
little appreciation of the extent of these gratuitous labors of medical
men. True it is that the Inferior Court, under existing laws, is re-
quired to provide for the poor, and the physician pays his part of the
annual tax, levied for this purpose. But, whether from defects of law,
or gross neglect of the Courts, it is well known that the instances in
which the poor are thus provided for are very few, and the procuring of
medical services and drugs do not seem to be regarded as belonging to
their list of duties. Indeed, except in cases of Lunacy, or in extreme
and rare instances of helplessness, where the subject has been entirely
abandoned by his acquaintances, it is seldom that the Courts make any
provision whatever. Yet even in these extreme cases, deserted by all,
the physician alone is expected, without compensation or thanks, to give
not only his personal attention, but his money, to the relief of the suffer-
er. At all seasons, in all kinds of weather, in the dark hours of night
when others are asleep, the medical man passes from one scene of dis-
tress to another, bestowing his labor, risking his own health, and dispens-
ing drugs to the indigent sick. To this course he is impelled by two
powerful forces. The first and greatest is the demand of humanity,
which to a conscientious man leaves often no alternative by which to es-
cape the call. The second is the force of public sentiment which will no^.
tolerate in the physician that freedom of action which it allows to others.
The merchant may refuse credit to whom he chooses. The druggist may
decline to sell to an insolvent customer and it is well, but the physician
who exercises this liberty brings upon himself the severest censure, and
consequent injury to h\$ character and business.
To the many cases of casualty and death which occur in this fast age,
a large proportion of which is amongst the poorer classes, the physician
stands a ready servant, subject to every beck and call, and is expected
and required to have in readiness all the appliances and material, at
whatever cost adapted to every emergency. By his promptness and
benevolent agency he relieves large numbers, and oft times rescues them
from impending death. When, under analagous circumstances, a party
is snatched from a burning dwelling, or a watery grave the individual
1861.] Jllisccllaneoits. 349
who performs the deed is exalted into a hero. When a mariner rushes
to the rescue of a distressed crew, he gains for himself Laurels of Praise
and Medals of Honor. Not so the Physician. He is regarded as hav-
ing discharged a mere common-place duty, and scarcely meets with a
passing commendation. And such is the tyranny of custom and law,
that if he fail to respond to every call, he encounters the indignant frown
of the community, and failing from want of proper facilities or other
cause to adopt the most scientific treatment he becomes liable to prosecu-
tion and heavy damages. Although medical men, as a class, are pro-
verbially benevolent and kind, and are ever ready to heed the call of
suffering humanity ; and while they claim and desire no special exemp-
tion from the moral responsibilities and duties incident to their noble
profession; yet* they feel that the public authorities can and ought to do
more than is or has been done for the poor in this particular, and that
they ought not to require the physicians services nor his drugs without
compensation ; much less to heighten the infliction by imposing a speci-
fic tax. If it be urged that a physician's profession is his capital and,
therefore, ought to be taxed, we reply that it is taxed, and that heavily
in the manner, and for the reasons above stated. The calls of humanity,
and the necessities peculiar to the practice of the medical profession ; the
exposure, irregular hours, impairment of health, encountering contagi-
ous maladies and raging epidemics, witnessing painful scenes, suffering
and death, and the moral and legal responsibilities incurred ; all bear
heavily upon the practitioner, and can find no adequate compensation,
even though the tax were removed, and the ordinary fees allowed in all
cases.
We, therefore, respectfully petition your Honorable body to abolish
the specific tax, and extend such relief to the poor and the medical pro-
fession in the matter under consideration, as wisdom and justice may
suggest to the patriotic Representatives of a great State. And we feel
well assured that such legislation so obviously necessary, so manifestly
just and proper, and so highly called for by the growing philanthropy and
benevolence of the present age, cannot foil to meet the sanction of a
liberal and enlightened constituency.
Robt. 0. Word, M. D., Home, Georgia.
Robt. Southgate, M. D., Augusta, Georgia.
.1. <r. Westmoreland, M. I)., Atlanta, " Committee.
8. W. Brn.NEY, M. ])., Forsyth,
B. B, Brown, M. D., Dalton, " J
350 Miscellaneous. [April,
ETHER VERSUS CHLOROFORM ET. AL.
Having received the following Circular, and seeing that it interests the
whole Profession, we submit it to our readers in the hope that by so do-
ing we may promote the laudable purpose of the learned Society at whose
instance the appeal is made for facts tending to settle the question of the
relative danger of some of the anaesthetics in most common use :
Boston, Massachusetts, U. S.
The question of the entire immunity from danger which is claimed for
Anaesthesia produced by Ether, being still under discussion, the Boston
Society for Medical Improvement has appointed the undersigued a Com-
mittee "to investigate the alleged deaths from the inhalation of Sulphuric
Ether, and to report thereon,"
They would, therefore, request the Medical Profession, or any person
into whose hands this may fall, to communicate to either of them such
cases, coming within their observation as shall serve to this end ;
giving the place, time and circumstances of their occurrence, with
the mode of iuhalation adopted, and, especially, information in regard to
the following points :
1st, The kind of Ether used, whether pure Sulphuric Ether, Chloric
Ether, or Ether combined with Chloroform.
2d. The period after inhalation at which death occurred ;
also any other facts which may enable them to form an opinion on the
subject to their investigations.
Richard M. Hodges, M. 1>.
George Hayward, M. D.
Solomon D. Townseno, M. 1>.
Charles T. Jackson, M. ]).
J. Baxtkr Upham, M. J).
February, 186 1.
Have you known death to occur from the inhalation of pure Sulphuric
Ether ?
Where did this occur ?
" At what date ?
For what purpose was Ether administered ?
What method of inhalation was adopted .'
What kind of Ether was used ; was it pure Sulphuric Ether, Chloric
Ether, or Ether combined with Chloroform ?
At what period after the inhalation did death occur, and how did death
take place ?
1 'lease state may other circumstances connected with the case.
(Signed)
1861.] Miscettmec 351
ON DISEASES PEC/ULIAR TO WOMEN,
Including Displacements cf the Uterus. Bj Hugh L. Hodge, M. D.,
Prof of Obstetrics and Diseases of Women and Children in the
L'niversity of Pennsylvania. With original illustrations. Philadel-
phia. Blancha&d & Lee, lsGO 8vo. pp. 470.
Book-making is so often resorted to as a mere trade by persons of in-
experienee, that we instinctively welcome the productions of those who,
like the author of the volume before us, bring forward the result of ex-
tensive observation, enlightened intellect aud mature judgment. Zeal-
ously engaged in the practice of his profession in a large field for up-
wards of forty years, the unostentatious record of his final conclusions
must be of great value ; and although he may sometimes differ from
whose opportunities are equally advantageous, the student of truth
will thus, like the juror in a court of justice, have the benefit of argu-
ment upon both sides of difficult questions. In the author's neat letter
to Prof. Meigs he says : "I know well that our productions each char-
acteristic of its author differ exceedingly in theory and in practice; but
aevet be student who examines each book may discover the
truth more clearly, and be prepared to render such truth more efficient.
The very opposition, which may be perceived in the views of experienced
men in the profession, is often beneficial ex collisione scintilla."
.Prof. Bodges1 work is divided into -\ parts; the 1st comprehending
the"! of Irritation;" the k2d, 'Displacements of the Uterus;"
and the 3d, the "Diseases of Sedation," As the limits of this notice will
not permit any comments upon the special views of the author, we can
only indicate the scope of the work by a brief reference to its contents.
In Part 1 he treats of Nervous Irritations and its consequences; irrit-
able uterus, its local and general symptoms, its progress and result.-, its
and pathology, its complications, and its treatment. Under the
bead of displacements of the Uterus, we find chapters devoted to the
anatomy of the pelvic organs, to the various displacements of the uterus
and their causes, to the symptoms of these displacements, and to their
:ient by hygienic and by mechanical means, of which latter he pre-
fers the "Lever pessaries," designed by himself. The diseases of seda-
tion are disposed of in three chapters on sedation and its consequences,
sedation of the uterus, amenorrhaca, and diagnosis and treatment of
lion of the uterus.
This volume is destined to take a conspicuous place among the most
valuable original contributions to American medical literature. We,
therefore, cheerfully recommend it to the attention of our readers.
352 Miscellaneous.
THE BLOOD IN MANIA.
In England the investigations of W. C. Wood, M. D., as far as they
go, indicate that there is a marked deficiency of fibrin during the period
of maniacal excitement, and a correction of this deficiency during con-
valescence.
RESIGNATION OF PROF. MEIGS.
We learn that Dr. Charles D. Meigs has resigned the Professorship of
Obstetrics, etc., he has so long filled with marked ability in the the Jef-
ferson Medical College, Philadelphia. Professor M. is a Georgian by
birth.
Hydrocyanate of Iron in Ejrilejisy. The Cincinnati Lancet &
Observer says: "Dr. G. S. Bailey, a retired physician of Iovra, states in
a letter to the editor of the Journal of Materia Medica, that his only son
after having been treated six years for epilepsy with every remedy that
medical skill could suggest, without success, was finally cured with the
hydrocyanate of iron, by Prof. D. L. McGugin of Keokuk. The formu-
la employed corresponds with the one used by Dr, Treat (Cin. Lancet &
Obs., June, 1860, p. 388); hydrocyanate of iron, one drachm; powder
of valerian, two drachms ; extract of Indian hemp, one drachm, being
originally added by McGugin. Make into one hundred and twenty pills.
One of them is to be taken three time3 a day. gradually increased to
four.
How to Improve the Taste of Cod-Liver and Castor Oils. The
Louisville Medical News says : "Cod-liver or castor oil, shaken up with
an equal volume of water distilled off the leaves of the wild cherry-tree, in
a manner similar to that directed in Edinburgh or Dublin Pharmaco-
poeia for cherry laurel water and left to rest forty-eight hours before
separation, acquires by this simple operation an extremely sweet per-
fume and agreeable taste of almonds ; the taste remains as long as the
digestion lasts. Oil flavored in this way could be taken by many
patients who reject it in its natural state. Castor oil is not affected in
its purgative action by this process."
Criminal Insane. A State Asylum for the Criminal Insane comj
prising 290 acres of land, and accommodations for 500 convicts, is about
to be completed in England. The number of this class of persons has
steadily increased for several years, until, at the beginning of the pre-
sent year, not less than 731 were reported. American lournal of
Insanity.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL.
(NEW SKIM!
[TIL AUGDSTA, GEORGIA, HAY, 1861. NO. 5
ORIGINAL AND ECLECTIC.
ARTICLE X.
Tape Worm The Symptoms, Progress, Development, Duration
and Spe< ." itment of a case*
The writer was for several years a subject of the disease
of tape worm ; a statement of his case may prove beneficial
to others similarly affected. It is given as follows :
During the year 1835 he had frequent attacks of what
was Bupposed to be cholic, returning at Intervals, to Janu-
ary, ISoT ; but not of a character to excite much alarmy
though accompanied by sick stomach, predisposition to
vomit, and piles.
The usual alleviatives for the supposed disease, were re-
sorted to without relief; the patient being also subject to
frequent cramps of the abdomen, in the region of the right
side, especially after inclining the body downward in that
direction, on resuming an erect posture.
At the' time last named (January, 1857) the disease was
demonstrated to . be tape worm, by the voluntary es-
*T!. -port is by a distinguished gentleman of the legal profesion
in this city. We regard the paper a highly useful <>ne, for while this report
;:.d intelligently made, the statement is freed from a vast
nt of unnecessary detail, which too often encumber the reported
The al>-. ihnical terms, apologized for, is
not to be deplored and will be regarded by ourreadera rather a relief limn
otherwise. M. & >. Joub.1
28
854 A Case of Tape Worm. May,
cape of several separate joints, crawling away, they being
alive and continuing to move l>y extension and contraction.
The specimens were of rather a fiat round, an inch in length
near the size of a common broom straw, square at one end
and tapering at the other, and most exceedingly tenacious
oflife under experiments, to which they were subjected.
The escapes, either voluntary, in detached pieces, or on
being expelled by remedies, sometimes in joints and at
others in continuous pieces, varying from 3 to 14 feet in
length, continued to May, 1841, at an average per day of 12
joints, or one foot; though irregular, sometimes daily and
then at intervals of 3 to 5 and 10 days, increasing in quan-
tity in proportion to the length of the interval, the voluntary
escapes producing an unpleasant itching and tickling sensa-
tion about the anus.
In these intervals the abdomen became distended and
painful, the breathing short, with frequent cramps, such as
before described, accompanied by an internal lowering
down of the intestines and aggravation of the piles.
Throughout the disease, contrary to the generally existing
belief in the subject, that in such cases the patient was sub-
ject to a ravenous appetite, in this instance it was the re-
verse, being quite moderate, the health very delicate, and a
general debility of the system.
From the development of the disease to the cure, many
physicians wrere consulted ; but four of whom professed any
practical knowledge as to the disease or its treatment. It
being, I suppose, somewhat rare, there being but two who
pi-escribed remedies producing any sensible relief.
The first was the family physician of the patient, the late
Dr. Milton Antony, distinguished for his skill in the sience
of his profession, at the head of which he stood in this, his
native State, and the first President of the Faculty, and
founder of the Medical College of Georgia, which position
lie retained during his lite. He was first consulted and pre-
scribed spirits of turpentine, which finally effected a remedi-
al cure.
1861.] AQiseofTape Worm.
The other was quite a young, bat very intelligent gentle-
man, Dr. Thompson, not a graduated M. D., hut a man of
reading, who was met with in 1838. in Louisville, Ky. lie
prescribed assafoetida and gum camphor, in parts of of
the former to J of the latter. This produced temporary re-
lief; the assaf etida, acting as a gentle cathartic, relieved
the bowels of the accumulation of the disjointed pieces of
the worm; while the camphor counteracted the too great
relaxing tendencies of the other component on the system.
These. two remedies were resorted to alternately from 1838
to 1840, the pills "being taken from 3 to 5 at a dose.
The prescription of Turpentine and the mode of adminis-
tering it were as follows :
Fast 12 hours (or rather abstain from all hutliquids), then
empty the bowels with salts ; afterwards take a teaspoon-
ful of spirits of turpentine in loaf sugar, and this repeated
in 15 or 20 minutes, and followed by castor oil in thirty
minutes.
This course was always effectual in expelling portions of
the worm; but its effects on the system of the patient were
such as to deter a repetition until compelled by after ac-
cumulations and the accompanying symptoms before des-
cribed ; it leaving the patient under strangury and a gener-
al affection of the kidneys and spine, and consequently was
not resorted to except from necessity, and at intervals of 2
months. In the meantime the pills were taken for
temporary relief; but the odor being so offensive as to deter
their use as long as could be dispensed with.
The gentleman who prescribed the pills, though not a
lar practitioner, had been compelled to put into requisi-
tion his skill, as an acting Assistant burgeon, at a United
States Military post in the West, in the absence of any one
larly in charge, of that department, and during such
time he stated that two cases of similar disease had been
temporarily relieved by that treatment; and in the case of
the writer the prescription came fully up to the representa-
tion.
356 A Case of Tape Worm. [May,
In 1839 the lamented Dr. Anthony was one of the early
victims of the yellow fever of Augusta of that year, and
the patient was deprived of the further benefit of his skill
and left to the use of his prescribed remedy at discretion,
and having read some few miscellaneous articles on the
subject, and attetively noticed the effects of the prescription
in the disease, as well as on the system, it occurred to him
in the fall of 1840 that there might be propriety in varying
the manner of administering the turpentine from two tea-
spoonfuls at an interval, to that of the wholejquantity at one
dose. He made the experiment, taking a desert spoonful
at one time. The change was successful, acting instantane-
ously and directly on the worm, aiding the oil as a cathartic
wihont entailing the previous injurious effects on the kid-
neys and spine and resulted in expelling 14 feet.
Thus encouraged, it was repeated at shorter intervals,
with similar success, the specimens exhibiting irregular and
imperfect formation ; but showing that there was a square
break-off, leaving a portion behind. Again, in 1 to 4 weeks
this treatment was repeated till 1st of May, 1841, when 5
feet was expelled, tapering from the full size at one end to
nearly a point at the other, having rather a soft, jelly-like
appearance. This suggested the propriety of immediate
perseverance, and the treatment was repeated in 3 to 4 days,
which happily resulted in bringing at that time 3 feet, about
half the usual size at the large end and tapering to a point
at the other, not longer than the point of a common darn-
ing needle, perfect in formation, the joints shortening
as they decreased in size. At the time, this was believed to
be an entire relief from all remains of the worm, and has
been verified by a lapse of near 20 years without any return-
ing symptoms whatever.
It may be remarked as showing the obstinacy of the dis-
ease and the tenacity of the worm, that during its continu-
ance the writer was, in 1830, a subject of the yellow fever,
having a dangerous attack, and for which he was treated
with the appropriate remedies for that disease. On conva-
1861.] Bkbad. Thpe Worm. 357
Lescing, he flattered himself that the remedies for the fever
had subdued the worm; but was disappointed in finding
that by the time lie was able to Leave the house the old dis-
ease returned in all its symptoms.
The appearance of the disjointed portions have been des-
cribed. Those connected, of various lengths, resembled
gourd seeds strung lengthwise on a thread, and varied from
3 to 14 feet.
After a la] ime 10 years the ease, with the particu-
lars, &C, was related to a friend, a highly respected and
eminent gentleman of South Carolina, and which had pass-
ed from the memory of the writer, till recalled about 3
vears since bv a letter referring; to the circumstance and
stating that he had a son 10 years of acre similarly afflicted;
and that none of the physicians consulted seemed to under-
stand either the disease or remedy, and requesting a full
statement of my ease with the symptoms, prescriptions, &c,
it was given with full directions: but suggesting the pro-
priety, if the turpentine was resorted to, of leaving it to a
phpsician to prescribe the decrease in the proportion for the
child, as compared with an adult.
Some two or three months afterwards a second letter was
received from this friend, communicating the pleasing in-
telli_ >r his having used the prescription as directed,
with complete success, his son being entirely cured, and ex-
pressing his grateful acknowledgements, and the belief that
I had. under Providence, been the instrument in saving the
life of his child.
nsidering the result in this latter case us establishing
the efficacy of the remedies in the two, it was determined at
leisure time to make a statement of the same for the
benefit of the public, waiving all apparent delicacy involved,
believing that the cause of humanity demands it, that purpose
has been delayed to the present onlyvby other engagements.
Medical readers, as well us others, will, doubtless, make
due allowance for the absence of the use of t<'clmi<-;il terms
ne not versed in them.
358 Berlingkbr. Becicd Touch. [^foy>
ARTICLE XT.
Rectal Touch w early Pregnancy. By Martin Bellinger, M.
[., Barnwell, s! 0.
The diagnosis of utero-gestatiou lias drawn the attention
of medical philosophers from the earliest age. Its import-
ance behooves every one to investigate the signs closely, for
at every step in prorfessional life occasion may call for a
prompt and decisive opinion. Xot only in a medico-legal
point of view is it of importance, but the moral integrity
of the family circle may rest on the medical man to estab-
lish, or refute the suspicion of conception, and his fiat con-
signs to ignomy or restores to social purity. The suspect-
ed female may traverse an humble path, may be a slave to
minister to the wants of those to whom God has given her
services, but her social rights must be maintained. She
may be the highest lady in the land, whose hand it was an
honor to touch, and yet the fell suspicion can rest heavily
on her and drive her to seek companionship with degraded
beings. Her own sexw^ouldbe the first to spurn, for her hyper-
critical at all times towards each other, they pitilessly lash
the fame of the frail sister who deviates from rectitude.
More vindictive than the slouth hound, for he pauses at
blood ; the shroud of female scandal often envelopes the
pale remains of the fallen.
The object of this paper is to call attention to an import-
taut element in the physical diagnosis of pregnancy. It is
presented in this crude form in the hope that some of my
'professional brethren may deem it of sufficient moment for
the subject of investigation. To those of ample obstetrical
practice, each day will furnish opportunity for the truth of
the sign herein mentioned, and to those I look to prove its
truth or falsity.
I will briefly relate the circumstances which led me to its
observation. Several years since, when first commencing
to practice, I was requested by Mr, Andrew Dunbar, a
planter of this vicinity, to ascertain if one of his negro
women was pregnant, the work allotted to such being lighter
1861.] Bellinger. Rectal Tmoh 35^
than otherwise. She was said to be two months advanced,
I found morning Bicknees, suppressed menses and depres-
sion of the aterus with enlargement of its neck. The
mamma afforded no evidence, as she was nursing a twelve
months child, which, of course, roughened the nipple. In
addition to these Bigns 1 could detect no evidence of dis-
. nor was there any complaint made. My opinion,
therefore, to the owner was that though far too early to form
a positive one. in all probability the woman had con-
ceived.
Time proved it to he a false diagnosis the woman was
not pregnant It was a ease of amenorrhea, with slight en-
_e:nent of the cervix uteri.
Cliarles Wot says, that he who learns truly from person-
al ohscrvation, derives benefit even from his errors ; that
his mistake will serve as beacons to indicate the breakers
among which he was once wrecked. Bat the lesson taught
here never to give an opinion till the case was sufficiently
advanced to be unmistakable was of little avail. For, in a
lice almost entirely of negroes, where the question of
morality could never be considered, cases of amenorrhea
would come and had to be discriminated from pregnancy.
And frequently it is of primary importance to know the
true uterine condition to avoid the detrimental use of certain
drug
So that whether I expressed an opinion or not, I was often
compelled to form one or refrain from decisive treatment of
the e:
Tired of this uncertain course, I read every available
work relative to the subject, but none, not even the work of
the great Montgomery, afforded satisfaction. My attention
er, drawn to Meigs' two recorded cases of al>-
Uterus, and especially the means by which his
ed.
In case No. 1 he writes : "J requested the lady to lie on
her back, and introducing the index finger of the right hand
360 Bellinger. Rectal Touch. [May,
as far as possible into the rectum, I explored with it the ex-
cavation of the pelvis, in order to discover any tumor or
organ that might he contained within that cavity; hut as
all the tissues were ductile and very yielding, I began to sus.
pect there was no womb in the case. Therefore, laying the
fingers of the left hand upon the lowest part of the hypo-
gaster and pressing them firmly towards the finger that was
used in exploring the internal parts, I found they could be
brought so near each other as to make it perfectly clear that
there was no womb in the case; otherwise I must have felt it,
so near was the approximation of the fingers of the right
to those of the left hand." (Meigs' Treat. Obstetrics, p.
153.)
Whilst a student I read the above case, merely regarding
it as a good description of lucus naturcv. Now it acquired
the utmost importance, for the deduction drawn was that
the same procedure by which the absence of the uterus
could be noted, would determine not only its presence but
condition whether enlarged or not.
Since then I have in numerous instances put the idea to
the test of experience and every investigation, but serves to
confirm my opinion of its value.
I can speak with confidence as regards the rectal touch
of pregnant and unpregnanted uteri of child-bearing woman.
It has never fallen to my lot to examine the virgin uterus.
The normal position of the unimpregnated uterus of the
child-bearing woman is with its fundus on a level with the
interoseous cartilege of the first and second verteba?. This
point is distant, per rectum, from the anus about 4 J inches.
If the anus is pressed strongly toward the uterus the dis-
tance is lessened from \ to \ inch. When conception takes
place the uterus, increasing in weight, decend still lower,
there to remain till a little beyond the third month, when it
gradually ascends into the abdomen.
When a woman is to be examined, she may be placed on
her back, or what is better, on the left side in the ordinary
1861.] Bellinger, Rectal Touch. 361
obstetric position. One hand of the accoucher is placed on
the hypo-gastrium and pressed firmly downwards and
backwards toward the uterus. The middle (being the long-
finger of the other hand is well oiled and passed into
the rectum as far as the metacarpo-phalangsel joints. The
finger now comes in contact with tbe uterus, situated an-
teriority. If pregnant it will he found encroaching on the
rectum, its characteristic pear-shaped enlargement well de-
fined ; if not pregnant, the finger carried strongly fowards
ascertains its size.
The second and third months arc the most favorable
period- tor exploration for then the uterus is fully within
reach of the finger audits enlargement more plainly noted.
Rut even up to the fourth month it can he examined with
sufficient accuracy to form a diagnosis.
It may he established as a principle that the uterus in the
female can he examined per rectum with the same facility
as the prostate gland in the male, and any deviation from
the ordinary size as accurately detected. On this principle
ts this simple means of diagnosis. Applicable only to
the early months, at a time when all other symptoms are
ohseure, it is of great value. As a negative sign it is abso-
lutely certain, for the ahsence of uterine enlargement indi-
cates its non-impregnated condition. It is not an absolutely
positive sign because merely increased uterine size can
never he held as pathognomonic of utero gestation. Here
the method of diagnosis by exclusion must he instituted,
having reference to uterine hypertrophy, tumors, &c. And
when the enlargement is pear-shaped, when its progressive
increase corresponds with other (per se equivocal) signs of
ad where there is an ahsence of all evidence of
. the woman on the contrary in blooming health,
we will have woven a tissue of evidence before which all
must vanish.
362 Neeson. Dislocations of [May,
ARTICLE XII.
A Diagnosis of the Dislocotions of the Hip Joint By Horace
Neeson, M. !>., Augusta.
| A s a supplement to an excellenl inaugural thesis, our
iV'u'Tul Dr. Horace !N"eeson, presents the following sugges-
tions on the diagnosis of dislocations of the hip joint. It is
highly gratifying to us to find that the prolific idea of our
distinguished colleague, Professor L. A. Dugas, has been so
ingeniously extended and applied by one of his own pupils
in the Medical College of Georgia. It will be remembered
by our readers that I>r. Dugas presented his new method of
diagnosis in a communication to the American Medical As-
sociation during its session in the city of Nashville, Tenn.,
in the year 1857, and that it was published in the succced-
ng volume of the Transactions of that body as well as in this
journal, with four excellent photographic wood cut illustra-
tions, showing definitely the idea of the author. Dr.
Xeeson, whose ingenuity and thorough apprehension of the
principle, is not the less entitled to great credit, deserves
the thanks of the profession for thus adding his own valu-
able quota to a, sometimes, difficult point of diagnosis.
[Eds. S. M. & S. Jour.]
It has ever been the desire of man to do something for
the good of his fellow man, from the raising of a blade of
grass to the giving up of his life for a friend, so have I ad-
ded this diagnosis in my thesis with the, perhaps, presump-
tuous hope of assisting my fellow students, and not with
any view towards extending it over a greater space. In
studying Professor Dugas' diagnosis of the dislocation of
the shoulder joints, I concluded that as the mechanical ar-
rangement of the glenoid cavity in the upper circle of
bones resembled that of the acetabulum in the inferior
circle^ that this diagnosis could he applied to the dislocations
of the former, if I. could learn the principle upon which it
acted. Accordingto a well known geometrical axiom, "the
zadii of all circles of the same length and with the same
axis will describe the same arcs."
1861.] The JI<p J 368
Now, in the dislocation of the shoulder joint, if we take
the glenoid cavity as the axis of a circle and the humerus as
its radius, it will describe many arcs of circles, in this posi-
tion which it will ho impossible lor il to do in the dislo-
cated state. One of Huso arcs which it describes in the
normal state is the placing of the ulna radial end of the
humerus against the pazieties of the chest and moving it
upwards towards the ensiform cartilage until the hand of the
rotating arm can be placed upon the sound shoulder. This
circle, or segment of a circle, our distinguished Professor of
Surgery has often proved to he impossible for it to describe
in the dislocated state. Now, if we will, in like manner
take the acetabulum as the axis of a circle and the os femozis
as one of its radii, we will find it will also describe arcs of
circles in its normal position which are impossible for it to
perform in the dislocated state. The most prominent of any
of these arcs, that I have noticed, is that described by the os
femozis in crossing the legs. If we thus cross tlie legs in
the sound subject by letting the ankle fall, or pass just over
the external condyle of the opposite femur we will be able
to rotate the flexed leg though quite a large segment of a
circle. Suppose we place the axis of this circle back upon
the dorsum of the illiuni above the acetabulum. It would
first be impossible to cross the legs, either at the knees or
placing the ankle of the injured by upon the opposite knee,
much less to flex it after crossing them. Thus it will be
the same with any other displacement of the head of the
humerus. This is not the case with a fracture of any part
of this bone the great difficulty there is that it rotates too
freely.
Hoping that I have made this sufficiently lucid to be
comprehended, I mi ctfully submit this means of di-
agnosis to the consideration of those capable of b ling
its value than mvself.
3G4 Lectures on [^fay,
/ fares on the Theory and Therapeutics of Convulsive Disea
especially of Epilepsy, By Charles Bland Radcliffe, M. 1).,
Fellow of the College, Physician to the Westminster
Hospital, etc.
LECTURE III. (CONCLUDED FROM APRIL NUMBER.)
///. The Theory of Spasm. 1. In catalepsy, the state is
closely akin to that of a corpse. The blood, indeed, is well-
nigh Btagnant in the vessels ; and it may bo necessary to apply
the car to the chest to know for a certainty that the heart
continues to beat.'
hi tetanus there is no fever. All observers are agreed upon
this point. It is found also, that the spasms are apt to become
more general and more violent as the pulse weakens and the
animal heat departs. The bouts of spasm, moreover, are dis-
tinctly coincident with paroxyms of difficulty of breathing;
and in this way the spasm would seem to be connected, not
with excitement of the circulation, but with a state in which
the aeration of the blood is considerably interfered with.
And, in the tetanus caused by strychnia, there is certainly
nothing like vascular excitement; indeed, as we have already
seen, the experiments of Dr. Harley afford conclusive proof
that the addition of a very minute quantity of the poison to
the blood might be considered as equivalent to a loss of two-
thirds of the whole amount of blood, inasmuch as it diminished
by two-thirds the power which the blood has of absorbing
oxygen, and so becoming arterial.
During the spasms of cholera, the skin is frigid, clammy,
and blue, the breath cold, the pulse well-nigh imperceptible ;
and that the coincidence of this state of collapse with the
spasm is more than accidental, would seem to be evident from
the fact that the spasms relax pari passu with the reaction of
recovery.
In hydropholtui, the state of the circulation is the very op-
posite of fever, as is proved by the cold hands and feet, the
perspiring skin, the quick and feeble pulse, the sobbing and
sighing respiration, as well as by the fact that the agitation,
spasm, and convulsion increase in violence as the circulation
fails. Jt would seem also, that this very depression of circu-
lation must be connected with the agitation, spasm, and con-
vulsioo ; for, on looking over the histories ^i' a large number
of cases, [find that there was less agitation, less spasm, less
convulsion where the circulation was less depressed than usual.
In spasmodic ergotism, so far as we know, the pulse pre-
sents no siii-n of excitement throughout tin1 whole course oi
the malady.
1861.] Convulsive Diseases. 365
In the "early rigidity" of cerebral paralysis, there may he
at first no very evident alteration in the cireulation, and the
heat may nut fall below the normal standard ; hut before long,
both pulse and heat fail in the paralysed parts. In " late
rigidity," the local circulation is always feeble, and the heat
in the part is kept up with difficulty.
In acute spinal meningitis there may be symptoms of active
fever at the onset, but, if so, these symptoms very shortly
lapse into those belonging to the typhoid condition. Usually,
however, the symptoms have a typhoid aspect from the begin-
ning, and the respiration is too labored and imperfect to allow
of a different state of things. In acute myelitis, the circula-
tion is utterly without power ; and, as a collateral evidence of
this fact, there is a marked disposition to slough in all the
parts subjected to pressure. In chronic spinal meningitis, and
10 chronic myelitis, the state is one of hectic exhaustion.
In the different forms of minor spasm there is, for the most
part, no evidence of over-action in the circulation ; nor is it
otherwise when the phenomena of fever are mixed up with
the spasm, as in whooping-cough. For what is the fact \ The
tact is that the whoop, which is the audible sign of the spasm,
- not make its appearance until the febrile or catarrhal
stage has passed off; that it disappears if pneumonia, bron-
chitis, or any other inflammation be developed in the course
of the malady; and that it returns again when the inflamma-
tion has departed. In this case also, as in laryngismus stridu-
lus, the way in which the spasm is mixed up with the phe-
nomena of partial suffocation is an argument that the blood is
imperfectly arterialized during the spasm.
1. In the more severe forms of the disorders which arc
characterized by spasm, the mental state is indicative of ex-
haustion, prostration, or inaction. In catalepsy, the mind is
in a deep sleep, or else lost in some dreamy vision. In tetanus,
the patient is alarmed, absorbed in Ids sufferings, agitated.
The cramps of cholera are attended by indifference to the
future and utter hopelessness, than which there can bo no
surer sign of utter mental prostration. In hydrophobia, every-
thing denotes the want of mental energy, for the state is an
exaggeration of delirium tremens. In ergotism, the mental
borders closely upon fatuity. In both form- of the rigi-
dity <f cerebral paralysis, early as well as late, the brain has
n r.eriously damaged by white softening, by apoplectic
effusion, by red-softening, or in some other way, and the
mental power has suffered accordingly. Nor is the case dif-
ferent in other forms of spasm
866 Lectures on fMay,
The state of mind, indeed, is what it might be expected to
be from the depressed state of the circulation ; and the de-
pressed state of the circulation (to use once more the argu-
ment used on so many previous occasions) is one which neces-
sitates, as it would seem, a corresponding state of inaction,
not only in the brain, but in the medulla oblongata, the spinal
cord, and in all other parts of the nervous system. Nor do
there appear to be any objections to this view in the back-
ground.
The traces of inflammation which are occasionally met with
in the brain or spinal cord of persons dying of tetanus need
be no such objection. It is evident that inflammation of these
organs or their coverings is not an essential condition of the
disease, for in the majority of cases as in those occurring in
Guy's Hospital since 1825 there was not the slightest trace
of such a lesion. Nay, it may even he said that the inflam-
mation, where present, had served to mitigate or antagonize
the tetanic contractions ; for it is certain that these contrac-
tions may be developed in their most violent and perfect form
where inflammation is most unequivocally absent, and that
the contractions may be absent where- (as in many cases of
inflammation of the cord or its membranes resulting from ac-
cident) inflammation is most unequivocally present-
In hydrophobia, also, as in tetanus, the cases in which traces
of cerebro-spinal inflammation are not found after death are,
to say the least, quite as numerous as the cases in which they
are found ; and hence it is equally impossible to suppose that
such inflammation is essential to the malady. It must be un-
derstood, also, that the traces of inflammation in hydrophobia
are met with almost anywhere and everywhere ; and thus it
may be conjectured, with no small share of reason, that the
inflammation in this malady is in reality a depurative process
by which the system strives to rid itself of the virus, and that
traces of inflammation are not usually found because death
has happened before there had been time for the development
of them. This vagueness in the seat of the traces of inflam-
mation is well seen in a careful analysis of forty-six cases of
hydrophobia by my brother, Mr. Kadeliife, of Guildford-
Btreet.
And certainly it is not easy to suppose that inflammation of
the spinal cord or iis membranes is necessarily concerned in
the production of spasm. On the contrary, it may be held
that the inflammation lias antagonized or mitigated the spasm.
For if violent and general tetanic Bymptoms may be developed
in cases where the spinal cord is altogether untouched by in-
1861.] :>,;
{lamination, as in many cases of tetanus : and if, as is certainly
the case, the tetanic symptoms are comparatively slight and
fined to the back and nock, where the spinal cord is actu-
ally and unmistakably Inflamed, Is it not fair to suppose thai
the inflammation has had the effect of antagonizing or miti-
gating the spasm \
As in the different varieties of tremor and convulsion,
therefore, so in the different varieties of spasm, the facts would
seem to be altogether at variance with the idea that the mus-
cles are provoked to excessive contraction by excessive stim-
ulation of any kind. The facts, it would seem, are at complete
variance with this idea, and in as complete harmony with that
theory of muscular motion which was propounded in the first
lecture. It would seem, in short, that the key to the pathology
is supplied by the physiology, and that the physiology is con-
tinued and established by the pathology. It is the same story
throughout.
J I. The Therapeutics of Convulsive Diseases. Arguing
from the physiological and pathological premises, it may be
inferred that the fact of tremor, or convulsion, or spasm, can,
in no single instance, be urged as a plea for the adoption of
" lowering measures." It may be inferred, indeed, that the
great desideratum in every convulsive affection is a more vig-
orous circulation and a purer blood, and that the remedies to
be sought after will be those which bring about these changes.
1. I know of no facts which show that a low diet is bene-
ficial in epilepsy. On the contrary, I know of many instances
where the patient has been undoubtedly benefitted by the
abandonment of such a diet. The meals, of course, must
always be regulated .-< as t<> guard the stomach from an over-
load of food; but of the two evils, abstinence is more to be
dreaded than repletion. It would seem, iifdeed, as if the sto-
mach of a confirmed epileptic can never be allowed to remain
entirely empty, without some risk of an attack. As a rule,
Qulants, of one kind or another, would seem to be very
serviceable, in some cases, it is true, malt Liquors may be
objectionable: but in thi >s it will generally be found
that unquestionable good will result from a proper allowance
nerrv, weak brandy-and-Water, or, belter still; of claret.
Indeed, I am satisfied that epileptics, and nervous patients
rally, will have good rea overlook the shortcomings
aty by which, at reasonable rates, they will
substitute the light wines of France for tin- fiery
wine- Mt" Spain and Portugal, and the strong ales of our own
bre . would Beem to bo a more suitable
3G8 Lectures on [May*
beverage than its Lees stimulating companion, tea, particularly
at an early period of the day.
It is, no doubt, of extreme importance to prevent the accu-
mulation of effete matters in the bowels, and to remove such
accumulation when it lias taken place; but whether purga-
tives are the proper remedies is not quite so certain. If the
bowels do not act with sufficient regularity, there is, in all
probability, some error in the diet some excess of animal
Food, some deficiency of culinary vegetables and fruit; and
the first thing to be done is, obviously, to correct this error.
And this is often all that is wanted, if care be taken to explain
to the patient that his bowels can act without purgatives, and
that he need not particularly if advanced or advancing in
life be altogether cast down if now and then they do not act
every day. Indeed, if the diet be properly regulated, and this
explanation made, the patient will generally have the satis-
faction of finding his tongue clean, when he remembers to
look at it, and of forgetting his stomach and bowels altogether.
Or if the result be not quite so satisfactory, an occasional
injection of cold water or brine, on getting up in the morning,
will rarely fail to set matters right, and that without disturb-
ing the digestion in any way, or producing disagreeable feel-
ings of depression or irritability.
As to the rest, it appears to be advisable to order the habits
in such a way as to save the strength as much as possible.
Proper exercise is, of course, necessary ; gymnastic exercise,
by which the chest is expanded, and the respiratory capacity
increased, are valuable adjuvants; but it is no less certain that
muscular exertion upon or beyond the verge of fatigue must
be looked upon as a common cause of the epileptic attack.
As a rule, also, it would seem that epileptics require more
than the average amount of sleep, to enable them to recover
from the multifarious fatigues of the day and night.
The more strictly medical part of the treatment of epilepsy
is a subject of no small difficulty. The treatment of the pres-
ent day is very different from what it was when almost all
disorders were referred to inflammation or over-action of one
kind <>r other. Practically the lancet is new abandoned, and
leeches are in a fair way of being left undisturbed in their
swampy homes; practically, also, it has ceased to be the habit
to distresf the Btomach and bowels by the frequent use of
strong purgatives or emetics ; and this change may be appealed
to as an argument that " Lowering measures" had disappoint-
ed the hopes of those who had tried them so long and so pa-
tiently, and who gave them up so unwillingly. Be this as it
18G1.] Coi> 369
may, cliaoge has come over the treatment of epilepsy,
and the remedies at present most in vogue in this country arc
f zinc, copper and silver, particularly the
le of zinc, ami the ammonio-sulphate of copper.
r fancy for oxide of zinc has been caught from
M. Herpin, who has dei ibstantial volume to the pnr-
ihat many cases of epilepsy may be cured by
the vigorous and persevering use of this remedy. In this
work, M. Herpin relates thirty-ei f epilepsy or epi-
leptiform disease, in nearly all of which he gave the oxide <>t"
zinc; but, as I have elsewhere shown, the favorable opinion
of thi - I > the virtue of this medicine is by no
means home ont by an analysis of those cases. It would ap-
pear, liar M. Herpin himself has become less con-
fident than he was in 1852, when he wrote the work in ques-
a more recent statement is, "que l'oxyde de zinc, ne
mt point d'etre convenable pour les enfans et les vieil-
lards, echoue tres souvent chez les adults." M. Delasiauve,
liese words, tells us that one reason for this change
of opinion was the absolute failure of an experiment in the
Bicetre, in which one of the physicians of the establishment,
M. Moreau, treated eleven adult epileptics in every particular
after M. Herpin's method. M. Delasiauve also tells us that
M. Herpin now gives the preference to the ammonio-sulphate
: in the treatment of adults. I might argue, also,
that his faith is even shaken in this remedy, for I have recently
ne patient, who had previously been under
him, in wIioe lie abandoned the copper after a very short
ble simple, of which I shall have
.1 speak favorably as to the re-
the trials, nine in number, in which 1 gave oxide of
zinc after M. Herpin's method ; and my experience in this
ct agrees fully with that of my friend and colleague Dr.
Marcet, who, more perhaps than any other man in this cpun-
put this ' treatment to the test of experience.
At the same time, it does not follow that zinc is of no value
in epilepsy. On the contrary, the probability is, that it is a
lerable value in the proper case and in mod-
and thi- opii a little supported by the
-ult.- which Dr. Marcet has recently found to at-
tend In many form- of nervous excitability. Of the
rprepan zinc it is no! ak, for there
ilieve that their action for good or evil is
ride.
It i tain any sound evidence of the value of
24
870 hires on [^ay
tlir aminonio'sulphate of copper in epilepsy. Speaking of the
cases recorded in his published work, M. Herpin says that,
including relapses, he obtained fourteen cures in eighteen pa-
tients; but when these cures are fairly analyzed, they do not
turn out to be a whit more satisfactory than those which he
ascribes to the oxide of zinc. Nor do I know of anything
thoroughly satisfactory in the experience of others. For my-
self I oughl scarcely, perhaps, to express an opinion, for I
have never given the medicine a fair trial ; hut I have met
with several patients who have taken it, under the advice of
other physicians, and of these I have no hesitation in saying,
that n<>r a few, on being asked how they were affected, have
said that they felt more nervous while taking it, and that no
beneficial change was produced in the fits.
With respect to nitrate of silver little need be said. I have
had three patients under my care whose skin, before they saw
me, had been tinged of a dismal grey color, and whose fits had
been worse, rather than better, during the time they were ta-
king the silver ; and many cases arc on record which show
that this evil may happen without any countervailing good.
"Of all the metallic remedi s Dr. Watson, " I should
prefer some preparation of zinc or iron ;" and I believe there
are signs of change of opinion in the minds of many thought-
ful men, and that before long iron maybe placed before zinc,
and not after it. If, as has been said, the inferences from the
premises is that the desideratum in epilepsy is a more vigo-
rous circulation and a purer blood, it is to be expected that
iron may not unfrequently be wanted ; and this expectation
is not belied by my own experience. At the same time I
must confess that there are many cases in which this remedy
fails to bring about any beneficial result, and where harm
rather than good may be said to attend its use.
In many cases, also, another common remedy, which is not
mentioned in Dr. Watson's chapter on epilepsy, and which is
also overlooked by almost every other author, would seem to
do good. This is quinine. But with this remedy, as with
iron, it must also be confessed that there arc other cases in
which, to say the least, the good done is not unequivocal.
In a w<rd, it i> exceedingly difficult, in the present state of
our knowledge, to decide as to the value of these remedies in
epilepsy; bur that zinc i- no specific, and that the common
tonic- mentioned are not of themselves sufficient, must, I doubt
not, be the c d "T every one who has had sufficient ex-
perience in the matter.
Where, then, must we turn for what is wanting? Is it to
1861.] 871
remedies of a directly stimulating character! Is it to reme-
dies which may be supposed to purity the blood from certain
matters which ought to be excreted, but which being retained
produce a depressed or oppressed state of the circulation \
"It"." saysJ)r. Watson, "] were called upon to name any
single drug from which, in ordinary case.- of epilepsy, I should
hope for relief, I should Bay it was the oil of turpentine.
And 1 find that other physicians have come to the same con-
clusion. Dr. Latham, the elder, was, I believe, the first per-
son who made known its efficacy in this disorder. Foville
states that he has seen excellent effects from it. It is highly
spoken of by Dr. Perceval in the 'Dublin Hospital Reports'
It is not given in large doses, but in smaller ones frequently
repeated ; from half a drachm every six hours/' And that
turpentine is a valuable remedy in epilepsy, very valuable, I
have no doubt whatever.
Another remedy which puts in its claim for approval is
valerian. This is a very favorite remedy, both in this coun-
try and elsewhere, and its claims, though not equal to those
of turpentine, appear to be in every way deserving of atten-
tion. Recommended by Aretaeus and Dioscorides, and in use
ever since, it was never other than a favorite remedy. Xow
the prominent action of valerian is that of a stimulant an
action depending upon the presence of a composite volatile
oil, of which one portion is a volatile acid, capable of forming
It with bases, and known under the name of valerianic
acid : and it is a natural guestion, after what we know of tur-
pentine, whether the stimulating action of the drug does not
show that it may be efficacious, and explain the secret of its
efficacy.
It is somewhat significant ako, that the sclinuni palustre is
one of the four principal remedies to which 2>I. Iierpin has
pinned his faith ; and not only so, but the one to which he
gives precedence. These four remedies, ranked in the posi-
tion belonging to them in an ordre dt are sclinum
palustre, ammonio-sulphate ot copper, oxide of zinc, and vale-
rian. Now, selinum palustre is an unbelliferous plant, of
which several grammes may be taken at once ; and, on ques-
tion] four patients who have taken it, the answer
was that they were warmed ami comforted by it. In other
words, it- action would seem to be that of a feeble stimulant.
circumstances, therefore believing that a more
act/ of the circulation is a desideratum in epilepsy, and
having these practical i ats in favor of turpentine and
valerian a sufficiently natural question was whether cam-
372 Lectures on [May,
phor, naphtha, or ether in its various forms, or any of the
stimulant gum-resins, or musk, or castor, or some other stim-
ulant would be of use in epilepsy. Nor, if I can read aright
the lessons of my own experience, is the answer different from
what mighl be expected.
That camphor is often a very valuable remedy in epilepsy,
I have no doubt in my own mind. In doses of about three
grains, twice or thrice a day, for a time, I have seen such re-
sults as to justify me in ascribing to champhor all the virtues
belonging to turpentine, with this addition in its favor that
it is not unpleasant to the taste, and that it exercises, or seems
to exercise, a directly quieting influence over the generative
and urinary organs.
Naphtha also would seem to have the advantages without
the disadvantages, of turpentine. In doses of from half a
drachm to a drachm, and taken for some time, I have often
had what seemed to me unequivocal evidence of its beneficial
action. As a rule, also, a patient soon becomes indifferent to
the taste, particularly if it has been redistilled more than once.
Of the stimulant gum-resin, my experience is not very am-
ple ; but I think I have seen enough to satisfy myself that, in
several cases, they are of considerable value. Of musk and
castor I have no experience.
With respect to the different forms of ether, Hoffman's
anodyne, chloric ether, spirits of nitric ether, and so on, there
can, I think, be no doubt as to their great value as occasional
remedies; and the same may be said of ammonia. In the
majority of instances, it is only to this class of remedies we
can trust for warding off a fit. In some cases, also, ammonia
would seem to be of much use as an alkali in a point of view
of which we have now to speak. But however beneficial
stimulants may be, it is necessary to confess that they will not
do all that is wanted. It would appear, indeed, as if some-
thing were wanted which will carry out the second indication,
and ensure what has been spoken of as a purer condition
of the blood. Xor are we here altogether in the dark.
" About fourteen months ago," wrote Sir Charles Locock
in 1S53, "I was applied to by the parents of a lady who had
had hysterical epilepsy for nine years, and had tried all the
remedies that could be thought of by various medical men
(myself amongst the number) without effect. This patient
began to take oromidi of potassium last March twelvemonth,
having just passed one of her menstrual periods, in which she
had two attacks. She took ten grains three times a day foi
three months; then the same dose tor a fortnight previous to
v / 878
each menstrual period; and for the last three or four months
she lias taken them for only a week before menstruation.
The result has been that Bhe has not had an attack during the
whole of the period. I haw- also tried the remedy in fourteen
or fifteen cases, and it has only failed in one, and in that one
the patient had tits not only at the times of menstruation, hut
als.> in the intervals."
In using bromide of potassium in these cases, Sir Charles
Locock's object was to calm an erotic disposition, which at-
tended and aggravated the epileptic symptoms, and this end
may have been, and in all probability was, answered. But
this is certainly not the only way in which this remedy acts
beneficially. On the contrary, after trying it in scores of
- during the last two year.-. I can testify that bromide of
potassium is a very valuable remedy in cases where there is
not the slightest sign of an erotic disposition. I can testify,
indeed, that this remedy has proved more or less serviceable
in cases the most dissimilar in character so serviceable that
the name of Sir Charles Locock ought always to be remem-
bered with gratitude by every epileptic, and by many suffer-
ing from other kinds of convulsive disorder. How to explain
the modi ndi of this medicine is no very easy matter ;
but I am inclined to think that this in part at least, is by an
alterate action upon the blood analogous to that produced by
iodide of potassium and common salt an action by which,
sibly, the blood may be kept free from compounds analo-
gous to uric acid. And this I do, because for a long time, 1
have found decided benefit from occasional doses of a mixture
containing bicarbonate of potass and iodide of potassium, with
or without a drop or two of tincture of colchicum or wine of
white hellebore At any rate, the alkaline character of the
pound would seem to be necessary in some cases; for on
looking over about thirty cases in which I tried bromide of
iron, as well as bromide of potassium, I find that in the ma-
jority the latter preparation had a more beneficial action than
the former.
At any rate there can be no doubt that a healthy action of
the kidney, and of every organ by which the blood is kept
in a state ofpuri ssential to the successful treatment of
epih
But, it may be asked, what is to be said of the thousand
which have been recommended from time to time \
What, amongst others of strychnia, belladonna, conrum, coty-
ledon, umbilicus, poudre de Neuchatel, tracheotomy and cau-
terizatic i
374 Lectures on [May,
Strychnia, as all know, was a favorite remedy with the late
Dr. Marshall Hall ; but the dose was attenuated to such a de-
gree as to render it somewhat difficult to believe that much
good came of it. Dr. Hall, indeed, distinctly allowed that
harm is done if the dose be sufficient to produce the physio-
logical effects of the drug.
Belladonna a remedy recommended by Stoerk, and used
some years afterwards by MM. Debreyne and Bretonneau
has been again brought into notice by M. Trousseau, who
says he has employed this remedy for twelve years, and al-
ways had under treatment from eight to ten patients. He
says, further, that of 150 persons so treated, 20 have been
cured, or, at any rate, that their fits have not returned; and
that Mr. Blacke> who employed it during the same period in
a large private practice, has met with a like proportion of suc-
cesses and failures. It is a fair question, however, whether 13
per cent, of successes (which may, possibly, in part at least,
be explained in a different way) can be regarded as sufficiently
conclusive evidence in favor of the remedy ; and this the
more, as other practitioners, M. Delasiauve among the num-
ber, have been less successful. Judging from my own expe-
rience, my impression would be that belladonna is of very
doubtful value. JSTor is a more favorable conclusion to be
drawn respecting conium. I have tried this remedy in several
cases, in small and also in full doses; but the result was no
more satisfactory than that which had been already arrived at
by Professor Sc'hroeder Van der Kolk.
With regard to cotyledon umbilicus, it is not very easy to
believe in any powers beyond those which may be derived
from the imagination acting upon a new and innocent medi-
cine. It is very possible, also, that some part of the benefit,
where there has been any benefit, may.be ascribed to the
leaving off of some less innocent drug.
Poudre de JS'euchatel is a remedy which has some credit in
Switzerland, and which has lately been brought prominently
under our notice by having been given in some of the cases
recorded by M. ITerpin. And what is this remedy ? It is
none other than the powder of taupe grille in plain English,
fried mole. It is, indeed, a relic of the days when animal re-
mains, of a more objectionable character, fried or otherwise,
were offered to the unhappy epileptic, hi justice to Mr.
Herpin, however, it must be said that he does not believe in
this out-of-the-way remedy. lie enly tries it when other
remedies have failed.
And certainly it must be allowed that tracheotomy does not
1861.] 375
realize all the original hopes of Dr. Marshall Hall. It does
not always, perhaps usually, make the convulsion slighter.
It does not prevent danger, for (as I have shown elsewhere) of
the few patients upon whom the operation was performed,
three have died either in the tit, or in connection with the fit,
and of the three the opening was free from all obstruction, at
least in one. The first two eases, indeed, were calculated to
damp the hopes of any one less sanguine than Dr. Marshall
Hall. In the first case, the patient was a boatman, aged
twenty-four, epileptic for seven or eight years, and whose tits
were frequent and severe. The operation was performed by
the late Mr. Cane, of Oxbridge, during a fit of uasphyxial
coma," which had lasted nineteen hours. The relief was im
mediate, and for some months afterwards the fits were absent;
but unfortunately for the credit of the operation, the patient,
not liking the gurgling noise and the muteness consequent
upon the unnatural opening in his windpipe, had chosen to
icear the tube with its opening carefully corked up. This in-
formation I had from Mr. Cane himself. Very soon after-
wards the man was lost sight of, having been discharged from
his situation for drunkenness. In the second case, that of a
woman, aged thirty-six, death happened in a jit about twenty
months after the operation, and it is certain that the tube was
open at the time. It is certain, also, that the fits continued
after the operation, possibly a little less frequently and se-
verely, but decidedly of the same.
As to the value of cauterizing the larynx, it is less easy to
come to a conclusion. Dr. Brown-Sequard says that a third
of his epileptic guinea-pigs were cureel by this mode of treat-
ment, and that all the rest, with the exception of two or three,
were relieved ; and he suggests a similar mode of treatment
in epilepsy. A little later, Dr. Eben Watson, of Glasgow,
recommended a similar mode of treatment, and relates three
cases two by himself, and one by Dr. Horace Green, of New
York in which the treatment appears to have been carried
out with benefit. Dr. Brown-Sequard also lays .-tress upon
cauU parts, as in the nape of the neck, and
especially in the neighborhood in which the aura originates,
and he prefers the moxa or hot iron to milder measures. This
practice, he tells us, proved wry successful in his epileptic
guinea-pigs. In a word. Dr. Brown-Sequard furnishes us with
some additional facts in favor of counter-irritants as a means
of cure in epilepsy ; and not only so, but he gives a hint which
may prove I some practical value, in pointing out the
larynx, and the locality in which the aura originates, as sites
376 Lectures on [May,
in which "counter-irritation" may le especially serviceable.
Now, the verdict of past experience is very much in favor of
counter irritants, and I can well believe that this verdict is
true true because the inflammation caused by the counter-
irritant may for the time rouse the sluggish circulation of the
epileptic towards a pitch of safety, and because the discharge
may tend to rid the blood of some impurity ; but my own ex-
perience in this matter is too limited to enable me to arrive at
a sound conclusion.
With regard to the treatment of the epileptic lit little need
be said. As a rule, it will be only necessary to take care that
the patient does not injure himself ; that the head is not al-
lowed to hang too low ; and that any necklace or neckerchief
be loosened. If salt be at hand, a spoonful may be put into
to the month ; if water be within reach, a little may be sprin-
kled upon the face, though the advantages of such a practice
are scarcely sufficient to compensate for disadvantages and
risks arising from wetted garments. In ordinary epilepsy, it
can scarcely ever be necessary to have recourse to chloroform,
as it may be in some prolonged epileptiform affections ; but
if the convulsive stage is unusually prolonged, no remedy
would seem to be more appropriate and effectual.
In concluding these brief remarks upon the therapeutics of
epilepsy, we may say with Marshall Hall "There is no royal
road to the cure of epilepsy. The idea of a remedj^ for the
disease is unphilosophical ; and the treatment should consist
in a well-advised plan, embracing every means of good, and
avoiding every means of harm."
2. A single word must serve for what has to bo said upon
the therapeutics of other convulsive diseases. Where these
diseases are of a chronic character, whether the convulsive
symptom be tremor, convulsion, or spasm, it matters not which,
there appears no reason for adopting an opposite plan of treat-
ment to that which has appeared to be necessary in ordinary
epilepsy. Nor does the case appear to be different where the
convulsive symptom is associated with disease of an acute
character, inflammation, in itself, is no longer regarded as a
sound argument for the adoption of lowering measures ; and
if inflammation in itself does not cull for these measures, it
certainly does not follow that a louder call is made by the oc-
currence of tremor, or convulsion, or spasm, before or after
the inflammation. On the contrary, the natural inference
from the premises is, that the convulsive movement might
often have been prevented by more carefully husbanding the
strength" of the patient. According to the premises, indeed,
mvnlsion, or spasm, would be a reason
Casing blood, ratber tban for abstracting blood exccp ,
>erbap in one single case, and there is where, from the unn-
El prolongation and severity of the asphyxia in a first atta ck
3Ua i .. t v . ... ,a+ ,n Kviin'ini nun's. And
;Ul>lVH01l'r;iUi'iianu .^^l.^. -- ,
ttere is danger of baemorrbage into tlie Wain and lungs. And
Mainly there is no practical ob ection to bis view, or all
, st know that we have no reason to be satisfied with the re-
Ste of a lowering plan of treatment m acnte convulsive dis-
ordci
er
m
si
Rattlesnake Bites. 3??
he Treatment of Rattlesnake Bites, with Experimental
ms upon the various remedies now in use. Jiy b.
Wler Mitchell, M. D.
The subject of the poisons made use of by certain animals
has been in all times of the utmost interest to the popular
bind That it has failed to attract an equal or proportion-
al amount of scientific investigation, can only be accounted
for by supposing that the popular aversion to serpents as
Cell as the real danger which more or less surrounds the
pursuit have combined to deter toxicologists from engaging
In such researches. The admirable effort in this direction
bade by the Abbe Fontana, who has left us the record ol
periments on viper poisoning, may also have done
to prevent further study of this serpent, since
his opinionshavebeen reverentially received as imaland the
multitude of his experiments has caused them to be looked
a as exhaustive of the subject.
In other than European countries, and where the moic
virulent poisonous snakes abound, observers have been
wanting, or they have lacked those means of pursuing the
study which only a great city affords. It has thus happened
that through want of material where observers were plenty,
or lack of these where material was abundant, the know-
iedg pent venoms has advanced but little Bince the
davs of Fontana. .
JBefore the time of thai great toxicologist, viper venom
had tudied by Charas, 1669, Redi, 1672 and 1675,
aiul vi A multitude of others had also touched
the - but on the whole, they added nothing import-
rmation which came down from the Greek
nan fathers of medicine; or. when they added any-
tlli] tape of fanciful conjecture, and served
oni, Qore difficult thetask of unraveling the united
Rattlesnake Bites. [May,
web and woof of popular and scientific beliefs as to venom-
ous serpents.
Without carefully reviewing this mass of strange
opinions and superstitious conceptions, it is not possible to
appreciate the services done by Fontana in clearing the
ground for modern research and in setting at rest a host of
minor absurdities. .Most of the definite and novel views
which he put forth as the direct results of his experiments
have been more or less unsettled by various partial inquiries
of more modern date: but, on the other hand, some of the
most valuable facts which he discovered have never been
questioned; and, as a whole, his essay, or series of essays,
is still a monument of industry, ingeniously directed, and of
experimental sagacity of the highest order.
From 17(37, the date of his essays, no contributions of any
moment were made to the toxicology of venoms until the
publication of Russel on the Poisonous Serpents of India,
in 1787.
%In 1798 and 1709 appeared in this country Dr. Barton's
ys, which were rather records of his own thoughts and
of popular and other opinions than of original research. In
1817, Mangili settled the question of the innocency of venom
taken by the mouth ; and 1843, Prince Lucian Bonaparte
analyzed the venom of the viper, and determined its albu
minous nature. At various periods also appeared numer-
ous papers by East Indian surgeons and European physi-
cians on the therapeutics of snake bites; but with trifling
exceptions, no further experimental papers were produced
until Drs. Brainard and Green recorded their researches in
1853. Dr. Brainard's separate Essay, 1854, contained in-
teresting observations as to the phenomona of venom poi-
soning, but the main object of both ihe papers alluded to
was the examination of the value of iodine used locally as an
antidote. The tendency to regard the subject chiefly from
a therapeutical point of view has indeed prevailed through-
out nearly all of the res< made either in this country,
in India, or in Europe, so that if we omit the essays of
Bonaparte, Mangili, Russel,and Davy, the work of Fontana
still remains without a companion no one since his time
having examined any one serpent poisonas to its chemistry,
toxicology, and mode of formation. Yet, as every physician
musi concede, the treatment of snake bites can never be
rationally understood until we retrace our steps and study
anew and more profound the venom malady and its cause,
II.] Rattlesnake Bit 379
in place of playing at perilous hap-hazard with its difficult
therapeul
Whenlfira tudy of the venom of the
rattlesnake, it was with the intention of ascertaining what
value Bibron's antidote possessed. To effect this single
end I procured four or five snakes from th< ylvania
Alleghanies and proceeded to subject animals to their fangs,
and afterwards to give the supposed antidote.'
After destroying many animals and attaining only nega-
tive results. I began to perceive that I was working in the
dark, and that it was altogether impossibe to obtain useful
results without possessing definite knowledge as to the
nature of the venom, the mode of its formation and ejection,
and the whole natural history of the disease to which it
gave rise.
The information which I desired was yet to be created.
It existed in none of the hooks, and even so much of it as had
[uired by Fontana with regard to the viper, might
rue of the rattlesnake.
With a clear sense of these deficiencies in the present
knowledge as to venom poisoning, I laid aside my
on remedies, only to resume them after the
mmers had removed from my path the im-
pediments which have hitherto rendered the study of anti-
dotes practically . The result of these research*
riled at length in a paper recently published by the
Smithsonian Institution, and to which I desire to refer the
Ler for full details of my experiments, and for the con-
- to which they led me.* The principal difficulty
which I encountered at the outset was the want of snakes ;
owii . to the ready and constant aid which I re-
from the Smithsonian Institution, I was enabled to
ply from the Virginia Alleghanies, and
with these and such other chance supplies as I could pur-
rocured for me through the kindness of
:ahled to pursue ray purpose with only
long to the subject.
difficulties which lay in the way of one
ition
Wier
ition.
Jam: Vv> Vrk: 1)
380 Rattlesnake Bites. [^fay,
studying the treatment of snake bites were among the most
easily resolved of the many questions which multiplied in
number and increased in perplexity as I advanced on this
interesting path of study, fn fact,* I cannot but perceive
that I have re-opened a field of research which promises
most valuable and strange results to the toxicologist, nor
can [fail to comprehend that the whole subject of venom
poisoning is to be reconstructed, and that on no branch of
science are we so utterly ignorant as on this one. M. Ber-
nard alone, of all the recent writers, seems to be aware of
our lack of knowledge in this direction, and strongly urges
a re-examination of the principal animal poisons, such as
the venom of toadsf and serpents.
At the close of the Smithsonian Essay, just referred to,
1 have given a brief statement of my views as to antidotes,
and as to the great difficulties attendant upon their thorough
study, and I have appended a short discussion of the rela-
tive value of various remedial means now in repute for the
treatment of snake bites, as well as my own opinion on the
rational method of treating these injuria
The object ot this present essay is to consider all the best
known antidotes by the light of the practical criticism of
experiment, and, finally, to point out what means of treat-
ment appear to be best calculated to relieve the sufferers
from these dreaded accidents.
The course of study thus laid down will involve an ex-
amination of the following points, which I shall consider at
such length as my space permits:
1. Fallacies in regard to the use of antidotes of all kinds,
arising from want of exact knowledge as to the secretion ot
venom, and the mode in which the serpent uses its fangs and
ejects the poison.
2. Falacies as to antidotes, arising from want of informa-
tion on the natural history of the disease caused by the
venom.
3. General considerations as to antidotes, and as to the
mode of conducting researches in this direction so as to
avoid errors.
ind Gazette, Sept. i2-.m1i. I860, p. 296. M. Bernard
mak< teresting remarks on the venom Of the toad. ~S\. Gratiolel
had already examined thissnbjecl mid arrived at somewhat similar con-
clusions, to which, however, M. Bernard does not allude. See Gratiolet.
Oomptes Rendus, vol. xxxiv. p. 732, 1851.
1.] fi / 381
Description of the ph< a of rattlesnake
anal tc.
:al treatment Experimental examination of tho
medication most in repute.
aeral or constitutional treatment. Experimental
examination of the principal constitutional remedies.
7. Sketch of the author's views as to treatment, local and
general.
1. Fallacies in regard to the use oi antidores oi all kinds,
arising from want of exact knowledge as to the u of
venom, and the mode in which the serpent uses its fangs
and ejects the poison. When antidote has been given,
any treatment used after a snake has bitten a man or a lower
animal, it is usually taken for granted that the danger of
any two bites is much the same if the subjects of the bites
are alike in age or vigor. Xow, even when the serpents are
themselves of equal bulk and have at disposal drop for drop
the same amount of venom, it may chance, that the danger
of the two bites is utterly unequal, and thus that in one an
antidote might fail, and in the other appear to succeed.
This arises from one of the following reasons :
The snake fails to elevate its fangs sufficiently when
striking, and the fang points touching the skin are driven
backward toward their usual position of repose without
irating the part aimed at. When this accident occurs
no wound is inflicted unless the teeth of the lower jaw be-
. tangled in the skin of the bitten part, in which i
the small wounds thus made maybe easily mistaken for
fang mark-. When experimenting with Bibroh's antidote,
in duly, 1859, a large dog was scoured and placed within
:h of a -make which struck it fiercely and became fasten-
ed for a short time, so that I was able to perceive that the
fangs were doubled backward, their anterior convexities
the skin to which the Berpent was attached
by the curved teeth of its lower jaw. The wounds made by
-e teeth were of c and the d^'j; experienced
no further inconvenience. Thie >f failure in the bite
rt be difficult of detection, under ordinary circumstances
the s!iak ', since it would be dangerous to ap-
proa e the snake is usually entangled i'nv
out a brief period. When, however, ti held
by the middle, in a leathern loop at the end of a stiif, and
thus allowed to bite, they not unfrequently fail to elevate
triciently, and, as in experiments on antid
382 Rattlesnake Bites. [May,
it is often necessary to secure the serpents in the manner
described, the possibility of this occurrence should not he
overlooked.
'When tin1 rattlesnake bites, whether it he at perfect free-
dom or not, both fangs do not always pierce the skin of the
animal stricken. I have sometimes suspected that the ser-
pent does not always elevate hoth fangs. This, however,
is a point which does not readily admit of direct observa-
tion in snakes at liberty, and can only add, that of seven
dogs bitten by serpents at freedom, four had two fang
] narks, and three had hut one. Now, as the fang, duct,
and gland of one side are quite distinct from those of the
other, if only one fang he used, the dose of poison adminis-
tered will he hut one-half of that which would he injected
were hoth fangs employed.
Apart from the possibility of the snake using only one
fang at will, there are other facts in this connection which
may enahle us to explain the frequent occurrence of single
fang marks. When, for example, the snake strikes
obliquely at the Hank of an animal, one fang sometimes
remains out of reach of the part penetrated by the other,
and this is the more apt to occur, because, in elevating the
fang teeth, at the moment of attack, their extremities are
made to diverge widely.* For a like reason, when the ser-
pent strikes a small limb or member, it sometimes chances
that the fangs either straddle the part completely, or that
entering it, the other passes it to one side without in any
way injuring its tissues.
Besides these cases of fang marks, many instances occur
in which, although hoth fangs penetrate the opposing tis-
sues, only one is in reality active, or, hoth entering the flesh
for reasons to be presently detailed a part,. or perhaps in
some cases the whole of the venom fails to he injecteel, and
the danger of the wound is materially lessened.
"When the fangs in biting arc fixed in the flesh, the lower
jaw of the serpent is pressed upward against the part bitten
and at the same instant the temporal muscles, and especial-
ly the anterior temporal, compress the venom gland, and
Tin- object of this Beemsto he to protect the lower jaw from injury in
:iis< their aim and are driven downward, in which cases
they would pierce the lower lip of the snake were it not that their diver-
throws their points outside o\' it.
1861.] 383
urge its accumulated venom along the duct and through the
!i. In most rhere both fangs have been used, the
actions which bury the fangs more deeply, and inject the
- 'ii, are consentaneous on both but sometimes a
perceptible interval appears between the contraction of the
right and left sets of muscles, so that a sudden motion of
the bitten animal occasionally libera fang 1><
charge of venom lias been duly deliver*
Still more curious, however, is it, that we may have both
fangs deeply buried in the flesh of an animal, and yvt not a
drop of venom injected. The explanation of this source of
fallacy in the use of remedial means is to be found
in the following facts li, in his >hes on
viper venom, published in 1675, Btates that the poison } i
es down alongside ol the fang, and between it and the
mucous cloak which covers it when at rest, and which is
now known as the vagina dentis. Fontana disproved this
statement, showing that the venom passes out through the
canal of the fang. If, as I presume is the case, the arraj
ment of which I shall presently speak belongs to the viper
ell as the rattlesnake, both were right and both were
wrong. Professor Christopher Johnston, of Baltimore, and
Professor Jeftries Wyman have both of them recently des-
cribed the venom duct of the rattlesnake as ending in a
papilla, which projects into the basal aperture at the base of
the fang. Upon close inspection it can be seen that no
tissues connecting these two parts together in any direct
manner, the end of the duct being held in close contact with
the tang by the gum, which envelopes flic tooth, and through
which the extremity of the duct When the far.
couched, at rest, in its mucous sheath, the apposition of the
tang and duct is still kept up, but is less perfect than when
the fang is erect, since then the mucous cloak is thrown off
the anterior convexity of the fang, and gathered in firm
folds at the base of the tooth, firmly presses the papillary
end of the duct into the lower orifice of the flu
h being the case, it can be seen that if the fang is not
fully erected, or if, from any cause, the end of the duct is
rated from the fang opening, a part or the whole of the
m may escape between the fang and its mucous cloak,
and tail innocuous on the skin of the bitten animal, hi a
modified form this result often happens, and a part at least
of the poison is cast on the skin, the larger portion travers-
ing the duct, and probably the excess alone being wasted.
384 Rattlesnake Bites. [Majl
In direct experiments on animals I have often noted tin
escape of venom alongside of the fang, and in general, the
mure serpent's motions are interfered with during the experi
ment the more likely is it that the whole or apart of the poisoi
will he lost in the way I have mentioned. It thus happens thai
\\w most vigorous serpent may become innocent at the verj
moment of the bite, and that not even the most watchful
attention will enable the observer to say that the remedj
given was the cause of a bite proving mild in its effects!
I have here urged, this, like other sources of fallacy, is
most apt to appear when the serpent is held, and when thus
we endeavor to cause the bite to occur in a particular part
of the body of an animal.
2. Fallacies to the value pf antidotes, arising from wan]
of information in regard to the natural history of the dis-
ease caused by the venom of serpents. There exists as
idea, not confined to the popular mind, that the bite of the
rattlesnake is an extremely fatal accident. Although wc
have no full statistics which are available to settle the mat-
ter, I have gathered enough information from various sources
to enable me to assert with great confidence that it is fai
less fatal than has been supposed. When making this
statement, I do not mean to be understood as saying thai
the rattlesnake is not a dangerous animal, but only that
neither man nor dog need be regarded as condemned to
death when wounded by it, whether remedial means arc
afterward employed or not. A large rattlesnake long re-
strained from biting will use his weapons no doubt with
deadly effect, and'hence, when showmen have been bitten,
they have rarely escaped. On the other hand, the greater
number of such accidents, arising from serpents at freedom,
will be apt to prove serious in their results, but not very
often fatal. Of fifty-seven cases of rattlesnake bites which
are given in full or merely mentioned in the journals, only
five died ; and even if we make every allowance for the
character of the reports, this evidence still remains sufficient-
ly strong; nor have I found that it lost force in the pre-
sence of such facts as my experiments on animals have
brought before me. A close analysis of the table of casei
in my Smithsonian essay, (p. 100,) with reference to the
treatment and the result, brings us to the conclusion either
that all treatment (oil, alcohol, iodine, ammonia, etc.,) is
successful, or else that the greater part oi the cases must
have survived under any form of medication. It can be
1861.] fi
shown, moreover that most of the plana of treatment em-
ployed are utterly useless.
Here, then, is a malady from which at least seven-eighths
of the patients recover. The mere fact of their surviving
can assuredly be no test of the value of apian of treatment.
. that this or that ease did not die has been thus con-
strued, and this cardinal error exists in almost all of the
earlier examinations of antidotes, and in some of the later
ones.
Authors who have reported successful cases of the treat-
ment of snake hires hy various means, have been further
misled by a want of knowledge as to the duration of cases
not treated at all, and as to the character of the recovery.
general survey of a number of cases, and a careful study
of animals bitten and not treated, can alone supply this lack
of information as to the average natural nistory of cases un
disturbed by any therapeutic resorts. Ai the result of such
study, we learn that a few cases of rattlesnake bite die, that
a few linger long ere recovery is complete, and that the
larger proportion get well, and that with a degree of sudden-
- which is sufficiently surprising, considered with refer-
to the serious character of the symptoms, and well
calculated to deceive the credulous therapeutist.
In many cases this abrupt departure of all serious symp-
toms at remarkable ; a man is bitten, thought to be
dying, treated this or that way. and on horseback or t
work forty-eight hours from the time of the bite. In dofc?
bitten, alike result obtains and the recovery after the mot*,
urgent symptoms is usually rapid and compl
Now nothing is more gratifying to the physician thai.
the sudden effect of his remedies; and the speedy and
favorable change of a case from an appearance o\% extreme
danger to one of relief and convalescence, naturally leads
him to attribute that result to his medication, which really
was natural to the malady. A fuller acquaintance with the
rt annihilate this source of error for any but the
r incautious minds,
[t will now be fitting to consider the third section of
our subject, and to comprehend clearly how we avoid the
of falacy above pointed out, and how the study of
antic1 serpent] should be conducted.
And first, what is an antidote ': The popular mind usu-
ally conceives of it as a remedy having power to neutralize
directly in the system a given poison, destroying its potency
".s'i Rattlesnake Bites. [May,
by acting upon it chemically or otherwise, in some more
mysterious way. It is possible that agents of this kind may
exist, lmt thus far we are ignorant of any possessing such a
relation to the venom of the rattlesnake. The pretensions
of remedies supposed to he so gifted may be easily settled
by mingling them with the venom, and afterward injecting
the mixture into the tissues ot an animal.
The more rational conception of an antidote, is of an
agent which merely counteracts the effects of the poison,
and which may have no chemical influence on the poison
itself. Such an antidote may enjoy no power to affect the
toxic activity of venom when mixed with it, and yet may
prove to be an active constitutional preservative against its
effects. Just this position seems to he held by one of the
supposed antidotes most in repute.
So far as I am aware, no great difficulty is likely to arise
in the study of antidotes, owing to their nature as such, for
although some of those most in esteem, such as Bibron's
antidote (bromine) and the Tanjore pill, (arsenic,) are poi-
sonous in a high degree, it is easy to learn how much may
be given with impunity. Hence, although in one or two
instances observers have actually and plainly destroyed ani-
mals with the very agents which were designed to relieve
them, it is not probable that errors of this kind will be per-
petuated, or even occur so often as to bring into disrepute
any really useful remedy. The mode in which the study of
antidotes and local remedies should be conducted, so as to
avoid all the fallacies to which I have alluded above, will
now claim our attention.
Opportunities of studying the use of remedies, local and
general, in connection with cases of venom poisoning in
man. are of course more or less rare, and it is scarcely pos-
sible to eliminate or allow for the varied fallacies which sur-
round with difficulty this method of studying the subject.
Owing to this, and to the comparative ease with which the
means of study may be created in animals, it is preferable
to employ these, and to use only such treatment in human
cases as may appear to promise enough of success to justify
its usage.
The larger the animal employed the better will it be for
the purpose, since the symptoms are more easily studied in
large animals, and since they are less likely to be injured
by active antidote-. Almost all toxicologists who have; in-
\ estigated this subject, have been content to submit animals,
L] Rattlesnake Bit 887
as dogs, etc, to be bitten by the serpents themselves. We
have seen, however, that when this course is followed, a
number of fallacies interfere to prevent the observer, from
drawing satisfactory conclusions, and although great care
and thorough acquaintance with the anatomy and habits of
the serpent may enable us to overcome this difficulty in part,
some portion of the obstacles in question are in the nature
of things unavoidable. In my own researches I have
sought to escape from these embarrassments: first, by a
fill study of the natural history of venom poisoning in
- and other animals : second, by injecting into the ani-
mal experimented upon known quantities of venom previ-
ously removed from the ducts of active serpents. The
venom to be thus employed is secured in the following man-
ner :
A serpent is seized by the middle, with a leathern loop at
the end of a stall'; then the neck is caught and held down
on a table with a notched stick, while a tube an inch and a
half in diameter, and holdidga sponge soakedin chloroform,
is slipped over the snake's head, and by a dexterous motion
carried downward so as to include one-third of the length of
the serpent, the notched stick being at the same time re-
moved. About twenty minutes are required to stupefy the
snake. It is then seized by the neck, and the i^d^c of a
slipped under the upper jaw, so as to elevate the
fangs. This is done by an assistant while the operator with
his right thumb and forefinger strips forward the glands
and ducts on both sides. The yellow venom runs out
through the fang and along- his weapon. A known
amount of this fluid may then be injected into the tissues
of an animal, the instrument employed being a minute tro-
car and Itmaybe objected to this method of us-
ing the venom, that it is supposed by many persons that the
poison i- less fatal when used artificially than when injec
by the snake. Of this, however, there is no adequate proof,
and Iha nothing to induce me to believe that it is
at all correct. On the other hand, the advantages arising
i the artificial use of the venom are manifold and obvi-
. ami it is only essential to know what amount of venom
troyadogifno remedial agency intervenes,
a addition to this, th wr is thoroughly cognizant
te ordinary phenomena of ti he will
table ni< ansof insuring accuracy, which
are now attainable. Antidotes mav then be used internallv
388 Rattlesnake Bites. [May,
in one or two ways to be hereafter illustrated, or mingled
with the venom, and injected where this mode of study is to
be desired.
Before stating my experiments upon the plans of treat-
ment now or recently in repute, it will he proper to give the
reader certain necessary information as to the nature of
venom poisoning, the forms it affects, and the symptoms
which characterize its varieties. These details must of ne-
sity be brief, and the reader who wishes more complete
information is referred to the author's previous paper.
The venom of the rattlesnake is a yellow, albuminous
fluid, of an acid reaction of a sp. gr. of 1044, and coagulable
at a temperature of 140 to 160. Its toxic activity is un-
affected, or but slightly affected by boiling, and not at all
by freezing. Acids and alkalies, alcohol, etc., do not de-
stroy its virulence, and when dried it retains dreaded power
for an unlimited period of time. Closer qualitative analysis
discovers in it at least two albuminous substances: one co-
agulable by boiling, either when alone or diluted with
water, and also by alcohol ; the other, also albuminoid, co-
agulable by alcohol only, and constituting the active ele-
ment of venom. This latter agent I have described as cro-
taline.
Effects of venom on man and animals. When an animal
receives in any way a dose of venom, one of two things
happens. If the animal is small, or at all events if relative-
ly to the size of the animal the amount of venom injected
is large, the animal dies very suddenly, acutely poisoned.
If, on the other hand, the dose of venom is relatively small,
the animal suffers to some extent with the symptoms of
acute poisoning, and then passes into what I shall term the
stage of chronic or secondary poisoning, which may endure
for an indefinite period, and end in death or recovery.
Acute poisoning in a man is rare,* and is more and more
common the smaller the bulk of the animal bitten, until
we arrive at cold-blooded creatures, in whom this sudden
ending is the exception, and great prolongationof the mala-
dy (/'. e, secondary or chronic poisoning) the rule. In dogs I
ugh rare, not impossible; men have died from this cause within
ty minutes of the time of the bite, although no such cases are oo
rd in the journals, and arc only known to me by personal informa-
tion.
;L] RaUUsnah B
have rarely seen the very rapid death I speak ofj but it is
not ancommoD whore the serpents are large and active and
their venom abundant
Let it be clearly understood then, that when man or ani-
mal is poisoned by venom, a set of symptoms occur which
wind up with death, or. being prolonged, pass into others
of a somewhat different nature, constituting the chronic
r those which survive long enough to exhibit the
- which characterize the secondary poisoning.
When, for instance, a pigeon is bitten, or receives in any
way three or four drops of venom, it walks a few m
crouches, - i'ov breath, rolls over and is dead in a few
minutes, convulsed or not in the moment of agony. So
sudden and speedy is this ending in some eases, that the
pigeon may die within a minute. The only additional
symptoms which we can percriveare the rapidly quickening
and enfeebled motions of the heart, and sometimes vomiting
and evacuations from the cloaca. In larger animals the
same symptoms take place, but the vomiting is more com-
mon and the expression of general debilitv more percept-
ible.
Men who have been bitten describe their symptoms
much the same in kind, but, as before stated, they rarely
end in death in thia t least : the power of resistance
acquired by increased bulk being, I presume, the chief pro-
tective agency. In some eases the more formidab
of prostration do not declare themselves before some
minutes or even halt* an hour has passed. In one
man engaged in splitting wood was bitten ; lie picked up a
stick and pursued the snake a few feet, when suddenly he
:: at the stomach, complained of deadly nausea
and general weakness, reeled a few steps farther, and fell
on the ground. In another instance, the sufferer walked
briskly for twenty minutes before the symptoms of debility
;.me very well marked.
It - important to our purpose to decide th<
mptoms and what organs are affected. .Ml
auth s in speaking of the condition as one of debility
and all describe the pale face and cold the hurried
ih and (piick and feeble pulse. If we examine an ani-
mal dying rapidly with these symptoms, we find absolutely
no 1 ihe blood and the t. re alike healthy in
app- both to the naked and I eye.
of experiments, the relation of which would be misplaced
)00 Rattlesnake Bites. [May,
here, lias shown that the heart does really become enfeebled
and that the arterial pressure is singularly diminished, and
this appears to be a direct effect on the arterial system,
since it is impossible long to sustain life by artificial respi-
ration ; at the same time the nerve centres are attacked,
and the respiratory movements failing on this account,
become jerking and labored; the sensory and motor
nerves seeming still to preserve their functional in-
tegrity. Such, in general terms, I suppose to be the
causation of death in these cases. Far different are the
symptoms which arise for study when the patient sur-
vives the stage of acute poisoning. The duration of this
stage is indeed difficult to define; this only we know, that
alter a time the debility continuing, as shown by vomiting
and syncope, the blood becomes affected in a marked and
singular manner, while the relations of tissue and fluid are
so altered that passive hemorrhages take place ; jaundice
occurs, and a variety of symptoms declare themselves as .this
or that organ becomes diseased and the seat of congestion
and eechymosis. Meanwhile the local symptoms assume
an importance which they do not possess in the acute stage
and may even become paramount influence in deciding the
fate of the patient.
If then the patient die very early, there are symptoms of
weakness alone, and there are no perceptible lesions of
1)1 ood or tissue ; supposing life to be prolonged, the early
symptoms continue, while signs of blood poisoning appear
in addition, and lesions closely resembling those of yellow
fever are found post-mortem. If, again, the patient success-
fully resists the secondary evils here described, he may still
perish from the results of the local injury, which increases
in danger and importance as the case progresses.
To make this matter clear, we will now examine more
accurately the various symptoms and the character of the
wound.
Wound. The wound is usually described as very painful,
but so far as my own experience informs me it is not always
so in animals, nor do all men who are bitten speak of it as
painful at first. Indeed, the wound has sometimes been
for a while disregarded, and at all events the hooked form
of the fang, the forcible injection, and the sudden with-
drawal of the weapon, account sufficiently for the pain,
without supposing it to be specific. The succeeding local
ymptoms are rarely notable when the patient dies within
a.] Eaitl make Bii 393
half an hour, except that in animals the muscles twitch most
violently, of which wo hear nothing in the human ca
advances, the part swells, becomes discolored
and increasingly painful, and these4 changes extend np the
limb involved, and, reaching the trunk, swell and bloat
side, or the whole body.
This swelling is not inflammatory, but arises from the
gradual effusion of blood, which has lost power to coagulate
and which therefore extends from the broken vessels, at the
seat ot the wound. The later swelling is also due moi
ma than inflammation, although it seems probable thai
in man the tendency to inflammation under venom poisoning
eater than in the lower animals. In dogs bitten, the
local swelling is sometimes slight, sometimes enormous, and
and when cut into is found to depend on a collection of
blood, either fluid or semi-coagulated. The pain which ac-
companies the swelling is excruciating in many cases, and
- not lessen until the part becomes vesicated, loses heat
and falls into gangrene. Ln man this process destroys the
skin only, or the whole of the limb, but in dogs I have seen
no such extensive sloughs, and the skin often escapes, so
that we find only a small opening, and beneath it a cavity
containing the debris of broken-down tissues, mixed with
pus. I suspect that in man the swelling would occur I
rapidly were it not for the constant use of the ligature about
or above the wounded part. If the case be a serious one,
the early constitutional .signs of prostration continue ;
casional vomiting, or at least nausea, is present, frequent,
syncope occurs, and the pulse continues weak and rapid.
In general the bowels are constipated, unless the case be
greatly prolonged, when diarrhoea, may take place as a sequel.
The mind is. in most instances, clear up to the time u{'
death, or at all events it is only confused, excited, or sub-
ject ry delusions, while convulsions seem to be of
extreme rarity in any period of the malady in man. The
tall of temperature in the skin is usually described as an
early symptom of the general weakness, but no accurate
thermometric observation have been made in human cfl
The duration of cases of rattlesnake bite is very various,
although both in dogs and men the recoveries are often
rapid and unex]
- it is impossible for me to dwell in full detail upon the
symptoms of the venom malady, and equally impossib]
cribe the great variety of lesions which may occur, I
392 Rattlesuake Bites. [May,
have thought best to state three typical eases of poisoning
in animals, and two in men. The following arc quoted in
full from the essay so often referred to :
" Eperiment. The dog, a small terrier weighing about
fifteen pounds, was intended to make one of a set of obser-
vations on the value of Bibron's antidote. For this purpose
he was placed in the snake-box, where instantly he was
struck twice by a large snake, both wounds being double
fang marks, and both being in the right flank. On remov-
ing him I observed that from one of the wounds blood was
running in a thin stream. After it had run for some time,
I caught a few drops in a watch-glass, and found that it co-
agulated well. Before I thought fit to use the supposed
antidote, I was called away. Returning at the end of an
hour I found the dog standing with his head pendant, having
just vomited glarily mucus. His pulse was quick and feeble,
his respiration occasionally panting. The hemorrhage had
ceased. Owing to an accident which at this time deprived
me of the supply of Bibron's antidote, which I had pre-
pared, I was unable to employ the animal in the manner
proposed, and not desiring to lose the observation altogether,
I made use of the opportunity in the following way :
" One hour and a half after he was bitten I drew a
drachm of blood from the jugular vein. It clotted perfect-
"Four and a half hours after the bite a drachm of blood
from the same vein coagulated equally well.
" Twenty hours from the time of the poisoning, the dog
was found on his leftside, having passed slimy and bloody
stools in abundance. At intervals he seemed to suffer
much from tenesmus, but was so weak that he stood up
with difficulty. His gums wTere bleeding, a symptom I had
seen before, and his eyes were deeply injected. At this
time about two or three drachms of blood were drawn. It
was very dark, and formed within five minutes a clot of
feeble texture.
" Twenty-seven hours and a half after the time at which
he was bitten, the dog was weaker. His hind legs were
twitching, and the dysentery continued. Three drachms of
blood were drawn as usual, but no clot formed in this speci-
men although it was set aside and carefully watched for
some time. While I was collecting the fluid for observation
the dog suddenly discharged per anum at least four ounces
of dark, grumous blood. At this time I supplied the dog
1861.] Rattlesnake 398
with water, and left him. Fifty-four hours after the bite
he was seen again, and found to have drunk freely of water
and to have passed fewer stools. Up to this date he de-
clined all food.
" From this time he improved rapidly, and took with
trness whatever nutriment was offered^ On the fourth
day his blood again exhibited a clot, although it was very
small and of loose texture. 1 made no further examination
of the blood. The dog lost flesh as he gained strength, and
had profuse suppuration from an abscess in the bitten flank.
At the close of two weeks he was active and well, except
that the wound was still open.
" The case last related is doubly valuable, as pointing out
even in a single instance the time at which the blood be-
came altered, and also as showing, once more, how pro-
found may be this change, and how perfect the recovery.
* Experiment. A dog of mongrel bull-terrier breed,
weighing thirty-one pounds, was lowered into the cage,
where he was struck on the outside of the right hind leg in
the thigh. He drew up the leg when released, and whined
for a few minutes. The wound, which was a double fang
mark, bled a drop or two, and the muscles about it twitch-
ed considerably at intervals for an hour, when this symptom
was obscured by the swelling. His pulse, which was natur-
ally about 145 and irregular, was, at the fifth minute, 140
and regular, respiration 35. At the fifteenth minute lie lay
down much weakened, pulse 1G0 and feeble, respiration 40.
At the twentieth minute the bowels moved loosely, with a
gray discharge, and there seemed to be some tenesmus in
the rectum. Twenty-fifth minute, pupils so far natural and
mobile ; he could stand when urged, but lay down again at
once, and was much weaker. Forty-fifth minute pulse 160,
respiration 45 and laborious. Fifty-fifth minute, loss of
power in the hind legs. Eightieth minute, quick and
labored, and so irregular as to make it impossible longer to
count the heart pulses. The eyes were natural, and follow-
ed motions ; and lie wagged his tail when fondled. At this
time the observation was temporarily interrupted, and, on
its resumption at the third hour, the dog was found dead,
lb- had no foam about his mouth, and probably died
quietly.
"Post-mortem section. The whole muscular and areolar
tissue of the leg and thigh, lnilf way up and down the limb,
was dark with infiltrated blood. About the wound the
394 Rattlesnake Bit [May,
swelling was due bo a mass of blood partially coagulated.
The extravasated blood extended through the limb, and on
the inside it passed halfway up the sartorius and adductors,
and along the Bheath of the vessels to within two inches of
the femora] ring. Nearly an inch of the sheath was clear
of it, but one-half inch below the ring tissues were shaded
with blood, and the same appearance was ^aon around the
ring itself. From this point the extravasation extended
under the peritoneum, into the pelvis, and on to the inner
face of the ilium. The color of the tissues thus stained was
a brilliant scarlet. The abdominal viscera were healthy,
]>t that the mucous membrane of the lower bowels was
somewhat congested. The lungs were sound. The heart
was relaxed, the right side full, the left nearly empty. The
blood on the right side was a little darker than that on the
left ; on both sides and even-where else it was perfectly
fluid and free from clots. Placed in a phial, it remained
fluid until decomposition enusued. Two hours after
death, some of the blood globules found in the heart were
slightly indented ; those taken from the small vessels of the
ear were perfectly normal. At the period of examination,
the muscular and nervous irritability had entirely de-
parted."'
A third observation on a smaller animal, and also drawn
from a like source, will answer my present purpose.
"Experiment. In this instance the animal, a rabbit, was
struck once in the back by a large snake already exhausted
by frequent use. A few minutes after the bite took place,
the rabbit was seized with weakness, gritting of the teeth,
and rapid respiration. It passed urine and feces, and re-
mained feeble during some hours. From this period the
weakness abated somewhat, but the back continued to swell.
On the second day the local signs were improving, but the
animal had passed a very albuminous urine, and a large
amount of blood mixed with The symptoms of
general weakness now increased, the hind legs began to drag,
the motions were uncertain, and the bloody purging grew
worse. The rabbit died on the third day, during my ab-
Bencj
"Post-mortem section. Kigor well developed. The
period of death being uncertain, the irritability of the tissues
was not toted. The wound was surrounded by half an
ounce or more of dark fluid blood. The vessels in the
liborhood were full of a similar fluid, but there was no
L] Rattlesnal
ilar redness, like that of acute inflammation. The
muscles in the track of the bite, which double fang
mark remarkably softened and could be torn with the
utin The brain was highly congested, and there
was a good deal of bloody serum in the cavities of that or-
gan. Similar congestion existed in the spinal canal, and at
several points the white nervous tissue was Btained with
small patches o( blood. The lungs were healthy. The
pericardium was curiously distended with bloody serum.
The heart was contracted and contained hut little blood,
that dark and diffluent. Tl e intestine- were spotted at
intervals with ecchymoses lour to five lines in diameter and
apparently just beneath the serous covering, the cavity of
which contained a little bloody serum. The intestines from
the oesophagus to the rectum were dotted with ecchymoses
and tilled, especially tie gut, with hlood and mucus.
The right kidney was large and absolutely soaked with dark
rluid blood. The left kidney was more healthy. The blad-
der and ureters contained a good deal of bloody urine. How
the rabbit lived so long with such a singular complication
-ions it is difficult to conceive. In most cases
ironic poisoning, some one or two organs may become
of local extravasations, but for extent and character
of lesions this case stands alone in my experience."
Ti. i its given ly our own authors of the cases oi
human poisoning stremely meagre and unsatisfactory
the best reports being those by Sir E. Home* and M.
Pih' ith of whom described cases which took place
in showmen.
{Dr. Homer's case is perhaps one of the best among our
own reports, but like the more curious one given by Sigaud,
the patient was not altogether a healthy subject. I shall
quote Dr. Korni with the statement that the local
vere belter illustrated in the second case quoted,
that by Dr. R. Hark
ol., vol. viii. i,.
ains the follow]
every
a the bite of the
896 Rattlesnake Bites. [May,
\d;iiij Lake, aged about 40, a robust, muscular man,
acting in a laborious capacity, and wbo, from his own ac-
count, was in the habit of drinking from half a pint to a
rattlesnake cures the leprosy (lepre leontine of Alibert) without injury to
the patient. Many facts would seem to show that lepers have been bit-
ten without fatal results, not only by thecoroline viper, by the jararaeasu,
but even by the rattlesnake. Among these tacts may be cited those
which have been collected by Dr. Jacintho Pereira Reis, and by the
deputy, Estevao, Rafael de Carvalho. The firsl is that of a leper of the
district of Rio-das- Velhas, in the province of Minas Geraes, who having
been bitten by a rattlesnake, was cured of his disease in fifteen days. The
second is furnished by a negro slave of the province of Maranhao, who
recovered from his leprosy in a very short time after having been bitten.
>.i. de Lima assures as that being one day in the town of Saint Charles,
province of Carabobo, in Colombia, he observed a man whose face was
covered with a single large cicatrix, which at first he attributed to a burn,
but on inquiry learned that it was the result of a radical cure of a case of
leprosy, by the bite of the rattlesnake. The same observer tells us that
an opinion favorable to this means of cure is entertained throughout the
district of Caracas and Apure, where leprosy is common. These state-
ments which, after all, are but hearsay, induced a leper to resort to this
tearful mode of relief. According t< Dr. Jacintho Rodrigues Pereira Reis,
another leper bad already made this experiment in this capital, (Rio de
Janeiro.) This person had the courage to allow himself to be bitten at
one time by the coraline viper, and at another by the jararaca pre^uicosa.
Each time he was left for (lead, but notwithstanding, gradually revived
without aid. After this he still had the pain to observe that his original
malady continued its fearful progress.
"Case. Mariano Jose Machado, born at Rio Pardo, province of Rio-
Grande do Sud, aged 50, had been for six years afflicted with tubercular
lepra, during 4 years he had resided at the leper hospital, at Rio de
Janeiro. On third of September, he came out, resolute to put to the tot
the bite of the rattlesnake, despite the prudent and wise counsels of divers
physician8, who saw in the means he desired to employ a more than dubi-
ous chance of SUCC6SS, and who also were aware that the patient had not
exhausted all the more available and proper remedies. The patient final-
ly resorted to the Louse of M. Santas, a surgeon, Rue de Vallonga, No.
61, who possessed a rattlesnake."
After describing the appearance and character of the leprosy, and
mentioning those who were present, M. Sigaud continues as follows:
"Marianno Jose Machado, before proceeding, declared that he acted on
his own responsibility, and then having signed a paper to this eifect, put
his bund into the cage and twice 3eized the Berpent. The reptile at first
and finally licked his hand, but, feeling itself pinched with force,
turned and bit him at the metacarpal articulation ofthe little finger and
ring finger. The bite took place at 10 minutes of 12, September 4th. The
patient did not feel the bite, and only knew of it by the remarks of those
around him. His hand wasa little swollen, but painless, and bled some-
what, the pulse and respiration remaining normal, five minutes later,
d a Blighl sensation of cold in the hand, with a little pain
in the palm, which, in a few minutes, increased considerably. 17th
1.] Ttatllesnah
pint of alcoholic liquors daily; on Friday, July 1, 1831,
was in a crowd collected at Fisher's tavern, in Kensington,
to witness a popular exhibition of rattlesnakes, confined in
minute, pain in the wrist. 20th minute, hand swelling. 80th in., pnlse
nger and fuller, mind tranquil. 55th in., sensation of swelling in
sides and back of neck ; size of hand increasing; pain extends to two-
thirds of the forearm. 69th m., general numbness. 1 hour and 20 min.,
general tremor; hyperesthesia, I h. ,,,' m., mind troubled, j>ul>e more
frequent; difficulty in moving the lips; tendency to sleep; choking sensa-
tion; intense pain in the hand and whole arm: hand swelling. 1 h. 45 m..
pain in tongue and pharynx, extending to the stomach; increased pain
and swelling in the bitten hand; feet cold. 2 h. 5 m., difficulty Gf speech,
and a little later, difficulty of swallowing; anxiety; copious sweating
the chest :' h., weakness; nose bleeding; inquietude; pulse %. 3 h. 4
general sweat, and a little after, involuntary groans; pulse 100; greal
pain in the arm; face injected; continual epistaxis. .'5 h. 35 m., the patient
swallowing wine and water readily, and changes his shirt; a red color i-
throughout the body, and a little blood leaks out of one of the pus-
tules under the arm; the color deepens, especially in the bitten limb ;
atrocious pains are felt incessantly in the arm-; the throat seems to be
narrowed, and the breathing becomes difficult. At 4 h. 30 m., pulse 104;
salivation; great heat of body. 5 h. 30 m., pulse 104; torpor; urine abun-
dant: saliva thick; muscular weakness; groans from excessive pain; respi-
ration tranquil; pulse lull: increased, swelling of the bitten hand. 7 h..
'leiiee: awaking, oompls .r pain in the chest, and of a sense
ttstriction in the throat; free and full urination.-; deglutition more
difficult; saliva abundant; continued epistaxis; entire inability to swallow.
8 h.. inquietude; copious urination. ! h. 15 m., profound sleep. 10 h.,
patient took .3 teaspoonfuls infusion ofguaco; refused sugar & water which
were also offered; the epistaxis ii" regular; thelep
tubercles o:i the face and arms are a little depressed, and have erysipelat-
ous look. 1" h. 20 m., made two ounces of clear urine: betl for a
few moment-; pain in the ches i. and pain is now felt in the legs
and feet, which with the bitten hand are -till cold; : liar;
thirst; the patient drinks water; sitting up with facility. At 11 h., I
-poonfulsot Btrong infusion ofguaco. 11 h. 45 in., urinated a col
urine; continues to drink without trouble: pulse 119; arm and hand much
inflamed, with excessive pain. 12 h., sleep: excitement; urination. 12 h.
- face: cries of pain; the patient demands tic last of
of his church, and refuses remedies. Rather later, emission of urine;
jrreat heat in the limbs; the patient take- two do
re half hours; symptoms as before. 14 h., -its up twice, to drink
:: the difficulty of Bwallowing augmenting. 14 b. 13 m.. takes the
-: pulse 110. 15 h. 30 m., mictural 15 h. 45 m..
the remedy; in voluntary movement- of the right hand ami
Left leg. 16 h. 46 m.. tak aful of the remedy; repose; pulse 100;
>f urine during 17th and 18th hour-; respiration being <
21 h. 45 m.. L'reat prostration; convulsive mo jaw and lower
tromil ly urine. 22 h.. pulse quickened and absent at ]on;_r inter
val-: increase of convulsive movement-: diminution of swelling of extremi-
398 Rattlesnake Bites. [May,
a cage. hake being somewhat intoxicated, opened the
door of the cage, and allowed one of the animals to creep
oul and ascend his hare arm ; as it was going up, he caught
the animal somewhat abruptly by the neck, it immediately
struck at him, and inflicted two small wounds. In the evening
he felt some itching about the bend of his arm, and he rubbed
it accordingly, without thinking of the snake. The itching
increasing, he was induced to examine the part, and there
he found a little red spot. The recollection of the rattle-
snake then occurred to him, and he began to bathe the part
in salt water. This not relieving him, he called upon Dr.
Elkinton, at which time the whole extremity was swollen
to neatly double its size, and was very painful. Dr. Elkin-
ton applied a dry cup over the part which had originally
itched, and was bitten; it was near the cephalic vein at the
bend of the arm; scarified cupping was also done in three
or four places in the same region, and some ounces of blood
were extracted by a repetition of the cups; the forearm
was also rubbed with the terehinthinate tincture of canthari-
des, which produced vesication. In the course of the even-
ing, some doses of spirit of hartshorn were administered,
and also some tablcspoonfuls of the expressed juice of plan-
tain (alisma planlago,) and hoarhound, (marubium milgare.)
"The next morning (July?, 1831,) the patient was
brought to the almshouse, about half-past eight o'clock. He
bad vomited in the conveyance, lie was sensible, and
stated that the scarifications had bled much during the
night; they were then bleeding freely. The arm, from
the shoulder and front of the thorax to the fingers, was
swollen to twice its natural size, and was very painful when
moved. His pulse was almost imperceptible and thread-
like, his extremities cold he was disposed to cramp in the
legs, and his debility very great. His respiration was natur-
al and easy. His eyes were muddyand heavy; his face was
somewhat bloated. Feeling the desire to go to stool, he
ties and of the dark color of the skin; deglutition very difficult: breathing
labored; blisters were applied to the thighs, and the infusion of guaco
givi i). 22 h. 50 in., convulsive; motionless; an inject ion of brandy given.
22 h. 55 in., oonvulsions Btopped. 23 !u same condition; an ounce of oil of
1 given by the mouth; was taken with great difficulty. Death, at ::':
h, 30 in. The corpse became livid, and swelled considerably in n few
hours, being mottled with violet-colored spots, The odor was such, next
day. as to forbid an examination post-mortem."
I.] Uattltsnak
was assisted from his bed for that purpose, but was seized,
while on his way, with a general spasm, without foaming at
the mouth: being laid down on the floor of the ward, ii
went off in a few minutes, and lie there had an involuntary
evacuation from the bowels, of a dark billions color. This
occurred before 1 saw him. He received from the resident
physician five grains of ammonia and an ounce and a half
ol. blivarum.
"Sinapisms were also applied to his ankles and breast;
lie was directed to take liquor volat ammonia, 5j ; sp. vin.
dibit, .vs. every two hours, and intermediately use ol. oli-
varum. Si - of the former prescription, he took two doses be-
fore he died, and one of the oil. Another application of
cups over the old scarified parts was made, and the hemorr-
hage from them diminished. The extremity was then en-
veloped in cloths, dipped into ice water.
" The symptoms continued stationary till 11 J a. m., he
then complained of violent pain in the course of the colon,
and on taking his last dose oi' medicine, he said, he felt
sleepy, closed his eyes, and in a few minutes died without
agony or convulsion.
"Dr. Harlan's case. On Monday, the 13th of Septem-
ber, 1830, Daniel Steel, a showman of living animals, in
this city, was severely bitten by a large male rattlesnake, im-
mediately below and on the metacarpal joint of the index
finger of the left hand ; the accident occurred about four
o'clock, p. m., <>n a warm day, while he incautiously seized
the reptile by the neck, not so close to the head but that the
animal was able to turn upon him. Immediately after the
bite, the blood flowed freely from both the fang punctures;
the parts in the immediate vicinity of the punctures became
tumid and livid, notwithstanding the efforts of the patient
at suction with his mouth which faintness obliged him
to relinquish. On my arrival, about half an hour
after the accident. I found him extremely pale 'and faint,
and was informed that he laid fainted several times, the
whole of the back of the hand was puny and tumid, with
infused non-coagulated blood, which appeared to have in-
filtrated from t; els and forced its way through the
cellular tissue; a ligature had been, previously applied on
the wrist ; another was now.placed ^m the arm, the forearm
having already commenced -welling.
'I'; e situation of the wound rendered the use of cups in-
applicable, and the flow of blood was bo rapid as to make
400 Rattlesnake Bites. [May,
their application inexpedient. The punctures were separ-
ated some distance from each other, which rendered it re-
quisite to excise two large portions of integument; the ex-
cisions extending down to the tendinous fascia; the blood,
which flowed freely after the operation, did not appear dis-
posed to coagulate; cold water was now poured on the
wounds in a continued streams, from the mouth of a pitcher,
held at a considerable elevation, and the swollen parts in
the vicinity of the wounds were forcibly passed, in order to
expel the effused blood. The patient again became very
taint, and was held in a recumbent posture. The wounds
were next washed with spirit of hartshorn, several doses of
which were administered internally ; butbeingnow inform-
ed that the patient had drunk freely of sweet oil, the harts-
horn was omitted, until the stomach should be evacuated
by drinking warm water. A poultice of bread and water
was next applied, to encourage the bleeding, and the patient
was put to bed. At ten o'clock p. m., I was sent for in
haste ; the patient was thought, by attendants, to be dying.
The bleeding of the wounds had been extensive, the tume-
faction had extended up to the arm, the inner and inferior
portions of which were discolored by effused blood; the
patient vomited incessantly ; he complained of insatiable
thirst, and drank cold, water cve,ry few minutes ; he had
pain and stricture at the pit of the stomach, great restless-
ness and anxiety, cold skin, with the exception of the
wounded arm, which was verypainful; add to which, there
existed delirium, singultus, difficulty of breathing, and pulse
at the wrist scarcely perceptible. The poultice, banda<
and all ligatures were immediately removed; the back of
the hand was blacker and more swollen, and the skin of
the forearm was hot and tense. As a substitute for the
poultice, and in order to suppress the bleeding, which ap-
peared to endanger the life of the patient by the debility it
occasioned, large Hat pieces of fresh meat, were bound on
the wounds, hand, and forearm. Before this operation was
completed, the patient exclaimed, 'That feels comfortable.'
The indications arising from the present syptoms, were:
1. To allay irritation and thirst.
'2. To arrest the vomiting.
3, To procure sleep, if possible.
4. To excite the sanguineous I the depres-
sing power of the poison, which had so emphatically mani-
fested itself on the >vtein in general.
1861.] Rattlesnake Bit 401
A mustard plaster was directed to be applied to the pit
of the stomach; Bixtydrops of laudanum to be administered
every half hour, until the vomiting should be arrested ; al-
ter which the following bolus, to be taken every two hours
until sleep should he induced :
R. pulv. opii, six grains : puiv. gum. camph., 18 grains ;
pulv. carb. ammonia, 30 grains. M. ft. in three holuses.
Big. as directed.
Of these pills he took three before the effects desired
wxre manifested. On the morning of the second day, his
pulse was raised : the extreme thirst and irritability of the
Btomach were allayed, and re-action of the system in sever-
al respects was manifested; but the tumefaction of the arm
had extended to the shoulder, with broad black streaks up
to the axilla: Btricture at the breast and great local pain
were now the chief complaints. The application of raw
meat was renewed, as it afforded comfort to the patient, and
appeared to reduce the swelling of the hand, and by pres-
sure, had nearly suppressed the hemorrhage. In order to
allay the pain and tension of the whole arm, he was direct-
ed to expose it naked to the fumes of burnt wool, in a con-
venient apparatus, which was attended by BUch marked al-
leviation of symptoms, that the patient himself was desirous
to have the operation frequently repeated, and continued
for two or three days: the swelling always dimishing after
each application ; it caused the arm to perspire profusely,
and covered it with blackish soot impregnated with am-
monia, resulting from the decomposition of the wool. Dur-
ing the intervals, the arm was rubbed with volatile liniment,
raw meat having become offensive from its disposition
to ferment and putrify, was omitted, and flaxseed poultices
substituted: the anodyne boluses were continued in half
d<-es through the day, and the quantity increased at night
t<> produce Bleep. The system again became depressed and
appeared to struggle with the effects of the poison ; as the
patient had been somewhat addicted to intemperance, he
3 allowed milk-punch to support his strength. On the
third day, a greater degree of reaction was obvious; the
bowels wei lated by castor oil; the dose of the
anodyne was diminished, and by carefully nursing the arm,
in less than u week suppuration supervened, and the patient
was able to leave his bed."
ft is much to be regretted that physicians in this country
Bhould have paid so little attention to the venom malady as
26
402 Operations on [May,
only to report cases in which the}- supposed themselves to
have been successful. Hence is it that no good history of
the disease can be made out from their statements, 'and
hence it is that post-mortem examinations of the lesions are
almost unknown there being only three on record, of
which two took place in Europe. The reader need not be
surprised then at the small amount of accurate knowledge
of symptoms placed at the author's disposal: fortunately
the ability to create the disease in animals enabled us in
some measure to fill up this gap.
The information now in possession of the reader will
enable him, I trust, to follow the remarks upon the use of
remedies. A number of these, whether local or constitution-
al, may be readily dimissed, either because their value or
want of value is plain, or else because former observers have
settled their therapeutic position in some conclusive man-
ner.
In treating of this matter, I have been obliged to deny
notice to a host of herbs which enjoy repute in small sections
of our country, and which, in turn, have once possessed and
lost a wider reputation. The reader who calls to mind what
has here been said as to the many fallacies which surround
the observer, will not fail to perceive in the accounts of
these remedies given by authors the reason of their apparent
success and ultimate los3 of favor. North American Medico-
Chirurgical jRevkw.
A Statistical View of Operations on the Tongue, and more es-
pecial!.}/ in reference to their danger from Hemorrhage. By
Otto Just, Jr., M. D., of Zittan.
Dr. Just divides the different methods of removing the
tongue into the following groups : A. Operations with the
knife. 1. Amputation or partial excision. 2. Amputation
bv iiap-incision, or wedge-like incision. 3. Total amputa-
tion or extirpation. B. Ligature. C. Ecrasement lineaire.
I). Cauterization. 1. By the actual cautery, galvanocaustic.
2. By the potential cautery.
A.* Operations with the knife. i. Amputation. Dr.
Just has collected thirty-three cases of partial removal of
the tongue for carcinoma, and sixteen for hypertrophy. To
render the organs more accessible to the knife, as well as to
1861.] The Tongue. 403
ligature the vessels with more facility, it should be fixed
by forceps, or by a stout ligature carried through its entire
thickness. When the incisions have to extend toward the
base of the tongue, on account of the small space we have
to operate in, the procedure becomes more difficult and the
arrest offiemorrhage is not so easy. In these cases more
room can be gained by slitting open the cheek of the affect-
ed bide, or by drawing out the tongue through an aperture
in the neck, or by sawing through the symphysis of the
lower jaw. These me thous will, however, be unnecessary
if the lingual arteries he previously ligated. '2. Wedge-like
excision. Under this head are mentioned 12 cases of can-
cer, one of telangiectasis, and 11 of hypertrophy. 3. Extir-
pation. The author considers this operation justifiable
when the whole of the tongue is diseased. Ofthree cases,
one recovered.
Methods of stopping the hemorrhage. The following
means were emploved for the arrest of hemorrhage, in 62
cases in which it is mentioned : In 20 cases, ligature of the
Is in the wound : in 2, ligature en masse ; in 7, pro-
phylactic ligature of the lingual artery; in 7, the actual
cautery; in 6, ice and cold water ; in 7, suture of the edges
of the wound after dap-incision ; in 3, styptics ; in 1, bleed-
ing spontaneously stopped. Ligature of the arteries in the
wound is the method, and has never been followed,
when employed alone, by secondary hemorrhage. The
actual cautery, cold or styptics should bo restricted to slight
S ;ondary hemorrhage ensued rather frequently
when the actual cautery had been applied. Suture of the
- of the wound is unsafe, for in three-sevenths of the
cases it was followed by secondary bleeding. Ligature of
the lingual artery above the hyoid bone should be resorted
to when the base of the tongue is diseased and the mouth of
large size; two of these cases died of pyaemia.
Period of recovery. The most rapid recoveries took
place when sutures hail been used after excision of a wedge-
shaped piece; in 16 of these cases, 14 united in from 6 to
14 days. After amputation in general, it required from 12
day- to 4 weeks. The cases treated by -awing through the
symphysis took from l to 1 months.
Result Eight of 86 cases terminated fatally, being U|
per cent. In 5 cases death resulted from pyemia.
B. Removal by ligature. Nineteen cases are quoted of
ligature for cancer, and 7 for hypertrophy; and 2 of tic
404 Operations on the longue. [May,
ended fatally, 1 from pyremia, and 1 from poisoning by
the offensive discharge. This method is troublesome and
disgusting from the very fetid discharge, occasioning the
patient great misery. Gangrene commences in about 24
hours after the application of the ligature, and on an aver-
age 11 days are required for the separation of the mass.
The wound left after the detachment of the slough will heal
generally in about 14 days. Hemorrhage occurred in three
instances, twice from too early a separation of the ligature,
and once from the wound made for the passage of the
thread.
C. Amputation by means of ecrasement lineaire. The
ecraseur has answered an excellent purpose in removal of
the tongue, hemorrhage being effectually prevented when
the instrument is made to act slowly. Twenty-one cases
were treated by this method, and all recovered, the period of
convalescence averaging three weeks.
D. Amputation by means of the cautery. 1. By the gal-
vanic cautery. Eight cases come under this head, hemor-
hage attending 4. The vessels required ligation in the
wound twice, and once after previous ligation of the lingual
artery. Secondary hemorrhage followed in about one-third
of the cases. To prevent bleeding, the wire should be thick,
the galvanic current weak, and the wire of the loops should
not be heated beyond a black heat, 2. Extirpation of the
whole tongue by means of the potential cautery. One case
only is given, in which the organ was destroyed by means
of chloride of zinc.
The author has collected 72 cases of cancer of the tongue,
in 49 of which the subjects were males, in 23 females ; the
frequency in males being pretty nearly in the ratio of 5 to 2.
In 63 cases the age is noted, showing that it occurs most
frequently between 40 and 60 years. In 55 cases the seat of
the disease was, in 7, the tip of the tongue ; in 9, the whole
breadth of the organ ; in 19, the right ; and in 20 the left
side. In 72 cases there were 18 recurrences ; but the num-
ber is too small, as many of the cases were published soon
after the operation.
To sum up the different methods of treatment, we find
that the knife is especially adapted for removing small por-
tions near the tip of the organ; the ligature has but one ad-
vantage, that of preventing hemorrhage, and the ecraseur
has shown more favorable results than those of the knife.
Jjondon Medical Review.
1861.] khicum. 405
Further Experiments Relating to the Dieuretic Action of
Ichicum. By William A. Hammond, M. D., Professor
of Anatomy and Physiology in the University of Mary-
land.
In the Proceedings of the Academy of Natural Sciences,
of Philadelphia, for November, 1858, 1 gave the results of a
series of investigations relative to the diuretic properties of
digitalis, juniper, squill, and colchicum, by which it was
shown that the latter alone possesses the power of increas-
ing the amount of organic matter eliminated by the kid-
neys. From this circumstance, the argument was adduced,
that this substance, of all those experimented with, was the
only one that could be regarded as a true depurator of the
blood.
The results obtained by earlier investigators cannot be
regarded as satisfactory, owing to the .faulty manner in
which their analyses were made. The urine was concentrat-
ed by heat, and thus a large quantity of its organic matter
underwent decomposition.
Since the publication of my experiments, Dr. Garrol, of
London has studied the physiological action of colchicum :
but, led away by his theory of the nature of gout, he limited
his researches mainly to the determination of its influence
over the excretion of uric acid, which, as is well known,
forms but a small proportion of the total amount of organic
matter excreted by the kidneys. As the result of his inves-
tigation he announced that colchicum does not increase the
quantity of uric acid contained in the urine, and. that it is
not by any action on the kidneys that the remedy in ques-
tion exerts its curative influence in gout. His result, as
relates to the uric acid, does not, so far as I know, conflict
with mine, as I did not separately determine the quantity
of this substance present ; but his conclusion, that colchi-
cum is not a diuretic in the true sense of the term, is cer-
tainly not borne out by his own experiments, and is direct-
ly at variance with those which I performed.
It was, therefore, obviously necessary that additional in-
tdgationa should be instituted, and I accordingly under-
took the task of furnishing further contribution- to the sub-
ject. Before proceeding to detail these, I desire to call at-
tention to the valuable memoir of Prof. Austin Flint, in the
number of this journal for November, 1800, entitled "Clini-
cal Researches on the Action of Diuretic Remedies." In
406 Colchicwn. [May,
this essay, in addition to much other valuable matter, the
conclusion at which I had arrived relative to the action of
colchicum is confirmed ; Prof. Flint finding it to produce a
marked increase in the amount of solid matter eliminated
by the kidneys, without, however, increasing the quantity
of water of the urine.
The investigations to which the present paper relates
consisted of experiments upon adult males, in a good con-
dition of health. In all cases, the officinal tincture of the
seeds of the colchicum autumnal e was given.
The determinations made were the following:
1st. The quantity of urine.
2d. Its specific gravity.
3d. The total amount of solid matter.
4th. The quantity of inorganic matter.
5th. The quantity of organic matter.
6th. The amount of uric acid.
The quantity of urine was determined in cubic centi-
metres.
The specific gravity was ascertained by means of the
specific gravity bottle and a delicate balance.
The tula! amount of solid matter is given in grammes,
and was determined in the following manner :
Ten cubic centimetres of the urine were evaporated to as
complete dryness as possible in vacuo over sulphuric acid,
and the residue accurately weighed. By simple proportion
the amount of solids in the whole quantity of urine was
easily ascertained.
Although it is impossible to get rid of all the water by
this process, the quantity remaining is extremely small,
and the results obtained are far more accurate than those
obtained by evaporating to dryness in the water-bath, as
generally practiced. No matter how carefully this latter
process is conducted, the loss of urea by decomposition is
always an important item, and involves far more serious
errors than the imperfect declaration by the former pro-
cess.
For the determination of the amount of organic and in-
organic matter separately, the solid residue obtained as
above was mixed with ten or fifteen drops of moderately
strong nitric acid, and gently heated till the mass was well
dried. The heat was then gradually raised till all the car-
lion was consumed, and the mass, in c< nsequence, became
white. It was then cooled in vacuo over sulphuric acid.
1861.] Colchicum. 407
and weighed. The inorganic matter was thus determined,
and the loss showed the proportion of organic substance.
The quantity of uric acid acid was determined by adding
chlorhydric acid to a known volume of urine.
The tirst experiments were instituted upon myself. In
three days immediately preceding their commencement, the
average quantity of urine for each day was 1425 cubic cen-
tum specific gravity 1021.73. The average amount
of solid matter was 64.28 grammes ; of which 30.18 were
inorganic, 34.10 organic substances. The average amount
of uric acid excreted for each period of 24 hours was 0.77
gramme.
Daring the experiments with the colchicum my manner
of living was not materially altered from that of the three
days above referred to : i. e., I ate the same food and took
the same amount of exercise, and endeavored to make all
the collateral circumstances the same, so as to ascertain
as nearly as possible the exact effect produced by the col-
chicum.
First day. Cm this day I took one fluid drachm of the
tincture, three times: at 8 a. m., - p. m., and 10 p. m. The
total quantity of urine excreted was 1685 cubic centimetres,
o^ which the specific gravity was 1021.50. The total amount
of solids was 70.15 grammes, of which 30.90 were represent-
ed by inorganic, and 39.25 by organic matter. The quan-
tity of uric acid was 0.81 gramme.
cond day. One and a half fluid drachms ol the tincture
were taken, as on the previous day. Quantity of urine.
17:20 cubic centimetres: specific gravity. 1020.87; total
solids, 75.29 grammes ; inorganic solids. 32.44 grammes;
organic solids, 42.85 grammes : uric acid, 0.69 gramme.
Third day. Same quantity of colchicum taken ason previ-
ous day. Quantity of urine. 178-1 cubic centimetres ; spe i
fie gravity, 1022.57; total solids, 80. 13 grammes; inorganic
solids, 35.11 grammes ; organic solids, 45.03 grammes; uric
acid. 0.82 gramme.
Fourth day. On this day the quantity of colchicum was
reduced to half a fluid drachm, taken as before. Quantity
of urine. \'Ao cubic centimetres : specific gravity, l<'ii:;.17 :
total solids, 69.23 grammes; inorganic solids, 31.09; or-
ganic solids, ;.;*. 14 gramme- ; uric acid. 0.78 gramme.
Fifth day. On this day the quantity of colchicum was
increased to 1] fluiddrachms of the tincture before mention-
ed. Quantity of urine, 1698 cubic centimetres: specific
408 Colchieum. [May,
gravity, 1023.08; total solids, 70.14 grammes; inorganic
solids, 83.26 grammes ; organic solids, 42.88 grammes ; uric
acid, 0.7(5 grammes. On this day there was some derange-
ment of the genera] health, manifested by increased heat of
shin, fever, and severe abdominal pains. There was also a
little diarrhoea. The experiments were, therefore, discon-
tinued.
From an examination of the results obtained b}T the fore-
going investigation, the effect of the colchieum upon the
urinary excretion cannot fail to be perceived. The conclu-
sions which I think may be formed are:
1st. That the colchieum increases the quantity of urine.
2d. That its increases the total amount of solid matter
eliminated.
3d. That this increase is mainly due to an augmentation
of the organic matter.
4th. That the amount of uric acid does not appear to be
affected.
These conclusions are rendered much more probable from
the fact that on the fourth day, when the quantity of the
tincture of colchieum taken was reduced one-third, the ef-
fect upon the urine was less decidedly marked; and that
when, on the fifth day, it was again augmented to a drachm
and half, the urinary excretion was materially increased in
quantity, and the solds, the organic especially, remarkably
raised in amount. The relation of cause and effect would
therefore appear to exist; and accordingly, it would be
contrary to the principle of sound reasoning to assert that
the change in the composition of the urine was accidental.
It is doubtless true that the urine changes greatly from day
to day, and even from hour to hour; but this fact is due to
the other fact, that we are constantly varying our food, ex-
ercise, &c. When, however, as in the investigation cited
in this paper, these circumstances are tixed, and only one
difference exists between the ordinary mode of living, and
that practiced during the continuance of the experiments,
we arc justified in attributing any change in the urine or
in any other excretions to the influence produced by that
difference.
Tn the next series of experiments the effect is just as di-
rectly shown, though, for reasons beyond my control, they
were not continued as long as was desirable.
The subject of these experiments was a young man 23
ra of age, and weighing about 140 pounds. Before tak-
L] Cbkhkwn. 400
ing the colchicum, I examined bis urine whilst be was
taking a fixed quantity of food and exercise, he being at
the time an attendant in the hospital under my charge. As
the results of these examinations for three consecutive
davs, 1 obtained the following as the averages for each
day: Quantity of urine, 989 cubic centimetres; specific
gravity, 1020.14 : total solids. 51.20 grammes; inorganic
solids.' 22.4.~> : organic solids, 28.75; uric acid, 0.47 gramme.
First day. On this day one drachm oi the tincture of col-
chieum was taken three times. The effect upon the urine
was as follows : Quantity, 1021 cubit centimetres; specific
gravity, l<>24.18; total solids, 64.25 grammes; inorganic
solids, 23.57 grammes : organic solids, 40.68 grammes ; uric
acid, 0.59 gramme.
cond day. One and a half drachms oi the tincture
were taken to-day three times, as previously. Quantity of
iirin cubic centimetres; specific gravity, 1026.11 ;
total solids. 60.25 grammes; inorganic solids, 20.38
grammes; organic solids, 30.87 grammes; uric acid, 0.51
gramme.
On this day diarrhoea was produced. This was of quite a
severe character, and in consequence, the colchicum was
not further continued.
The remarkable effect of the colchicum in increasing the
amount of organic matter excreted is, however, very de-
cidedly shown. This increase is so great as to render the
probability of its being accidental extremely small, and wc
cannot do otherwise than regard it as being directly due to
the infiuence of the eolchienm.
The details of the third case in which the colchicum was
given have been unfortunately mislaid. I am, however,
enabled to Btate with certainty, that the same well-marked
er the amount of organic matter excreted by the
kidi exerted as in ti the particulars of which
have been in full. The experiments were continued for
>ix days, with variable quantities of the tincture.
What are we to infer from these investigations ? It ap-
pears to me that the conclusion must 1>" admitted that col-
li true deputator of the blood, and hence we
have an explanation of its good effects in those blood dis-
>ut and rheumatism.
that no constant effect was produced upon the
quantity of uric acid eliminated, and hem experi-
ments do not conflict with those of Dr. Garrod* We are
410 .Delirium 'Iremens. [May,
not, however, hound to admit the presence of uric acid in
the blood in increased amount during a paroxysm of gout or
rheumatism, is the cause of that paroxysm ; and conse-
quently, because colchicum docs not increase the quantity
of this substance found in the urine, we are not to srfp]
that the remedy in question does not exert its influence
through the kidneys. Am. Med. Monthly,
The following are from Dr. O. C. Gibb's Monthly Sum-
mary :
Delirium Tremens treated with Digitalis. In the American
Medical Times, for December 1st, is the report of two cases
of delirium tremens, treated with large doses of digitalis,
by the advice of Dr. Stephen Smith. In botli cases the
delirium was active at the commencement of treatment.
Tinct. of digitalis was ordered in two-drachm doses, and to
be repeated every two hours until the patient slept. After
the administration of the second dose both patients be-
came quiet, and one of them slept ; the other slept after the
fourth dose. In one case the pulse came down from 108
to 82.
It will be remembered that, some month ago, we recom-
mended veratrum viride in the stage of excitement of de-
lirium tremens. The indications for the use of the digitalis
are based upon the same principles. We cannot help
thinking the veratrum viride is the safer of the two. Qui-
nine and strychnine we would recommend after the stage
of excitement is passed, to give tone to the nervous system.
Though we have never used it, we cannot help thinking
that from 10 to 15 grains ol quinine might be given with
benciit, even in the stage of excitement : we should expect
it, in connection with veratrum, to produce quiet and free
perspiration. We believe that opium has been the death of
many patients suffering from delirium tremens.
Diphtheria. In the American Medical Times, tor Dec.
8th, Dr. Win. M. Turner has an article upon the subject of
diphtheria, and more particularly its treatment. Jlis views
are stated with earn- and his treatment given in de-
tail, and in a tone that gives evidence of a supposition ot'
novelty. His views of its pathology are doubtless correct.
l.] Glycerine and Camp) 411
and bis treatment judicious : l>ut the pathology and treat-
ment arc such as have been for some time advocated by the
first physicians of Europe and this country. But one novel-
ty is mentioned, and that will be alluded to. In regard to
its nature he L think the disease Is owing to malarial
influence, and that it is essentially a blood-poisoning, with
sneracy and breaking down of the vital force."
\\ e will not enter into detail in regard to treatment; it is
thus briefly stated: "Tonic and disinfectant, (the latter in-
ternally and topically,) all combined with rich diet. Best
.! disinfectant, in form of gargle, Labarraque's solution
,ua pura, or any gargle in which, with other ingredi-
ents, a disinfectant bears a large proportion." The novelty
to which we have referred, and because of which we have
referred to this paper, is in regard to local means. lie
Bays, *! studiously avoid probangs ; 1 look upon them as
instruments of torture and of death. I know I have seen
lich died from the constant mopping to which the
throat was Bubje
Among the local means employed, the following is well
"Equal parts of ol. olivse and spir. terebinth," *
be applied with a soft rag, and touched very
gently.'" In addition, a flannel irated with ol. tere-
binth lied to the neck externally.
-in tiie Savan-
nah Journal of Medicine, for Xovember, Professor Juriah
Han n article upon the influence of remedial agents
in a: etion of milk in the human female. In
Madonna, he says, he has u<ed it often and per-
ringly; and over milk secretion, he says:
"In this, I have been invariably disappointed. In no case
up to my expectations ; indeed, I have never
any beneficial results from its use." Tone isult
have used it fifty
disap-
' premature delivery, where the
cpected,and also where the child
f mature birth, we have commenced
ract
i. and a mammary .
us as the sequel of such When we r< member how
mon such al were wont to be. in such cases, in our
412
Sutures-.
[May,
practice, anterior to the use of belladonna, we cannot think
this different result is altogether accidental.
Prof. Harris prefers, and speaks highly of, a saturated so-
lution of camphor in glycerine. With this he lubricates
the surface of the gland, and covers the same with a flannel
cloth moistened with the same 5 the application to be made
at least three times a day. lie regards it equally efficacious
in sore nipples: though, for this purpose, he usually adds
four grains of tannin to the ounce of the mixture.
Silver Sutures, In the American Medical Times, for
December 15th, Dr. T. C. Moffatt has the following remarks
upon silver sutures : " For three years past I have used
nothing else in operations of every kind where sutures have
been required. In all amputations, from that of the thigh
to the fingers, I have almost invariably employed the silver
suture alone. Its advantages are manifold and palpable;
indeed, I can heartily subscribe to all that an enthusiastic
friend has said of them, so far as my experience will war-
rant me in saying anything, at all. My custom is, in large
amputations, to put in so many of them as perfectly to co-
aptate the flags, and to leave them in as long as they sub-
serve any useful purpose. They may be allowed to remain
for an indefinite period, without the risk of exciting undue
inflammation, or even irritation. I have often left them in
until after the stumps had entirely healed, without occasion-
ing inconvenience of any kind. They always hold the
parts in more perfect apposition than silk can do, for the
reason that they do not appear to cause any suppuration at
all."
As connected with this subject, we would refer to a paper
by Dr. John Swinburne in the Medical and Surgical Re-
porter for December 8th. He there recommends as a uni-
versal substitute for all forms of sutures, to be applied upon
the surface of the body, the common entomology pins. lie
says: "The introduction of small entomology pins is attend-
ed' with but little pain in comparison with that produced by
the passage of a needle and thread. The points are 80
carefully prepared and the instrument so perfect that
patients declare the pain to be much less than that accom-
panying the drawing through the thread, even after the
needle has perforated the skin. By the use of those, the
edges of a wound can be approximated in the nicest pos-
manner by means of the thread as used in ordinary
1861.] Varusasi Vans oftfu Leg. 413
hare-lip operations, so that union by the first intention
is more Btire to follow than in any case of simple interrupt-
ed or even quilled sutures. This pin, from its tenderness
and pliancy, will bond and accommodate itself to the parts,
thus doing away with the chief objection to the use of the
stiti' common pin." He says further: "I have used the
silver wire a long time, and believe that the encomia pag
upon it are deserved ; but that it is, on the whole, unequal
in value to, and not BO worthy of employment, as the pin,
will he evident from a tabular comparison :
Silver Wire.
1. Expensive and difficult to obtain.
*J. Pain and difficulty in introducing.
S. Danger of tearing soft and tender skin in the process
of twisting.
4. The interstices between the sutures have to be sup-
plied by adhesive plaster, &c.
Pin Suture.
1. Cheap; 75 cents per thousand.
2. Less painful, and easily introduced.
3. The most delicate skin is in no danger of being lacer-
ated.
4. The edges of the wound are completely covered by the
thread through its whole extent.''
Entomology pins were, perhaps, firsl used by Prof. Alden
March, of Albany (see Transactions of the Medical Society
of the State of New York, for 1855.) Prof. March, how-
ever, only used them as hare-lip pins. This priority of use
by no means detracts from the honor due to J>r. Swinburne,
who recommends them as universal sutures.
of the Leg. The treatment of this trouble-
some affection is a matter of interest, and more particularly
s> because surgeons of equal eminence differ in regard to
it. We quote a lew opinions that have fallen under our ob-
servation during the last month. In the American Medical
Times, for December 1st, Prof. A. ('. Pos1 makes the fol-
lowing remarks: "The treatment of varicose veins is palli-
ative or radical. The radical treatment consists in obliter-
ation of the diseased v. ,d the process is always at-
tended with more or less danger to life ; it should theref
her- . _ avated cases. The palliative treatment
consists in giving a uniform support to the limb by means
ot bandage-, or of elastic laced stockin. We have pre-
414 Varicose Veins of the Leg. [May,
viously referred to the radical treatment of varicose veins by
subcutaneous application of the metallic ligature, as prac-
ticed by Dr. 1i. J. Levis. En a private letter to us, Dr.
Levis says his method of cure "in always efficient, and is
absolutely safe." [n the American Medical Times, for
December 15th, Dr. T. C. Moffatt has a lew remarks upon
the treatment of this affection by injection into the diseased
vein. We quote one case in illustration. The case referred
to was an unusually bad one. Dr. Maffatt says: "Placing
a tourniquet upon this (themostprominently enlarged vein)
above, and making pressure below, so as to isolate about
two inches of the vein, I threw into it eight drops of the
persulphuret of iron diluted with as much water. (Squibb.)
The instrument used was the syringe commonly employed
for injecting morphia into the cellular tissue. After a few
minutes the pressure was removed, and a hard plug re-
mained; the blood coagulated almost instantly. The in-
flammation which followed was not immoderate. Cooling
anodyne lotions were applied, and subsequently lead poul-
tices. A very slight amount of suppuration resulted, and
in just three weeks the limb was perfectly cured."
Bearing upon this point, Prof. E. 8. Cooper, in the Octo-
ber number of the San Francisco Medical Press, has a few
remarks. He has not much confidence in the treatment by
injections of Monsel's salt. That the injection will produce
an immediate clot, he does not doubt ; but this clot will ar-
rest the undecarbonized blood in its way back to the heart,
and this arrested blood will become a great source of irri-
tation. He says. "After trying the various methods of treat-
ing varicose veins of the lower extremeties, we are convinced
that there is none like that of free incisions, followed by
keeping the wound open until granulations begin to till up
the incision, in the mean time keeping a roller as tightly
upon the limb as the patient can conveniently bear, com-
mencing its application at the foot. By this means, blood
is prevented from entering the veins to any considerable
extent."
Besides the objections to the injections above stated he
says : "We do not believe that even a very small quantity
of Monsel's salt can be introduced into a blood-vessel, with-
out risk of fatal consequences."
1861.] Lectures on Diphtheria. 41f>
Lecture* hfhcri'i. \ Eqyptian Disease.) Delivered at
L'Hotel Dieu9 i By M. Trousseau,
entlemen: For several years the reports sent to the
demy of Medicine, the communications addressed to
various scientific journals, have indicated that fatal epidem-
ics of diphtheria prevailed in different parts of France, in-
vading' all departments ; those of the south, as well as those
of the north, of the west, and of the east. These epidemics
also prevail abroad, in England, where for sixty years it
has hardly been known ; in America, in Germany, and in
the Spanish Peninsula. The attention of the public, as
well as of physicians, is more than ever aroused in relation
to this dreadful calamity. The cases which have lately in-
creased in my service afford me the opportunity of giving
you my ideas upon this important subject, and it is my
duty to communicate them to you. I shall, then, in a series
of lectures, consider this disease, one of the most serious
which affect humanity. I do not intend to exhaust the
subject, promising some day to write a treatise upon diph-
theria. I shall, therefore, take up only the most practical
points, illustrating them, as far as possible, by the patients
we shall see together. Do not expect, gentlemen, a resume
of the numerous observations which, have been made under
your eyes, hi making use of them, in sustaining my pro-
positions by the experience of my confreres, and that of dif-
ferent authors who have written upon the subject, I shall
be chary of long histories, citing only what is necessary to
make everything I say clear and comprehensive to you. I
shall also insist, .gentlemen, upon the necessity of a treat-
ment the utility of which is to-day questioned. I shall
oppose that deplorable tendency among observers of the
highest order to leave the true road, which has been pe
vered up to this time.
Diphtheria is a specific disease, par excellence, contagious
in its nature, displaying itself upon the mucous membranes
and the skin, and presenting the same characteristics in
both places. I say, that it shows itself upon the skin and
mucous membranes, because, in fact, diphtheria has this m
common with certain specific and contagious diseases
eruptive f e philis ; with this difference, however,
that it affects the external teguments only when it is denu-
ded of its epidermis. Still, the disease which we are about
to study shows a marked preference for the pharynx, for
the air-, j, the larynx especially, constituting the af-
41G Lectures on Diphtheria. [May,
fections commonly known under the denominations o
malignant, false membranous angina, otherwise designated
gangrenous sore throat, suffocating angina, and now more
particularly called croup, when the angina seizes upon the
larynx. Diphtheria is frequently observed to attack the
nasal mucous membrane, the buccal mucous membrane,
the vagina, the prepuce, the glans penis. Of all the differ-
ent forms, whether pharyngeal, laryngeaul, nasal, buccal,
vaginal, anal, or cutaneous, the first is by far the most
common. In certain epidemics, it is this form it almost
exclusively assumes, destroying those affected, by its exten-
sion to the larynx and trachea, by croup, in a very different
manner from malignant diphtheria, which kills by a kind
<>f general poisoning like septic and pestilential diseases.
To this first form the attention has always been more par-
ticularly drawn, because it is the most common ; it is this
which has been described by the older writers, and which
served as a type for the treatise on diphtheria by M. Bre-
tonneau ; it is with this that we shall commence the study
we are about to undertake.
Diphtheritic Angina and Croup. (Pharyngeal and Lar-
yngeal Diphtheria.)
A young boy, four years old, in excellent health, was
suddenly taken with symptoms in the throat, which at first
were so slight that they did not alarm his family. After a
day or two, it was noticed that he grew pale : that he was
quieter than usual, and remained indifferent to his ordinary
playthings. lie coughed a little, but had no fever, and
although his appetite was not as good as usual, lie still sat
up all day. Accident alone revealed the disease with which
lie was attacked. The family physician, who had been
called to see another infant affected with epileptiform ver-
tigo, was casually consulted for the boy. lie was struck
with the pallor of the skin, and perceived a slight swelling
in the submaxillary region. Thus, having ascertained the
existence of tumefied ganglions, he examined the throat,
and found the pharynx and the tonsils quite red, while the
latter were increased in size, and one of them, the right,
was covered with a quite thick grayish membrane. He
immediately decided that the case was one of diphtheritic
angina, and acting upon this belief, he instantly cauterized
the diseased part with the caustic nitrate of silver, taking
care to detach the false membrane by means of the nitrate.
1861.] hares on Diphtheria, 417
The cauterization was repeated the same evening, and the
next day both morning and evening, and in the interval
between the cauterizations he made, or had made, several
insufflations of the powder of alum. The child was well
fed, according to the express instructions of the physician,
and took, besides, a tonic mixture, the base of which was
the wine of cinchona. The disease was arrested, but the
general pallor continued for some time, and a paralysis of
the veil of the palate succeeded. The child was taken into
the country, returning at the end of six weeks in perfect
health.
This, gentlemen, is an example of pharyngeal diphtherit-
ic angina. The insidious maimer in which the disease began,
the mildness of the general symptoms, the absence of fever
at the time the physician ascertained the condition of the
patient, the soberness of the child, the pallor of the skin,
the tumefaction of the submaxillary ganglions, and finally,
the presence upon the right tonsil of the characteristic false
membrane, abundantly sustain the diagnosis. The para-
- of the veil of the palate, which occurred a few days
after, also confirms it, and I have no doubt the energetic
treatment adopted in the early stages cut short the disease,
which might have extended by degrees, and having invaded
the larynx, would have produced croup.
Pharyngeal diphtheritic angina is ob'served at all seasons,
in all climates. It is not without a certain degree of aston-
ishment that I somewhere read that, this disease was seen
more especially in northern countries, in cold and moist
climates, and that it was almest unknown in the south of
France and Italy. Whoever advanced this singular asser-
tion," must have had a very slight knowledge of the history
of medicine, not to know that the cisease described by Ar-
18, and which was none other than a pseudo-membra-
nous angina, was endemic in Egypl and Syria, whence the
name ot Egyptian Ulcer and Syrian Ulcer, which was given
to it at an epoch contemporaneous with Homer rather than
Hippocrates, according to M. Bretonneau, or not to know
that Carnevale, Nbla and Bgambati have given to us histo-
Inopp this proposition, we recollect thai an author of the
last century, Wedel, has said, that diphtheritic angina, which he called
'lis contagiosa, was more frequent in Italy than in the north
of Europe. --In Italia frequenMor quam "]>>/</ Boreale* magU Ehtropaos."
De Morb. Iitfant., cap. 20, page 77.
418 Lectures on Diphtheria. [Ma
ries of epidemics of the morbus strangulatorius which reign(
in Italy at the commencement of the 17th century; whi
Villareal, Fontecha, Nunez, Ilercra de Heredia, Mercatu
and Tamajo ohserved it at the same time in Spain. At th
time we see that these same sore throats prevail throughoi
all France, as I have already said. It would seem that 3
the same latitude pharyngo-tracheal diphtheria becom<
developed at the time that catarrhal affections are mo
common.
Diphtheria spares no age; still, it principally attack
young subjects, and ordinarily those between the ages c
three to five and six years.
It commences by a greater or less redness of the pha
ynx, by a swelling of the tonsils, most usually of one 011I3
upon this is soon seen to appear a very sharply circun
scribed whitish spot, at first formed by a layer resemblin
coagulated, semi-transparent mucus, which becomes thiol
er, and very rapidly takes on a membraniform consistenci
This exudation, when first formed, is easily detached froi
the mucous membrane, to which it adheres only by ver
fine filaments, which penetrate the muciparous follicles.
The mucous membrane underneath is perfectly healthy
with the exception of the destruction of the epithelium
and if sometimes it appears furrowed, it is, because aroun
the exudation it is swollen, and forms, by this means,
kind of depression. Ulceration is the exception. Gene]
ally, I repeat the mucous membrane is healthy, or at leas
presents no alteration beyond an increase of vascularity, fo
upon detaching the false membrane with care, it can be r(
moved without being followed by the least sign of blooc
By means of the microscope, the epithelium of the mucou
membrane, with its vibrating cilia, may often be seen upo
its adhering surface.
After a few hours the pseudo-membrane, convex at it
centre, thin at its edges, has increased ; it now covers a'
most the whole tonsil, is adherent at the points where i
first appeared, and has taken on a yellowish-white coloi
This color may vary from a yellowish-white to a deep ye
low, to a gray, or even to a black. Then the veil of th
palate usually commences to be inflamed, the uvula swells
and after a few hours more, or a day, the side of the uvul
corresponding to the tonsil which is covered with a fals
membrane becomes covered with an exudation of the sam
color. Frequently, within the space of twenty-four c
1861.] iwres on Diphtheria, 419
thirty-six hours, the entire uvula is enveloped like the fin-
ger of a glove. At the same time, a spot of the Bame nature
appears upon the other tonsil, which is soon entirely cov-
ered by it. The bottom of the pharynx beginning to be
lined upon both sides, long, narrow. Longitudinal streaks
of a deep red are sometimes seen, in the midst of which art'
formed lines of concrete mi unetimes membranous
patches, which finally unite with each other. At this time,
if the child he docile, and can be easily examined, by press-
ing down the tongue, the uvula, both pillars of the veil of
the palate, both tonsils, and the bottom of the pharynx will
be found completely covered with the coating I have just
described. Portions oi% these false membranes can be de-
tached by means of a pair of forceps; we have removed
some in this manner, which, having enveloped the uvula,
had the form of a sewing thimble.
Generally, from the commencement, the lymphatic gang-
at the angle of the jaw, those necessarily which cor-
respond to the tonsil first attacked, are engorged. This,
gentlemen, is an almost invariable symptom, which is not
absent once in ten times. Its impc rtance is then consider-
able, so much the more for the reason, that in ordinary an-
gina, a disease usually of no serio .^ness, but which might
nfounded with the disease of which we are speaking,
this ganglionar;/ incut is g nerally absent ; or if it
be present, it is in a much less degree than in pharyngeal
diphtheria.
On the invasion of the die fever is high, but it
diminishes after the second day, and entirely subsides the
.lowing day. or tie- day after; the patient feels only a
slight m ridenced by a desire to be at rest; a sense
of feebleness ; and as the only thing complained of is a dif-
ficulty often very slight, in deglutition, the beginning of the
liso:t ; usually alarming.
Left to itself, it remains for three, four, five, or six days
limited to the pharynx; the older the person, the longer
>d of development, the longer it takes for the (lis-
to invade progressively the parts within sight. If it
that false membranes form more rapidly in in-
fants than in the adult, it is, perhaps, because the blood of
former is richer in plastic materials than the latter. It
I always v that in children of three, lour, five, and
ix years, the two tonsils and the posterior part of the phar-
ynx can ered with diphtheritic concretions within
420 Lectures on Diphtheria. [Mi
thirty-six to forty-eight hours ; in the adult, and parti*
larly in old persons, five, six, seven, and eight days p:
before all the parts are completely covered.
In patients whose pharynx can be well examined, t
false membrane may be seen increasing each day by t
addition of new layers which are formed underneath th(
first developed. These different layers take on a stratifi
arrangement. The most superficial become softened, a
are easily torn ; altered in their color by the food, the drir
the matters vomited, the medicines taken by the patiej
by blood from the pharynx or posterior nares, these me
brancs become grayish, black, and resemble the detritus
gangrene. The resemblance is the greater, from the fi
that, in these conditions, the false membranes putrefy a
exhale a very repugnant foetid odor. This was the ca
you may recollect, with the young girl twelve years old,
recently had under our observation in the ward St. B
nard. Her breath had an insupportable gangrenous od
and when we removed the detritus which covered the t<
nils and the veil of the palate, by means of a pledget
charpie, we found it to be composed of a grayish matt
which was very like the detritus of gangrene. And yel
was not, for when the diseased surfaces were afterwai
cleaned, the mucous membranes, but a short time bef<
covered with false membranes, appeared red, hardly ex<
riated, but showing no traces of gangrene.
This appearance of gangrene which the diphtheritic p:
duction assumes, is a point sufficiently important to be cc
sidered more particularly. It explains to us how, for a lo
time, diphtheritic angina was confounded with gangrene
angina, and gave rise to the names of angina, of gangrem
sore throat ; names which some physicians use even at tl
time.
If we study diphtheritic angina in the infant and co
pare it with what occurs in the adult, we shall observe tl
the disease almost never presents the gangrenous aspe
which, on the contrary, is very frequently seen in the adi
Should we therefore conclude that gangrene is really p
sent in diphtheria of the adult? No ! These are only
pearances of gangrene, and do not exist in the adult a
more than in the child; there is no true gangrene, unl
in exceptionally rare cases ; so rare, that, in the wh
course of my medical career, I have met only three exa
pies of it. I admit it is very difficult not to believe in
$61.] fures on Diphtheria. 421
ven now, although I have so seldom witnessed gangrene
these cases, although I know when a recovery has taken
ace, or when, at the autopsy, with the pathological speci-
ens in my hand, I discover no traces of sphacelus upon
e tonsils or the mucous membranes, finding only some
ght excoriations, and in many cases not even these; not-
ithstanding this, I cannot at first, even now, disabuse
keif of the idea that gangrene exists. In the young girl
the ward St. Bernard, I was sure that there was no gan-
ene, and you also were convinced of it; still, the extreme
kidity of the breath, that grayish secretion which covered
)th tonsils, could not fail to suggest to our minds a mor-
ication of the mucous membrane, a sphacelus of the sub-
cent cellular tissue, or even a deeper destruction of the
5sues.
These are the reasons why diphtheritic angina has been
nfounded with gangrenous angina; why certain physi-
;11 confound these two diseases; and why, in the
scrip tion of epidemics of croupal angina, you still often
ar of gangrenous sore throat, even when they were only
llicular or pseudo-membranous affections.
One word more, relative to the mode of circumscription
the membranous exudations at the points upon which
ey are developed. Sometimes they are surrounded by a
lall bright-red line ; sometimes they do not appear limi-
i; and. as I remarked in the beginning of my lecture, the
Ise membranous concretion, growing thinner at its edges,
reads out over the surrounding parts. In such a case, the
dency to spread is greater and more to be feared than
former.
If pharyngeal diphtheritis, left to itself, does sometimes
come limited to the pharynx, examples of which have
en cited by M. T>retonneau, and which every one may
serve in certain epidemics, it usually, however, continues
; .In some eases it passes into the oesophagus,
d reaches even to the cardiac orifice. The distinguished
in of Tours lias reported two instances of this char-
ter, and Borsieri has instanced others; but almost inva-
-bly it invades the larynx and trachea, and constitutes
its ordinary course, the most common ter-
nation of diphtheria. In fact, we see more persons al-
ied with this disease die of croup, than from those malig-
nt anginas, of which I shall speak hereafter, which <!<-
oy life in the manner of septic disea-
422 Diphtheria. [May
The propagation of the diphtheritic affection to the laryru
was noticed a long time ago. Aretseus speaks of it in hii
chapter, I)e tcnsillarum utceribus, where you will find tin
first mention we have of membranous agina, which In
designated under the name of ulcera pestifera, repeating the
names of Egyptian, Syrian ulcer, by which it had been call
cd. Read the histories of epidemics recorded in the annali
ofmediciue, and you will see that the propagation of tin
disease to the larynx was perfectly well known, and that i
particularly occupied the attention of physicians. "What-
ever name was given to it, the laryngotracheal affection u
indicated as the cause of death, and hardly anywhere if
there any mention of the malignant form of which I have
just spoken.
I repeat, then, that persons affected with laryngeal diph
theria die from croup ; and I speak not only of that disease
which is developed in isolated cases of sporadic diphtheria
but also of that which takes place in a great number of case:
during an epidemic.
When, then, arc the symptoms of that affection called h\
the Spaniard and Italians of the 17th contury, garrotillo
male in carina; by their physicians, moeiis strangulator ins ,
by the Americans, at h.-^ close of the last century, suffocat
ing angina, and which we to-day recognize as croup, a name
given to it by the Scotch ? Am. Med. Monthly.
Idlic ri a.
The subject of diphtheria receives more than usual atten-
tion in the journals for , of which the present article
is a summary. Risking the charge of repetition, we shall
endeavor to give, in ai few words as possible, the practical
import of the papers that have come under observation. In
the Maryland and Virginia Medical Journal, for the montli
above indicated, Dr. [. W. ['Anson, has an article on thic
subject. In the treatment, unmends, first, an emetic
of salt and water, or ipecacu nha, to be repeated as occ;.
may require, to clear the throat. After the cinesis, he would
move tli'' bowels with oil and turpentine, and subsequently
keep them open with rhubarb, should medicine be required
fortius end. k'A stimulating and supporting plan of treat-
ment should now be adopted. rucIi as camphor and quinine
1 to 5 grains each." "Capsicum, used in
i
!.] Diphtheria. 423
combination with the powder of camphor and quinine, will
und an excellent remedy." In cases complicated with
nenmonia, ;> the main reliance must be placed in repeated
ering, both in front and behind the chest. At this stage
advantage will be derived from the use of spirits of
turpentine, together with simulating expectorants, as decoc-
tion of seneca and syrup of squills."
- local remedies, he recommends nitrate of silver, 20
i\ to the ounce of water, to be applied only once a day.
We have ordered a saturated solution of common talt to be
thus used, and to be repeated every hour or two, wish decided
relief. It clears the mouth and throat of the adhesive and
nauseous secretion better than anything else we have tried.
After the removal of the diphtheritic membrane with a strong
solution <f nitrate of silver, the salt and water, thus applied,
will prevent any extensive subsequent formation. In pneu-
ic complications, he would advise mercury until the
gums become tender.
He says he lias treated over thirty cases, with but two
deaths. We should consider the mercurials objectionable,
but then his experience is satisfactory. He says nothing of
whisky as a stimulant. In our experience, as has been stated
in former summaries, we have regarded it of the first impor-
tance. In about twenty cases, we have had two deaths, and
both . t' these refused the stimulant. All the others expressed
a confidence that the milk punch or egg-nogg was staying
them up against the excessive feeling of prostration.
In the Berkshire Medical Journal, for January, Prof. Win.
H. Thayer has an article of thirty-eight pages upon this sub-
ject. He shows a thorough acquaintance with the literature
of diphtheria, and enters quite fully into its history. We
shall deal only with his treatment, which is not dissimilar
from that previously advised by other writers. 11^ Bays,
phtheria is clearly not a self-limited disease; and in order
to make treatment effectual, it mast be begun at an early
Of local means, he gives his preference to the nitrate
! that in nearly or quite full strength. k> I prefer
to apply the stick to the exudation, and a solution of ii dr. t<>
surrounding mucous membrane for the early ap-
plications, to be omitted or diminished as the disease begins
A variety of chlorinated mixtures arc Bpoken of,
lapted to the milder cases, or the convalescing Bta
ral treatment, muriated tincture of iron, chlorafe
quinine, turpentine, and alcoholic stimulants, are
mmeuded. "Chlorate of potash has an advantage over
424 Dtphtneria. [May?
the tincture of the sesquichloride of iron, as an alkali in its
resolvent effect on the fibrin of the blood, and hence a proba-
bility of its diminishing and arresting the exudation.'' In our
experience, this statement has hardly been borne out. AVe
think we have seen the most positive results from the tincture
of iron. "Besides quinine, chlorine, or turpentine, diphtheria
requires alcoholic stimulants. The flagging powers of life
need frequently repeated excitants to sustain them against the
steadily depressing influence of the disease." these, he
thinks, can usually be commenced with as early as the second
or third day. We have frequently commenced with them on
the first manifestation of the disease, and are confident that
we have seen those severe neuralgic pains, so common in the
outset, yield to a full do? e of hot sling. The absence of sur-
face heat he regards as an indication for the commencement
of the stimulant, and adds, " but we might, without hesitation,
say that the presence of the disease is alone a sufficient
indication."
In one regard Prof. Thayer and Dr. I' Anson are at variance.
Prof. Thayer says, " I cannot avoid thinking it especially ill-
judged to mercuralize v patient if wise at any stage at the
somewhat advanced period at which the croupal symptoms
usually appear in diphtheria, as the peculiar adynamic condi-
tion also is approaching, if not already begun, which must be
hastened and aggravated by a mercurial course." As in
typUoid fever, so in diphtheria, he thinks a tongue dry and
black requires turpentine, and not calomel. We have used
the turpentine in about half of our cases, in all that were
protracted, and at any time gave a dry and red, or black
tongue, and always with an e idence of improvement.
In an article of twenty pages upon diphtheria, by Dr. C.
II. Cleveland, the subject is discussed with some novel views.
As his treatment is somewhat different from any previously
given, we subjoin it in substance. Dr. Cleveland thinks
alhalien are of the first importance, and recommends the bi-
carbonate of soda, to be given in from one to ten grains, ac-
cording to the age of the patient, every half hour, or every
hour. As a local application, he prefers a strong solution of
common salt. We make one quotation: "A gargle, com-
posed of a very Btrong solution of common table salt, if the
pellicle is not ycl formed, will produce an osmotic flow of
fluids through the epithelium, and thus cause the fauces and
throat to be too moist to allow a pellicle to be formed. It
taken early in the attack, repeated very often, at the same
time that plenty of soda is taken internally, most cases of
I
L861.] 425
diphtheria will pass off without any appearance of the mem-
branous exudation. Without doubt, By thus preventing the
formation of a pellicle, many cases of genuine diphtheria
have been made to remain so mild in their action, that even
rvant physicians have been led to suppose the
Lse was simply an ordinary pharyngitis."
In the Nashville Journal of Medicine and Surgery, for
January, Dr. J. 0. Calhoun lias a short article on this subject.
He says that last fall the disease prevailed in an aggravated
form. The first few cases he treated "in the usual manner,
with alterative d mercury, an occasional emetic, and
nitrate of silver to the throat," and all died. (Dr. Calhoun
should know that this is not the usual treatment.) " But
Bince we have adopted the following treatment, not a single
has terminated fatally, so far as I have heard :
It. Two table-spoonsful of fresh tar.
The yolk of an egg.
Spread on a piece of coarse cloth, cover it with a piece
of old muslin, and apply to the throat. This plaster should
be removed once in eight hours, li the subject is an adult,
direct him to use a strong decoction of cayenne as a gargle,
every two hour-. For children a weaker decoction should bo
used, and applied to the throat with a mop. This, together
with keeping the bowels in a soluble condition, will as cer-
tainly cure diphtheria, as quinine will arrest intermittent
:*. The efficiency of the above treatment has become so
generally known in this locality, that physicians are seldom
called t<> diphtheria patients."
This statement, in our opinion, is quite too sweeping. We
are not prepared to believe that an external application to the
throat will cure a constitutional disease, of the severity which
diphtheria frequently assumes, with that certainty "'if It which
in the Medical ami Surgical Reporter, for January 5th and
12th, Dr. W. Pepper has lectures npon diphtheria. We sub-
join the more important points of treatment. "1 am in the
habit ing the muriated tincture of iron, in fifteen
a day, and sulphate of quinia in
that fiv all bo taken in the coin-
the ne tin.' . tain the
(1 water, wine whey and porter, and
ration present, 1 employ
itine, the ric (typhoid)
mercury, lie thinks there are
420 . Diphtheria. [May,
some cases of u sthenic character that may be benefitted by
the use of mercury, under certain conditions ; but in adyna-
mic cases, he thinks there is no doubt of its impropriety. He
also uses the chlorate of potash. As to local remedies, he
thinks powdered alum, or borax and sugar, preferable to
nitrate of silver in substance. He thinks there are many
cases, the local symptoms of which might have remained
mild, but lor an aggravation by the use of the nitrate of silver.
He occasionally uses the nitrate of silver, but in weak solution
under twenty grains to the ounce. Where emetics are
indicated, he prefers alum with ipecacuanha.
In the St. Louis Medical and Surgical Journal, for January,
Dr. S. T. Newman has an article upon diphtheria. He con-
cludes his paper with a letter from Dr. J. W. Bright, of
Lexington, Ivy., in which a slight modification from the or-
dinary treatment is advised. Dr. Bright commences the
treatment with a gentle purgative, and afterwards the bowels
are kept soluble by means of oil and turpentine. The mem-
branous exudation he removes with a fine sponge, and applies
a solution of nitrate of silver, 50 grs. to the 5j., or the sulphate
of copper, 3j. to 5j- of water, once a day. For general treat-
ment : "I give the muriate of ammonia in full doses, say, to
a child eight years old and upward, 10 grains every two
hours (in solution), and ten drops of the sesquichloride of
iron in the intermediate hours ; and these are not to be
omitted for thirty-six hours ; then rest four or five hours, and
again give them in like manner. Continue this treatment for
four or five days, according to circumstances."
" The cure should be completed by the uye of tonics ; I have
found beeberine the best. Diet nourishing. I have treated
three hundred and thirty-four cases after this method, without
the loss of one" The result is quite satisfactory.
In the American Medical Times, for January 19th, Dr. E.
W. Spafford has a short article upon the treatment of diph-
theria. He says, " I have lost none to whom I was called
within Ibrty-eight hours after the attack. My first business is
(if it has not been done) to relieve the stomach and bowels of
their morbid contents by the use of a gentle cathartic ; apply
//. iodine to the neck, three times per day, and with a sponge
probang, alternately apply a solution of chlorate of potash and
nitrate of silver to the ulcers in the throat ; sponge the body
with diluted nitro-muriatie acid; give gum water, beef-tea,
wine, quinine and iron, as the case may require. Tonics are
indispensable. If neglected or too sparingly used, alarming
debility may ensue, the surface of the body become colorh
1 .] Diphtheria. 427
muscular power in a very short time lost, and the patient soon
- to breathe.
* 1 have been much gratified at the beneficial results grow-
ing out of the use of mtro-muriat ' \ the surface. It not
only acts as a counter-irritant, but as a tonic. Where I have
had opportunity to use it early in the disease, I have not
witnessed the debility, the flabby, soft condition of the
muscles, or colliquative sweats, which bo often lead us t<> an
unfavorable prognosi
In the American Medical Times, for January 20th, Dr.
Jonathan Kneelaud has an article upon this subject. In
< raondaga and vicinity diphtheria has prevailed somewhat
an epidemic since July last. About eighty cases have
occurred, and A. a deaths. Of these eighty cases, Dr. Knee-
land lias treated seventeen, all of which have recovered. AVe
shall make a few extracts from his treatment, and thus give
what is peculiar. " En giving briefly the treatment I found
. [ would claim no other merit but that of
having somewhat early learned that we must at the onset
ain our patients by specific constitutional remedies, and
much on local treatment. "
The bowels were first emptied, in Dr. KneelaiuFs course,
and then the patient put directly upon the chlorine mixture :
* R. Chlorate of potash, 5ii.
Hydrochloric acid (dil.) 5ij.
Water, Sviij.
sweetened to the taste, giving from a dessert-spoonful to a
large spoonful, according to the age of the patient." To this
nail amount of morphine was added in some cases; and if
muriated tincture of iron was considered advisable, it was
given in connection with this mixture, in which connection he
thinks it is better borne than when given alone. Quinine, in
iders all-important : " In no disease have
ell borne." Like almost eve rver,
Dr. Kneeland found "good broths and food ^( easy assimila-
tive capacity ttial service. He says, "1 have found
nitro-muriatic acid (equal parts of each acid), given in doses
in water, and taken atb . well
borne in patients, who did not bear either the iron or
chlorine mixture well." Alcoholic drinks
in aid ' f quinine, general stimulants and nourishing broth-,
id in some cases. But li wc found that the
:i-eed
better than ardent spin We have more confidence in ap-
428 Diphtheria. [May,
propriate stimulants than anything else in diphtheria. Upon
this subjeet we have frequently expressed our opinion. A
few days since, a gentleman called upon us for advice, in re-
gard to a sore throat and general prostration of the system.
( )n examination, we found the fauces soft, palate and roof of
the mouth presenting that erysipelatous redness peculiar to
the first stage of diphtheria. Ilis business was such as to
render it important that he should keep about. I advised
him to use all the rye whisky that he could and not become
intoxicated; also, to use a saturated solution of potash as a
mouth wash and gargle to the throat. We should have said
that his tongue was swollen, so as to leave the prints of every
tooth upon it, and was heavily furred, and ulcerations had
appeared at various points. My directions were adhered to ; a
pint and a half of whisk}' was used daily, and the patient re-
covered without taking his bed at all. In regard to hard
cider, we have seen many cases of typhoid fever, in which
this stimulant has been almost irresistably craved ; in such
cases, we have always gratified the desire, and good lias al-
ways resulted from it.
As an article of diet, Dr. Kneeland recommends the fol-
lowing : " As an article of diet, remedial, and yet palatable, I
would recommend, where they can be obtained, sour-baked
apples, mixing the tender pulp with sugar, or giving them
alone, if the patient so prefers them. For many years I have
used apples in this way as the diet par excellence in scarlatina;
and how many grateful little ones, nauseated with pap, por-
ridge and panada, have risen up to call me blessed, for the
grateful change to the apple diet !"
As a local treatment, he has no very high opinion of nitrate
of silver; "To prevent the secretion from forming after re-
moval (as it often does), I would use tannin and dried alum,
applied with a soft linen rag, or on the moistened linger, to
parts within reach, and blown into the throat through an
ivory or glass tube; or two or three quills introduced into
each other answer a good purpose ; no harm follows inhaling
this powder, as a short paroxysm oi' cough clears all out
again.1'
The pulverized burnt alum we first saw recommended in
the N. 0. Medical and Surgical Journal, by Dr. Bigelow,
then of Paris. We have used it often, and with satisfactory
results. We prefer it to nitrate of silver. For a gargle, the
loll., wing is my preference, after trying a variety:
1861.] Strangled Hernia. 42!)
R. Hyd. chlo. ammonise, 5jj.
Iffi niuriat., oiv.
Pulv, capsici, ' jj.
Yin. 5ij.
And <>ne and a half pints hot water; cool, and use freely.
If any is swallowed, no harm foil "::" "I
apply externally, over the throat, salt pork, moistened with
turpentine, and <]uiekened with pal. sem. sinapis, or capsi-
cum, it' need be."'
The views, of Dr. Kneeland, in regard to treatment, corre-
spond very well with our own ; we conclude with the follow-
ing paragraph in regard to its nature : u From what I can
gather from the recorded or narrated knowledge of others,
and my own knowledge of the disease as gleaned from a
limited number of cases, I have concluded that diphtheria is
a blood-changing disease, and that lesion of function in the
spinal nerves occurs early in grave cases ; that we would not
wait for sinking, but, if possible, anticipate and prevent it ;
and, finally, that to oxygenate the blood, and rouse and vita-
lize the nervous system, are the leading indications to be
_ht.v American Medical Monthly.
Strangulated Hernia. Chloroform. Unless chloroform be
given to a very free extent, it does not produce perfect re-
laxation of spasmodically contracted muscle, hence in
^ of strangulated hernia it must be given so as to pro-
duce a perfect state of comia, as indicated by stertor. If
this be produced there are but few cases of inguinal hernia
which will not yield to efforts at reduction, if the case is
seen sufricienty early. Success to the same extent cannot
be hoped for infemoral hernia, as statistics show that this
form of heri requires operation 25 per cent, more fre-
quently than inguinal. Mr. T. Byraat, p. 167.
Incontinence oj . In a boy of fourteen, give one-
third of a grain of extract of belladonna twice a di.y in cin-
namon-water, in thofi where the affection issuspe
from weakness or paralysis of the sphincter of the
bladder. Belladonna acts by toning or exciting the gang-
lion, m, and depressing the cerebrospinal system.
Dr. R. Hughes, p. 395.
430 Mitorial [May,
EDITORIAL AND MISCELLANEOUS.
OUR PRESENT NUMBER.
We call attention to the original department of our present issue. The
three short articles here presented arc, each, of much practical value to
the physician. The paper on Tape Worm presents the details of a case
"by a most intelligent patient and his observations, though not those of a
medical man, will he found suggestive and practical. Turpentine, it is
well known, has been long regarded as among our most valuable anthel-
mintics, but heretofore, it has been thought more particularly adapted to
the lumbricoid form of parasites the experience of the two cases re-
ported in our present number, certainly appears to admit its claim as no
less reliable in Tape Worm. The mode of its administration should be
well considered and followed by any of our readers who may wish to ap-
ply the remedy in a similar case.
J)x Bellinger's paper, on the Diagnosis of Early Pregnancy by Rectal
Touch, presents many points of originality and practical value. It can-
not be denied that our means of the certain diagnosis of early pregnancy
are deficient and though Rectal Touch may not present an unquestion-
able criterion, still we are disposed to give great credit to any extension
of our means of determining a matter, often, of so much importance.
Dr. Bellinger deserves the thanks of the profession for this valuable
contribution.
No less valuable than the two foregoing is the communication of Dr
Horace Neeson, on Dislocations of the Plip Joint. Wre forbear extended
observation on his views, in this place, as we have already discussed their
merits in our introductory remarks heading the paper.
We again earnestly call on our correspondents for contributions No
scientific work can be supported and kept valuable except by the joint
labors of both its readers and editors. The South is teeming with
knowledge and experience of the most valuable and practical kind. It
requires but little industry and self-sacrifice to place all this before the
profession and to render what is now but "the property of a few, attain-
able by all." We say, then, to our readers, still let the Southern Medi-
1861.] Miscellaneous. 431
cal and Surgical Journal remain, as it lias ever been, an object of inter-
est to (ill sections, if not for the spirit and vigor of its editorial disquisition g
at least because it furnishes fully and fairly its own quota of experience to
the general fund of American Medicine.
Hypodermic Injections of Atropine and Cutaneous Revulsions
in Sciatica. Hypodermic injections with narcotic fluids do not, as
might have been expected, relieve pain in all cases of neuralgia. "When
the symptoms remain unaltered after such injections, various therapeu-
tical resources are left ; and it would appear in sciatica, for instance
that linear cauterizations with sulphuric acid along the course of the nerve
niay prove very efficacious. This was lately proved by M. Legroux,
physician to the Hotel Dieu of Paris, in two cases, Both patients were
men, aged 35 years. Injections of sulphate of atropine, one grain to
one hundred of water, did not remove the pain, though giving rise to
symptoms of Belladonna poisoning. Sulphuric acid was now applied
by means of a brush rapidly carried from the origin of the sciatic nerve
to the ham, the skin being thus cauterized in a linear direction. The
severe pain caused by the acid not did last long; and the neuralgia gradu-
ally diminished. In the two cases alluded to, several operations were
necessary ; but the complaint was completely subdued in a few days.
London Lancet.
Obstinate Neuralgia. ElcUricity. It is well known that if an
instense current of electricity be applied in the course of a nerve, its
sensory power is benumbed for a time, and the same result follows if the
nerve is the seat of neuralgic pain. After a time the pain returns, but
on repeating the electrisation the recurrence each time at longer and
longer intervals, until finally a cure is effected. Sciatica, lumbar, inter-
costal, crural, and trifacial neuralgia may be thus treated successfully.
Nineteen cases of scatica, many of them old standing and obstinate cases
have been cured by this plan of treatment. M. Becquerel, p. 49.
Atropine Strength of Solution used. When it is wished to di-
late the pupil for ophthalmoscopic investigation, the strength of the so-
lution used should not be more than half a grain of the sulphate to an
ounce of water. This will suffice for the purpose, and the unpleasant
effects of a stronger solution will be avoided. Mr. 11. Walton, p.
Vaginitis. Tannin Ointment. In cases of simple vaginitis, or
superficial inflammation of the neck of the uterus, an excellent local ap-
plication is an ointment composed of tannin and lard. This may be
smeared over a piece of wadding and introduced through a speculum, a
thread being attached to it, so that the patient can remove it herself.
This docs not supersede the use of constitutional remedies as well. Dr.
Foucher, p. 264:
432 t/fa/ieous.
Tetanus. Aconite. It is worth while to try the affect of aconite in
tetanus, as from souk: cases related its employment seems to have been
followed by some amelioration of the symptoms. In one case five
minims of the tincture were given every two hours at first, then increased
to eight minims. The improvements in the symptoms dated from the
employment of the aconite. The patient was well sustained by beef-tea
and brandy. This remedy must be administered very cautiously, how-
ever, as though it certainly is a powerful nervine sedative, it acts much
more powerfully on the heart. Death from aconite usually occurs from
Byneope. It is cumulative in its action. Ed. Lancet, p. 45.
Profuse Moist ruation Quinine. The periodicity of tWb menstrual
process is to be referred for its cause to the ganglionic system of nerves.
There is considerable analogy between each individual menstrual flow
and an attack of ague. Now, when the process occurs too frequently,
every fortnight or three weeks, it may generally be controlled by quinine
(unless owing to severe inflammation of the neck of the womb). The
quinine may be given in doses of two or three grains every night or
every other night, and if nervous symptoms predominate, it may be com-
bined with sedatives, or if anaemia is present, with iron. Dr. E. J.
Tilt, p. 286.
Pulmonary Hemorrhage. In the intercurrent haemoptysis of ph-
thisis, the tincture of larch-bark, in doses of half-a-drachm to a drachm
every second or third hour is a very effectual remedy, succeeding in
some cases when the usual remedies (ipecacuanha, lead, tannin, and gallic
acid) had failed. It is now the remedy principally used in these c
in the wards of St. Vincent's Hospital.
Flooding after Delivery. Inject about half a pint of very cold
water (iced if it can be obtained) into the rectum ; at the same time give
cold brandy and water, with otic drachm of Cnrtis's liquor secali cornuti
in it. Mr. T. Ilubbcrt, p. 244.
Larch Bark is also recommended in cases of purpura, hsematuria, and
metorhagia. The tincture may now be obtained of most respectable
chemists^ Dr. J. M. (J'Fcrrc?l, p. 77.
" Solution of Gold in, the Body. By T. Wordsworth Poole, M.
1). Saving known considerable anxiety caused by the swallowing of
pieces of dentists' gold plates, I was led to make a few trials on animals
with solid mercury and diluted sulphuric acid, given some time after the
gold was swallowed. The gold was rendered brittle and partly dissolved
in the mercury, and the animals seemed to suffer no bad consequen
I hope that by your permitting this suggestion to appear in the Lancet
some one of more experience may undertake the matter, and form a
di terminate method of treatment.''
SOUTHERN
MEDICAL AND SURGICAL JOURNAL.
(XEW SEKIEtf.)
Vol. XVII. AUGUSTA. GEORGIA, JUNE, 1SG1. NO. I!
ORIGINAL AND ECLECTIC.
ARTICLE XIII.
A Lecture upon Tetanus. By L. A. Dugas, M. 1)., Professor
of Surgery in the Medical College of Georgia.
GENTLEMEN: Having studied with you the nature and
treatment of wounds in general and in particular, it remains
for me to direct your attention to a very remarkable affec-
tion which occasionally presents itself as an effect of injuries
apparently trivial in themselves ; I allude to tetanus. This
is a spasmodic affection of some or many of the muscles of
voluntary motion, which usually shows itself between the
nth and tenth days after an injury, and which most
frequently terminates fatally in a few days. Tetanns is said
to be partial or general, according to the number of muscles
implicated, for it may be in its early stages, and sometimes
throughout the whole case, restricted to a xavy small num-
ber of muscles, whereas in other instances it will invade
them extensively. Tetanus isalso said to be idiopathic and
traumatic,
1 have, however, never seen a case I considered strictly
idiopathic. There is occasionally some difficulty in ascer-
taining the seat of the injury, for this is sometimes so trivial
scaped the notice of the patient. Some patients
will also pertinaciously conceal the truth, as I have had oc-
casion to see in two instances in which the injuries had been
BUStained under circumstances that would not be confessed,
but which I fully verified.
28
j
434 Dugas. Lecture on Tetanus. [June,
Most writers speak of tetanus as being either acute or
chronic. This is a distinction I think calculated to mislead
the inexperienced, i fwe carefully study the natural history
of this disease, unmodified by ])erturbating influences, we
will find that while the fatal cases terminate in a few days,
those thai arc successful occupy a much longer time to run
their course. As a general rule, the disease cannot be cut
short by treatment, nor does it ever abruptly give way, if
let alone It may terminate abruptly by death; but
when this does not occur and the disease is allowed to pass
through all its stages to a favorable termination, itprogress-
rradually to its maximum of intensity and declines by
degrees almost imperceptible from day to day, until, at the
end of weeks or even months the last symptom of rigidity
will disappear. What is called chronic tetanus, then, is in
reality nothing but the regular course of the disease when
it does not terminate fatally. It is always a matter of prim-
ary importance to know the course a disease will run when
left to the unaided efforts of nature, for without this know-
ledge we cannot treat it judiciously. Is it not probable that
much of the want of success in the management ot tetanus
is attributable to a neglect of this study ?
This disease is infinitely more common with the African
than with the Caucasian race ; so much so, indeed, that
injuries which excite little or no apprehension in a white
person, are never considered without danger if sustained
by a black and the danger lessens in a direct ratio with
the infusion of the Caucasian element into the constitution
of the individual. Among our domestic animals the horse
is exceedingly liable to tins affection, especially when prick-
ed in the foot.
The scat of injury seems to exert a decided influence in
the development of tetanus, for it unquestionably oftener
follows wounds of the extremities, especially the foot and
hand than those o\' the trunk. Wounds of the external ear
and of the occipital region are also thought to be peculiarly
apt to induce it.
1861.] Dugas. Lecture on Tetanus. 43o
Suppurating wounds are less dangerous than those appar-
ently more trivial. Veterinarians are so well aware of this
that when a horse is pricked in the foot they lose no time
in provoking active suppuration by pouring spirits of tur-
pentine into the wound and searing it with a hot iron.
They consider the horse comparatively safe if they can se-
cure a free flow of pus, for eight or ten days. Our negroes
act upon the same principle witli their children ; hut after
using turpentine they paddle the sole of the foot instead of
resorting to the hot iron.
Tetanus is thought to he more common in hot than in
temperate climates. It is certainly very common in the
West Indies; hut it is not satisfactorily estahlished that
white persons are more subject to it there than in the tem-
per zones of Europe and America. The negro population
beinii: very large in those islands will account for the fre-
quency of the disease. Sudden or prolonged expose to cold
will frequently induce tetanus in those who would probably
have escaped it, as the records of military surgery abun-
dantly testify. AVounded persons should not be allowed
even in warm climates, to be exposed to cold or moist air.
especially during the night. It is still worse in cold climates
a> has been often painfully exemplified in the case of
wounded soldiers left exposed to freezing weather without
adequate protection. The intense cold of arctic regions has
induced it among the explorers of those inhospitable locali-
ties, probably in consequence of previous frost bites.
Men are supposed to be more liable to tetanus than wo-
men and children; and the young more so than the aged.
This may probably result from the circumstance that men
are more exposed; moreover, the statistics are chiefly derived
from army practice where men are almost exclusively treat-
ed. I doubt that in civil practice those positions would be
sustained. In my own the number of males is only slightly
n excess of that of females.
Symptoms. In studying the smyptomatology of tetanus
ou must bear in mind that this is essentially a spasmodic
136 Dugas. Lecture on 'lelanus. [June,
affection and that its manifestations must, therefore, be
sought for in the muscular system. The functions of the
other organs suffer comparatively little modification until
the disease has progressed considerably, as I will point out
as we proceed. The inception of tetanus is not preceded by
premonitory indications, and is often so insidious as to es-
cape observation for sometime. Usually the first smyp-
toms are a sense of stiffness in the back of the neck and
the occipital region, with an inability to open the mouth
widely. The rigidity extends to the temporal and masseter
muscles, thus increasing the difficulty of opening the mouth,
and down the back giving to the trunk a peculiar air
of stiffness. The patient may be still walking about the
room, under the impression that he has caught cold in the
muscles or that he is rheumatic. Muscle after muscle be-
comes implicated, however; those of deglutition obey the
will so imperfectly as to make it difficult to swallow without
being strangled; the jaws are locked; the abdominal
muscles become tense and hard to the touch ; the diaphragm
draws painfully upon the ensiform cartilage as it were ;
the sterno-leido-mastoideus feels like a cord on each side of the
neck ; and all the muscles of the face become so fixed as to
give to the countenance an expression so peculiar and char-
acteristic as never to be forgotten when once seen. Every
feature appears immovable and sunken as though greatly
emaciated.
In violent cases the body may be bent in various direc-
tions, constituting peculiarities designated by authors as
opisthotonos, when the body is carried backwards, empros-
thotonos when it is drawn forward, and pleurosthotonos when
the inclination is to one side or the other. The most com-
mon form is that in which the body is bent backwards, and
cases are recorded in which this was so extreme that thehcad
and heels were brought nearly in contact. I have never
Been an instance of this degree of violence.
A- tin- disease progresses all the respiratory muscles be-
come more or less rigid so as to interfere materially with
1861.] Dugas. Lecture on Tetanus. 487
respiration, which is then short, and will he found, by dose
observation to be tremulous. The abdominal muscles in-
eluding the diaphragm are so fixed that the respiration is
almost entirely thoracic, the shoulders being seen to rise and
fall in each act of inspiration and expiration. Many cases
proceed to a fatal termination without any serious rigidity
of the limbs; but these are often found affected the lower
extremities more frequently than the upper.
I have thus far spoken only of the persistent rigid-
ity of the muscles. I say it is persistent, because, although
under the influence of sleep or of powerful medication, the
tension may be temporarily lessened, it never ceases
entirely. But I must now direct your attention to a
peculiarity which may be regarded as characteristic
dt this affection, and which has, therefore, been
termed the "tetanic jerk." Every now and then, at in-
tervals varying froml to 15 or 20 minutes, or even longer,
thejoatient experiences a sudden and forcible contraction of
the muscles implicated, resembling very much an electric
shock, and which is more or less painfhl. Sometimes he
will simply groan as it occurs, but in some instances he
will cry out with pain. In the beginning of the attack you
may have to watch the patient half an hour before you can
detect one of these jerks; but as the disease progresses the
intervals become shorter and shorter, until they will not
exceed a few minutes ; and the violence of the shocks in-
creases correspondingly. They are then induced by the
slightest circumstances, such as addressing the patient, ask-
ing him to move, or to show his tongue, giving him food or
drink. If any one walks in, or any noise is heard, they are
induced. Hence the importance of great quiet in the treat-
ment. I should have mentioned that these shocks or jerks
are attended with a sudden closure of the larynx, which
produces a sound not unlike that of hiccough or singultus,
but occurs only once at each tetanic jerk.
During this dreadful perturbation of the muscles of
voluntary action those of organic life seem to be entirely un-
concerned. It is true that the heart may be somewhat
438 Duqas. Lecture, on Tetanus* [June,
accelerated in its movements; but this seems to be only
secondarily probably in consequence of the modification
in the act of respiration and the pressure of the inter-mus-
cular blood-vessels. There is not usually much febrile ac-
tion, if any. If the bowels are slow this may be accounted
for by the rigidity of the abdominal muscles and by the
small quantity of food taken, rather than by any impair-
ment of peristaltic action. We have, I say, no positive evi-
dence of any affection of the involuntary muscles. The
intellect remains unclouded almost to the last gasp. The
temperature of the surface is rarely much increased; the
skin feels soft and pleasant ; but as the disease advancei to
a fatal termination a copious sweat breaks out and continues
to the end.
Such are the symptoms usually observed ; but you will
find them more minutely detailed and sometimes different-
ly interpreted in the books.
Diagnosis. The only affection with which tetanus might
possibly be confounded is hysteria, in some of its protean
manifestations. But in this disease the mind is more or less
distempered and the spasms instead of being marked by
persistent contractions and sudden exacerbations or tetanic
jerks, have more the character of convulsions, that is to say
of alternate contractions and relaxations of the muscles in
rapid succession. The whole history of the case will also
aid in our diagnosis.
Pathology. With regard to the pathology of tetanus we
arc still very much in the dark. Postmortem examinations
have failed to throw any light upon it, unless we give more
importance than I am disposed to do to the occasional de-
tection of morbid appearances in the nervous filaments in
proximity with the traumatic lesion. We have seen that
the danger of tetanus is by no means proportionate to the
violence done to the tissues but that, on the contrary,
slight injuries are more apt to induce it than severe ones.
The morbid condition of some of the nerves leading from
the -rut of injury should, it seems to me, rather be regarded
1861.] Dugab. Lecture on Tetanus. 439
as a mere coincidence than as the immediate cause of the
dreadful developments of tetanus. The brain and spina'
marrow have boon most serutinizingly inspected without
revealing any condition or lesion peculiar to tetanus. We
must, therefore, look to physiology, natural and experiment-
al, for an explanation of the phenomena of tetanus, as well
as ot other spasmodic diseases.
Physiology teaches us that while strcng impressions in-
duce pain and perhaps inflammatory sequelae, slight ones
provoke convulsive movements at a distance and general
exhaustion. Laughing, sneezing, vomiting, kc, induced
by the slightest titilation of the peripheral extremity of the
nerves are familiar instances of physiological convulsions
and cannot be provoked by violence. Here we have a
slight irritation transmitted to the nervous centres which in
their turn excite contractions in muscles more or less re-
mote from the seat of original impression. This is the re-
flex action of modern physiologists, and this explanation is
applicable alike to pathological and to physiological cases. A
pin gently passed across the sole of the foot will cause con-
vulsive movements in the muscles concerned in laughter ;
this is physiological ; but let the loot be pricked with a pin
and we may have induced all the phenomena of tetanus.
In both instances we have a peripheral impression, or irri-
tation, which is perhaps a better ;erm, followed by a pertur-
bation of remote muscles which, the irritation could not
have reached without passing through the nervous centres.
We therefore arrive at the conclusion that tetanus is a morbid
reflex action induced by a morbid irritation of certain nerv-
ous extremities. But, you may now a-k, why it is that the
same morbid irritation does not always induce this morbid
action? [ answer that all persons are not equally suscep-
tible; some are very easily thrown into violent tits of
laughter by being tickled, whereas others bear it with im-
punity. In like manner morbid inita .ions which are harm-
affect other constitutions with spasmodic dis-
It would seem, therefore, that the induction of
440 Duoas. Lecture on Tetanus. [June,
tetanus depends in a groat degree upon a morbid suscepti-
bility or irritability of the nervous system, which we cannot
however, recognize before the development of the disease.
We have observed that negroes arc more susceptible to
tetanus than whites. Why this is so we cannot determine.
Tbe persistence of this perturbation of the muscular ac-
tion is exceedingly exhausting, especially when respiration
is much impeded ; and if to insufficient aeration be added
deficient nutrition, in consequence of' difficult deglutition,
you will readily perceive that fatal exhaustion must be in-
evitable. The victims die, then, from exhaustion of the
vita] powers induced by excessive muscular action and in-
anition.
You are now prepared to appreciate what we have to say
with regard to treatment.
Treatment. In determining the treatment of any given
disease we must take into consideration its pathology, its
natural history, that is to say, the course it usually pursues
when not modified by perturbating agents, and finally the
teachings of experience. I ought, perhaps, to have placed
the results of experience first. But while in many instances
our most valuable resources have been acquired by mere
accident, we have nothing to boast of under this head with
regard to tetanus. We have accidently discovered that
cinchona is a specific in intermittent fevers, and can, there-
fore, treat this disease very well without reference to either
its pathology or its history. Xow, if we knew any agent
that' would act as a specific in tetanus, I would advise you
to go no further. I would certainly not stop to consider
whether its action accords with my pathological views.
With regard to tetanus, however, we know no specific; ac-
cident or empiricism has really taught us nothing valuable.
We are, therefore, necessarily thrown upon first principles,
and if our pathology and history be correct, we ought,
assuredly, to be able to indicate the most rational treat-
ment.
We have here, a susceptibility of the nervous system so
L861.] Dugas. Lectureon Tetanus. 441
morbid thai a trivial irritation of its periphery lias induced
a most alarming perturbation of its functions so far as they
relate to the muscular movements ; and history teaches us
that unless the disease be arrested by death, it will occupy
pal weeks in running its course to resolution. We
know also that this perturbation is attended with the most
exhausting effects. Is it not evident, then, that we should
endeavor to remove the cause or source of irritation, to
lessen the susceptibilities of the nervous system, and to
sustain the vital powers by nutrition, instead of attempting
by violent means to arrest the disease?
You should, therefore, remove the offending cause if you
can. The splinter or other foreign body may still be in the
tissues : if so, take it away. You may find pus that cannot
escape ; if so, let it out by a free incision, and favor its issue
by lye poultices. Xervous filaments may be lacerated;
you should then make a clean division of them. If the
injury be to one of the small extremities, a finger or a toe
for example, amputate it at once. The propriety of ampu-
tating a leg or an arm must depend upon the extent of the
injury. A crushing or lacerated wound of the hand or foot
is a common cause of tetanus, especially in negroes, and
however great may be your desire to save the limb, you
should not hesitate to amputate upon the slightest manifes-
tation of tetanic symptoms. Indeed I do not think that in
the ease of slaves you should, under such circumstances,
run the risk of waiting for such manifestations. It is better
to amputate as early as possible in such cases, for the rea-
sons I have urged upon a former occasion, when speaking
of amputations in general. I insist that Ave have no right to
risk the life of a slave for the purpose of saving a limb, be-
- neither he nor his family will suffer for the necessar-
f life in consequence of the maiming. His master will
ide them as abundantly as if nothing had happened to
impair his efficiency. We may sometimes yield t<> the so-
licitations of a white man who is willing to risk his life to
a limb, without which lie could support neither him-
442 Dugas, Lecture on letanus. [June,
self nor his family ; but the slave is more fortunately situ-
ated and our first duty is to save his life. This may be a
new doctrine in surgery ; but I think it correct.
I do not wish you to understand me as attaching much
value to amputation after the development of the disease
for experience has but too often demonstrated its inutility.
I think, however, that the successful termination of one of
the cases I managed was promoted by the prompt removal
of a finger, in which a bit of needle was lodged, upon the
first manifestations of the disease. It is true that the symp-
toms were not arrested by the operation, and ran their
course for several weeks, but they were mild.
AVe pass now from the local to the general treatment
and we should select from the materia medica those agents
Ave know to be most effectual in lessening nervous irrita-
bility. These are unquestionably quinine, opium, and assa-
fcetida. Use these with discretion and they must be bene-
ficial, but you should bear in mind that they are to be given
only as palliatives, for you cannot arrest the disease except
by death. If you give opiates in the enormous doses some-
times recommended you may overcome the rigidity, but the
case will terminate fatally. I was once called in consulta-
tion to a case in which the patient had taken half a grain of
morphia every hour for 24 hours, besides inhaling large
quantities of chloroform and yet the attending physician
was surprised at the inefficiency of such active treatment !
The patient died shortly alter I saw him. A grain of opi-
um with 5 gr. of quinine and as much of assafoetida, ad-
ministered twice or three times in 24 hours, might have al-
lowed him to live through the disease.
But these antispasmodics will do no good unless aided by
nutrition. As nothing makes one so nervous as abstaining
from food, so there is nothing so bracing as well digested
nourishment. Let him have such as he will relish and as
much as his instincts will require. Animal food is best.
Brandy is an excellent adjuvant and should be prescribed.
Those who are in the habit of drinking should use it liberally.
1861.] Dug as. Lecture on Tetani -443
The appartmeut should be kept dark and perfectly quiet.
No visitors should be allowed admission and none buta dis-
creet nurse should be in attendance. No allusion must be
made to the nature of the affection and the patient should
he cheered with the belief that he will gradually recover.
Micturation and defecation should be attended with the least
sible exertion. AVlicn the bowels become uncomfortable
from the retention of feces or flatus, let them be washed out
with an enema of warm water and soap, or oil.
I dislike to mar the simplicity of this plan of treatment
by recounting to you the numerous remedies alternately ex-
tolled and repudiated by systematic writers and journal re-
porters. Indeed this would consume too much of your
valuable time. Blood-letting, revulsives, mercury, emetics,
cathartics, tobacco, indian hemp, and finally chloroform
have all been more or less lauded. I have tried most of
them without any evident advantage. They are all more or
destructive of the energies of the system ; whereas I
wish to impress upon you the great importance of husband-
ing the resources of the economy. Strive to enable your
patients to live through the disease instead of endeavoring to
arrest it, and you will every now and then have the satifac-
tion of witnessing a recovery.
Trismus Xascentium is a form of tetanus which occurs in
new-born infants and is known by the people as the "ninth
day fits" because of the period at which it usually shows
itself. This is also much more common with negroes here
than with whites. Its real cause is not known, although
some think it connected with the state of the umbilicus.
Some negro families are peculiarly liable to it. I have seen
a striking instance of this. A negro, of apparently good
constitution, married a woman who had previously had
ral healthy children; but who lost, with trismus nascen-
tiura, every one she had by this marriage, seven in number,
then died and her husband married another woman
who had likewise reared several children by her first hus-
band. But the only child she had by this man died with
Ml Doughty. He port of [June,
trismus. I examined a number of these children and could
detect nothing wrong about the nmbilicus. As the women
were attended by difterent midwives, it is not probable that
there was any special mismanagement of the cases.
Note. Since this Lecture was delivered and written onr. I have read
with much interest a valuable and suggestive paper upon the pathology of
tetanus, hv W. llanna Thompson, M. I)., published last February in the
American Medical Times, of \e\v York, in which the author advocates
the doctrine that tetanus depends upon a morbid condition of the blood
either acquired or induced by some peculiar poison. The nervous phe-
nomena would then be referred to the influence of morbific agents conveyed
by the blood, instead of regarding them as the mere effect of irritation
upon inordinate susceptibility. The treatment lie proposes consist- of
"hematic agents, such as iron, mercury, iodine and bromide of potassium'1
with such "nervine stimulants as asafoetida, musk, camphor and alcohol,
to uphold the sinking nervous force, while the hematic agents are coun-
teracting the toxic cause in the circulation."
ARTICLE XIV.
Report of Hospital Cases. By Wm. IT. Doughty, M. D.,
Physician to Augusta City Hospital.
Opacity of the Cornea. P. G., aged 45, entered the Hos-
pital April 29th, 1860, for acute catarrhal ophthalmia of both
eyes. The left eye yielded kindly to treatment after a short
time, but the right continued highly inflamed and painful;
at present, however, the inflammation does not involve the
palpebral conjunctiva. The cornea partook of the inflam-
matory action, as a result of which it has been left in an
opaque state, sufficient to prevent the detection of objects
only a few feet from the individual. From the outer cir-
cumference of the eye, two or more large capillaries are
'i extending to the centre of the cornea. The sensibility
of the organ to light is at that the patient keeps it
covered with a handkerchief. The following treatment was
continued for two months, at the end of which time, the
Stil.] Hospitm 44.")
ase had improved so much that the individual could dis-
3h objects at the distance of an hundred yards, and
,t his request) waa dismissed. All inflammatory action has
d, and very little obscurity of the cornea remains.
Constitutional treatment was 5 grs. blue mass at night,
hree times weekly ; and one teaspoonfui of the following
nixture, three times daily :
lv. Potass Iodid, 5ij
Tr. Iodin gtts* xxx.
Aqua ad Sij.m.
Locally the frontal and temporal regions were sponged
Veelv with cold water, and the following wash used twice
laily :
1\. Argenti Xit, grs. iij.
Aqua, 5ij
Open the eyelids and drop in a few drops. The enlarged
apillaries were also cut in several places; and occasionally
i small blister applied to the temple.
'Remarks. The satisfactory results of the above treatment
ias alone caused the selection of this case for publication.
jfcs purely practical character will render it acceptable to the
-ion.
Amputation of the Leg for Ch.ro/>:, Ulceration. For four-
teen years Mr. U. C. W. had been afflicted with chronic
Qceration of both legs the right, however, being worse
ban the left. As is common with such cases, the ulcers,
rhicb were large, irritable and offensive, would occasionally
ical and then spontaneously break out again. They have
lot been healed foi eighteen months or more, and on the
ight leg they are so extensive as to have embraced almost
ire region between the tuberosity of the tibia and
he malleoli. He is a printer by trade, is foud of whiskey,
tnd has led an irregular life which facts are quite sufficient
:o explain the permanency of the disease. Neverth<
lie looks quite robust, and his general appearance is by no
- that fa person whose constitutional vigor had been
leriously impaired. He first entered the Hospital about
440' Doughty. Report of [June,
the middle of January, and was under treatment until
March. The ulcers were healed, though the eicatrices and
newly-formed tissues were tender and weak. ITe returned
to his trade and usual habits, against which lie was cau-
tioned ; and, on April 10th, applied for re-admission, for
the purpose of having the right leg amputated. The ulcers
had broken out with renewed vigor, and verily the last state
of thai man was worse than the first. Of course he was ad-
vised against amputation, and urged to remain long enough
in the institution after the healing of the ulcers to enable
the tissues to acquire strength ; and also to quit his trade,
which required him to stand many hours without intermis-
sion, as well as all stimulating drinks. It was much
easier to suffer amputation than to undergo the latter
privation he thought, and further remarked that his
brother printers had kindly offered to furnish him with
a cork leg. A week was allowed him for reflection
during which the parts improved, at the end of which,
however, was as clamorous as ever for its removal.
Being persuaded in our own mind that the circumstances
necessary for the preservation of the limb in a permanently
useful state would never be observed, we determined to
gratify him by taking it oft'. Accordingly, on 17th April, the
operation was performed by Dr. J. S. Coleman, of this city,
in a skilful manner, at the point of election, a few inches
below the tuberosity of the tibia. The circular method
was adopted, and after the tying of the blood-vessels, and
the application of the usual dressings, the patient was put
to bed. For several days he had high fever, and much pain
at intervals in the stump, for which quinine, laxatives, and
opiates were given.
April 21st. Patient comfortable; pulse natural in fre-
quency and volume. Stump examined, and a portion of the
indurated integument that was necessarily retained, found
to be in a sloughing condition.
The usual dressings were applied, and a nourishing diet
ordered.
1861.] Hospital Cases. 447
April 25th. This is the second dressing since last ex-
amination. Doing well.
May 18th. Stump in tine condition.
Remarks. The ulcers on the left leg are completely
healed, and it is probable that by the time the artificial leg-
is procured, it will be firm and strong. Before amputation
was performed, a written certificate, with witnesses thereto,
was required of the patient, relieving us of all legal respon-
sibilities on his part, and all others interested. This was a
necessary precaution in view of the peculiaries of the case.
Autopsy of a Case of Phthisis Pulmonalis. This subject,
K. M., was an Irishman, 75 years of age, of irregular habits,
He had the general appearance of a patient far advanced in
in phthisis, being pale, emaciated, &c., but when his case
was fully investigated its tubercular character was not so
evident. His disease dates from a severe cold contracted
eighteen months ago, occasioned by wet feet, wdiich con-
fined him to bed for several weeks ; since then he has been
scarcely able to go about. For three months or more he
was an inmate of one of the Charleston hospitals, where,
according to his statement, he was treated for chronic bron-
chitis. With the general appearance of a consumptive, yet he
had no hectic paroxysms, and night sweats; no diarrhoea; no
marked acceleration of pulse and respiration ; no chronic
laryngitis. His breathing was labored and oppressive, but
not increased in number, and his pulse, though feeble and
irregular, was still scarcely over the standard. The only
rational evidences of phthisis were cough, labored breathing,
and general marasmus, and muco-purulent expectoration.
Physical examination gave abundant evidence of disease,
but as there are no signs dissevered from rational symp-
toms that may be regarded as certainly indicative of phthi-
was insufficient to establish its existence. Bronchial and
broncho-vesicular respiration, bronchophony, pectoriloquy
and cavernous respiration (in rare instances), as well as the
adventitious rales, may exist occasionally, as fully marked
in chronic dilatation of the bronchial tubes as in phthisis.
448 Doughty. Report of [Juno,
The same is true of the percussion sounds, for degrees of
dulness, varying from simple appreciable dulness to almost
flatness; tympanic dulness and its various modifications are
also incident to it. The physical signs elicited in this case
were such as might he ascribed to either disease. Under
these circumstances, the importance of the rational symp-
toms became greatly enhanced, for upon them must turn
the diagnosis. The leading rational symptoms of advanced
phthisis were absent, and so far it favored the presumption
of its absence. Doubtless it was this circumstance that in-
duced others to regard the case as one of chronic bronchial
disease. Irregular cases of phthisis are occasionally met
with, and hence wc were vigilant to detect it if possible.
This case was made the basis of a lecture on consumption,
embracing also a brief notice of the differential diagnosis
between it and bronchial dilatation, before the attending
class of the Medical College of Georgia, which was after-
wards published in the Southern Medical and Surgieat Journal,
Nlarch 30. In it the main points were discussed, and the ir-
regularities set forth. The position then assumed was, that
it would be unsafe to declare that tuberculosis did not exist.
It affords us pleasure to review the conservatism of that
position: a post-mortem examination alone could settle the
disputed point, a s}mopsis of which is hereto annexed. It
should have been remarked that there was no hereditary
predisposition to consumption on the part of the individual.
April 20th. Autopsy one hour after death. On opening
the chest, the left lung was found collapsed ; at its apex it
was slightly adherent to the wall of the chest. Its upper
third, particularly the apex, was occupied by aggregated
tubercular masses, firm and resisting to the knife; the mid-
dle and lower thirds were also filled with tubercles in a dis-
seminated state, varying in size from a mustard seed to a
large-sized pea. The right lung was adherent to the pa-
rietes of the chest throughout, and so firm were the attach-
ments that in some places the knife was necessary to sever
them. The entire upper lobe was a solid tubercular mass.
1861.] Hospital Cases. 449
and iu its posterior part was an excavation of some size.
Within and about this region, the structures seemed iu a
transition stage approaching decomposition ; some parts of
it were indeed so much softened as to render it impossible
not to tear it in our efforts to break the adhesions.
The lower lobe was also occupied by tubercles in small
masses ; and the base of the lung was. as it were, firmly
glued to the diaphragmatic pleura.
Heart. Xot the least interesting was the condition
of the heart. There was fatty degeneration, with ex-
tensive softening. The muscular tissue when cut or
torn, had a decided yellow tinge ; and so greatly softened
was it, that it trembled like jelly when exposed to view.
There was no firmness about it, and when held in the hand
gave sensations such as would be experienced by a loose
bladder partially filled with water. The valves of the pul-
monary artery were slightly thickened ; and at the aortic
orifice only one of them appeared at all altered.
Remarks. This examination fully demonstrates the cor-
rectness of the position taken in our lecture, and as satis-
factorily teaches us the importance, aye, the necessity of
bearing in mind the possible occurrence of cases of pul-
monary tuberculosis, which may display but few of its ra-
tional symptoms. And this is the more necessary, since it
is one of those rare junctures in which physical examina-
tion fails to discriminate, the differential diagnosis turning
upon the rational evidences of the disease. This would not
be so if there were any physical signs distinctive alone of
phthisis ; as it is, however, the rational symptoms place, m
a degree, a special interpretation upon the latter, which en-
ables us, in a large majority of cases, to make a successful
diagnosis. The question, so often asked, "how few physi-
cal signs, taken in connection with symptoms pointing to
tuberculous disease, are sufficient to establish the diagr-
nosift?" has its converse in that which may be asked, " how
few of the rational symptoms of the disease, in connection
with abundant physical signs, can suffice for the differen-
tial diagnosis?"
29
450 Cutaneovs Discolor ations. [June,
t 'llnical Researches into Morbid Pigmentary Changes in the
Complexion. By Thomas Laycock, M. D., &c, Professor
Of the practice of Medicine and of Clinical Medicine, and
Lecturer on Medical Psychology and Mental Diseases in
the University of Edinburgh.
It is well known that the tint of the skin in disease is an
easily available, and often an excellent guide to diagnosis and
treatment. This disease arises mainly from the fact that
changes in it indicate any important change in the constitution
of the blood, but more especially of the blood corpuscles. Its
physiognomical uses are well known in showing the race or
temperament of the individual, and therewith his mental and
corporeal tendencies. In these and various other similar ap-
plications, the tint of the skin is due to the presence or ab-
sence of the animal pigment, with or without changes in
the blood.
Although these color characters are capable of such varied
and important applications to practical uses, they arc so im-
perfectly understood as to their nature and origin, that changes
in the complexion in disease have had little more than an
empirical value in medicine, and have, indeed, not infre-
quently led the observer into error ; thus, the tint in "Addi-
son's disease " has doubtless led to its being mistaken for
icterus until very lately. The coincidence which Dr. Addi-
son showed to occur between structural disease of the supra-
renal capsules and a pigmentary deposit in the skin of wdiites
(and whose conclusions have been confirmed by others) has of
late years directed my attention to the clinical meaning and
pathology of morbid pigment-deposits and pigmentary changes
in the complexion. Although the results of my inquiries are
not so definite as further delay might have no difficulty in
showing very conclusively that clearer views as to the patho-
logy, diagnosis, and treatment of certain related groups of
constitutional diseases may be deduced as well from the ab-
sence of pigment-deposit as its presence.
The following are the conclusions at which I have arrived,
and which I propose to illustrate :
1. That besides blue and green, of rare occurrence, there
are two common and well-marked and distinct forms of morbid
discoloration, due to pigment deposit the yellow or sallow,
and the black or swarthy.
2. That both yellow or swarthy discloration of the skin will
occur from the action of local irritants as heat, light, cutane-
ous parasitic fungi, blisters, sinapisms, and the like, or in the
1861.] Cutaneous Discolorat' 4ol
progress of various cutaneous diseases of the skin and its
appendag
3. That the absence of pigment (leucopathia), as well as its
deposit, may be caused by inflammatory and other diseases of
the skin, affecting its chromatogenous function.
. That morbid states of the cerebrospinal centres will in-
fluence the deposit or non-deposit of pigment
5. That morbid states of the genito-urinary organs in both
sexes, acting probably through the nervous system, will deter-
mine the election of locality of pigment-deposit, according to
the same law, by which the development of sexwil hair and
pigment is regulated.
6. That structural disease of the abdominal viscera and
peritoneum also exercise an influence through the nervous
system upon the local deposit of pigment in the skin.
7. That in the diseases of the supra-renal capsules, the
bronzing of the skin, whether swarthy or yellow, is partly
nervous, and due to the direct or indirect influence of the
capsules or the kidneys and nervous system ; partly haemic,
and in so far due to the morbid influence of "dyscrasic"
blood.
x. That pigmentary changes in the skin of both whites and
blacks may be the result of morbid causes, and yet may re-
main after the operation of the causes has ceased, and assume
a physiological character.
9. That although local morbid pigmentation of the skin may
occur exclusively from local causes, or the influence of the
nervous system, in the majority of cases there is a morbid
condition of the blood.
10. That the morbid conditions of the blood associated
Bt commonly with pigmentary changes are characterized
by those changes in the blood corpuscles (leukaemia, leu-
ytosis) which are observed in cachectic states of a con-
stitutional character (pregnancy, chlorosis, tertiary syphilis,
chronic rheumatism, cancer, &c.,) or which are intimately
connected with " dyad'asic," visceral or glandular diseases
(of the spleen, supra-renal capsules, lymphatic glands.)
11. That the tendency to discoloration increases {cceteru
'paribus) with age after a certain period of life.
12. That the morbid pigment-deposits proper, as distin-
guished from masses of altered blood-corpuscles, are car-
bonaceous excretions, and are often vicarious with the
suspension or imperfect elimination of other carbonaceous
excretions as the carbonic and lactic acids, and the pig-
452 Cutaneous Discolorations. [June
ment constituents of both the urine and bile ; and are con-
sequently associated with morbid states of assimilation, as
well as of elimination (through the skin, lungs, liver,
kidneys).
] 3. That amongst the morbid states of assimilation, the
rheumatic and gouty are especially to be classed, as well as
those coincident with anaunia.
Semeiologg. Pigmentary changes in the skin, and pig-
ment-deposits in the tissues, are observed clinically under
the most varied conditions, and have given trivial names to
groups of symptoms. Jaundice (jaune, yellow) is. the simplest
illustration ot these. The deposit of black, or brown, or blue
pigment in the skin of white races, has led to the various
nosological terms indicative of the change as melasma, me-
lanopathia, nigrities, bronzed skin, blue skin or cyanopathia,
mcliceris, stearrheca, flavescens, stcarrhwa nigricans chlorois (or
green sickness), melancholia, melanchlorosis, melasicterus, &c.
As to the absence of pigment we have alcura, leuce, leuco-
pathia, vitiligo, caniles, &c. The congenital absence known
as albinism has always excited curious attention, and, as
those who have treated albinos know, coincides with pecu-
liar forms of disease. I need not refer to the albino forms
of animals, nor to the curious ethnological doctrines and
oppressive laws which have originated in the presence or
absence of cutaneous pigment, except to say that a better
knowledge of the pathological forms will necessarily throw
much light on the physiological.
Classification of Morbid Pigments. The pathological pig-
ments are of two kinds. 1. The spurious, which consists
either in foreign carbonaceous matters, or in direct modifi-
cations of the coloring matter of the blood corpuscles after
they have died ; these pigments are all some form of hse-
matine, and presents all the shades of black, brown, yellow,
and purple. 2. The true, being those pigments which are
products of the transformation of the living blood corpus-
cles, or tissues, and which must be held to differ from the
preceding in the circumstance that they are the results of
the action of the vital forces. They are of all colors ; cor-
respond in this respect to the normal coloring matter of
animals ; and are found in the cutaneous appendages and
excreta, but especially in the urine and bile.
Le Cat, a surgeon at Rouen, was the first to examine
systematically the moioid pigmentary changes of the hu-
man skin in their relation to anatomy, physiology, and
1861.] Cutaneous DSscdtoraHons. 153
organic chemistry. lie details cases of melasma and ni-
grities, and distinguished evidently what was a case of
"bronzed skin" from ordinary melasma and icterus.* He
examined the pigment (which lie termed "^Ethiop*B mine-
ral") chemically, and showed that the coloring matter of
the ink of the cuttle fish was identical in nature with that
of the skin of negroes, and of the choroid coat of the eye.
He was also the first to observe that the encephalic tissues
of the negro were of a darker tint than in whites an ob-
servation subsequently confirmed by Meckel and others,
and very recently by M. Gubler. Although considerable
progress in observation has been made during the last cen-
tury, we may still say, with Alibert, " Les lois de la colora-
tion sont encore couvertes d'un voile epais.*'
Modern inquiries have ascertained that black pigment
is deposited morbidly in the tissues, mucous membranes,
and capillaries (melanosis), as well as in the skin (melasma),
and that it is sometimes present in considerable quantity
in the blood (melanamia). Its nature and composition have
also been carefully examined of late years. Baruel first at-
tempted to show that the chemical composition of the black
deposit in melanosis was identical with that of the coloring
matter of the blood. Breschet founded upon this analysis
and upon his own researches the conclusion that the de-
posit was due to effused and modified blood with a large
proportion of true coloring matter: and flcusinger, Lob-
stein, Andral, Trousseau, and Leblanc, J. Vogel, Bruch,
Rokitansky, Virchow and others, have theorised as to the
mode in which the pigment is formed from the blood. | It
is now well established that although the pigment in nu-
merous cases really consists of modified lnementine, derived
directly from the blood-corpuscles, the deposit in melan<
melasma, and nigrites is not of this kind.
The term melanosis was first used by Laenncc, who
pointed out three forms of the disease. 1. Those in which
the pigment is deposited in masses, whether encysted or
not. 2. Free deposits of pigment in layers in serous mem-
branes. 3. Infiltrations of pigment. t In ;i*21, Breschet
* Traite de Couleur de la Peau Humaine. 6c., p. 158. 1765.
ompare Kokitansky's Pathol. Anatomy, Sydenham Society's trans-
lation, vol. i. p. 204, and Virchow's elaborate paper, li.' Pathol Pig-
mente, in Arch, t Path. Anatomic and Physiologic, vol. i. art. '.'.
: Bulletin de la Soc. de l'Ecole de Medccine, No. 2. 1860.
454 Cutaneous Discolor ations. [June
added a fourth, the fluid form ; and in 1829, Andral asked
whether certain eases of pigment-deposit in the skin should
not be classed with melanosis. Andral also called attention
at the same time, not only to cases of inky discloration of
the intestinal mucous membrane, in which pigment ap-
peared as a deposit into the tissues, hut to another class
(some observed by himself), in which it appeared on the
surface of that membrane as a secretion.* These deposits of
pigments in the tissues, that is to say, externally to the
blood-vessels, are now well established.
Breschct and Oruveilhier seem to have been the first (in
1821) to detect pigment in the blood-vessels in the form
of black, sharply-cut masses.f It was considered to be
rather a post-mortem phenomenon than a true pigment-
deposit, and what they observed was probably due to the
hsematine of the altered blood-corpuscles. In 1823, Dr.
Haliday published a case of melanosis, in which he found
fluid black pigment in the vessels at the base of the brain,
and in those of the choroid plexus. t In 1825, Billard and
Bailey observed capilliaries of the brain to be obstructed by
pigment. Several years subsequently, Mr. Holmes. Coote
recorded a case of melanosis of the eye, in which he found
a black matter present in the blood-vessels of the recti mus-
cles of the globe, between the blood and lymph-corpuscles
in appearance, and which moved with the blood-corpusles
when pressure was made on the vessels. || Of late years, this
deposit of pigment in the blood-vessels has been frequently
observed and connected with the presence of free or celled
pigment in the blood and certain viscera, but especially in
the spleen. German observers have largely contributed to
this portion of the subject, particularly Meckel, Ecker, Vir-
chow, Planer, Heschl, and Frerichs.
The term melancemia (first used by Frerchs) has been
applied to that condition of the blood in which the pigment
has been found. Seeing how readily the carbonaceous
matter is deposited in the skin and tissues in melanosis,
and how abundantly in the capillaries the conclusion was
natural that in all cases it was a deposit made directly from
PreciH (TAiiat. Path., torn. i. j>i>. 460-1,
Considerations sur une Alteration Organiqne Degenerescenoe Noire.
1 82 1 .
; London Medical Repository. 1828.
Lancet, Ang. 1846.
1861.] Cutaneous Discotora: 455
the blood, without the intermediate ^ ital action vf the tis-
sues in which it was deposited. Now, this mechanical
theory maybe admitted as to the blockade of the capillaries
by pigment granules, the products probably of altered cor-
puscles, but it is by no means sufficient to explain the usual
phenomena of melanosis or melasma. As to the latter, it
may be observed especially that the deposit takes place in
a tissue, the normal function of which is at least to receive it,
but perhaps to excrete it: hence the change is in one sense
a physiological process; whereas in melanosis and in block-
ade of the capillaries, the change is in no sense physiologi-
cal, but purely pathological.
As I shall have to refer to mdana-nila from time to time,
T would observe here, once for all, that although the facts
are so numerous and apparently so decisive as to the pres-
ence of free pigment in the blood, they require confirma-
tion, and have in tact been controverted. In 1852, Zeroni
stated in a contribution on the Treatment of Ague by Ar-
senic,* that he had examined the blood of ague-patients for
the pigrneut-cells described by Ileschl, and, to his great
delight, he found them at once ; but on examining the blood
in other cases, and in the spleen of a fatal case, he could no
longer find them, but discovered that lie had used glass
covers which, under a power of 300, showed objects mar-
vellously like Heschl's drawings of his pigment-cells, Pro-
bably the doubts thus thrown on Heschl's researches
are not altogether inapplicable to the researches of other
inquirers, for Zeroni indicates a very certain source of
fallacy. I have examined the blood of several individuals
(certainly not fewer than 100). and am satisfied that nothing
is more difficult than accurate observation of the pigment-
elements. The slightest particle of dust, coal, or ash, is
sufficient to give the appearances described by Planer and
Ileschl. Even a microscopic particle of dried blood, re-
maining on the slide, shows as brown pigment, in a freshly-
drawn specimen of blood taken on the slide. So that the
utmost care will hardly suffice to avoid fallacies in observa-
tions at the bedside. It appeared to me that the only
method by which even an approach to accuracy can be ob-
tained clinically, is by examining the blood of a number o\'
persons under the same conditions as to time, place, state of
* Deusche Klinik. Xo. 40, 41.
4oti Cutaneous Discoloration*. [June,
slides, and method of taking the blood, so that all the ob-
servations are equally liable to the same class of fallacies;
in this way a comparison of the differences in the pheno-
mena observed could be instituted. The results of clinical
examinations thus made, I shall state shortly, believing
that, although not strictly accurate, they are sufficiently ap-
proximative for the first steps of a clinical inquiry.
Melasma considered generally. There are two forms of
pigmentation observed in the skin of men and animals ;
namely, those of the skin proper, and those of the appen-
dages to it, as hair, quills, feathers, scales, shells. The pig-
ment of the skin proper of man is contained in the soft,
newly-formed cells of the epidermis, formerly termed the
retemucosum, into or by which it is secreted. That of the
hair, scales, and other similar appendages, has fundamen-
tally the same origin ; for they are either compressed epi-
dermic products (as scales), or produced from follicles which
are fundamentally involuted portions of the derma proper.
The function of these follicles is, however, modified by the
fluid which is poured into them from the sebacceous glands.
But these again are involutions of the derma. Hence the
general relations to the pigment of the skin appendages are
the same in both ; it is contained in cells having a common
origin at the surface of the body.
The skin in all men. whether white or dark, has nor-
mally a function of pigmentation, although the activity of
it differs greatly in extent in different races, and even in
the same race, from va^'ing circumstances as to climate,
food, and exposure to climatic influences. In white races
this coloriferous function is almost in abeyance, especially
in the clothed portions of the body, but it is easily devel-
oped under certain circumstances. In all, however, the
anatomical relations of the pigment to the epidermic cells
appear to be the same. Thus the pigment-deposit in
"bronzed skin" has been found by various observers to
have the same relation to the epidermis as in sun-freckles
(epheUs), and as in the colored races. The cells in which it
is contained in the form of minute granules arc covered
with a colorless epithelium in the ordinary cases of melas-
ma, chloasma, ami the like, but in certain morbid states of
the skin, in which there is rapid production of epithelial
scales (desquamative or squamous diseases), the epithelium
contains abundant coloring matter. This is observed clini-
cally in pityriasis versicolor, in various forms of ichthyosis,
1861.] Cutaneous .Disco/orations. 457
in cases of true leprosy, known as ti black " leprosy, and in
lepra nigricans. A similar rapid production of pigment
may take place cither within the hair follicles or the seba-
ceous glands, and be poured out on the surface of the skin.
This is seen in stearrhaa nigricans and stearrhosa Jfavescens.
It is probable, however, that it is poured out also as an
excretion from the sudoriparous glands.
Leueopathia in relation to Melasma. It is not every part
of the human body which is equally dark, or has equally a
tendency to become dark ; on the other hand, in colored
races, and in portions of the skin or its appendages of the
whites, which are naturally dark, there is sometimes a
morbid defect in the pigmentation. This state has been
termed white disease, or leueopathia. It is to be observed,
however, that there may be a pathological leueopathia ;
that is to say, white spots due to morbid changes in the
skin may appear amongst colored patches of white skin due
to excited action of the epidermis. This gives a mottled
appearance to a bronzed skin i. e., a skin darkened by
disease, and may tend to puzzle the observer. In particu-
lar it may lead him to mistake a pathological tint for the
dark tint of sordes of the skin. The mottling of the skin
in cases of melasma, indicates a true pigment-deposit, for
the white patches are due to the absence of morbid pig-
ment, just as leueopathia in the negro indicates the absence
of normal-pigment. Xow, as the pigment-deposit in these
cases of melasma is due to morbid excitation of a normal
hut suppressed function of the rete inucosum in whites, the
white mottling indicates a morbid condition of the skin at
the places where the skin or the hairs remain white, when
all around is darkened. This morbid condition can often
be traced to some eruptive disease of the skin by which the
function of the rete mucosum, so far as the production of
pigment is involved is interrupted. In other cases, it is due
to some other cause or causes. I have seen, for example, a
case of syphilis, in which the hairs of the entire surface of
the body, cap-a-pie, fell off, and pigmentation therewidi
~cd. The patient was a young man of dark complexion,
and when the colorless downy hairs reappeared on his pink-
looking skin, he presented a curious contrast with his for-
mer appearance. Again, although leueopathia may be thus
traced to changes in the disease induced by locally inflani
matory or constitutional causes, and the result of which is
to interrupt the ehromatogenous function of that portion of
458 Cutaneous Discolorations. [June,
the skin affected, there are forms of leucopathia wholly un-
connected with any such structural chenges, and which are
probably due to changes in the innervation. Thus, a man
with renal and cardiac dropsy had broad patches of liver
color (melasma) and leucopathia on his right forearm. No
structural change could be traced in the site of the latter,
while it was observable that the hairs of the spot were
white, so that the production of pigment was suppressed in
them, as well as in the rete mucosurn. Such cases as these
1 would term melasmic leucopathia.
On the other hand it is to be noticed that portions of the
skin, which have been the seat of considerable structural
change, are the seat also of pigment-deposit. The deep
cicatrices left by a severe attack of small-pox may be ob-
served sometimes to be thus colored ; it is no uncommon
thing to observe the same appearance in the cicatrices of
old ulcers on the legs, especially of gouty old people. In
these cases the pigment-deposit is manifestly due to another
kind of action than that which occurs in the rete mucosurn
or cutaneous glands in instances of melasma. In the latter
it is a natural function of normal structures exalted by sonic
special conditions; in the former the normal structures are
destroyed, and the process is purely morbid. These two
forms of cutaneous pigmentation are, in truth, typical
forms, and correspond to what maybe termed carbonaceous
excretion and carbonaceous deposit (melanosis proper.)
The black, yellow and blue stains following upon bruises
are, of course, wholly different, being due to the effused
blood-corpuscles.
Local Causes of Melasma. The conditions under which
morbid pigment-deposit takes place, being so very complex,
it becomes necessary to determine the more important by
illustrative cases. These conditions may be classed under
three heads, as they involve the blood, the nervous system,
and the tissues themselves. As regards the skin and its
appendages, it may be here observed generally and by way
of preliminary, that any stimulation or irritation applied to
the skin under certain conditions of the blood, the nervous
system, or the system generally, will induce pigment-
deposit. Thus, heat and light tinge the rete mucosurn of
certain persons. Id old people, the Bhins get to be of a
brown or liver color, from exposure to the fire ((aches dc
brulure). The same thing happens in certain cachectic
states, as in the syphilitic cachexia, in anaemic conditions
1861.] Cutaneous Liscoloratr 459
(chlorotic girls), and the like. In a similar class of c<
the irritation of a blister suffices to cause pigment-deposit,
bat the exact size and shape of the blister is indicated
dusky brown or liver colored patch. Various skin
- have a similar effect, as the furunculoid, eczema,
psoriasis, &c. In an inveterate case of peoriarsis, treated
in the clinieal wards during the session 1869-60, a man.
aged about fifty-eight, after convalescence the entire surface
of the back and trunk was almost wholly covered with large
confluent patches of dark pigment-deposit, indicating the
portions of the skin which had been the seat of the disease.
And seeing this result, it was not difficult to understand
how, in cases of this kind, the complexion of the individual
might be indelibly changed, so that he would exactly re-
semble men of the colored races, in that particular at least,
just as in some cases of leucopathia in negroes, the skin has
become as white as in the white races. Now, in these cases
of cutaneous pigmentary change, after convalescence from
skin diseases, I have observed that the patient lias been
either advanced in years or cathectic (if young), or both
aged and cathectic.
Psoriarsis, for example, is very common in young and
healthy adults, but in these cases, stains are very rarely left
after cure, as in the aged and cathectic. It occurs in the
ptions. I think, because the patient is of a dark com-
plexion, and is therefore predisposed naturally or normally
to pigment-deposit, just as a woman of such a complexion
will have a darker mammary areola from pregnancy than a
fair-complexioned woman : and this indicates one of the
most common conditions under which pigment-deposit will
vary in intensity namely, the ethnic, or conditions proper
to the mee. Probably to this class of conditions may be at-
tributed, in part, the difference between swarthy and yel-
low bronzings in the diseases of Europeans.
The mode in which the sun's rays excite freckles (ephelis
or lentigo) >hows, however, that there are conditions in the
skin of the face and neck which predispose it to the deve-
lopment of pigment in the small patches termed freckles,
otherwise the change in color weuld be uniform. Some-
rimes this appearance is x^vy remarkable, as in a youth of
twelve, just arrived from India, who came under my notice.
and whose face, after exposure to the sun, was suddenly
dotted uniformly over with round brown spots of the
rgepin'fl head. In the- the deposit may be due
460 Cutaneous Discolor ations. [June,
to irritation of the rete mucosum at points where a group
of sudoriparous or sebaceous glands pour out their pro-
ducts, or if not to this, to the same class of elective causes,
by virtue of which herpes, variola, and other circumscribed
inflammations of the skin, are induced. It is to be ob-
served, too, that red-haired persons are more liable to this
lenticular pigment-deposit (laches de rousseurs) than the
dark-haired, in whom the pigmentation is more uniform.
I shall, however, refer to these special forms of pigmenta-
tion or leucopathia when I discuss more particularly the
causes of melasma, and with these preliminary remarks will
now give some illustrative cases.
Caih.ectic melasma (?'. e. swarthy bronzing, as distinguished
from yellow) is the most commonly observed ; it is that
specially designated by the term melasma.
Case 1. Mottled swarthy bronzing (melasmic leuco-
pathia) of thorax and abdomen, mistaken for sordes ; ab-
dominal tumor; enlarged lymphatic glands. Reid, a tailor,
aged about thirty-live, was admitted into the clinical
wards, 27th May, 1856. On admission it was found that he
had a pulsating tumor about four inches in diameter, oc-
cupying the middle line of the epigastrum, and extending
thence "into the left hypoehondrium. In addition to the
tumor proper, there was a supplementary enlargement
caused by faecal accumulation at the left angle of the colon.
Complained of constant constipation and severe shooting
pains in the back and loins, extending to the left groin.
rain also more particularly referred to the region of the
kidney, where there was tenderness on pressure. On care-
ful examination the tumor was found to be not expansile,
but a loud stystolic murmur was heard over il. The skin
of the trunk was universally of a darker hue than natural,
but more particularly over the abdomen ; the dark surface
was mottled with white spots, which, on inquiry, we found
to be the sites of a previous pustular eruption. Face pallid
anaemic ; axilliary and inguinal glands enlarged. In dis-
cussing this case at the bedside, I pointed out the bronzing
of the skin, but the appearance was so like that of sordes,
that several of the class got soap and water, in the confident
expectation that they could tl wash the Ethiope white."
The only result was to bring out the dark and white spots
more distinctly.
Symmetrical Melasma. In the cast- just detailed, the
change in color was limited to the trunk; it is sometimes,
1861.] Cutaneous Biscoloratlons. 461
however, symmetrical, both as to morbid whiteness and
morbid dinginess ; and although it by no means follows
that, beiug symmetrical, it must be due to changes in the
centric nervous system, yet in the absence of any other
cause, we may fairly refer it to these, as they probably
were influential in the following case.
Case II. Long-continued diathetic eczema and erythema;
enlargement of lymphatic glands ; symmetrical pigment de-
posit on the skin ; melasmic leucopathia. P S ,
aged sixty-two, a workman in an iron foundry near Glasgow,
admitted into the clinical wards 22d July, 1860. He states
that he had always enjoyed good health, with the exception
that in youth he had frequent attacks of headache until six-
teen years ago, when his lips became red and swollen and
covered with small vesicles, accompanied with exces-
sive itching. In three or four weeks he was cured by the
application of a yellow ointment, but the affection recurred
annually every spring, and at each recurrence extended
over a wider surface. About four years ago the shoulders
became affected, and for the last two or three years there
has been no remission. The itching is very distressing,
and the desquamation from the parts affected considerable.
About three years ago, he observed that the glands of
the groins were becoming large, and shortly after those of
the axillse. About this time, also, three abscesses formed ;
one in the right groin was opened, two others lower down
in the right thigh burst. They commenced with shivering,
thirst, and other febrile symptoms. Two years ago, while
feeling a little weak, small brown spots began to show
themselves on various parts of the skin of the groins, back,
and abdomen. He cannot remember whether one patch
preceded another, or whether they all appeared at the same
time. He has never had rheumatic fever, but when forty
years of age he suffered from three or four attacks of lum-
bago. His father was rheumatic, his mother not.
Examining the patient more particularly, it was found that
he complained of no pain, only of a troublesome itching
extending over the whole body. The skin generally is of a
pinkish-red color where not discolored, showing a deficiency
of pigment, gives off* abundant scales, and is universally
thickened, but more especially so on the legs, where it pre-
sents the appearance of ichthyosis. Symmetrical brown
patches, as large as two hands, are observed over each
shoulder-blade, and which extend across the median line;
4(>2 Cutaneous Discoloration*. [June,
another large patch surrounds the neck, and extends sym-
metrically up to the face, which is uniformly dusky, pre-
senting no patches. Symmetrical patches occupy each
axilla, extending forwards to each nipple; there is a simi-
lar patch around the umbilicus, and also in each groin.
The superficial lymphatics generally are enlarged in the
groins, both above and below Poupart's ligament, in the
axillee, at the elbow, and in the neck behind the sternomas-
ioid. There is also an enlarged moveable gland over the
left tenth rib.
The head is covered with hair, which is almost uniformly
white, contrasting with his dusky face. The facial and
other characteristics are those of a degenerate form of the
gouty or rheumatic diathesis. The lips do not exhibit any
peculiar pallor.
The blood was examined microscopically, and found to
contain an abundance ot white corpuscles. (Leucocytosis.)
A cardiac murmur is heard with the first sound, loudest
at the apex; pulsation visible in the neck ; pulse G9; the
appetite is good; the bowels regular; urine abundant, of a
light amber color, with the normal amount of chlorides,
and affording no traces of albumen or sugar. As the
wards were closed for the autumn shortly after his admis-
sion, the termination of the case was not observed.
In this instance the symmetrical deposit of pigment in
certain spots of the skin, and its absence in others, is the
most striking point. It is also to be classed with Case Xo.
I. in regard to the affection of the glandular system. The
melasma presents resemblances to that observed in some of
the recorded cases of bronzed skin. Thus, in No. G of Dr.
Additon's cases,* the patches of discoloration were asso-
ciated with patches of leucopathia, in which the skin pre-
sented " a singularly white or blanched appearance : the
hair upon these patches were also " completely white." The
axillee and groins are also very commonly the seat of dis-
coloration in Addison's disease, and in some of the cases B
symmetrical deposit has been observed, as in this. Sym-
metrical deposit is not confined, however, to these consti-
tutional forms. In chronic peritonitis and chronic struc-
tural diseses of the abdominal viscera ot' all kinds, it is not
uncommon to find a darkened hue of the skin of the abdo-
* On the Constitutional and Local E of the Supra-renal
Capsules, p. 2~>.
1861.] Cutaneous Discolor ations. 4G3
men, approaching in sonic case- to a deep tint of Indian ink.
In one of this class (evidently cancerous) which Dr. War-
burton Begbie kindly brought under my notice at the
Edinburgh Royal Infirmary, there was not only this pig.
ment-deposit in the skin of the abdomen, but it extended
symmetrically downwards along the groins to each thigh.
" Desquamative Melasma. The desquamation in Case No.
II was not pigmented. There are cases, however, in which
the scales either contain or excrete abundant pigment.
Schilling* mentions the ease of an infant with previous
k* hyperemia " of the skin, whose entire surface was covered
with a lamp-black matter, which came oft* with the linen.
The following presents one of these forms of pigment-
deposit.
Case III. Xigrities of trunk with extensive desquama-
tion (pityriasis versicolor) ; eczema ; yellow bronzing of face ;
profound ameniia. Elizabeth Fleming, aged sixty-six, ad-
mitted into the clinical wards May, 1856. On admission,
physical signs of bronchitis, with slight consolidation of
lung, blowing stystolic murmur loudest at the base, oedema
of legs, recurrent headaches, and attacks of diarrhoea.
On the surface of the bod}- were the remains of an ecze-
matous eruption, the lips very pale, face and hands strik-
ingly anaemic, but of a pale straw color (yellow bronzing),
contrasting strongly with the hue of the arms, trunk and
extremities. These were of various shades of bronze and
black ; bronze on the forearms and legs, but deepening
upwards towards the trunk, which was very dark, and, in-
deed, almost black in the axillae and over the abdomen.
Al she recovered her health under chalybeates, wine and
generous diet, desquamation came on, and the epidermis
came off in dark flakes, leaving the skin paler, but of its
natural hue. Xo sporules of the pityriasis fungus (the mi-
croscoporon furfur) could be detected. The skin over the
abdomen and other pigmented parts was mottled over with
pale spots, which had evidently been the seat of the ecze-
matous eruption. This was a second attack of the kind, for
the patient stated that five years previously she was simi-
larly affected, and that it ended then in desquamation.
This case presents an obvious point of resemblance to the
two preceding in the circumstance that leucopathia, from
* De Melanosi. p. 83.
464 Cutaneous Discolor ations. [June,
the inflammatory affection of the skin, was associated with
the nigrities. In other words, that some morbid condition
of the skin caused a deposit in one portion of it, while
another morbid condition prevented the deposit. In the
blood condition there was also a point of resemblance.
Visceral Melasma. The cutaneous pigmentation ob-
served in Addison's disease has been termed melasma supra-
renale. This term is "premature and objectionable, because
it assumes the accuracy of the theory which connects the
eutaneous pigment-deposit neccessarily with structural dis-
eases of the supra-renal capsules. In some of the cases
there is melanosis as well as melasma, and these two patho-
logical changes are, as we have seen, very distinct in their
nature. The general symptoms arc anamiia, gastric and
intestinal irritation, and various neuroses, as neuralgic
pains, convulsive movements, and mental despondency.
The following case presented these, together with melasma :
Case IV. Addison's disease ; intense swarthy bronzing;
recovery. Stevenson, aged twenty-nine, a ship carpenter,
from North Shields, was admitted into ward No. 1, on the
18th June, 1856. Naturally of a dark complexion, he pre-
sented nothing particular in this respect until the month of
August previously, when, without any serious ailment, he
began to be dark and yellowish in color, and was treated
for jaundice, without any alteration in his complexion.
Feeling pretty well, he engaged as ship carpenter for a
voyage, but hardly had been four days at sea before he was
seized with most violent vomitting and purging, accom-
panied with a feeling of great uneasiness in the lumbar
and right iliac regions. He returned from London (where
he was treated) to North Shields, and had another attack on
the way. Six weeks before admission he again engaged to
serve on board ship, but the first night he was seized with
a rigor, which continued a quarter of an hour, and was suc-
ceeded by a cold sweat. During this he became uncon-
scious, and was carried ashore in that state. Again, on
June 7th, he was seized with violent vomiting that con-
tinued four hours, and with purging and abdominal pain,
especially in the right iliac region, with great weakness,
headache, and total loathing of food. Has had seven such
attaeks. His complexion is absolutely that of a mulatto,
so that on admission he was taken for a man of color. His
hands and feet are brown, like his face ; dark patches in
axilla* and groins ; conjunctiva1 and nails white; the mucous
1861.] Cutaneous Discolor -ations. 46o
membrane of month and lips patched with dark inky spots;
the same spots seen on the side of the tongue. Tongue
clean, bowels costive, moved once in four or five days ;
pulse 80. feebl i : cardiac impulse leeble, and sounds very
faint. In left lung posteriorly crepitation. Hands very
cold and moist; feet cold. Complains of pain in the
spine at the level of the crest of the ilium. Under the mi-
croscope blood showed abundance of small white corpus-
cles. He was ordered the persesquinitrate of iron, wine,
and a generous diet, but diarrhoea came on and he lost
strength and weight, so that on 1st July he was reported
to have lost one pound and a half during the preceding
k. On that day he was ordered full doses of glycerine
daily, and in addition to the other remedies. He now be-
gan to improve rapidly in both strength and weight, so that
by the 14th July he was so much better in every respect,
except his complexion, that he went home convalescent.
This case was in all particulars so similar to the forms of
melasma accompanied with anaemia which JDr. Addison
has described, that I have no difficulty in classing it with
them. Of course it may be objected, that there was no
proof there was disease of the supra-renal capsules, because
there was no post-mortem examination to determine the
fact, and that as all true examples of the disease have al-
ways been fatal, the simple fact of recovery is opposed to the
diagnosis. I cannot admit, however, that every case present-
ing the group of symptoms known as " Addison's disease"
must necessarily end fatally, or that the concurrent disease
of the capsules is necessarily structural ; nor is it a legiti-
mate exercise of the art to establish no diagnosis except by
examination after death. The case presented all the path-
ognomic symptoms of Addison's disease, and ought there-
fore to be placed as such nosologically.
There is one point in the history of the melasma in these
cases of considerable clinical importance. The morbid con-
ditions which lead to the pigment-deposit may be removed,
and yet the deposit itself may remain ; or, in other words,
the primary disease may be curable, but the melasma be
permanent or incurable. A patient (Lawson), aged fifty-
four, was admitted into clinical ward No. 1, under my care,
in profound anaemia, apparently the result of starvation.
His color was universally of the swarthy hue of a mulatto,
but deepest in the face, lie spoke with the strongly
marked Scotch accent, or he might have passed for a Las-
30
466 Cutaneous Discolor ations. [June,
car just arrived. To all inquiries as to his color, he only
answered that his mother told him he was white until he
was four years old, when his skin changed to dark after
an illness. It is possible that the maternal history may
have been a myth, for Le Cat quotes a case in which the
blackness of the child of a lady was attributed to her hav-
ing seen a negro. A case related by Dr. Parkes of this
kind, is, however, conclusive: A man, aged fifty-nine, was
treated in the University College Hospital for jaundce.
He left the Hospital apparently well ; but four or five
months afterwards portions of the skin became gradually
dark first on the face and neck, then in patches on the
body, arms and thighs, until the hue was very deep. For
five years afterwards no change in tint took place, when he
was again admitted into the hospital (seven years after the
attack of jaundice), with ascites dependent on contracted
liver. At this time he was like a mulatto, there being only
slight variations of tint on the face, neck, shoulders, and
arms ; but over the trunk, and especially the abdomen,
thighs and scrotum, there were white patches (melasma
leucopathia) ; below the knees the skin Avas of its natural
tint. There was a little pigment on the conjunctiva, and a
dark patch on the mucous membrane of the lips. ISTo ex-
cess of white corpuscles or free pigment were detected in
the blood. After death pigment-deposit was found be-
neath the epithelium of the peritoneum (melanosis). The
supra-renal capsules were found to be perfectly healthy.
JN'ow, in this case the pigmentary changes were consequent
upon the attack of illness which occurred seven years before
death. If they had depended upon supra-renal disease (which
may have been the case), then that had evidently been of a
curable character, and the organs had been restored to a
healthy condition. In any case the melasma and pigment-
deposit were exactly like that which occurs in "Addison's
disease," as Dr. Parkes very truly observes." We may,
therefore, conclude from these examples (and others might be
added) that melasma may occur in whites as a permanent
coloration of the skin, resembling that of the colored races in
all essential particulars ; and although the result of the dis-
is not itself a morbid 6tate.
Yellow bronzing. 1 have hitherto described more espe-
Medical Tiinesand Gazette, Dee. 11th, 1858.
L861.] Cutaneous Discolor ations. 467
jially the cases of morbid pigmentation in which the discol-
oration was swarthy or dark. In Case III., however, although
.warthy on the trunk, it was yellow on the face. As these
?ases of yellow bronzing are little understood, yet more com-
non even than the swarthy, the discoloration requires a more
particular investigation than it has hitherto had. For example,
in all the recorded cases of " Addison's disease," the swarthy
tint has, I believe, been exclusively looked for and described,
so that examples of supra-renal disease in which the discol-
oration was yellow have been recorded as instances in which
there was no pigmentation whatever. That yellow discolora-
tion of the skin is as possible an occurrence as black discolora-
tion in diseases of the white races is clear from the simple
tact that the races of mankind of a yellow color, or of yellow
shaded with brown, are as numerous as the swarthy or dark
races. The complexions of the numerous and widely-spread
Mongolian race and of its various offshoots and branches have
yellow as a basis. When, however, such yellow tint (known
llowness) has been observed in various morbid states as
icterus, hepatic and splenic diseases, chlorosis, scrobutus, can-
cer, tertiary syphilis, and the like, the change has not been
connected with morbid pigment in the epidemic cells, but
exclusively with morbid states of the blood. Now, that it is
often due to these is certain ; but there are numerous facts
which incontrovertibly show that this doctrine is wholly in-
sufficient to explain all the phenomena of the discoloration,
even in those of a pure case of icterus, when bile can be de-
tected in the blood.
Before we can form a correct diagnosis in the class of cases
in which there is a morbid deposit of a yellow or xanthous
pigment analogous to the swarthy, we must examine more
carefully the order of the symptoms upon which our diagnosis
lid be founded. Ordinary swarthy bronzing (as in " Ad-
dison's disease") is easily mistaken for the tint of biliary dis-
: by the inexperienced eye; now, the condition of the
blood in the vessels is our guide in these cases. If the con-
junctiva be white and pearly, the nails white, and the mucous
nembranes very pale, it is inferred that the discoloration is
ot due to biliary disease, because bile-tinted blood gives a
ellowish tint to the conjunctiva, nails, and mucous surfaces.
)n the other hand, a careful examination of the discoloration
that the color is not in truth that of a diluted bile be-
lt too dark, but rather of diluted Indian ink. Cases of me-
ns may, however, present this swarthy complexion ;
ut for the most part the diagnosis of the tint in " Addison's
468 Cutaneous Discolor utions. [June,
disease'' from that of hepatic disease may thus be made.
Now, ir is obvious the diagnosis of yellow bronzing must be
made on the same principles, but more weight is necessarily
given to the pallor of the conjunctiva than in swarthy bronz-
ing, and less to the differences of tint, because the sallowness
pigmentation differs little from the sallowness of the
icteric tint.
1 would not, however, be understood to regard the color of
the conjunctiva as an absolute guide in diagnosis, for it is also
pigmented in the colored races as well as the skin, and there-
fore there may be pigment-deposit in it in disease ; and we
have seen that this occurred in Dr. Parkes' case, before
quoted. It is not difficult to understand how this may be.
The conjunctiva contains all the elements of the skin, for the
eye itself, qua development, is a skin product. Hence, not
only pigment may be deposited therein, but hairs may grow
from it. My friend, Mr. A. M. Edwards, lecturer on surgery
in Edinburgh, showed me an interesting illustration of this
fact, in a portion of conjunctiva with the hairs attached,
which he had removed from the eye of a girl, aged eighteen,
in whom the deformity was congenital.* Tnese observations
equally apply to the color of the buccal mucous membrane
and of the tongue, as both these surfaces are normally the
seat of swarthy pigment-deposit in lower animals. It may bo
objected, that the presence of bile in the urine, its absence
from the faeces, and other circumstances, may serve equalh
well, as the color of the surfaces indicated to diagnose morbic
pigmentation from biliary blood ; but in practice it happen:
that the most difficult cases for diagnosis of this kind are jus
those in which there is simply a bilious tint without any im
portant or noteworthy change in the secretions.
Yellow bronzing may pass into swarthy bronzing, or b
conjoined with it in as in Case III., or it may be symmetrica
Le Catf quotes cases of this kind from the Journal Encycl
pedique, for March, 1744. A man had an apoplectic attad
after being x^ry angry, which ended in hemiplegia of til
right side ; at the same time this side of the body becarf
completely yellow, without excopting the right half of t,
nose Another man, addicted to drunkenness, experienced
painful feeling of numbness on the right side ; when it pass!
.ii account of the case, and reference to others, may he found in
: er number (1800) of the Edinburgh Veterinary Review.
t Ti ait de In Couleur do hi Peau Humaine, p. 108 et sc
1861.] Cutaneous Disc.olorations. 4G9
off, the face became green, the right side black, the left side
yellow. The urine was sometimes black, sometimes green.
Having taken salt o\' wormwood (carbonate of potash) for
ral days, the color changed, the face and the right side
became yellow, the left side black. h\ about twenty days a
yellow tint only remained, and this gradually disappeared.
These are not, by any means, solitary cases, but it is unneces-
sary to multiply examples. The following illustrates yellow
bronzing in a case of supra-renal disease, expressly recorded
by tW reporter, as being opposed to the conclusions of Dr.
Addison :
Case Y. Yellow bronzing; disease of supra-renal capsules ;
multiple cancer. Leclerc, a laborer, was admitted into the
Hospital Beaujon, April 3d, 1S56, under "M. Gubler. His
previous history could be ascertained with difficulty on ac-
count of his remarkable " insouciance," but two months pre-
viously he was attacked with a painful feeling of distension of
the abdomen, loss of appetite, occasional vomitings, and habi-
tual constipation. He became pale, and thin, and weak, the
abdominal pain increased in violence, recurring in paroxysms,
and for a fortnight before his admission he had been confined
to bed.
On his admission, the most striking characteristics were his
extreme thinness, and the remarkable pallor of the surface,
which also presented in a remarkable degree the yellow
straw tint [feinte jaune-paitte) of the " cancerous cachexia."
No icterus, the sclerotica being of a very pure white, no trace
of bronzed discoloration or vitiligo ; bellows murmur in the
neck ; cough, with expectoration of greyish sputa ; abdom-
inal symptoms those of cancerous disease ; urine of an ochre
yellow, and containing uric acid, no albumen nor sugar.
As the disease advanced the yellow tint became deeper and
deeper, the epigastric pain more intense and cons! ant, and ex-
tending thence to the base of the thorax and the lumbar
region. A little to the left, and below the umbilicus, two
tumors appeared which were the seat of a powerful impulse
and loud murmur. The patient died twenty days after ad-
sion.
The post-mortem examination showed that, although the
liver was very voluminous, and the substance matter hypertro-
d, bile had been freely secreted, for there was abundance
it in the biliary canals; the gall bladder was large and
filled with greenish bile ; and although the common duct was
surrounded by cancerous masses, its calibre was rather in-
creased than diminished. The stomach, pancreas, and supra-
470 Obscure Trunk Pains. [June
renal capsules were the seat of cancer, as were also the mes
enteric and dorso-lumbar glands. The spleen healthy and
small ; the kidneys large, anaunic, but not cancerous. No
examination of the blood. *
In this case the post mortem condition of the liver and bile-
duct was conclusive as to the correctness of the diagnosis dur-
ing life namely, that as the schlerotic was of a pure white,
there was no icterus. The yellow bronzing could not be due,
therefore, to the presence of bile in the blood, while the ex-
treme pallor showed it was not owing to change of color in
the blood-corpuscles. Hence the only remaining conclusion
that it was caused by pigment-deposit.
The examples of yellow bronzing are so common in prac-
tice that I need only leave it for further and closer observa-
tion, as a true form of morbid pigmentary change. But I
may remark, by way of caution, that while the coloring mat-
ter of the bile will give a yellow tint, it must not be forgotten
that a thin layer of blood corpuscles separated upon the der-
ma, will also stimulate yellow bronzing. The most familiar
illustration of this is to be found in bruises or in scorbutus ;
but it also takes place in yellow fever, and, perhaps, other
forms of fever not, however, to the exclusion of biliverdin.
Amongst the most interesting forms of morbid pigmentary
changes, are those which are associated with emotional states
of the nervous system, or with peculiar conditions of the
genitory-urinary organs. They may be termed the neutrose
forms, but as the entire group requires special and detailed
examination, I shall reserve the consideration of it for a
separate paper. British and Foreign Medico- Chimrgical
Review.
[to be concluded in our next.]
Obscure Timnk Pains ; or, Chronic Pains in the Abdominal and
Thoracic Walls. By James Jago, M. D., Oxon, Prysician
to the Cornwall Infirmary.
The great multitude of patients who seek advice on ac-
count of obstinate pains in the walls of the chest or of the
abdomen, and the obscurity that frequently hangs over the
M. Ferreol ; Gazette Hebdomaire. August, 185'
L] Obscure Trunk Pains. 471
origin of their sufferings, must always claim the indulgence
of "the physician for any attempt to throw another ray of
light on their modes of production. I shall, therefore,
venture a few remarks on the subject, premising that these
will be of an elementary character, chiefly aiming to show
that the weight of the upper portion of the frame often con-
tributes to engender Bufferings in those parts, in ways not
commonly suspected ; and that thus there may be simple
means at hand of affording relief in cases beyond the reach
of drugs. Whilst such is my main purpose, I may be
tempted to illustrate the views submitted from collateral
sources.
It is an old remark* that rheumatism is oftener found
associated with the tendinous and aponeurotic continuations
muscles, especially at the junctions of these with bone, than
with the muscular fibre itself. And Dr. In man, of Liver-
pool, has ably maintained"}" that much of the pains expeu-
enced in the structures now mentioned are due to a stretch-
ing of fibrous tissue by the contraction of muscle, or by its
excessive tension produced by any othermeans. He elabor-
ately distinguishes between the pains thus engendered in
the muscular fibre, as cramp or spasm, and those resulting
from strain along the line of osseous attachment, or line of
union between the muscular and tendinous fibres. And he
insists that in a weakened condition of the animal system
the muscles are more liable to cramp than in a robust,
and pain more likely to be felt along the said lines of junc-
tion.
Xow, I have no further exception to" take against this
doctrine, but I do not think that it embraces the whole
series of such kind of pains as it aims at accounting for.
I would affirm rather, in general language, that all the
tissues of the body in their several degrees become painful
when they are either stretched or compressed ; in other
words, that there is a state of equilibrium for the structures
throughout the animal frame, which is the only one in
which they remain free from pain; that the amount of suf-
fering consequent upon the disturbance of this balance of
opposing forces depends ordinarily upon the extent of the
lacement, or the time during which it is kept up, that
*Copel:m<r< Medical Dictionary, vol. iii, pp. 616-9.
al irritation, or Myalgia, 8vo, 1858; second edition. 1860.
472 Obscure Trunk Pains. [June,
is, making allowance for the higher nervous endowment of
one part than another, and taking for granted that in such
a case the structural points to which the nerves of common
sensation, or their ultimate subdivisions are distributed,
alone be squeezed or stretched: for if a nervous trunk be
thus affected, painful phenomena will, of course, accrue,
radiating beyond the point mechanically interfered with.
To explain what I have just stated by example. In a po-
sition of case, the hand rests pretty much flexed. But, if
we spread it flat upon a table, we soon begin to feel incon-
venience from the tension of its skin and other tissues.
And if we close the lingers tightly upon the palm, we soon
find their tops in the fist becoming sore.
Or I may take another example, which may be regarded
as furnishing an epitome of the principles I wish to supply
in this paper. The eyeball is a globe suspended, as it were,
by its muscles, in a fatty bed, and rotated so gently and
equably as to preserve usually its proper form. If we make
the slightest pressure of the finger through the e}-elid over
the sclerotic coat, we become informed of the compression
of the retina along the line of greatest flexure by a lumin-
ous image of the contour of the applied portion of the
finger ; whilst we feel pain along the corresponding portion
of the occular globe the visual sentient elements in which
the optic nerve ends, manifesting in this way the effects we
experience in the tactile sentients. In like manner if we
strain the eye by resolutely staring in a given direction, the
orbital muscles warp the globe out of form, the false im-
pressions of light result, and the power of seeing external
objects is almost obliterated, whilst the orbital muscles are
thrown into spasms, insomuch that Ave have a feeling of
soreness and fatigue in them, with a tenderness of the ball
itself, for many an hour after the experiment. Even any
lengthened exertion of the eyes in our habitual occupa-
tions is attended with such results in an appreciable man-
ner.
These illustrations will, I hope, help to a readier appre-
hension of oar peculiar liability to sufferings of this order
in the regions of the thoracic ami abdominal walls, if it shall
be made to appear lliat these are very variously exposed to
he forced out of the position of structural balance, and that
force applied hereabouts in one part often entails a displace-
ment of the greatest magnitude in some others, in a manner
that is not usually thought of.
1861.] Obscure Trunk Pains. 473
Let ua imagine, as a rough approximation, all the human
body, exclusive of the lower extremities, in the sitting pos-
ture, as a heavy lever or abeam revolving about tubcraischi-
orum, as an axis of fulcrum. And let us assume that the
centre of grauity of this beam lies between the middles of
the i Then in the upright sitting position the whole
ght of the beam falls upon the tubcra. In the horizon-
tal the weight will be borne up distributed along the
whole length from the head to the buttock. If we recline
so that the back rests at some point against a prop, we may
rind the portion of the weight supported by the prop, by
drawing a perpendicular to the beam at the point of con-
tact with the prop, and then a perpendicular to this line
from the fulcrum, as also a perpendicular from the fulcrum
to a vertical line passing through the centre of gravity; when
the pressure upon the prop will be to the wdiole weight of the
beam, as the latter of the perpendicular let fall from the
fulcrum to the former. Thus, the nearer to the buttock the
prop is placed, and the more the body is made to recline,
the greater pressure falls upon the prop. Whilst it is ap-
parent that should we, whilst w^e sit, lean pretty much back
against a single prop meeting the spinal column at any
point whatever, a considerable pressure must be endured
by that part of the body in contact with the prop, which is
a general statement sufficiently accurate for the purpose of
a practical essay like the present.
Xow let us further assume that the back whilst we sit is
supported entirely by two props of equal height,and several
inches asunder, bearing each, similarly, against one of a
pairaf ribs. In this instance pain from compression w^ould
be felt at the points of contact, as is obvious. But there
result also certain secondary effects which, I think, we are
apt to overlook. The two ribs are made to revolve by the
pressure upon their vertebral articulations, and the numer-
ous ligaments that bind them to the vcrtebne and neigh-
boring ribs are stretched, and pain is occasioned in those
parts. In addition to which, this movement causes an
alteration in the shape of the ring made with the interven-
tions of the vetebral column, their cartilages, and the ster-
num by the pair of ribs. Had such a ring as this been of
uniform texture and shape all around, one effect of letting
it bear merely its own weight upon two of its under points
in the manner here imagined, would be that of fiatteningthe
ring above. In such a combination of structures as do
474 Obscure Trunk Pains. [June,
exist in these rings, the result must somewhat differ. Yet
we may be sure of this much, that, in the cases before us,
much displacement must occur along the most pliant part of
the ring that is, along the cartilaginous portion, and at
the articulations of their cartilages with the sternum ; for
the costal rotation at the spine tends to bring the sternal
ends of the ribs nearer to each other, that is, to bend them
at their junction with the sternum, independent of the
weight of the upper portion of the ring depressing that
Lon. In other words, pain would be developed at other
parts than those where the direct pressure is applied.
Had we placed the two props much further apart, and so
as to take the weight of the trunk at the back part of a
lower rib on one side, and of an upper one on the other,
consequences very similar to those detailed in the case of a
pair of ribs must have ensued. The ribs would have been
pressed in upon the lungs behind, the cartilages would
have been bent, and the sternum itselt in young subjects
at least somewhere along the imaginary lines drawn di-
agonally across it, that joins the articulations with the ster-
num of the two ribs selected. This may be regarded as a
general sketch of what takes place in such an experiment;
but it must not be forgotten that a pressure received by any
rib will, in some degree, be transmitted to adjacent ones.
And it can scarce need to be added that if our back be
supported at more than two points, or even along its whole
length, the effects here described will only be diminished
in amount, and not be entirely obviated.
Now, in the sitting posture, if the support of the back
happens to be a flat surface, as in a church pew or box in
a theatre, the back rests against the shoulder-blades, that
is, virtually the upper ribs ; and ((fortiori, it the support for
the back consists, as in most chairs, of a series of a few
horizontal concave bars, the ribs are likely to have to bear
at a distance from their vertebral articulations, a large
amount of pressure. In weakly persons such a posture
produces not to dwell on that occurring posteriority
Bufferring in the anterior part of the chest, especially along
the margin of the sternum. For not only from what has
been stated must this happen, but in addition, the thrusting
forward i f the -boulders renders the pectoral and great ser-
rate muscles lax, and thus deprives the ribs of the support
due to the elasticity of these inspiratory muscles, increasing
liability to the kind of inconvenience we are discussing;
1861.] Obscure Trunk 475
whilst a con lined play ot' the respiratory movements is in-
duced, entailing other evils. Even lying upon the back in
bed more completely still if soon a hard mattress without
elasticity enough to expand itself decidedly against the
spine along the interscapular gutter will leave the scapulee
that is, the upper ribs to bear a weight at least equal to
that of the whole thorax, and will occasion a strain along
either margin of the sternal gutter.
Having considered some effects upon the thoracic walls
of flexure in a plane perpendicular to the spine, let us now
turn our attention awhile to flexure in planes passing
through its axis.
We will take first the case of a person sitting on a chair
whose back does not rise to his shoulder-blades. As he
reclines, the centre of gravity of the beam falls above the
point of support, and the beam is only prevented from lift-
ing at the bottom by the weight of the lower extremities.
Indeed, did we propose to break a stick over the back of the
chair, we should pufit under the same conditions, confine the
end of the shorter branch, and apply our strength (the
weight of the head and shoulders in the example of the
beam) at the end of the longer one. We see the stick split
on the side opposite to that which rests on the fulcrum, be-
cause the forces applied tend to lengthen that side, and strain
most those fibres which are most remote from the fulcrum.
Just so the whole line of tissues along the paths of the recti
abdominis muscles and the sternum, from the pubes to the
clavicles, are laid under extreme tension; the ensiform car-
tilage and the whole sternum is depressed towards the
spine, and the pleural cartileges warped. And pain again
befalls the region.
It maybe appended that the actual fixed point at which
the trunk curves backwards is not where the spines of the
vertebra? are in contact with the back of the chair, but
rather at the posterior margins of the bodies of the said
vertebra?, and that* the spines gather nearer together and
the skin of the back into transverse folds, as we may have
observed the skin covering the stick, being broken as above
to do on the side next the fulcrum, because the fixed point,
or the unstrctched longitudinal fibre, is at the back of the
c itself. Again, if the sole transverse portion of the
chair-back consists of one bar at the height, say of the root
of the sitter's neck, unless great muscular effort be made,
the weight of the loins and thorax would cause tlie trunk
47 G Obscure Trunk Pains. [June,
to become convex behind, just as occurs when we stoop to
pick anything from the ground ; and we know how liable
such a stretching of the lumbar muscles is to be followed by
crick, and that it always takes a good interval to recover
from the soreness resulting from a prolonged stooping pos-
ture. JSut as the line that undergoes, in this instance, no
changein length, is somewhere along the anterior edges of
the vertebra1, the lower end of the sternum is brought much
nearer than before to the pubes, the contents of the abdo-
men pressed up towards the cavity of the chest, and the
abdominal muscles project forwards and cover the ensiform
cartilage, so that this, by their support, takes some of the
weight of the head and neck, and may thus be flexed, de-
pressed towards the spine, carrying with it the lower costal
cartilages of the left side, rather than those of the right,
which are supported by the liver. So that this very pain
may be produced in the district so much exposed to this
misfortune.
If we press upon the sternum directly, as in leaning over
a table to write, we may push it towards the spine and bend
the attached cartilages. If we curve the trunk laterally,
as in leaning on a table sideways, we stretch the opposite
oblique muscles, and may occasion pain either at their up-
per costal insertions or at their lower pelvic. The same
effect may follow by lying in a bed ; for on the side on
which we lie, by the weight of the lumbar portion of the
trunk, the natural concavity of the waist tends to become
obliterated; for this portion of the body is now primarily
supported at the brim of the pelvis and lower true ribs.
I must here conclude my anatomy of trunk pains, as I
believe I have indicated the fundamental way in which the
commonest of the chronic kind are generated. It were an
indefinite task to work at exhausting the subject. The
weight of the arm may make the muscles of the shoulder
ache; and it is conceivable that one might write a separate
history of the sufferings of all the muscles of the trunk.
Besides, the effect of the compression or weight of clothes
might be expatiated upon. Such effects as these, I pre-
sume, are likely to he detected with little difficulty, by
those familiarized with scrutinizing the sources of the pains
in the thoracic and abdominal walls, by first eliminating
those that may arise in any of the modes above described.
A- far as I haveheregone I am persuaded thatlhave nottrans-
secl the bounds of clinical experience, and that there is
1861.] Obscure Ihmk Paww. 477
not one of the ways of suffering just pointed out, which I
have not met with in several instances; and seen relieved
simply by precautions against the strain that occasions it.
To give cases in detail would only be repeating in the
form of narratives the foregoing explanations, sol will con-
tent myself with a simple sketch as a type of the class. I
once had to think for a young gentleman of rather studious
habits, of a slender symmetrical figure, but enjoying good
health, except that he was rendered miserable by attacks of
pain at the sternum, and along the cartilages of the ribs,
commonly about the lower end of the sternum, though
sometimes higher up a condition of things that existed for
two or three years in spite of tonic and other medical treat-
ment. But he having himself observed that he had once
been extremely afflicted after pressing the epigastrium
against a table in drawing, it soon came to light that all his
sufferings arose from posture. Even lying upon his back in
bed was found to bring on a fit of pain, and resting his
back against any support that threw the weight rather upon
the ribs than the spinal column did the same. He now
soon got rid of all his troubles by habitually supporting his
back, when studying, at the spine. I omit to state how, as
I mean to consider the best mode of doing this in another
part of this paper.
Perhaps it may not be superfluous to subjoin, that such a
relative depression of a rib with respect to those next it, as
may happen when it has to bear undue pressure in some of
the modes above treated of, may sometimes expose the trunk
of an intercostal nerve to squeezing or stretching. These
nerves are, indeed, curiously lodged in grooves along the
lower borders of the ribs, which guard them from accident;
but they traverse a short space from the spine to enter theso,
and do not seem to lie absolutely safe from mechanical
injury. I am not sure that I have not met with cases of
neuralgia shooting along their paths from this cause, wherein
no spinal deformity existed. It is the nerves most unpro-
tected against pressure and cold that appear most liable to
neuralgia. I am confident I have known sciatica to be en-
gendered by a habit of sitting sideways, in a partially re-
cumbent manner, on a sofa or chair, so as to squeeze the
sciatic nerve at its emergence from the pelvis into the thigh;
and several instances in which a fit of tic doloureux has
followed a nap upon a book or some hard thing for a pillow.
Nevertheless, these nerves cited in illustration are oftener
478 Obscure Trunk Pains. [June,
affected by their exposure to great differences of tempera-
ture, since even the sciatic, by careless sitting upon sur-
faces which rapidly conduct heat, are subjected to such
vicissitudes.
In juxtaposition with the reflections with which this paper
sets out, though I would be chary of applying them too far,
I ' have reason for surmising that there are some ailments
whose sen is arc among the abdominal or thoracic viscera
themselves, instead of in the trunkwalls, which can only be
understood by such rudimentary considerations. I will
touch upon two or three rarer examples which have fallen
under my own notice.
A while since a woman of about 36 years of age became
a dispensary patient of mine, for what, prima facie, seemed
to be a form of gastralgia common enough among such
patients. She asserverated that she literally feared to eat a
full meal, so greatly did she suffer pain at the pit of the
stomach, which radiated alongthe lower border of the thorax
for an hour or more after a meal; that she had become
very thin in consequence of enforced abstinence, and that
several medical men had failed to give her any relief.
Though her affirmed loss of flesh seemed justified by her
appearance, and her look of distress was great, yet she had
not the aspect nor any of the prominent symptoms of organic
disease of the stomach ; there was no chain of evidence to
convict it of scirrhus or ulcer. It was not until I had ex-
hausted in vain all the current remedies for facilitating di-
gestion that, upon a more deliberate sifting of the symp-
toms, I ascertained the curious fact that if she went to bed
immediately after eating supper, this meal gave her but little
inconvenience. Thereupon I directed her to lie down after
all her meals, and to eat good solid dinners of animal food
and vegetables, drinking bottled porter with them. With
some difficulty I got her to persevere in this practice, and
she was not many weeks before she was convalescent.
Xow, we cannot imagine that mere distension of the
stomach occasioned the suffering, because the recumbent
posture could not obviate such an effect ; nor that there was
an abrasion of the mucous membrane so placed in the or-
gan as to be brought more into contact with the food in
one posture of the body than another, for whatever may
have been fancied to the contrary, the pressure of the at-
mosphere must keep the stomach always closed tightly
'upon its contents. It seems to me that the pain was evolved
1861.] Obscure Itunk Pains. 479
through the weight of the meal by traction upon the
diaphragm at the cardiac orifice possibly, but mainly by
traction upon the liver by the lesser omentum, and thereby
upon the xiphoid and costal cartilages uniting with it. I
would compare the case with the two following.
About the same time I had under my care two cases par-
allel to each other in all essential particulars. The first was
that of a miner who had been for more than half a year
under treatment for what he described as a most severe,
pain along the margin of the cartilages of the lower ribs on
the right side, extending from the edge of the liver down-
wards, through the abdominal wall, and penetrating, he fan-
cied, inwards. He shrunk when I touched, the abdomen over
the parts referred to. It was only with difficulty he could stand
upright, or walk, or rather crawl about. Being unable to
discover anything amiss with the liver, or indeed, at first
view, any general sign of ill health, except lack of flesh, I
commenced a devious examination of his body, and, to my
surprise, found that he had effusion into the pleura, not on
the side complained of, but on the left. Posteriorily and
laterally the bottom of the chest on this side was much dull-
er on percussion than on the corresponding portion of the
right side, notwithstanding the hepatic dullness here exist-
ing. At the same time respiration on the left was barely
audible at levels, where on the right it was very so ; and
fremitis on the left was almost as barely perceptible, whilst
the intercostal spaces protruded. By putting him under a
succession of blisters over the diseased region, instead of, as
had before been done, over the region of pain, with iodide
of potassium, diuretics, and then tonics administered inter-
nally, the physical signs of effusion soon began to diminish,
and with this the pains in his right side.
A few months afterwards a once stout and lusty smith,
who had been working in London, returned to Cornwall in
a very weak state, wasting and laboring under excessive
pain at the right hypochondrium, and spreading over the
abdomen, which pain he accused as the sole cause of his
troubles. He had been perfectly well until about six
months before, when, after an imprudent exposure to a pierc-
ing cold draught of air, he became suddenly ill, his suffering
soon settling entirely on his right side. This man's story and
attitude reminded me so forcibly of the foregoing case that I
at once examined his chest, and discovered more strongly
marked symptoms of pleuritic effusion on the left side than in
480 Obscure Trunk Pains. [June,
that of the miner a condition of things which, as in that
instance, had been overlooked. Be commenced, too, to
recover from the moment the true scat of disease was be-
sieged.
With respect to the propagation of the pain to the op-
posite side in this pair of eases, it seems to me that the
mode might have been thus: The fluid in the left pleural
sae would have nothing to sustain its weight beneath the
diaphragm but yielding viscera, consequently the left half
of that muscle would be depressed below its usual region;
but this could not happen without dragging downwards the
right half also that is, not without pulling dowards upon
the liver, and exerting a force to rotate it on its anterior
border from the costal cartilages which cover it. In this
way not only would these cartilages themselves be warped,
but the ligaments of the liver would be made abnormally
tense, and therefore, their peritoneal continuations along
the parietal abdominal wall be unduly stretched, as well as
such tissues as it lines. I venture on this conjecture on
taking common survey of the three cases last introduced,
under guidance of the more general principles on which
this paper proceeds.
Infra-mammary Pain. I must emphatically repudiate the
idea that I would offer the preceding propositions as a key
for opening the mysteries of all the aches we meet with in
the thorax and adjacentjparts. In such an affection as hys-
teria, for example, perturbation of all the other parts of the
nervous system are far too transparent for me to go so far
as to say that the tactile nerves, or such nerves, if they be
other than these, whose office is to inform of violence done
to the tissues, may not also be morbidly affected. Never-
theless, let us see whether the pain under the classic desig-
nation heading this paragraph admits of a plausible expla-
nation by the principles submitted. In the autumn of 1858
this pain was made atopic of discussion in the medical
weekly publications. Dr. Inman, Dr. Fuller, Mr. Holmes
Cootc,and others, took part in the debate. I do not know
that I can do better than take the main points at issue from
their statement.* The first of these writers, in reply to the
Ihave not access to the second edition ofDr. [nman's 'Myalgia;? I .ni
therefore unaware ifhe has therein made any new observations upon this
'WilnV
1861.] Obscure Jrunk Perns. 48J
second, who had asked him why the seat of a chronic pain
is more commonly in the left than in the right side, remarks:
"At one period 1 thought L could trace some connection be-
tween the locality of the pain and the position commonly
adopted by the sufferer; but alter a more extended inquiry
I have been obliged to consider the tarts referred to as in-
explicable in the present state of our knowledge
Mr. Cootet comments upon this correspondence. Pre-
mising that it is not to be doubted that it may have " more
causes thau one,'' he affirms that he lias noticed it to be
one of the very earliest and commonest symptoms of in-
cipient lateral curvature of the spine/' and he reminds us
that it had been recognised in this point of view since
the days of Delpech (citing his 'Orthomorphie,' tome ii. p.
10,1828); "a constant pain somewhat vague in its seat,
which takes place sometimes in the side of the chest ; its
duration is usually constant, but it is infinitely variable; in
its periods of calm and exacerbation have nothing regu-
lar: there is no disturbance of the functions of the organs
in the seat of pain ; nothing quiets it, nothing relieves it.
It is accompanied by slow, progressive, and inexplicable
determination of the state of health. It is evidently allied
to something grave but quite clandestine." Delpech then
instances a girl of 11 years thus affiicted, who, by means of
a plumb-line, was found to have a Blight lateral curvature.
*-The greater frequency of spinal curvature," Mv. Coote
may explain in some measure the obedience of
infra-mammary pain to the same law." Whilst thus sug-
ingthe curvature or the pain inclines to one side rather
than the other.
However, as Mr. Coote had (as recently as in the
Lancet, Oct. 23, of the same year) given a graphic sketch
of the course usually taken by spinal contortion, I will con-
tinue to follow him: kiThe curvature ganerally commences
in the upper dorsal region, and extends directly to the right
in one even sweep up to the junction of the lower dorsal
with the lumbar vertebrae ; then the direction of the ar-
ticulating surfaces is altered, and the movements of the
spine change from the lateral inclination to the artero-pos-
terior movement, as in springing; a second curve forms in
^British Medical Journal, Novembe]
tBritish Medical Journal, December 4th.
31
482 Obscure Trunk Pains. [June,
the lower region to the left, acccompanied with a rotation
and twisting of the vertebrae" lie then proceeds to quote
from the plates and descriptions of M. Bourvier (Physician
to the Children's Hospital, Paris,) explanatory of the pack-
ing of the viscera found on dissection of cases of confirmed
lateral curvature of the spine. Tims, in what he calls le
'premier plan, that of the above type, the latter says the
"lungs are apparently not much deformed, when viewed
anteriorly. But the right is reduced in height, its base be-
ing pressed by the abdominal viscera; the left has its in-
ferior lobe compressed between the ribs and the heart. The
heart is voluminous and closer than natural to the ribs of
the left side. The liver is much deformed, deeply fissured,
and, as, it were, mounted (a cheval) on the crest of the
ilium."
Now, it is worthy of consideration whether we may, by
chance, find the cause of the preference of the line of
lateral curvature for one tide of the body rather than the
other, in a difference in the compressibility of the viscera
that are lodged against the parietes of the respective sides
If there be any just foundation in this notion, the only organ
within that seems at all capable of affording a relatively
greater support is the liver. This is a firm, resisting mass,
tilling the whole of the right hypochondrium ; and if the
spine becomes drooping and weak, or its muscles no longer
able to sustain the upper portion of the body erect ; if the
vertebral column begins to yield, so that a weight that it
should carry becomes cast upon the viscera, it seems not
absurd to regard it as not improbable that the circumstance
of the left lower ribs and cartilages covering compressible
lung and stomach, whilst the right are supported all along
within by a much firmer body, may be the means of caus-
ing the chest to arch inwards on the left rather than the
right.
The details of M. Bouvier give strong countenance to the
idea that the left pleural cartileges are more liable than the
right to be warped out of shape by any of the modes sug-
gested in the beginning of this paper. And thus the left
side will be more frequently the seat of pain than the other.
Bv whatever cause of ill health the general strength fails,
this liability will be more remarked. This seems a neces-
sary consequence of the manner of stowing the more mas-
sive viscera in the chest and belly. We may assert this
much without pushing our conclusion so far as to assume
1.] Obscure Trunk Pains. m
that infra-mammary pains can be of no other order. I can
well conceive that the rite of the liver may determine that
we are not left but right handed, because the pectoral and
other muscles that move the arm or shoulder upon the trunk
have, through the hepatic support, steadier points of resist-
ance on this side than the other : for this organ manifestly
plays an important mechanical as well as a more purely
glandular part, in the economy.
Having so nearly approached the subject, perhaps I may
be permitted to say a word or two on the thoracic distortions
in rickets. Dr. Jenner* speaks thus: "The deformity of
the greatest interest to the physician is that of the thorax.
The back is flattened. The ribs are bent at an acute angle
where the dorsal and lateral regions unite. At that part
the lateral diameter of the thorax is the greatest. From it
the ribs pass forwards and inwards to the point where they
unite with the cartilege ; on that line the lateral diameter
of the thorax is the least, the cartileges curving outwards
before turning in to unite themselves to the sternum. The
sternum is thrown forwards, and the antero-posterior diame-
ter of the thorax is abnormally great."
The great determining cause," he afterwards subjoins,
the thoracic deformity is the atmospheric pressure ; this
is aided by the elasticity of the lung, and the fact that the
more resistant viscera underneath are obstacles to recession
of the chest-walls where they lie. It appears to me diffi-
cult to account for the "acute angle where the dorsal and
lateral regions unite,'"' or the flattened back by such dif-
fusive pressure as must be produced between the air without
and the air-containing elastic lung within. On the other
hand, it is certain that if the rickety child be let to lie much
on its back, winch, from its inability to stand and sit up-
right, would inevitably happen, the weight of the chest
must so press upon the softened ribs as to tend to bring the
spines of the vertebras ami those of the shoulder blades on
the same level, or to flatten the back. Again the mere
weight of the costal cage of bone and cartilege tends to
flatten it in front (above), so that this cage would tend to
fall ilat in front ami to crack sharp off at the sides. Now,
when we take into consideration with these facts the obstacle
to i i of the cage in front furnished by such solid
al Times and Gazette. March lTtli
484 Obscure Trunk Pains. [June
parts as the liver, heart, and spleen, as Dr. Jenner himself
does, I think it may be worthy of reflection whether this
is not thesimple history of the development of the deformity
in question. Allowing that some deviations must be ex-
pected to be produced in the form of the chest by weights
thrown upon it when other posture are assumed, the prin-
ciple involved in this explanation would be in accordance
with Dr. Jenner's general mode of accounting for ricketty
distortions in the limbs, which he ascribes to their weight
or the weight of the other parts bearing upon them. He
remarks : "In excluding muscular action from all direct
share in the production of curvature of the long bones in
rickets, I am, so far as I know, unsupported by any author-
ity ;" this observation, it may be implied, he would extend
to the chest, as he cites Rokitansky's of the thoracic de-
formity being caused by a want of power in the inspiratory
muscles, and moots no other hypothesis but his own.
Finally, returning from these collateral meditations, I will
venture a word as the practical use of such considerations
as form the fundamental reasonings of this paper. If suf-
fering is occasioned in a patient by a disturbance of struc-
tural balance in any part, the obvious indication of cure is
to remove the cause of the disturbance. If any body De-
pressing upon the eyeball deprives it of its sphericity, re-
move the body that does so. If a patient leans against his
sternum in writing till he begets suffering thereabout, take
care he ceases to do so. Each case requires its special pre-
caution so clearly that it were idle to iterate the fact. JBut
I hardly think it unprofitable to invite attention to a very
homely topic before I take leave of this essay.
It has been shown how important it is that the structural
balance of the trunk should be ordinarily preserved. When
we walk, this equilibrium is stable, and when we lie it is
approximately just. But wTe spend a great portion of our
time in the sitting posture, and what provisions have we
that the balance shall be easily kept in this attitude? In
plain English, on what principle are the backs and other
upright supports to our chairs and sofas constructed ? Our
e isy chairs and couches, not to say chairs for general use,
show no conformity in the principles upon which those up-
rights are conceived. All looks as if there were no know-
ledge of comfort in such things. The majority seem made
with a view to torture rather than ease. 1 cannot, there-
fore, deem it a thankless task to endeavor to ascertain what
11.] Obscuxi Trunk Pains. 4R.">
are the requisites of such structures. At least. T will give a
device for what 1 have concluded to be the best torm of
chair as? an example. I will do >o in dimensions to fit the
)f a man of middle size. The chair shall he of wood,
for if it he easy in hare wood, it cannot fail to be so when
cushioned.
Let the seat he IS inches from the floor and of the shnpe
oi" a semi-circle of a diameter of 21 inches, whoRe straight
edge is the front of the seat, and let in, in a sfvle which is
common, he scooped towards the back to lit the nates.
ain, in the usual style of elbow chairs, let there he a
horizontal semic-circular bar for the elbows to rest upon, 11
inches above the seat and of its diameter, and let this elbov -
bar he supported on either hand laterally by four or five
upright bars with equal intervals.
In the middle of the hack let the support for the elbow-
arch he a Hat plank of 5J inches' breadth or rather, let two
short elbow-bars be let into such a plank rising f om the
middle of the posterior border of the seat, to the height of
aches, and let this plank be curved to the lateral con-
tour of the loins, as may be seen in the cushions of railway
carriages. Or in definite measurements let the plank, at
vertical heights of 2, 5, 10, 15, 22 inches, be gradually in-
clined backwards to the horizontal extent of J, J. 2$, 3J, 4
inches, respectively. Beginning at the top of the plank,
let a longitudinal groove be cut afoot down the ante . ior
face of the plank, of 1 inch wide .and f inch deep; let its
edges be bevelled away, as also other sharp edges of the
plank. Below the elbow-arch the plank may be hollowed
the in h< rizontal direction to coincide in curvature with
the :
aeefnl appearance apart, we have here the elements of
a comfortable chair. The lower portion of the hick will
form a cradle for the pelvis, and prevent its weight from
effecting pressure upon higher parts of the trunk; the
curved portion rising therefrom will bear up the loins and
lower part of the chest. The backpiec e will allow the mid-
dle channel of the back to rest against it at any* and even-
ts whilst its longitudinal groo\e will afford an escape
from pressure for the thinly-covered vertebral spines, leav-
ing this to be encountered by the bed of muscle at their
a. Then any pressure that might be extended to the
ribs would not affect the form of tl owing to the
short leverage at the vertebral articulations of the ribs along
486 Obscure Trunk Pains. [June,
the channels at the sides of the spine. The shoulders play
backwards and forwards without impediment; and since
the tmnk preserves its natural form as in a standing posi-
tion, the respiratory muscles meet with no hindrance in
their oitice. The arms, resting upon the elbow-bars, do
not cast their weight on the shoulders, whilst these are
steadied.
But the combination of contrivances fulfils more recon-
dite conditions. Not only do the ribs and abdominal sur-
face ebb and flow as we breathe, but the curvature of the
spine oscillates in degree. In this oscillation the backpiece
allows the vertebral calumn to roll, as it were, along it it
is a sort of involute, for the chain of vertebra', as the evo-
lnte, to wind and unwind upon. For these reasons I have
placed persons suffering from pains about the sternum,
which have been acquired by pressure habitually thrown
upon the shoulders, to sit against a narrow pillar or vertical
plank, as may be met with in pannelling, and the ready ex-
pedient has answered my expectations.
People do not sit long in one posture, and this chair al-
lows a considerable degree of snuffling about the sacrifice
of its presumed advantages. If to change the point of
chief pressure the nates be slid forwards, the backpiece will
take the spine, and chiefly at another spot, so as to relieve
the points of pressure along the back also ; and the semi-
circular shape of the back-cradle will give the sitter a fitting
support for his back, however he leans about.
Though it has been laid down as a rule that the shoulders
should not rest against any framework, it would not be
amiss if there were such a framework forming a portion of
a larger circle than the framework described, and crossing
the upright bar at the top posteriorly, so that this bar be let
into the upmost crosspiecein front, and that it project for
an inch beyond it, Thus this extra framework, which may
be partially formed by prolongations of the hinder upright
bars that support the elbow-arch, would form recesses where
the shoulders may be brought to bear a little to steady them
laterally, and that they may take a little of the pressure of
the trunk at our pleasure.
I have given the above description of still-lines for the
sake of being explicit and intelligible, but there is no rea-
son why elegance should not be realized in the design.
The elbows may be curved along their upper margin, the
bara replaced by ornamental carvin 2; or wicker-work, the
1861.] Diphtheria. 487
backpiece extended in a curved fashion below, or perfor-
ated for ornament, and may be undulating upwards, spread-
ing over the top of the shoulders on either hand. Cushioned
chairs may be so stuffed as to afford a backpiece as here in-
dicated, as well as the transverse projection for the loins as
they now commonly have ; and if carried as high as the
head, bear a cushion projecting well forwards, to take it,
without the neck being unnaturally thrown back. I have
thus devoted some attention to the analysis of the conditions
essential to comfort in an article in daily use by every
healthy person who is not destitute or a bad-liver ; and
whatever be thought of these reflections, it will not be gain-
said that they treat of questions of concern to the healthy,
and of vast interest to a host of invalids.
Diphtheria An Unsuccessful Case of Irackeotomy, and a New
Method of Treatment, Exemplified by Four Cases. By Jno.
O. Brinson, M. D., late Professor of Anatomy in the Xew
York Medical College.
The many methods which have been followed in the treat-
ment of the disease under consideration seem, as far as my
observation leads me, to be possessed of no very distin-
guishing characteristics one over another.
The one prevailing idea is, the evident prostration and
the seemingly i; tonic course to be pursued. The
results which have followed my efforts in the treatment of
the disease, governed by this idea, have been so unsatisfac-
tory, that I have been led to mark out and pursue an entire-
ly opposite course. In the case first mentioned, and in
which tracheotomy was performed, the tonic course was
pursued, and, as in nearly all previous cases, without a fa-
vorable result.
Ca-e A. Tracheotomy Performed. On Sunday, Decem-
23d, 1SG0, I was called to see one Daniel Ilorgan, set. 4
years and 7 months. He had been ailing for about a week,
though running about until the day previous to the sum-
mons. He had had a cold, and complained of a sore throat,
ior which his mother had given usual domestic remedies,
without any good effect. She therefore sought advice.
The little fellow was suffering with an inflammation of
the mucous membrane of the pharynx and larynx. Diph-
488 Diphtheria. [June,
theritie patches were developed upon the tonsils and on the
posterior wall of the pharynx. Prostration severe. Pulse
126. I prescribed tinct. ferri mur. and quinia} sulph. To
the inflamed parts argent, nitras., in solution, was applied.
On the following day, the little patient was not less pros-
trated. The diphtheritic exudation had extended but little,
if any. The treatment was continued, and wine whey or-
dered.
25ih (Christmas Day.) Called at 8 A. M., in response to
renewea summons. Patient much worse. Prostration ex-
treme. Great obstruction to the respiration. Fauces com-
pletely lined with exudation, which had undoubtedly ex-
tended into, and perhaps beyond, the larynx. Pulse 146.
Believing my only hope to be in tracheotomy, I proposed
the operation, which was acceded to by the mother.
Having obtained assistance, at ten and a half o'clock I
again visited the patient, prepared to operate. The lips and
countenance of the little patient, by their livid hue, beto-
kened early suffocation. Assisted by Messrs. J. E. Steele
and F. G. Sanley, medical students, I performed the opera-
tion speedily, with but trifling loss of blood, and with im-
mediate relief to the patient. A considerable quantity of
false membrane found exit through the wound, and after
the introduction of the tube, the child soon began to rally,
and seemed better than for two days previous.
Potass, chloras, quinia* sulph., and brandy were prescrib-
ed. At 3, and again at 9 o'clock, observations were taken,
and he had improved. Respiration easy. Expectoration of
tenacious mucus very considerable. Pulse 130.
26th Morning. Slept well most of the night. Respira-
tion free. Expectoration as the day previous. Pulse 126.
The treatment continued.
Evening Condition generally as in the morning. Ex-
pectoration, however, diminished. Pulse 130.
27th Morning. Expectoration much diminished. Res-
piration labored. Symptoms like those present previous to
the operation appearing; pulse 140. It is evident that ex-
udation has produced the fatal membrane in the bronchial
tubes.
Evening. Further efforts deemed unavailing.
28M,. Died at 5 a. m.
Examination fourteen hours post-mortem. Rigor mortis
complete. In laying open the thorax, the lungs did not
collapse; pulmonary emphysema general. Larynx, and
1861.] Diphtheria. 489
portion of the trachea above the point of entrance in the
operation, completely filled with false membrane. The por-
tion of trachea below the above-mentioned point exhibited
an ulcerated condition. The bronchial tubes, as far as into
the fourth bifurcation, were lined with the characteristic
exudation, at many points to the extent of entirely closing
the canals. Upon making examination of the wound, there
appeared to be no secondary exudation.
Case B. Adult. On the second day of January, 1861, I
was called to see Mrs. C, a native of this city, set oO. She
had been sick for several days, and was getting worse. She
was of a weak habit. I found her with a flushed face, hot
skin, sore throat, and anxious expression; pulse 145. An
examination of her fauces evinced the presence of diphthe-
ritic membrane on both tonsils, and on the palate.
Having concluded previously to institute a new method
of treatment upon the presentation of the next case of the
disease, I prescribed as follows :
R. Tinct. aconit. rad., 5ss.
Aquae pura?, giv.
M. Sig. Cochl. parv. quaque hora sumendufc.
R. Ammoniac mur., 5ij-
Aquse pur., 5yj.
M. Sig. Garg. quaque duo horis utenda.
On the 3d, I found the patient improved to this extent
skin cool, pain much diminished, deglutition much easier;
pulse 120. Treatment continued.
On the 4th, still more improved; pain but slight, skin
natural. One small spot of exudation three-eighths of an
inch in diameter present in the faucus; pulse 98. Treat-
ment continued.
On the 5th, throat clean. Inflammation entirely gone.
Aconite to be taken only once every three hours; the gar-
gle as before, every two hours ; pulse but 80.
On the 6th, the condition of the patient such, that tonics
and stimulants could be used with hopes of success. I
therefore prescribed as follows:
R. Quinia! sulph., >)j.
Fern Sulph.. vij.
Ext. nucis vom., gr. vj.
M. In pil. xx. div. Sig. L'nam ter in die capiat.
Wine whey, and such articles of solid fond as desired,
ordered to be taken.
490 Diphtheria. [June,
From this time onward, everything progressed most sat-
isfactorily, and the patient was discharged in a few days.
Case C. Adult. On the 17th of January, but a few
days subsequent to the preceding case, I was called to sec
Mrs. P., also a native of this city, set. 58. The condition ol
the patient was very similar to the condition of the previ-
ously cited case. She had not been so long sick, and ]
found the diphtheritic exudation on the left tonsil to be less
dense than elsewhere. It presented the appearance of a
frosted spider's web, and seemingly was more tenacious
than that fully formed.
The prescription was identical with that used in the pre-'
ceding case, and the result was even more perceptible. . In
thirty-six hours the membrane had entirely disappeared.
The pain, which at first was present in the throat, was ban-
ished at an earlier period than in case B. The after-treat
ment was identical in character and in result.
Case D. Infant. On the sixth of February, 1861, 1 was:
summoned to the bedside of a little girl, the daughter o:1
Mrs. D. The condition of the child was very similar tc
Case A, but with less laryngities ; pulse 150. Hoping t(
meet with like effects from the use of the same remedies
used in Cases B and C, 1 prescribed the aconite, with thu
modification: (the patient was but three years and sii
months old, and consequently could but receive a propor
tionate dose of the aconite, with any hope of success.)
R. Tinct. aconit. rad., gtt. vj.
Aquae, ojv.
M. Sig. Cochl. parv. quaque hora capiat.
The gargle was used as a lotion, by means of a probong
not diluted.
On the 7th, a great part of the exudation had disappear
ed from the fauces. The pulse of the patient had diminish
ed to 105, and in every other respect improvement was evi
dent.
On the 8th, the pulse had come down to 90, and tin
throat was perfectly clean. A diminution of all the symp
toms was present, and everything betokened a result simi
lar to the preceding cases. With wine whey only as a ton
ic, I was pleased to find the little patient put on its wontec
strength, and assume its former health.
Case E. Adult. I mention this case because it resem
L861.] 491
les the cj ses marked B and C, in respect to time and the
Bsappearance of the exudation.
On the first of March 1 was called to young lady,
et. 20, a native of France, having been in this country about
ighteeu months. The genera] condition of the patient was
nore extreme than that of the aforementioned cases. Skin
lot, dry, and flushed: throat swollen and painful; diphthe-
ritic exudation present on both tonsils, and on posterior
vail of pharynx. Pulse 153.
I considered the aggravation of the symptoms attributa-
ble to the torpid condition of her bowels, which had exist-
r some time. I prescribed ten grains of blue mass to
3e given at once, and followed in eight hours by six ounces
)f tiie solution of the citrate of magnesia. As soon as the
xnvels were freely emptied, the same remedies prescribed
n case B were ordered. In thirty-six hours the patient's
ondition was such that I felt that the remedies were almost
pecitic. In forty-eight hours all exudation had disappear-
d from the fauces, and the pulse, from 153, had come down
'. All pain had left the throat, and one small spot
lone showed signs of inflammation. On this spot I applied
i piece of the sulphate of copper, simply as a stimulant.
t was probably not necessary. On the following day all
symptoms of anything like disease were gone.
I prescribed as follows, the patient seemingly having a
sufficiency of iron in her system.
K. Quinifie sulph.,
Zinci valerianate 3j.
Ext. nucis vom., gr. yj.
Aloes socot., gr. v.
M. In pil. xxiv. div. Big. Unam term die capiat.
iVine at dinner made up the complement of directions, and
q three days' time all evidences of disease or debility had
lisappeared.
It would afford me much pleasure to have introduced a
arger experience in the treatment of infants after this mode,
ret I believe that the early and agreeable change which
i followed in the one be adult
A iase-. is evidence of almost a uniform result. We arc all
prell aware that the system bears up better under, and re-
lets quicker from, a condition of depression, than of ex-
citement. I deem the constitution of children poorly pre-
ared to bear the stimulus and tonic remedi< ivad-
492 Diphtheria. [June
ministered in the treatment of diphtheria, and if called ui
on to give testimony in reference to the matter, I shoulc
from my convictions, be obliged to say, that I believe man
succumb to treatment rather than to disease.
The following summary of experience on Diphtheria, w
find in the valuable Monthly collection Dr. O. C. Gibbs, o
Frew sburg, New York :
Diphtheria.
In the Boston Medical and Surgical Journal for Januar;
24th, Dr. L. H. Angell has an article upon this subject. W
make one quotation only. "Tonics and the preparations c
chlorine are indicated to arrest the febrile paroxysm, and
consequently, the formation of false membrane. I have prir
cipally relied upon quinine and the chlorine mixture, an
have not been disappointed in a single instance."
In the Cincinnati Medical and Surgical News for January
Dr. W. H. Matchett, of Ohio, has an article upon this subjec;
As Dr. Matchett's treatment differs somewhat from that w
have previously seen recommended, we shall attempt a synop
sis of it. After moving the bowels, he trusts the case, so fa
as internal remedies are are concerned, to quinine and iodid
f potassium, both in tolerably full doses, and frequently re
peated. In addition, he adds a generous diet. As loca
means, he recommends a gargle of pepper, salt, and vinegar
This is also applied by means of a swab, and then the parti
are dusted with finely-pulverized borax ; these local mean
are frequently repeated. A tar plaster is applied to the neck
Unlike Dr. Calhoun, of Georgia, referred to last month, In
does not ascribe the cure to the tar plaster, but to the quinine
iodide of potassium, and nourishing diet. He does not ap
prove of the frequent application of nitrate of silver to the di
seased parts. He says: "The frequency with which the soli"
tion of nit. arg., of the strength of 20 grains to the 5, is use
by some physicians, is, of itself sufficient to produce seriou
difficulty."
Partial paralysis, after diphtheria, is not a very uncommoi
affection. In such cases, Prof. Pepper, of the University o
Pennsylvania, makes the following prescription:
"K. Extract of St. Ignatius' bean, 8 grains.
Sulphate of quinia, 30 grains.
Yallett's mass, one drachm. M.
hi.] Diphtheria. 493
be made into 30 pills, of which one is to be given 3 times
after meals. At the same time electricity is to be ap-
ied to the throat."
In the Chicago Medical Examiner, for Januaiy, Dr. T. J.
'earce has an article upon diphtheria. lie has but little con-
idence in topical treatment : UI think the too frequent swah-
hng has been in many cases a fruitful source of mischief."
Be does not object to gargles. "As an external application,
Ken there is oedema or enlargement of the parotid or cervi-
|al glands, I have found nothing better than the free use of
dine. .V domestic poultice of equal parts of tar and
pheal bran may often prove serviceable." He, however,
llaces greatest- reliance upon general remedies : "We know of
lo course better than the free use of chlorate of potash, mur.
pet. ferri, and sul. quinia. The mur. tinct, ferri, I think, is
fenerally given too sparingly." When emetics are needed,
e recommends sulphate of copper, or, in croupal cases, sul-
haie of iron. As a gargle, he prefers the sulphate of copper
,ri solution.
The Special Committee of the Xew Jersey State Medical
Society, as per report in the Jledical and Surgical Reporter
lr January 2Gth, recommend the following, which does not
tfier from that usually relied upon : "The tinct. ferri sesqui-
lloridi, ten to fifteen drops, in water, every three or four
.Jours, with chlor. potassce and quinia, and brandy with milk,
Jiloric ether. .. are the articles chieily recommended."
Ts a local application, a solution ot nitrate of silver is pre-
irred.
1 Before the Paris, 111., yEsculapian Society, at a recent
i|ieering, the subject of diphtheria was under discussion.
r. Chambers reiied upon chlorate of potask, and large doses
' quinine, with the local use of nitrate of silver, "gr. 60,
the ounce of water." Dr. Tenbrook relied upon stimu-
nd tonics, and the solid nitrate of silver locally. Prof.
. S. Davis prefers the tincture of iodine, as a local applica-
>n, believing it will stop the spread of* the disease from the
roat to contiguous parts. We quote from a report in the
iner, for January, the remarks of Dr.
York : "Emetics should he used continuously ; of these
alum, one teaspoonful every twenty minutes un-
l vomiting. Avoid the too frequent application of caus-
es to th :'/ it produces mischievous irritation; not
tenen than once every day, or every other day. When the
has extended into the larynx and trachea, stop the
cal application of tincture of iodine, or nitrate of silver,
494 Surgical Miscellanies. [June,
(we should have observed that lie prefers the tinct. of iodine.)
It is then a useless annoyance. A vast majority of cases
die in which there is complete aphonia known of only four
recoveries from this condition. Here I give quinine very
freely, with Dover's powder."
We have thus endeavored to give a summary of the prac-
tical portion of the papers, upon the above subject, that
have come under observation in the journals of January. If
any papers have been overlooked, their respective authors
will please excuse us.
Surgical Miscellanies. By Furneaux Jorday, Assistant-Sur-
geon to the Queen's Hospital, Consulting Surgeon to the
Birmingham Eye and Ear Dispensary, and Professor of
Anatomy at Queen's College.
I. An undescribed Affection of the Leg. During the last
six years I have seen a few cases of a peculiar affection of
the leg, any description of which lam unable to find in sur-
gical literature. The cases to which I allude are undoubt-
edly rare less rare, however, I think, than many surgical
diseases of which we are supposed to possess an extended
knowledge. It is my intention, in these miscellaneous sur-
gical notes, to avoid the record of individual cases, and
state merely the conclusions which they have led me to
form. Let the reader test such conclusions by his own ex-
perience by his own recorded and remembered cases.
The disease to which I refer exists in two varieties, which
may occur separately or together. In the first there is a
convex enlargement or collar completely surrounding the
lower part of the leg immediately above the malleoli. The
second form is more common and less peculiar; it consists
in a slightly irregular, rounded, or hemispherical projection
seated below and behind the malleolus. The relative fre-
quency of the two affections may be stated as follows: little
frequent is that below and behind the outer ankle; less fre-
quent is the combination of the two; least frequent is that
around the tibia and fibula.
The rarest form of the disease, and the most characteris-
tic is a soft, elastic enlargement, occupying the entire cir-
cumference of the leg. its size and shape are the same at
the inner, outer, anterior, and posterior aspects. The ver-
tical measurement of the collar is about three inches. Its
18G1.] Uawes.
greatest thickness (an inch and a half) Is at the centre. The
margins are thinner, bnt do not become imperceptibly lost
in the parts above or below. The lower portions of the
malleoli are not involved. At no period in the formation
of the growth is there doughiness, or pitting, or pain, or
tenderness, or intcgumental discoloration. Indeed, the
skin is throughout perfectly healthy. The bones of the leg
are not altered in size. The formation appears to be grad-
ual, and unattended by noticeable constitutional phenome-
na. The word k' noticeable " is nsed designedly, because
the general health is certainly not good, and there are indi-
cations of cardiac or circulatory derangement in greater or
less degree. In the most typical case I have seen there was
marked mitral regurgitation, but there was no history of
acute rheumatism or any other acute disease. All the cases
were in young, adult, unmarried, and childless women.
In asking what the aiiection is, let us first ascertain what
it is not. It is not elephantiasis arabicum; elephantiasis has
a gieatiy thickened, hard, rough, nodulated, darkly colored,
and partially insensible skin. The bones, areolar tissue,
fat, and other structures (muscles excepted), share in the
enlargement. The toes and feet are implicated, and severe
pain is usually present.
It is not a cutaneous outgrowth; in the cutaneous out-
_ vth, as Mr. Paget remarks, all the tissues take part, and
the proper tissue and appended organs of the cutis are near-
ly as much exaggerated as the fibro-cellular substance.
Fibro-cellular outgrowths, moreover, are usually peduculat-
ed and attached to the parts in the vicinity of the vagina
and rectum.
It is not a fibro-cellular tumour at least if we use this
term in its strict meaning for, independently of the cir-
cumstance that the fibro-cellular tumour resembles in its
sites the cutaneous outgrowth, the enlargement I am at-
tempting to describe certainly could not be separated or
enucleated from the neighbouring tissues.
Erythema nodosum sometimes leaves irregular bulky
masses on the leg, but its history is unmistakeable, and the
enlargements which it leaves have no uniformity of config-
uration or locality. The term phlegmasia alba dolens has
an accuracy and significance of meaning which render any
observations on white leg a superfluous task.
That the enlargements in question are fibro-cellular in
structure I think there can be little doubt, though differing
49G Surgical Miscellanies. [June?
essentially from the cutaneous outgrowth and flbro-cellular
tumour. There is probably as little doubt that one of the
two following causes operates in their development. Eith-
er (1) there is a peculiar fibrinous oedema arising from ex-
treme obstruction (cardiac or other), of an extent so limited
and a duration so temporary as to permit of the organiza-
tion of the effused plastic material, or (2) there is inflamma-
tion which is neither acute, nor obvious, nor lasting. The
inflammatory phenomena, however, do not disappear until
plastic lymph has been effused in a locality and under cir-
cumstances favourable to organic development. The sec-
ond causal agency appears to me the more probable. In
dropsy, local or general, serum without fibrine is usually,
and always at first, effused. In extreme obstruction, such
as to involve exudation of fibrine, the large quantity of at-
tendant serum would have a historical value too great to
escape detection. But indeed fibrinous dropsy in the low-
er extremity, with or without general anaserca and grave
constitutional ailment, is altogether improbable. In the
hydrops fibrinosus of Yogel, where the fibrine was noticed
in the abdominal cavity, serious disease was certainly
present.
If, then, immediately above the malleoli, or beneath the
outer one ? Why in those localities particularly should the
inflammatory product be more susceptible of organization,
and less amenable to absorption than elsewhere ? Probably
from some evanescent and slight cardiac ailment, endocar-
dial, or pericardial, or, which is more probable, from a tem-
porary aggravation of a chronic disease, obstruction occurs
in the venous system. This, for many reasous, is chiefly
evident in the lower extremities. The internal and exter-
nal saphenous trunks, and the network of veins which con-
nects them around the lower part of the leg, are plugged
with coagula, which subsequently acting as foreign bodies,
cause a certain degree of inflammation attended with effu-
sion of plastic lymph. The inflammation terminating quick-
ly, permits the lymph to organize, probably by nucleated
blastema, as in the repair of subcutaneous wounds. Xow,
if the obstruction should be more permanent, or the inflam-
mation more severe, we should have not development, but
disintegration, in the form of ulceration, varicose or other-
wise. It is possible that the inflammation may be confined
to the radicles and the commencement of the external saph-
enous \ "in. which runs behind the outer ankle without any
1861.] Surgical Miscellanies. 407
muscular support, and which, as wo shall presently Bee, may
explain the Becond form of enlargement under considera-
tion. The obstruction and coagulation of blood in the veins
mnionly attributed to the hydrostatic pressure in a long
column of blood, as that in the internal saphenous vein.
Aparr from the fact that this hypothesis does not explain
the lesion in the external saphenous vein and its radicles,
it appears to me that a better explanation can be found, and
that the anatomist can more easily discover it than the me-
chanical philosopher. There is ample proof that muscular
eontraction plays an important part in assisting the flow of
blood in the veins. It is a remarkable fact that such assis-
tance is almost entirely absent in the lower third of the leg
and below the outer ankle. Tendons have not the slight-
ontractile, and therefore no expansive power. In the
lower part of the leg we find (for very good reasons too) ten-
dons only. The tendons of the deeper layer of muscles at
the back of the leg have muscular fibres joining them at a
lower level than is the case in the superficial layer, but they
are so tightly held down to the tibia and fibula by the deep
fascia as to exercise no influence on the superficial veins by
their contraction. Further, on each side of the tendo
Achillis there are large spaces filled with loose areolar and
adipose tissue, which afford the most favourable opportuni-
ties f>r the inaction and dilatation of veins. In exceptional
-. I may parenthetically remark, the soleus muscles send
muscular fibres to the under aspect of the tendo Achillis al-
most to its insertion. Such cases we may reasonably infer
would be little liable to varicose or indolent ucler, still less
to the peculiar enlargements under consideration. Again,
a third of the tibia is subcutaneous, and the veins (the in-
ternal saphenous especially) can receive no pressure from
BO passive an agent. Thus, then, many circumstances con-
spire to show how a lesion affecting the venous system is
prone to show itself in the snpra-malleolar region and below
the outer ankle. In the latter spot the external sophenous
vein lies on the flat calcaneum, totally unassisted by mus-
cular action. It is true that the two peroneal tendons run
obliquely across the outer and anterior part of the oa calcis,
but they have not the least influence in compressing the
veil
I have reason to think that the enlargement which I have
scribed as Beated below the outer ankle has been \'\-( quent-
]y, though vaguely, referred to synevial distension of the
498 Surgical Miscellanies. [June,
peroneal sheaths. On the super-mall eolar form of the di-
sease I have never known an opinion given.
If it be granted that I have shown sufficient grounds for
the dilatation and inflammation of certain veins, with the
possibility of an exudation of plastic lymph that shall, un-
der certain circumstances, be capable or organization the
circumstances, however, being so rare and so peculiar, that
varicose and indolent ulcers must always be more common
diseases than the one which forms the subject of these ob-
servations it will also be granted, the lymph having been
exuded, and the inflammation and other circumstances un-
favorable to organization having disappeared, that the same
agencies which operate against the flow of blood in the
veins will operate also against the absorption of the lymph
which is deposited in the areolar tissue at the lower part of
the leg. Here, then, there is none of that muscular pres-
sure which elsewhere is a most effective agent in the ab-
sorption of inflammatory exudation.
It is not improbable that the fluid exuded by the inflam-
matory process should escape notice, because the so-called
serum of inflammation is really liquor sanguinis, containing
all the material requisite for coagulation and organization.
Probably, too, the enlargements do not result from a single
pathological process, but from a series, each in itself slight,
painless, and unobserved.
I have indirectly referred to a new pathology for indolent
and varicose ulcers. At another time I hope to fill up the
outline, and suggest a treatment which is more analogous to
muscular pressure than any now in use, and which I have
adopted in practice with great success.
II. A Node on the Patella. In the 'Edinburg Medical
Journal,' in 1857, I described a case of bubo occurring with-
in the abdominal cavity. Last year another singular form
of constitutional syphilis came under my care. A hard, in-
dolent, partially tender, and nocturnally painful swelling
formed on the patella. This, after a lengthened period,
suppurated. A practitioner, under the impression that it
was an in flamed bursa, passed a seton through it. Inveter-
ate, though varying suppuration, and short, irregular sinu-
ses in the superjacent tissues, followed for upwards of two
years. The knee-joint was not affected, but the patella was
much enlarged, and its range of motion greatly diminished.
The tendon of the extensor of the thigh covers very closely
the anterior surface of the patella, and presents certain an-
1.] Whiskey as a ProphylaUc in Typhoid Fever. 49(J
alogies to the relation of the occipito-frontalis muscle to the
cranial bones, which are so obnoxious to syphilitic disease.
III. A Proposition for the Treatment of Aneurismal Yarix.
The rarity, in late times, of cases of aneurismal varix must
be my apology tor proposing a method of treatment before
1 have had an oppotunity of practically testing its utility.
It is common to do nothing in these cases unless the symp-
toms are very severe, when a ligature is applied above and
below the wound in the artery. It appears to me that, in a
large number of cases, especially in the extremities, very
-iderable, if not complete,' relief might be afforded by
on of the vein, above and below its communication
with the artery, by means of a needle and twisted suture,
- mie other method, as in an ordinary (and widely differ-
ent) varicose vein ; perhaps in some cases a needle might
- ed with advantage under the contiguous artery
for a short time, as in the acupressure method of Professor
Simpson. If the practicability of the principle be granted,
the method of applying it admits of great variety to meet
the requirements of individual cases.
J J hiskey as a ProphylaUc in Typhoid Fear. By Hugh Kellv,
M. D., of Iredell county, X. C.
The above announcement may excite surprise, increduli-
sgust in some; but all should, however, suspend their
-vment until they have had an opportunity to test it ful-
ly. I by no means advocate the regular or even the occa-
: ardent spirits as a beverage by persona in health,
for I hold that spirituous liquors arc in their proper sphere
only, when used and prescribed as medicines. Consequent-
ly, persons in health should not indulge, for by so doing,
they tax their systems beyond what they have a right to do.
Very frequently the stomach, lungs and kidneys are over
worked to dispose of what is not at all congenial to health,
and particularly to the natural functions of those organs.
What a very short period elapses betwixt the reception into
the stomach of a portion of spirits, and efforts for relief
thn and kidneys, rendering it very evident
that it is an intruder, all the energies of the system being
called upon to dispose of this unwel sow
In tin- spring and summer of 1847, there w as a great deal
of typhoidlfever in the neighborhood of Gold Hill (then a
500 Whiskey as a Prophyhtic in Typhoid Fever. [June,
village containing a population of some eight or nine hun-
dred inhabitants, white and black.) The fever made its
appearance in the latter part of April, was of a very grave
type, and was quite fatal among the blacks. The appoint-
ment of a nurse was almost equal to passing sentence of
death on the one so appointed. Some four or live of them
died. The whites suffered very much also, and a number
of fatal cases occurred. In one instance, where some sixty
or more negroes were employed by Barnhart Manney & Co.,
the number of sick was between thirty-five and forty; and,
in fact, all seemed to be dispirited and languid. Nurse af-
ter nurse dying, I feared that all might in a very short time
be confined to bed, whites as well as blacks. A short time
previous to this, I had read the history of typhoid fever in
an Irish Hospital, that had continued for some time, prov-
ing very fatal to nurses and physicians, and making it dif-
ficult to get those who were willing to take the places made
vacant by diseases. Only two or three nurses of the origi-
nal corps were left, and not one physician. One of the new-
ly appointed doctors, enquired of those nurses how they
managed to keep clear of the fever, theii answer was that
they took their whiskey three times a day, and plenty of it;
hence they did not fear the fever at all. The physician act-
ing upon this hint had all the nurses and doctors belonging
to the house to commence the use of whiskey, and he re-
ported that from that time no new case occurred in the
house. Finding myself to be similarly situated, I ultimate-
ly prevailed upon the company (all being temperance men)
to try whiskey, by giving from half gill to a gill three times
a day for an adult, and to children in proportion. I was
much gratified at the happy change effected. From the
day they began to give the hands, both white and black,
their allowance of whiskey, not a single new case occurred,
and the fever subsided in some two or three weeks, and all
were up again.
! was so much pleased with this result, that I determined
to try it further, and did adopt it in all the families to which
I was called, where they had fever of this type, from this
time, July 47, up to the time of my removal, December 54.
In not one single instance did a new case occur, during that
period, alter the family (I mean those that were able to be
up.) had commenced the use of this remedy. Since my
residence in Iredell, I have pursued this same course and
with the same success. Some persons in this section of
1861.] Varicose Veins. 501
country would not make a trial of this preventative, and all
or nearly all of their families were sufferers. A trial was
made in this neighborhood last summer, which resulted as
all the rest had done. Col. A. has a large number of ne-
ts who had the fever among them in June last. It was
of a malignant type, and after some three or four deaths, he
procured a barrel of whiskey and commenced giving it as
heretofore directed. The result was that not another case
occurred on his farm. Its modus opierandi in preventing
this fever, I leave for others to examine; that it is a preven-
tive, I am fully satisfied from an experience of thirteen years.
When called to attend on cases of this fever, I advise all the
family that are on foot to use this preventive, and to con-
tinue its use for sometime, at least until the sick are out and
able to take exercise; or for two weeks at least after the fe-
ver subsides in the family. In many instances where sever-
al members of the same family were attacked at or about
the same time, I have seen the remaining members of the
household adopt this prophylactic, and continue to watch
and nurse for several weeks in succession without one of
them taking the fever, which fulty sustains the opinion
formed of this agent. I suggest to all who nurse typhoid
cases to use this medicine, as constant exposure to the fever,
but for a very few days, may bring on an attack. That ty-
phoid fever is contagious to a certain extent I presume none
will doubt.
Remarks on Dr. Levis Application of (he Jletalic Ligature to
the Cure of Varicose Veins, with Report of 1 wo Cases.
By J. M. Boisnot, M. D., of Philadelphia.
It is more with the object of contributing something that
may substantiate an operation that the reaeers of the Re-
porter are already acquainted with, than to advance any-
thing new, that the following remarks are submitted. The
number of cases of varix existing, and the previous want of
an operation to safely effect a radical cure, make a method
likely to be followed by success, and especially one that has
simplicity and freedom from danger to recommend it, of
great importance.
Yarix depends for its existence upon two principal causes
an imperfect condition of the veins themselves, and any-
thing retarding the return of the blood through them; the
502 Varicose Veins. [June,
first being* clue both to constitutional and local causes ; the
second mainly to mechanical. To be more explicit: in a
person where the return of the circulation is unequal to the
distribution, we have a cause acting upon the veins that
will be followed by distention, not only in the main trunks,
but also in the branches. Imperfection in the valves is
what I refer to as local, and pressure the mechanical cause.
Varix of the lower extremities is essentially a disease of the
saphena interna; the continuous length and superficial; po-
sition of this vein explain, in a measure, why this is so.
A derangement of the circulation must first affect the
main trunk; afterward the confluent branches. Independ-
ently of the cause, therefore, we say, as it is the saphena in-
terna that first suffers so must it first be treated. The veins
in this disease may be compared to streams which, under
ordinary circumstances, are able to drain perfectly the ad-
joining land; but, hen unusually filled, suffer, not only in
themselves, but by communicating the force of the flood to
tributary branches, damage contiguous parts also. To ac-
complish the desired end, therefore, we must force the cur-
rent in a different direction, and away from the suffering
parts; this the operation under consideration does most ef-
fectually; and, as it is simple and productive of little or no
subsequent irritation, we see no reason why it should not
meet with general approbation.
The success of the operation so far has been such as to
leave no doubt of its efficiency, while its simplicity and free-
dom from danger tend strongly to recommend it. Subse-
quent irritation and inflammation seem to have been the
principal sources of objection to previous operations, but
this is overcome by the fact that silver wire is unirritating,
and subcutaneous operations, generally, do not produce in-
flammation.
Nearly all the operations heretofore advised for the cure
of varix have been opposed, or reluctantly performed, on
account of their liability to produce fatal inflammation, and
yet the idea that a certain amount of inflammation was in-
dispensable to effect a cure has been embodied in all of
them. Xow, it is this that is avoided by the operation un-
der consideration, and yet the desired end attained, viz :
obliteration of the veins ; and this we maintain is accomplish-
ed, not by inflammation, but in the same manner that the
umbilical vein and ductus venosus, deprived of their circu-
lating current, become reduced to fibrous cords.
1861.] Varicose V< W3
Case 1. Mrs. 1\.. 8Bt 42, came under my care in the au-
tumn of 1859. She was Buffering from a varicose condition
of the veins oi the right leg, and an under near the exter-
nal malleolus of the same. This condition had existed near-
ly three years, the varix having formed during a twin preg-
nancy, and the ulcer originated from a burs ted vein.
From the first she had been under medical treatment,
but no operation had been performed. The usual palliative
measures had been employed with the usual success.
I relied upon strips of adhesive plaster as the best means
for exerting a constant and uniform pressure upon the part.
The subcutaneous application of the metallic ligature had
not been advised. As soon as I was informed of this oper-
ation I resolved to try it upon the case under consideration.
In Xovember last I placed a silver ligature upon the saphe-
na interna, about three inches below the knee joint, and
one upon the tributary branch, midway between the knee
and ankle joints, in accordance with the directions already
given in this journal. Xo dressing was applied to the ulcer,
excepting dry lint, and at no time were the wires interfer-
ed with until their removal at the time of cure, which was
seven weeks from the time of operating.
Case 2. AVilliam G., t 63, called me to attend him
Xovember Oth, 1860. He was confined to bed by a very
large ulcer, situated just above the internal malleolus of
the right leg, dependent upon varicose veins. I was in-
formed that the ulcer had existed since 1824, and had never
been entirely healed from that date, being a duration of
thirty-six years. He was feeble, anemic, and unable to
go about, excepting from one room to another by the aid of
crutches. The ulcer discharged a very offensive, ichorous
pus, and presented an extremely indolent appearance and no
disposition to heal. He had been under the care of physi-
cians and surgeons of eminence, both in this city and New
York, without material benefit to either the ulcer or the
veins, although the latter had been subjected to the much
lauded caustic treatment.
I propose the operation of subcutaneous ligation, but was
not allowed to perlorm it before the 28th of Xovember.
The points of ligation were the same as in the previous case,
the ends of the wire were covered by strips of adhesive plas-
ter, a compress of dry, soft muslin was placed over the ul-
cer, and a roller applied from the toes to the knee. The
bandage was removed every two or three days for the first
504 Compound Fracture. [June,
two weeks after the operation, and the ulcer washed with
soaj) and water. This constituted the whole of the local
treatment. Constitutionally he received a nourishing diet,
with quinia and iron. The irritation from the wire was at
no time sufficient to produce more than slight redness at
the point of entrance and exit. On the forty-sixth day af-
ter the operation, finding the veins, where ligated, quite
solidified, and the ulcer entirely healed, I untwisted the
wires and withdrew them. The cure seems perfect, and,
at the present time, he is able to go about free from lame-
ness and in good health. Medical $ Surgical Reporter.
Compound Fracture. A Paper by Mr. Byrant, F. R. C. B.
Having recognized the fact that the science of Medicine
and Surgery was one purely of observation, and that its
principles and practice could only be regarded as sound so
long as they were based on facts, the result of recorded and
carefully-observed phenomena, the author went on to state
that he believed it to be the duty of every practitioner to
communicate to his professional brethren any positive ma-
terial he may possess, and thus to add his quota in building
up the noble art and science to which we have the honor to
belong. Jn conformity with such a principle he had the
pleasure of presenting to the Society a brief analj'sis of up-
wards of 300 cases of compound fracture of the extremities
omitting only those minor examples in which the smaller
bones of the hands and feet were involved, believing that
the results educed were not unfruitful either of interest or
instruction. The eases were all taken from the experience
of Guy's Hospital within the last twenty years, the earlier
ones having been collected from the records of the institu-
tion, and the author's own notes having furnished him with
the particulars of every case -admitted within its Avails during
the last seven years. He then proceeded to the analysis of
the whole number 802 eases:
IT or 5-6 per cent, were of the thigh.
198 or G3-9 " " leg.
35 or 11-:. arm.
57 or 18 -8 ' " forearm.
I 1 out of the 17 eases of compound fracture of the thigh
1861.] Compound Fracture. f>05
proved fatal, or 64-7 percent. 74 oi>t of 193 examples of
compound fracture of the leg were fatal, or 38-3 per cent.
4 out of the 85 cases of compound fracture of the arm died,
or 11-4 per cent. Ami 7 or 22-2 per cent, of the 57 cases
of compound fracture oif the forearm. Of the whole num-
ber, 96 were fatal, or 31-7 per cent. A table then followed
showing the causes of death in these 96 cases, from which
it appeared that in cases subjected to amputation pyaemia
was twice as fatal as in others treated on conservative prin-
ciples, and that exhaustion and gangrene were more com-
mon causes of death : that in cases treated on ordinary sur-
gical conservative principles delirium tremens and tetanus
were more common causes of a fatal result. Analysing the
17 examples of compound fracture of the thigh 9 under-
went primary amputation ; 6 died and 3 recovered. 1 un-
derwent secondary primary amputation ; fatal. 7 were
treated on conservative principles ; 4 died, and 3 recovered.
10 were thus treated by amputation, and 7 of these died,
or 70 per cent. 7 were left to Nature's efforts for repair,
and of these 4 died, or 57 per cent. Having given an out-
line of the fatal cases, the author went on to remark, first,
on the rarity of compound fracture of the thigh, the acci-
dent bearing the proportion only of 5-6 per cent, to the
other cases involving the larger bones of the extremities.
This fact, he stated, was well borne out by the experience
of all surgeons. The excessive mortality of these cases was
the second point to which he alluded, (J4 per cent, of the
whole number of cases proving fatal. In nearly 60 per
cent, amputation was had recourse to, and 70 per cent, of
these cases subsequently sank. The extreme severity of the
majority of these cases, he remarked, rendered primary
amputation absolutely essential, lie showed that more
than halt' the examples died, or 57 per cent., in which at-
tempts had been made to save the limb; and that in cases
in which recovery had taken place were in young and
healthy subjects. The author passed on to review the
opinions of some military surgeons on the subject, and
pointed out how Dupuytren, Ilennen, Larrey, Guthrie, and
LI agreed that in compound fracture of the thigh
Irom gunshot wounds, " in rejecting amputation, we lose
more lives than limbs;" and also, "that in the ex-
ceptional cases, which result in consolidation, the condition
of the limb i> not encouraging.'' lie quoted Macleod's
Crimean experie indicating the same opinion, this
506 Compound Fracture. [Juue,
surgeon advising amputation in all such cases when taking
place in the middle and lower third of the thigh, and hesi-
tating only in a like recommendation in cases of fracture of
the upper third, on account of the extreme mortality of such
amputations. Malgaigne's and Bauden's experience was
then quoted to prove the poor success of conservative treat-
ment in these injuries, the latter surgeon saving 2 out of
25 cases, and these two retained useless and deformed
limhs. The author then went on to say that the experi-
ence of civil surgeons was not unlike that of their military
brethren, although it was much more limited ; and ex-
pressed an opinion, which he believed to be generally en-
tertained, that a satisfactory result can rarelv be obtained
by conservative treatment, except in the most favorable
cases that is, when the subjects are young and the frac-
ture uncomplicated ; when the soft parts are not materially
damaged nor the bone comminuted. When the bone was
comminuted and the soft parts seriously involved (such a
condition being generally produced by local mechanical
violence), he believed that a satisfactory termination of the
case must be regarded with doubt. If the patient should
be old or unhealthy, amputation should be at once per.
formed ; and if there should be a doubt as to which line of
treatment to adopt, the safest is to decide on amputation.
But if the subject should be a young and healthy one, and
not subjected to injurious hygenic influences, the author
believed that a satisfactory termination might be obtained
by removing at once the broken and disconnected frag-
ments of bone (enlarging the wound if necessary), and by
maintaining the absolute repose which is so essential. lie
stated that he believed it to be bad practice to leave the
broken fragments in position, with the hope of union ; and
that by doing so we left a constant source of irritation,
which must retard the local process of repair, as well as
seriously weaken the powers of the patient, a subsequent
operation being almost necessarily required to remove what
will become necrosed bone.
Analysis of the 193 Cases of Compound Fracture of the
Leg. The author commenced by stating that these num-
bers included fractures of the tibia, and tibia and fibula
combined, the latter being the most numerous. Compound
fracture of the fibula was comparatively a rare accident.
129 were treated on conservative principles, 35 of which
died, or 55-55 per cent. 15 underwent secondary amputa-
1861.] pound Fracture. 507
tion of the leg, 10 of which died, or 66-66 per cent. G un-
derwent secondary amputation of the thigh, 4 of which
died, or 66-66 per cent. 74 of the whole number died, or
38-34 per cent. 27-13 of those dying which were treated
on conservative principles, and 00-U per cent, of those
treated by operative interference, hi 22 per cent, primary
amputation was performed ; in 10 secondary ; land in 67
per cent, conservative treatment was adopted. A table
was then given, showing the causes of death in the fatal
examples, from which it- appeared that of the fatal cases
operated on, about one-third died from pyaemia, and nearly
two-thirds from exhaustion or gangrene. That of the cases
treated on conservative principles, not one-sixth die from
pysemia, and something less than half trom exhaustion and
gangrene pysemia being evidently a more common cause
of death after operation. The author then went on to ob-
serve, that no comparison can be wo^l drawn between the
two classes of cases in which conservative treatment and
operative interference had been applied. In compound
fracture of the leg, he believed that the injury should be
very extensive to warrant such a practice as amputation ;
for most cases, whether treated by primary or secondary
amputation prove fatal to about sixty per cent. ; and when
attempts to save the limb are carried out, by care and
close attention good results may be anticipated. Let a free
exit be made and kept for the evacuation of all pus ; let
loose pieces of bone be removed as early as possible ; and
limb be preserved in absolute repose by any splints which
will secure such an end. Let the tendo-Achilis be divkled
if the slightest difficulty is experienced in maintaining rest,
and good support and nourishment freely given. Under
such treatment, apparently hopeless cases often turn out
well, and rewards the surgeon's attention by a successful
result. The author then dwelt at some little length upon
the necessity of making free incisions wdienever pus was
present ; it was a practice which he had never seen followed
by any other than good results, and strongly advocated its
adoption in appropriate instances.
Analysis of the 35 Cases of Compound Fracture of the
Arm. 14 were treated on conservative principles, and all
vered ; 4 were treated by primary amputation at the
shoulder-joints. 2 of which died from internal complications;
13 were treated by primary amputation of the arm, and 2
died ; were treated by secondary amputation, and re-
508 Epilepsy. [June,
covered ; 31 of the whole number recovered, and 4 died, or
11-4 per cent.
Analysis of the 57 Cases of Compound Fracture of the
Bones of the Forearm. 27 were treated on conservative
principles, and all recovered. 22 were treated by primary
amputation of forearm ; 2 died, or 9 per cent. 5 were
were treated by secondary amputation 4 of forearm, 1
died ; 1 of arm, fatal. 3 died from internal complications.
The author then drew attention to the fact of the favorable
termination of these two classes of cases, which the expe-
rience of all surgeons correctly indicated, lie stated that
such operation as amputation should be resorted to only in
the severest examples, and that in more favorable cases a
good recovery might with some confidence be anticipated.
lie drew attention to the fact that so large a proportion as
50 per cent, of the cases of compound fracture of the fore-
arm admitted into Gkiy's Hospital were subjected to ampu-
tation, and explained it by proving that the majority of the
cases were caused by machinery, which was too often fol-
lowed by a total destruction of the part. The author con-
cluded by expressing a hope that the analysis was of some
value and interest, although he was well aware that few
general deductions could be drawn, as there were no cases
in surgery which required to be treated more upon their
individual peculiarities than those of compound fracture.
Analysis of Fifty -two Cases of Epilepsy. By Dr. Edward
H. Sieveking.
This was the second contribution of the same character as
the one admitted into the Transactions of the Society for
1S57, and the author has limited the analysis to the same
number of cases, taken in the order of observation as had
been subjected to analysis on the former occasion. Only
those points were brought forward on which satisfactory evi-
dence could be obtained.
Sex. 23 were females, or 44-2 per cent. ; 20 were males, or
55 8 per cent. Taking the two series together, the ratio of
females to males was as 45-2 to 54-S.
Age. The following was the distribution throughout the
different periods of life: Under 10 years, 13 cases ; from 11
to 20. 25 cases, from 21 to 30, 7 eases ; from 31 to 4i), 3 cases ;
from 41 to 50, 2 eases ; above 51, -"> cases. The basis of tin's
1861.] Epilepsy. 509
calculation is the time when the epilepsy first showed itself.
Arranged according to sex, we iind during the first decen-
nium S males and i females ; during the second, 11 males and
le females ; during the third. 5 males and 2 females; during
the fourth, 3 males ; during the fifth, 1 male and 1 female;
during the sixth, 1 males and 2 females.
Causes. An hereditary taint was traceable in 11 cases, but
in S only ot' these was there evidence of epilepsy having oc-
curred in a near relative of the patient. The exciting causes
were traced in 37 cases, as follows : Uterine derangement, 9
cases ; venereal excesses, including masturbation, 6 cases ;
fright, 4 cases ; over-work, -1 cases ; anxiety, 3 cases ; dys-
pepsia, 3 cases ; denition, 4 cases ; scarlet-fever poison, 2
cases (doubtful) ; meningitis, anaemia, blood-poison, and de-
velopment of puberty, each 1 case.
Premonitory Symptoms. Comprising under the term
"aura" all symptoms indicative of a near approach of a
paroxysm, the author found in 21 cases, or forty per cent., or
less frequently than it was met with in the first series, where
52 per cent, of the cases exhibited premonitory signs.
Headache. Headache is very commonly associated with
epilepsy, but its significance varies much according to its
period of occurrence ; it may be habitual, or it may be con-
nected with the attacks only as a precursor or a sequela. It
was constant or frequent in 0 cases, 17-3 percent. ; it occurred
after the seizures only in 12 cases, or 23-0 per cent. ; it oc-
curred only immediately before or after the fits in 3 cases, or
5-S per cent.
Biting the Tongue. Although a large number of genuine
cases of epilepsy occur in which this symptom is never met
with, it is important as a corroborative symptom. In the first
series it was met with only in 32-7 per cent. ; in the present,
27 patients, or 53-S per cent., exhibited this feature. It did
not appear that the female sex, as might have been antici-
pated, were less prone to inflicting this injury upon themselves
than males; because of the 24 cases in which the tongue had
not been bitten, 1G were males and S females.
Urine. The author has found no constant derangement in
the urin ated with epilepsy. He has always failed to
discover any sugar, nor has he met with a constant or even
frequent r a diminution of urea. In
several ca?e.-5 he found the urine presenting a specific gravity
ranging about 1030, and containing a large excess of urea.
There was in the present series no case of albuminuria, ex-
cept, perhaps, in one instance, in which a Bmall quantity of
510 Primitive Gangrenous Angina. [June,
albumen appeared to be present for a brief period. An ex-
cess of phosphates was observed twice, oxalates in one or two
cases, and an excessive deposit of lithates in a small number
of cases.
Treatment. The author, while urging the value of treat-
ment in alleviating the disease and indefinitely postponing
the seizures in a large number of cases, admitted the doubt
which always attached to any absolute cure of epilepsy. He
advocated no specific, but the employment of all rational
means indicated by the constitution and peculiar symptoms
of each individual case. Above all, he considered persever-
ance in a combination of moral, regimenal, and medical treat-
ment essential. As many of the cases analysed had not been
under the authors care permanently, he did not regard the
results as to the treatment indicative of what might have
effected in the whole series, lie considered that he could lay
claim to eight cures, that fifteen were decidedly benefitted,
while the remainder were either uninfluenced by treatment,
or did not continue under observation for a sufficient period
to justify any positive statement as to the result. Medical
Times.
Dr. Henry Musset relates a case of gangrenous disease of
the back of the mouth which resisted all other remedies,
but yielded to the employment of perchloride of iron.
This medicine was administered in a draught at periodical
intervals, and under its use the fever abated, the delirium
ceased, and a large patch of ecchymosis wdiich had ap-
peared on the right side of the chest began to grow pale.
Broth and wine were then administered, and every day the
improvement continued ; the breath was no longer foetid,
the tissues became clean, and at length the patient, who
had appeared moribund, was restored to life. Dr. Musset
attributes the recovery entirely to the use of the perchloride,
because it was the only medicine employed internally from
the time when the worst symptoms appeared, and because
the improvement continued regularly as soon as its admin-
tration was begun. With regard to the patch of ecchy-
mosis which appeared on the chest, the perchloride seems
t have acted beneficially in removing it, whether this in-
teratrial hemorrhage was produced by the gangrencc hav-
ing destroyed some vein, or whether it was the conse-
juence of an alteration of the fluids under the influence of
a general cause. U Union Medicate.
1861.] Editorial 511
EDITORIAL AND MISCELLANEOUS.
MEDICAL COLLEGE OF GEORGIA.
Under cover of the present issue will be found the Thirteenth Annual
Announcement of the Medical College of Georgia with the catalogue of
its numerous alumni. By this our readers will find that the session will
open, as usual, on the first Monday in November, and continue until the
first of March following.
The College Edifice, lately much improved by the addition of a most
commodious Dissecting Room, is now undergoing thorough renovation
and repair, being painted from attic to cellar, and in every way prepared
to afford comfort and convenience to the class. The present political
distraction on our continent, and the din of actual war. may. for the com-
ing season, diminish the class, but thorough preparation and accumu-
lated facilities are the best means of securing success in teaching. In
these no medical institution, North or South, can surpass the Medical
College of Georgia. Every means of demonstration, and every ap-
pliance are accumulated within her walls, and each member of the Fa-
culty, well practised in the art of teaching, will give himself with energy
and devotion most earnestly to the task. Let Southern institutions of
learning, like all other departments of Southern enterprize, receive now
new life and additional impulse from the remodeling and regeneration
which must surely follow the present national troubles and disaster,
brought upon as by fanatical enemies, not only of the South, but of the
whole country. The constant dripping of water has at last worn away
the rock whose foundations seemed so deep and so firm that the shock
of a volcano could scarce have stirred its base.
Pulmonary Hemorrhage. In the intercurrent haemoptysis of
phthisis, the tincture of larch-bark, in doses of half a drachm to a
drachm every second or third hour is a very effectual remedy, suc-
ceeding in some cases when the usual remedies (ipecacuanha, lead, tan-
nin, and gallic acid) had failed. It is now the remedy principally
used in t: -.in the wards of St. Vincent's Hospital. Dr. J.
AC (TFerrall, p, 77.
512 Miscellaneous.
Notes on Diabetic Cataract. The author has collected from dif-
ferent sources about twenty cases of double cataract, occurring in patients
suffering from diabetes. These cases are of no small interest in con-
nection with the recent observations of Dr. Weir Mitchell* and B. W.
llichardson.f which show that, in several of the lower animals, the ab-
normal introduction of sugar into the system, whether by immersion of
the body in syrup for a sufficient time for the osmotic process to take
place freely, or by injection beneath the integument, in almost certainly
followed by the development of lenticular development. John F.
France.
Bronchocele. The author considers this disease as the result of a
perverted action of the nervous functions, at least in this country.
Acting on this theory he administers strychnia in these cases, giving at
first a dose of the sixteenth part of a grain three times a day ; if ac-
companied by anaemia, he combines iron with the strychnia in solution.
This treatment, from the cases reported, seems to be followed by good
results ; the enlarged organ shrinks, the improvement commencing
after taking the remedy a few weeks. Dr. Murney, of Dublin.
p. 281.
Chorea. Farardization of the skin in cases of chorea occasions a
rapid and marked diminution of the movements, and frequently effects
a rapid cure of the malady. It should be applied chiefly to the parts
most convulsed, every day, or every other day. M. Briquet, p. 70.
Headache, Congestive. Iu severe headache, owing apparently to
congestion, give the usual doses of the extract of belladonna, This
drug excites the ganglionic nerves, tones and strcngtJicns them, but
depresses the cerebro-spinal system. Hence its value in congestive
headache. Dr. R. Uughes, p. 300.
[We should rather doubt this being the true explanation. There is
just as much reason to think that the belladonna is valuable as a
sedative to both the ganglionic and cerebro-spinal nerves. Editor
Braithicaite's Retrospect oj Practical Medicine and Surgery. \
Neuralgia. Hypodermic Injection of Morphia. The hypo-
dermic injection of morphia is of no use whatever in cases where in-
flammatory disease (caries of bone) produces the pain. It was of tem-
porary benefit in a case of severe pain originating in inflammation of the
nerve itself, The cases best adapted to this mode of treatment are those
where the pain is of a purely neuralgic character, depending upon general
anocmia. Dr. J. K. Barton, p, 46.
' American Journal of the Medical Science, Jan. 1860.
; Di-. Brown-Sequard's Journal de la Physiologic, &c, July, I860.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
T.L XVII.. AUGUSTA, GEORGIA, JULY, 1861. NO. 7
ORIGINAL AND ECLECTIC.
ARTICLE XV.
/'/cry. By Tilmax Douglas, M. 1)., of Alexander,
I Georgia.
A disease produced by so many various causes ; affecting
the various ages and constitutions so differently ; involving
in its course such various portions of the lower part of the
canal, being sometimes simple rectitis, and then involving
the whole colon, and eviii the ileum; frequently compli-
cated with disturbance of the liver and febrile reaction,
makes the suggestion to treat the "case and not the malady"
a common sense precept.
The idea which I wish to impress will be best illustrated
by noticing, in their order, the classes of cases which were
produced Jyv their several causes.
Dysenterp from Improper Dieting. Case 1. Mr. ('., ag
GO, of good character and constitution; large, tall, well
formed, a man of indomitable energy, but \ery irregular in
his habits of eating. Would rise before day and ride till
dinner, when, tired and hungry, would sometimes indulge
too freely. 1 was called in great haste to see him, Septem-
ber 11, 1845. Found him with intolerable pain in the um-
bilical region, coming on in paroxysms, followed by tenes-
mus and passing only spoonfuls of mucus and then having
to throw up. I learned that he had been riding all the
mornin. >re day, looking after his stock, and that,
514 Douglas. Dysentery. [July,
ou his return, he took a very hearty dinner, which was the
first thing he had ate that day. Prescribed at once 10 grs.
calomel and followed in short time with three drops croton
oil, hot bath, counter irritants to the abdomen, but without
benefit. Sent home and got a long gum elastic stomach
tube, which I introduced far up into the colon and threw
about a quart of warm water. He said he felt the water
reach the part which seemed to be obstructed. Copious
discharges of hardened foeces immediately followed, and was
soon well.
Case 2. During the hog-killing season otthe same year,
when we of the country are so prone to indulge in "swines*
flesh and broth of abominable things," a gentleman, after
being cold and fatigued all day, partook too freely at night
of the rich fruits of his day's labor, and was tormented for
two days by paroxysmal pains throughout the abdomen,
harrassing tenesmus, great difficulty in urinating and fre-
quently passing small quantities of bloody mucus. Would
take scarcely any medicine or submit to the use of the
syringe, saying he would certainly soon be relieved, for he
felt as if he would pass the disturbing matter very soon.
TTas finally relieved by the hot hip bath, which brought
away large, hardened matters in abundance, followed by
the contents of that unfortunate supper.
Dysentery from Cold and Fever. Case 3. May 2nd, 1860,
called to see J. W. IT. B., Esq., aged about 30; of good
habits, medium size, well formed, dark complexion and
black hair ; constitution only tolerably good. His mother
died of chronic bronchitis, and he was very prone to be af-
fected by sudden changes of weather with cold and cough
of so serious a character as to keep him apprehensive of
evil. Also, subject to most distressing attacks of dyspepsia.
Mr. B. had recently taken cold which, instead of affecting
the lungs as cold usually does in his case, caused large, fre-
quent, serous discharges from the bowels, which very soon
became painful, strainiug, small, consisting of mucus and
blood, and attended with intermittent fever. Prescribed oil
1861.] Douglas. Dysentery. 515
and turpentine emulsion, as used by J)r. Kobert Campbell,
every lour hours, and 18 grs. quinine to intercept the next
paroxysm of lever.
May 3rd, Mr. 1>. had fever again. The condition of the
bowels was, if anything, worse. The oil mixture seemed to
have agravatcd the griping pains, and the tenesmus was
intolerable. Dyspeptic symptoms also being urgent;
patient was disponding. Gave an occasional dose subnitrate
bismuth, continued the oil mixture in less doses, and
quinine as before. Bathed the bowels with essence pepper-
mint and covered them with a folded blanket which caused
considerable burning and much relief.
May 4th. Discharged the same bloody, straining, mucus
character. Considerable fever. The oil emulsion, our
favorite remedy, had to be abandoned in this case. Substi-
tuted :
Mucilage gum arabic, 3 oz.
Cream of tartar, 1 oz.
Pure sugar, j oz.
Oil lavender, 4 gtt.
(I have used the spirits of lavender, but think oil best for
this mixture,) a tablespoonful every three hours. Quinine
as before.
May 5 th. Patient sitting up, reading convalescing.
I had two other cases at the same time, produced by the
same change of weather; so similar in character, treatment
and results I need not detail them.
The oil treatment in these cases was not successful from
the fact that they commenced with diarrhoea, which cleared
out the upper portion of the canal, and left the mucus mem-
brane so sensitive that the oil excited it to action. In cases
where dysentery has supervened a diarrhoea, cream of
tartar, in small doses, has acted, in my practice, like a charm
by making a slight renewed impression on the serous mem-
brane, which relieves the mucous surface by a revulsive ac-
tion. And it 18 evidently better than salts for that purpose.
516 Douglas. Dysentery. [July,
because less irritating. To the next case the oil treatment
was well adapted.
Case 4. February, 18G0, Rev. Mr. W., aged 20 years, a
young gentleman of unexceptionable character and habits.
'Fall, slender form, red complexion and sandy hair. By
taut travelling and exposure to cold and inclement
weather, had taken cold, bowels constipated, and had
irregular paroxysms of fever every forenoon, attended with
griping pains in the bowels and frequent small discharges
of bloody mucus. Prescribed 16 grs. quinine early in the
morning, and a tablespoonful of the oil mixture every four
hours. Bathed the abdomen with essence peppermint and
covered it with folded blanket, which afforded him so much
comfort that he pronounced it the only thing that saved
him.
The next day the fever had returned and agravated the
dysenteric symptoms. Continued the same treatment.
Third day the disease had so abated I left him and he was
>n well.
Dysentery, thesequd of Measles. Case 5. May 28, 1853.
A negro woman, aged 30 years, black, well formed and
good canstitution, belonged to Mr. II. Was suffering-
great pain low down in the abdomen, paroxysmal, attend-
ed with bloody, watery, mucus discharges and painful tenes-
mus. The womb was excited to action by the inflammation
and continued spasmodic action of the colon and rectum,
and fever of a remittent type agravated all the symptoms.
She had measles a month before in which the fever was
very high Nature had, as usual in such cases, abated the
lever by a diarrhoea, which terminated in dysentery. That
was thought but little of, and allowed to run until it became
alarming. Attempts were then made by the family to cure
the case with opiates and sundry astringent herbs, and then
;rge and repeated doses of calomel which brought her
to the helpless state of prostration in which I found her.
>on as the fever had abated a little, I covered the
abdomen with a blisterto be dressed with a hot poultice, and
1861.] Douglas. Dysentery. 517
put her on 3 grs. quinine and 1 gr. opium every three hours
to intercept the next rise of fever and to.quiet the action of
the uterus.
May -0. Had less fever and pain, but dysenti
persisted. Prescribed quinine disolved with elixir vitriol
in 1 gr. doses every lour hours, toast water, chicken water,
etc., under which she improved till the 2nd day of June,
four days from the time I first saw her, she had so far re-
coved I left her.
Case 0. June 12, 185G. A youth, son of Mr. II., of same
family, as the above, aged about lo, that tender age of boys,
had measles, and dysentery as its sequel at the same time,
was not thought to be so dangerous as to require my ser-
vices while I was attending the negro, hut was treated by
the family with repeated doses of ealomcl and astringents
and opiates.
I found him completely prostrate. Tormina in parox-
ysms, and most distressing tenesmus ; passing every few
minutes small quantities of watery, bloody mucus. Fever
had been intermittent but was now almost continued. The
treatment after I saw him consisted mainly of quinine dis-
solved with elixirvitriol and an occasional dose of opium
which the severe pain seemed positively to demand. And
copavia and gum water.
.:ses T and 8. Aged about 10 and 12, were younger
brothers of the above, who were taken while I was attending
6, and a milder treatment adopted from the-first, they
soon recovered.
Dysentery from Drunkenness. Case 0. November 1, 1 I
(/ailed to see Dr. M., a young professional brother, aged
about 25 years, who was universally respected for high
toned honor and gentlemanly bearing. Had gr
only three years previously in the Medical Col]
Georgia. Was pronounced by Dr. E. L. Anthony, his
ecptor, to have had the best physical constitution '
saw. But in an evil hour, while reading medicine in
Waynesboro, he glided gradually and imperceptibly into
518 Douglas. Dysentery. [July?
the habit of visiting the bai rooms, which so completely
undermined his moral sensibilities that lie did not more
than complete his education and get fairly into practice,
where an honorable and useful career awaited him when he
found his moral and physical energies paralized and he fell
back in hopeless despair. I found my young friend in bed,
emaciated, bloated face, and a countenance which indicated
the most dreadful horror. Very cautious in retrospect! ng
the history of his case. Had to get my information respect-
ing his past course from others. It made me sad. For
three years he had been in the constant habit of sending for
a gallon of spirits at a time, with the intention of taking
only a little as he needed it. That was, of course, when
fatigued and exposed to cold and wet on his visits at night,
&c. But instead of using it necessarily as he honestly in-
tended, he drank each new supply sooner than the former.
And being a man of means and social, liberal, friendly feel-
ings, he was not alone long at a time and his comrades were
not angels by any means.
I found him with a supply of wine, and about the only
information I could get directly from himself was that
brandy made him sick and could not be retained, that wine
was retained better than spirits and that it was impossible
for him to do without something of the sort. It just then
recurred to my mind that only a short time before that I
was passing his house late at night and saw him leaning
over the piazza rail heaving as though he was trying to
eject the whole abdominal vicera from his mouth. At the
same time had all the symptoms of the most distressing
and threatening dysentery. And so debilitated was he that
it was impossible for him to get down to the chamber on
the floor, and had a box fixed on a level with the bedstead
that he might glide off easily over the chamber. Once
while sitting on his box his hands were moving the soft
flabby muscles (once so plump and hard,) and while folding
and doubling them, and pressing with his fingers as if to
fool how near it was to flic bone, he sighed and said, spirits
1861.] Douglas. Dysentery. 610
has done all this ! and it was remarked by those who had
been with him constantly that that was the first time he
had over admitted that spirits was doing him any harm.
Now, it was evident that the whole canal was involved.
The Btomach could retain only a spoonful of anything at all
and nothing stronger than wine ; the duodenum and small
intestines were painful and distended ; the colon and rectum
inflamed, and constantly discharging blood and water and
muens and some pus, which was wasting him away. The
nutritive functions were so completely destroyed he must
have perished even though he could have eaten.
The thought of treating such a case farther than to soothe
for a few days would be absurd. Dr. E. L. Anthony, who
kindly came to my assistance, suggested salts as recom-
mended by Drs. O'Keefleand Dugas, but it only added to the
sensitiveness of the whole canal and rendered him still
more nervous. Nothing could be done but soothe with
wine and opiates so long as the system was susceptible.
Case 10. Called June 4, 1854, to see Mr. Q., an Irishman,
farmer, about 35 years of age. An honest, energetic-,
thrifty man of good constitution. Had recently great trouble
with his negroes, and went to Augusta to sell one, where
by drinking, exposure and improper dieting he had ;i lit, of
cholera morbus. A physician gave him a dose of lauda-
num and sugar of lead, which enabled him to get home. 1
found him next day with considerable fever, stomach very
irritable, and passing from the bowels every 20 to 30
minutes, bloody, watery mm* us, attended with griping
[tains and tenesmus ; bowels sore and distended, restless
and very apprehensive of a fatal result.
Prescribed small doses cream of tartar every three hours
and 3 gr. doses quinine, with ] gr. doses opium between
the times of giving the cream of tartar.
June 5. The cream of tartar had reduced the distension
of the bowels some, but the fever, dischargee arid tenesmus
about as yesterday.
June G. All the worst symptoms aomewhat abated and
520 Douglas. Dysentery. [July,
we were somewhat encouraged. Continued the same treat-
ment.
June 7. Discharges larger and less bloody, but fever
persisted. Dismissed the cream of tartar and continued
the quinine. *
June 8. Fever high, discharges frequent, painful and
.-training. Continued the quinine with occasional doses of
opium.
June 9. All the symptoms remaining the same and the
bowels being more distended, a blister was applied all over
the abdomen.
June 10. Fever had abated some and the passages les3
frequent and the pain had diminished very much, but now
the parotid glands had swolen enormously. Dr. E. L.
Anthony was called in consultation. Patient was put im-
mediately on Dr. A.'s favorite remedy, sulph. magnesia,
and quinine as before, and painted the parotids with tinct.
iodine.
June 11. The salts had caused enormous serous dis-
charges, but the patient was so prostrate it had to be aban-
doned. Continued the quinine dissolved in the aromatic
sulphuric acid and an occasional dose of opium.
June 12. Growing worse in all respects. Blister had
relieved the distension but slightly, and was itself exceed-
ingly troublesome and painful. The passages, frequent,
painful, bloody, watery, mixed with pus, and exceedingly
offensive. (If it be said he drank "rot gut whiskey," I re-
ply, all spirits rot the guts if we are to judge by the charac-
ter of the discharges in the last stages of drunkenness.) He
was restless and unable to get out of bed. Kept him on
quinine in 2 gr. doses, elixirvitriol and opiates, &c, under
the use of which he lingered until the 29th, 24 days after
liis return home.
Dysentery from Teething, Case 11. April 25, 18G0.
( ailed to a little negro boy two years old, property of Hon.
.1. A. B. Several teeth coming in a group, gums swollen,
had had diarrhoea for several days, passing large quantities
1861.] Douglas. Dysentery* 521
of watery matters, sometimes white, undigested bread, &c,
ed directly through him, at other times greenish. This
followed by bloody mucus in small quantities with pain
and tenesmus, complicated with remittent fever, and that
symptom so much dreaded in such cases hot head was
also very prominent. Prescribed the oil and turpentine
emulsion in small doses every four hours, a liniment of olive
oil, tinct. iodine and camphor for bathing the abdomen,
cold water to the head and quinine in 1 gr. doses every 3
hours.
April 20. Patient had more copious discharges and less
blood and tenesmus, but did not urinate freely. Continued
the same treatment with the addition of buchu tea.
April 27. Head less hot, dysentery persisting. The same
treatment was kept up with very little variation till the 1st
lay, four days longer without, any permanant change
for the better. The abdomen being distended, applied a
blister.
May 2. The benefit resulting from the blister had been
onl}- temporary, all the symptoms were worse. Continued
the oil emulsion, increased the doses of quinine and added
small doses ipecac.
May 3. Dysenteric symptoms persisting, little negro be-
ginning to look quite ghastly. Made him an emulsion of
Gum arabie, 2 oz.
Loaf sugar, \ oz.
Copavia, I dr.
One teaspoonful every 3 hours ; quinine and ipecac as be-
fore.
May 4. Much better every way. Continued the same.
May 5. Patient convalcssing left it. It bloated and
got up slowly, but surely.
X. B. This case commenced with diarrh rilar in
some respects to <
Case 12. ged about 20 months, a fine sprightly
522 Douglas. Dysentery. [July,
boy, son of Mr. F., of Savannah, was unfortunately weaned
while a group of teeth were just causing the gums to look
red and swolen. Diarrhoea set in in April, 1860, and was
checked with chalk and opiates. Dysentery soon followed
of so violent a character that Dr. Young, the family physi-
cian, advised its removal to the country as the only chance
for its life. It did not come to this place till June, two
months after, when I found it with fever, coming on late in
the afternoon and lasting all night, with hot head, continual
moaning, jumping, trying to get out of bed, screaming fre-
quently, as if frightened, and passing from half dozen to ten
bloody, mucus, greenish discharges during the night and
several during the day. The abdomen was much distend-
ed. Appetite sometimes entirely absent, at others voraci-
ous. The oil emulsion acted finely at first. Lessened the
frequency and improved the character of the discharges.
But the dysenteric symptoms would soon return. Lanced
the gums frequently and covered the surface of the body with
olive oil morning and night. The teeth which we thought
would be through in a few days remained at a stand, and all
the symptoms would return suddenly and blight our hopes.
I found the cream of tartar emulsion as used in the 11th
Case the best means of reducing and softening the distend-
ed bowels. Towards the last of June he was so emaciated,
his joints appeared so very large, limbs and neck so small,
had entirely quit walking and the head would hang on the
shoulders, and the tired, distressed countenance made his
look almost frightful. The discharges also had that rotten
flesh fetor, which led me to suspicion rachitis.
By the first of July the dysenteric symptoms gave way.
But the discharges continued frequent, watery and offensive.
And what to me was singular, a tumor appeared under the
tongue, which 1 at first took to be ranula. Prescribed so-
lution < him arabic, 2 oz.
Pure BUgar, q. s.
Cretap.pt., 3G grs.
Iodide potass., 24 grs.
Copavia, J drachm.
I.] f the Spinel Muse
onful every 4 hours, and cod liver oil twice
every day. which had a most happy effect* lessened the fre-
quency and offensiveness of the discharges, and made them
more coi , But the tumor under the tongue continued
some weeks, when he was found to bo salivated and the
tumor had disappeared. The same mixture, except the iodide,
was continued several weeks longer. The salivation sub-
sided and the tumor returned. Iodide potash was again
combined with the mixture, salivation soon appeared and
the tumor again subsided. But still the general improve-
ment was unsatisfactory. Sometimes feverish discharges,
too frequent, watery and now and then offensive, but little
improvement in appearance. About the first of August
commenced the inunction with olive oil again overthe entire
surface every night ; applied a flannel roller to the whole
body and dusted it well with red bark. That was continued
through August and September, and the above mixture,
minus the iodide, every four or live hours. Last of Sept.,
four months from the time he came under my care he was
found growing plump, lively and stronger, and re-
turned home in high hopes. II13 mother writes, Xovcm-
ber 1st, littl I still fattening.
I have treated dysentery during the Last spring a great
deal on the general principles above indicated, with the
ilts with on. exception.
i I By \)v. Zuradella.
Of this >llowingchai tics are summed
up:
1. Dull pain in the lumbar region in on long
ding and dimini lying down; in some people
neuralgia of the intercostal ional
Lhility of the Bpine.
. hi incurvation of the -pine ; in
that til- on the
'>. Excavi ti the yerte-
524 Lithotomy, fic.9 in Children. [July
bral extremities of the ribs may be more or less easily dis-
tinguished.
4. Some painful point exists on a level with a lumbar
spinous apophysis, owing probably to stretching of the
ligaments which have lost tonicity.
"5. In advanced cases a peculiar elasticity at the level of
the spinous and transverse apophyses of the vertebrae, due
to tension of the aponeurosis.
G. Impossibility in maintaining the erect posture without
support.
7. Incomplete power of extending the trunk without fixa-
tion of the upper limbs.
8. Alteration in the natural curvatures of the spine, the
concavity of the cervical region being the first to disap-
pear.
9. Eight declination of the whole spinal column to the
right side.
"lO. Incomplete straightening of the spinal column by
Farardization of the muscles of the vertebral gutters.
11. Freedom of movement of the cervical muscles, ex-
cepting the above-mentioned incurvation.
12. Increased mobility of the vertebra? one upon the
other, owing to the relaxation of the muscles, attended by
occasional noise like the crepitus of certain dislocations.
On Lithotomy and IMhotrity in Children. By M. Dolbeau.
M. Dolbeau, in temporary charge of M. Guersaut's wards
at the Children's Hospital, has taken the occasion of the
presence of two cases to make some interesting observations
upon the operations best suited for the relief of stone in the
child. One of these patients, lour years of age, had been
submitted to bilateral lithotomy by ]\f. Guersaut, and did
very well, except that, a month after the operation, a fistula
remained, which will require surgical interference. The
other child, seven years old, had a very hard calculus,
measuring three centimetres in one direction by two and a
half in another. M. Dolbeau Liberated him of this by means
lithotrity, eleven seances, each of about a quarter of an
hour's duration being required between the 11th July and the
L'Oth of A.ugust Chloroform was employed, and hut very
^861.] I
little local irritation was produced. The bladder, p<
but little power, discharged the fragments very imperfectly,
and considerable difficulty was often experienced in their
val.
In estimating the comparative value of the two operations
for children, in 1849 M. Guersaut gave the decided prefer-
ence to lithotomy, except in those cases in which the stone
admitted of being crushed in a single seance : but, although
this surgeon has published no statement since that time, AT.
Dolbeau now states that he performs lithotrity much more
frequently than he did, by no means limiting its application
to cases which can be disposed of in a single seance, and that
his success is tar more considerable than heretofore. Several
of the circumstances which have been objected to lithotrity
are really due to the want of skill on the part of the surgeon.
A serious inconvenience, however, is the engagement of the
fragments in the uretha a complication far more common in
children than in the adult. In place of moderating the efforts
at micturition, performing them in the horizontal posture, and
using various other precautions, they expel all the fragments
through the dilatable neck of the bladder into the uretha.
Other inconveniences of urine, and sometimes a very notable
diminution in the contractile power of the bladder, are in
general of no long duration.
In M. Dolbeau's opinion, the two operations may be thus
compared : lithotomy is applicable in all cases. It very fre-
quently succeeds, but it exposes to accidents, such as inflam-
mation and the establishment of fistula, which are difficult of
cure. As a general rule, the operation is simple and easy of
execution. Lithotrity is not applicable to all patients, but in
rminate cases its results are excellent. Its execution ne-
gates a special dexterity, as it presents greater difficulties
than does lithotomy. It may also give ri accidents, as
urethal fever, which may carry the patient off, the engage-
ment of fragments in the uretha (a omplica-
tion), and incontinence or retention of urine. As the opera-
ithotrity may. have to be extended <>. er a long period
(a child nine years of age, a patient of M. Civiale, required
. the health should be good, and the bladder
healthy and of good capacity. Nor must the calculus be too
too hard; its volume maybe considerable if if is only
friable, but in the case of a large stone, th] is an
extreme size. In spite of the success of lithotomy, it is an
ration that should not be performed except when lithotrity
ble. A seance of lithotrity may always be first
526 Fracture of tJie Scr alum. [Jul}*,
tried in doubtful cases, in order to judge whether this can be
borne, and that without any prejudice to the ultimate success
of lithotomy. Chloroform should always be had recourse to,
its advantages far outbalancing any inconvenience which may
result from its use. As none but small instruments will enter
an nretha of the amount of development in a child, the habit
of manipulating witli such must be acquired. The seizure of
the stone is a matter of difficulty, and that not so much from
the want of capacity in the bladder as from its form and situa-
tion. In place of being comprised within the pelvis, it occu-
pies a part of the abdomen, while the absence of the prostrate
prevents the formation of the depressed part termed the
basfo?icl, where in the adult the stone is so frequently found.
The bladder is large, since it mounts up into the abdomen,
and the very moveable stone has no fixed situation. In the
author's opinion, the manipulation is facilitated by leaving
only a little fluid in the bladder, and by raising the buttocks
so as to keep the buttocks so as to keep the stone in the most
dependent part of the bladder. "When the stone is hard and
large, owing to smallness in size of the instrument, it is held
and broken up with difficulty. When the stone has been
broken up, it is the engagement in the deep portion of the
uretha to be most feared. We must especially endeavor to
reduce the smaller fragments to powder, or they may some-
times be gently removed in the grasp of the instrument.
Fever seldom follows either catheterism or lithotrity opera-
tions in the young, and in consequence of the little reaction
which takes place, the seances may be longer or sooner re-
peated (every two or three days at most) than in tbe adult.
Monitewr des Hopitm
Cases of Fracture of the Scrotum. By MM. Hamon and
Mercer.
As this accident is of such rare occurrence, and is so con-
cisely treated of by writers on surgery, M. Hamon supplies
the details of a case which occurred in his practice.
A woman, aged twenty-eight, July, 1S56, fell upon her
seat from a height of about ten feet. On examination, the
lower part of the scratum, at nine centimetres above the
point of the coccyx, was found flattened and carried forwards,
free movement being imparted to the fractured portion, with-
1861.] Fracture of the Scrotum. 527
out any pain being induced when the linger was passed into
the rectum. The bladder and rectum were paralyzed, both
requiring aid for the removal of their contents. While nothing
remarkable was observed with regard to the thighs, the legs
were paralyzed. Seen two years afterwards; the rectum had
recovered its power, but the catheter still had frequently to
he used, while the paralysis was s< far amended as to admit
ot' the patient walking, although with difficulty and with the
aid of crutches. M. Hamon saw the patient last early in the
past year, and nearly four years after the accident, lie found
that menstruation, defalcation, and the discharge of urine, all
took place in a normal manner. A very projecting angle could
be felt at the seat of fracture. While the thighs were of their
normal size, the muscles of the legs had underwent consider-
able atrophy. The motors of the legs were only enfeebled ;
and although all movements of the foot were found to be im-
sible when it was held free in space, these became execut-
able as soon as the heel rested on the ground. All the motors
of the toes were completely paralyzed. Imperfect perambu-
lation by means of a crutch and stick was alone possible.
In reporting upon this case, which was read at the Paris
Medico-Practical Society, M. Mercer relates another example
of the accident, which occurred during his interned at the
Hotel Dieu : A young mason fell from a height on to a stone
in the sitting posture, and a compound fracture of the sacrum
was the result ; the fracture extending obliquely from one
side to the other, at three inches above the point of the
coccyx, and the detached portion being carried to the right.
The rectum, seen at the bottom of the wound, remained in-
tact. Ths skin covering the middle portion of the posterior
surface of the pelvis had lost its sensibility to the extent of
three or four inches transversely. Beyond this the sensibility
was preserved, and the lower limbs were not paralyzed. The
expulsion of neither urine nor faeces took place without aid,
hut after some days loose stools were discharged involuntarily.
The patient sank exhausted twelve days after the accident,
ge portions of the sacrum were found inseparable, and
bathed in pus. The cauda equina was destroyed, the inflam-
mation and suppuration invading the portion occupying the
the lumbar spine as high as the third vertebra. All the roots
of the sacral plexus, excepting the last lumbar and first sacral
pair, were destroyed.
M. Mercer concludes from these two c at the para-
plegia is much less the effect of the rapture of the nervous
Is compromised by the fracture, than of the itive
528 Ox- Gall in Frost-BUc. [July,
compression and inflammation of the nervous plexus of the
pelvis ; and he suspects that the prevalence of the paraplegia
in the slighter case, and its absence in the severer one (al-
though in this last any difference which might prevail between
the condition of the thighs and the legs was not sought for),
may depend upon the effused blood not obtaining the outward
issue in the one. case which it did in the other.
M. Mercer further draws attention to this question. Why,
in any case of paraplegia coining on rapidly, does the paraly-
sis of the rectum, and especially that of the bladder, habitually
commence with the retention of the contents, incontinence
manifesting itself only at a more or less distant period ? So
complete is this retention in some cases of lesion of the spinal
marrow, that the bladder would burst rather than allow a few
drops of urine to escape. Supposing there to exist an equal
inertia of the body and the sphincter ot the organ, the slightest
repletion ought to lead to a continuous discharge ; and ad-
mitting, what seems to be the fact, that the sphincter is more
under the influence of the spinal cord than the body of the
reservoir, it ought to be the first effected by such lesions, and
incontinence should at once appear ; while it is just the con-
trary which is observed to take place. The neck of the blad-
der, in fact, is not closed by a simple wrinkling, as is generally
supposed. The muscle, acting as the occluding agent, gives
rise to a true valve, which the tonicity of this muscle is en-
abled to keep closed until the distension of the organ and the
passage of instruments at last have destroyed the last remains
of the contractility of tissue. Then, not only is there regorge-
ment of urine, but a true incontinence. M. Mercier has ex-
pressed his views at length in the Gazette Medicale for 1854.
The remarks made on the tonicity of the sphincter of the
bladder may be applied to the anal sphincter. And, although
the functional mechanism of the latter is not so favorably
disposed', this is the less necessary, in consequence of its
strength, and the compact nature of the matters it has to
retain. L1 Union Medicale.
Ox-Gall in Frost-Bile .
jistant burgeon Moore, of the United States Army in
CTtah, states that he has employed in si i ox-gall in frost-bite
with great benefit, when the injury is superficial. It is ap-
plied as a liniment or on pieces of lint saturated with it.
m Med. Tim .
1.]
mischief among the French, causing serious mortali-
ither directly or indirectly, besides disqualifying large
numbers for service.
orvy was another dreadful enemy which the British
ami French troops were compelled to encounter in the
Crimea. It prevailed more or less extensively for a long
time and served to impart its livery to the other diseases of
the soldiery, masking their character, and remarkably aug-
menting their virule:
Considering, then, the frequency of the occurrence ot
5C disease-, and their excessive fatality, it behooves the
military surgeon to use every means in his power to guard,
in the first place, against their outbreak, by the employ-
ment of proper hygienic or sanitary measures, and in the
next, to treat them with all possible diligence and judg-
ment when their development is unavoidable. It is, of
course, impossible, in a work of this description, to enter
into any details upon the subject; but there are several
points which cannot, I conceive, be too forcibly impressed
upon the mind of the military practitioner. I refer to the
r. the paramount importance of 1st, proper isolation
of the sick, or, what is the same thing, the importance of
not crowding them together : 2dly, free ventilation; 3dly,
bodily cleanliness; 4thly, little medicine; 5thly, a good
supply of fresh vegetables and fruits, especially oral
and lemons; thly, careful and tender nursing.
Painful experience has shown in all parts of the world,
that the crowding together of the sick and wounded is one
of the worst calamities that can befall them. For want of
precaution. 3, otherwise easily manageable, often
Lme an epidemic character, or, in the absence of this
character, often battle the best directed efforts for their re-
lief. When the wounded are crowded together they fre-
quently become the victims of erysipelas, hospital gan-
grene, pyemia, and phlebitis ; occurrences which, under
better regulations, might in many cases be entirely pre-
vented.
Of the proprie instant and thorough , it
IS unnecessary t< speak. It pure air is so essential in
health, it is easy enough to Bee how important it must be in
sick:
88 of body Bhonld be regarded as a relig
duty; it may be effected with V je and tepid, cool or
cold water, according to the exigencies of the case, and can-
:J7
578 Military Surgery. [July,
not be performed too frequently or too thoroughly, care
heing, of course, taken not to worry or fatigue the patient.
In some instances the water may be medicated with com-
mon salt, potassa, vinegar, or Labarraque's solution. Noth-
ing is generally more grateful to the sufferer, in the differ-
ent kinds of fevers, than frequent sponging of the surface
with cool or tepid water.
The use of heroic medicines, or of any medicines in large
doses, in these diseases, and also incases of severe wounds,
cannot be too severely reprobated. More men, there is
reason to believe, have been killed in this manner in the
armies and navies of the world than by the sword and the
cannon. Let medicines, then, be administered sparingly.
Let the secretions be well seen to ; but purge little, and use
depressants with all possible weariness. Give iced water
but not too freely, and lumps of ice when there is much
thirst with gastric irritability and excessive restlessness.
Mild diaphoretics and anodynes, will, as a general rule, be
highly efficacious, but the latter should be exhibited with
great caution when there is cerebral oppression. Lemon-
juice and potassa are indispensable in scurvy, or where
there is a marked tendency to scorbutic disease. Quinine
is one of the great remedies in most, if not in all, of these
diseases, especially when, as is so often the case, they are
associated with a malarious origin. The good average
dose is from two to five grains, repeated from three to five
times in the twenty-four hours. When marked debility
prevails, the best stimulants are brandy, in the form of
milk-punch or toddy, and Madeira, Port, or Sherry wine.
Immense suffering and loss of life are often occasioned
for the want of fresh vegetables and fruits in military oper-
ations, as well as in the garrison and the hospital. A daily
supply of these articles should, therefore, be provided at
almost any hazard and expense. In all low states of the
system, however induced, the strength can never be rapid-
ly brought up without a diet which partakes more or less
of this character.
There is a form of dysentery, very common in India,
which is exceedingly apt, when large masses of troops are
habitually c together, to assume an epidemic
character ; and it is for this reason that it has often been
supposed to be contagious. For sncli an opinion, hewever,
there does not seem to be any valid reason. Ballingall,
1861.] Mititor ry. 579
who witnessed at least 2 oi this disei serts
that he never once met with a circumstance tending to
create such a suspicion : and the views advanced by this
eminent Burgeon are those now pretty generally, if not
universally, entertained by the British practitioners in
India.
The remote causes ot dysentery in India arc conceived
to be heat, particularly when combined with moisture; the
immediate and indiscriminate use of fruits ; the abuse of
spirituous liquors, and exposure to currents of wind and to
noxious night-dews." Troops recently arrived from Eu-
rope are particularly prone to the disease.
Tropical dysentery presents itself in two varieties or
form. tl. and the chronic. The first, which is an ex-
tremely fatal disease, is seated in the rectum and colon, the
latter being often involved through nearly its entire extent,
and it frequently commits very serious, if not irreparable,
mischief in these structures before the patient and the at-
tendant are aware of its true character, owing to the ab-
e of urgent pain and pyrexia. In general the attack
is ushered in by the ordinary symptoms of diarrhoea, such
piping pain in the bowels and frequent calls to stool
inin-g, the evacuations being, at first,
thin and copious but without fetor and but little streaked
with blood. The tongue skin, and pulse are nearly, per-
haps entirely normal. Gradually the pain becomes more
violent, as well as more fixed, and is felt in both iliac re-
>r even along the whole track of the colon ; the dis-
chai i sists chiefly of blood and mucus, or of a fluid
cabling water in which fresh beef has been macerated ;
ivered with a white coat; the skin is either
ho1 and dry. or bathed with clammy perspiration : and the
straining is so e as to occasion prolapsus of the
The pulse is, n at this stage, often but little
affected, being perhaps, only somewhat increased in qui
P, if is very full, bounding, and
vibi ity, and when this ia I
ccording to Ballingall, forebodes evil. Toward
the . the pass are frequently invol-
untary and intolerably fetid, gangrenous portions oi" the
mucous coat of the bowel are sometimes extruded, and
juliar cadaverous smell.
Tl. I at which death 0 about one
week, but many cases linger on much iong<
580 Military Surgery. [July,
The remedies upon whiclithe India practitioners mainly
rely in the treatment of this horrible form of dysentery
are venesection, mercury, and opium, leeches, purgatives,
diaphoretics, warm bathing, blisters, and enemata, being
employed as auxiliaries, venesection is always practiced
early, and, even when the patient is not very robust, bold-
ly, it being, apparently, regarded as the sheet anchor of the
physician's hope. Calomel is administered in doses of
from ten to twenty grains, along with two or three grains
of opium, twice or thrice in the twenty-four hours ; and,
while profuse salivation is discountenanced, production of
slight ptyalism is generally aimed at.
Such treatment as this seems altogether frightful to the
modern American practitioner ; it strikes him as unneces-
sarily harsh, and as well calculated to augment the mortal-
ity of the disease. "We might, in this country, perhaps
bleed, and that pretty freely, at the very commencement of
an attack of dysentery; at all events, leech very copiously,
but we would certainly draw blood sparingly if the attack
had already made serious constitutional inroads, or if it was
of an epidemic character, and, as to giving mercury with a
view to ptyalism, however slight, few men would, I presume,
be so fool-hardy. The India practitioners do not, it ap-
pears, employ quinine in the treatment of this form of dys-
entery ; a remedy so extremely needful in many cases of
this disease as it prevails in this country, especially in our
Southern latitudes, where it is not unfrequently of a malar-
ious origin.
The ehronic form of India dysentery, termed hepatic flux,
more frequently attacks persons who have been for some
time inured to the climate of that country, and is always
associated with biliary derangement. "This flux, like the
other, often assumes at its commencement the appearance
of a common diarrhoea, and becomes afterward character-
ized by frequent and severe fits of griping, resembling colic
pains, partieulary urgent about the umbilical region. Each
attack of griping is generally succeeded by a call to stool,
and the evacuations are always unnatural in color and con-
nce, free from any admixture of blood, but generally
of a yeasty or frothy appearance, and accompanied with
rges of flatus ; while in passing they are attend-
ed with a sense of scalding about the anus. The patient,
after each evacuation, lecls considerably relieved, andhopes
to enjoy an interval of ease,' but the recurrence of the
1861.] 'Hilary S
griping, accompanied with a ton of air passing through
the I and succeeded again by a call to stool, give him
little . From the commencement of the attack, the
patient complains of nausea, want of relish for his food,
and preternatural thirst, attended often with a disagreeable
taste in the month. The tongue is furred or loaded, and
not unfrequently covered with a yellow bilious coat. The
pulse is quickened and the skin parche 1.
C / i must, necessarily, in this country, especially
in our Southern latitudes, and during the hot summer
months, be a more or k iient attendant upon camp
life, although much may be done, by a proper observance of
hygienic laws, to prevent it. When the disease breaks out
it cannot be arrested too speedily. The most appropriate
remedies, particularly in its earlier stages, are perfect quie-
tude, abstinence from drink, sinapisms to the epigastrium,
and an efficient dose of morphia and camphor, or even mor-
phia alone. If torpor of the liver exists, blue mass or a
few grains of calomel may be advantageously combined
with the anodyne. The swallowing of small lumps of ice
will greatly assist in allaying the gastric irritability. A
mustard and salt emetic will be indicated if the stomach is
loaded withingesta. The bowels arc quieted with an ano-
dyne enema; and to relieve thirst, and reduce heat of skin,
the surface is frequently sponged with cool or tepid water.
A combination of carbonate of potossa and acetated tinc-
ture of opium, with fresh lemon-juice, in peppermint or
camphor water, will often act like a charm in relieving the
trie and intestinal irritability, the cramps, and other dis-
:ng symptoms.
The exposure of the soldier, both in the tent and on the
field, renders him extremely prone to rh n, frequent-
ly attended, with high inflammatory excitement and severe
pain. Such an attack is often effectually put to flight if, at
its inception, it be treated with a large anodyne and
retic mixture, as fifteen grains of Dover's powder, a third
to half a gram of sulphate of morphi with a fourth i
i of tartar emetic, or, what is perhaps still better, a
hm of the wine of colchicum in union with a full :
of morphia or black drop. When I
mad , an active purgative should precede
exhibition oi medicin<
*Ballingair.s Military Surgery, p. ."511, I
582 Military Surgery. [July?
Sore throat, tonsilitis, and catarrhal affections, or, what
in common Language arc called colds, are very common
among soldiers, especially the raw troops just mustered into
service, ill clothed, inexperienced, and unaccustomed to
camp life. The moment such disease sets in, no matter
how Lightit may he, the person should be compelled to re
port himself at the surgeon's quarters, in order that he may
receive the necessary attention and advice. Generally an
attack of this kind will promptly yield to a trifling pre-
scription, as a little hot drink, a mild aperient, or, "better
still, a quarter of a grain of morphia, a grain of opium, or
a large dose of Dover's powder.
In an army not under strict discipline, or where proper
care is not observed in enlisting,maraa apolu is very apt to
show itself, much to the annoyance of the nurses and the
physicians. If, in such a case, the patient he not well se-
cured, he may, in his perverted military ardor, do serious
mischief to himself and to his attendants. A moderately
active mercurial purge at the outset of the disease will often
go far in quieting the system and in abridging the attack.
After the medicine has operated, a mild opiate and seda-
tive treatment will generally be the most soothing. Al
coholic stimulants are, in general, to be witheld.
Nostalgia is another complaint liable to assail the soldier,
even the hardiest, especially if he is a person of strong do-
mestic attachments, or engaged in an "affaire du coeur." It
is more apt to show itself in soldiers enlisting for the for-
eign service, or in those who are forcibly expatriated, and is
often attended with great suffering, terminating in con-
firmed melancholy. It is characterized by a love of soli-
tude, a vacant, stultified expression of the countenance, a
morose, peevish disposition, absence of mind, pallor of the
cheeks, and progressive emaciation. Many of Bonaparte's
troops, during the campaign in Egypt, suffered from this
complaint ; some in a very distressing degree. In this
country, nostalgia will not be likely to occur, at least not to
any extent, as our people are essentially of a roving habit,
and ol an eminently social disposition. The treatment is
rather moral than medical;- agreeable amusements, kind-
ness, gentle but incessant occupation, and the promise of
an early return to home and friends constituting the most
important means of relief.
It is impossible, even under the most rigid discipline, to
prevent gonorrhoea among soldiers. They will expose them-
1861.] Military Surgery.
solves, in Spite of all that can be done to prevent it, and
they often pay a heavy penalty i'or their indulgence, not
only from the Buffering entailed by the primary disease, but
its different complications, especially chordee, cystitis, and
orchitis. The symptoms of gonorrhoea are too well under-
stood to require enumeration here. The treatment should,
from the start, be rigidly antiphlogistic : by rest, low diet,
active purgation, and Uie antimonial and saline mixture,
with the addition of a small quantity of copaiba. The
penis and scrotum are well supported, and covered with
warm water-dressing, the former organ being bathed in
tepid salt water, at least thrice daily, for twenty minutes at
a time. When the discharge is greatly lessened, but not
till then, recourse is had to injections of lead, sulphate of
zinc, or nitrate of silver, at first very mild and gradually
increased in strength, repeated every six, eight or twelve
hours. The treatment is continued, in a modified form, for
about five days after all the specific symptoms have van-
ished.
Chordee is best relieved by a full anodyne, as half a grain
of morphia, in union with the fourth of a grain of tartar
emetic, given toward bedtime, or by a large enema of lau-
danum : with warm water-dressings to the genitals.
>r the relief of cystitis the most appropriate remedies
are anodyne diaphoretics, in the form of Dover's powder,
or a solution of morphia and tartar emetic, ^aided by the
free use of bicarbonate of soda and moderate quantities of
diluents.
Or treated by suspension of the affected organ,
with strong lead and anodyne lotions, and the judicious
hibition of antimony, in union with morphia or black drop.
CI- must be thoroughly cauterized at tin; beginning,
either with nitrate of silver, nitric acid, or acid nitral
mercury; and subsequently, or after the disease 1:
. like any common sore, with mild measui
'\\(^ studiously withheld, except in the hard form
of the ai but not even then while there is much in-
flammation or inordinal rational en t. In a
measures must be avoided. 'Thepati
will g lydoatl ithout than with
mercury. ton must be paid to
cleanliness, and for this purpose the parts should be fre-
quently bathed in tepid salt water, aid<'d by the Byring
there be a tight
584 Military Surgery. [July,
warm water-dressing, covering in the entire genitals ; if
much swelling and pain are present, it may be advanta-
geously medicated with lead and opium. As the inflam-
mation subsides, the sore may be dressed with some gently
stimulating lotion, as two grains of tannin, the eighth of a
grain of sulphate of copper, and half a drachm of laudanum
to the ounce of water, a weak mixture of sherry and water,
or a solution of nitrate of silver, zinc or iodide of iron. If
the ulcer is disposed to spread, or presents a sloughy or un-
healthy aspect, it will be proper to touch it lightly twice1 a
day with the solid nitrate of silver, or a solution of one
part of acid nitrate of mercury to four parts of water.
The constitutional treatment is rigidly antiphlogistic, or
tonic and supporting, according to the particular nature of
the case. The bowels should receive early attention ; the
skin be kept moist ; and pain be allayed by anodynes. Per-
fect recumbency should be observed until the parts are near-
ly healed. If mercury be required, the best forms will be
calomel and blue mass, in small doses twice a day, with a
vigilant eye to their effects, ptyalism being studiously
avoided in every case.
If bubo supervene, the treatment must be prompt and ef-
ficient, with a view to the prevention of further mischief.
Recumbency, the topical use of iodine with warm water-
dressing medicated with lead and opium, light diet, and the
antimonial and saline mixture constitute the most appropri-
ate measures. If matter form, an early and free incision is
made, and the part afterward treated as a common sore, the
granulating process being promoted by mild means. Mer-
cury is carefully withheld, at all events in the early stage of
the disease.
The army is no place for soldiers laboring under seconda-
ry or tertiary syphilis ; the sooner they are dismissed from
the service the better, especially if they are volunteers.
Ophthalmia is one of the annoyances of the soldier's life.
Liable to be caused by cold, it is capable of assuming seve-
ral varieties of form, and sometimes prevails extensively as
an epidemic. The granular and purulent, in particular, are
to be feared, as they frequently destroy the sight, and even
the eye, in a few days, occasioning intense suffering. To
ascertain the condition of the parts, the lids muSt always
be gently everted with a probe or the finger. The greatest
cleanliness should be observed in these affections ; the pa-
tients should, if possible, be sequestered, at all events not
L] Military Surgery. 585
be permitted to use the same basins and towels ; the light
should be excluded from the apartment ; and the general
and local treatment should either he strictly antiphlogistic
or of a mixed character, partly antiphlogistic and partly
stimulant. The applications should he of the mildest des-
tion, especially those intended for the inflamed surface.
The Byringe is frequently used to wash away the secretions.
>ng collyria generally do immense harm in all forms and
stages of ophthalmia. Blood may he taken from the arm,
or by cups or leeches from the temples, if the symptoms are
unusually urgent and the patient plethoric. In rheumatic
inflammation of the eye, colchicum and morphia, given
freely at bedtime, will he of immense service.
When foreign matter gets into the eye, or becomes imbed-
ded in the cornea, speedy removal must be effected, and the
parts afterward treated with rest, cold or tepid bathing,"
gentle aperients, and seclusion from light. Particles of
1 and other sharp bodies are picked out with the point
of a delicate bistoury, or cataract needle. The effects of
lime and oth^er alkalies are neutralized by syringiug the eye
freely with a weak solution of vinegar ; those of nitrate of
silver, with a weak solution of common salt, a thorough
coating of olive oil being afterward applied.
boils, and aba which are of frequent
irrence in army practice, demand prompt attention, both
on account of the suffering they induce and the disqualifi-
cation they may entail for temporary duty. They should
be opened early and freely, and no time be lost in amending
the general health by gentle mercurial and other purgatives,
alterants, and tonics, particularly quinine aud iron. The
most appropriate topical remedies are tincture of iodine and
warm water-dressings.
In carbuncles the affected structures, after free division,
will generally require the thorough application of some
.arotic or detergent stimulant, as Vienna paste, nitric
acid, nitrate of silver, or acid nitrate of mercury.
Continued in -V
586 Health in the Camp. [July,
Health in the Camp. By Paul F. Eve, M.D., Nashville,
Tenn.
The science of medicine lias an intimate connection with
the movements of armies and navies, and in all civilized
nations is an important element in their organization. As
surgeons and physicians, our peculiar province is to miti-
gate the sufferings incident to warfare hy stanching the
bleeding, binding up the wounded, relieving pain, prevent-
ing disease, healing the sick. The high office of our noble
calling is to cure the millions, who for want of timely
care, would die of medicable wounds and remedial affec-
tions.
In all well regulated armies and navies, each detachment
or separate command and each vessel, however small, is
entitled to have a medical officer. Four or five companies,
each of from fifty to one hundred men, compose a battalion,
and two of these constitute a regiment. Each battalion
has its medical officer, so that in a regiment there are two,
known as the surgeon and the assistant surgeon, who are
also called the regimental surgeons. It is a part of their duty
to enter into battle with their battalions, so that all soldiers
slightly wounded may at once be attended to, and that thus
the combatants may not be reduced in the ranks during an
engagement. Two or more regiments form a brigade
commanded by a brigadier-general, and two or more brig-
ades a division, whose commander has the title of major-
general. Kow each general appoints in his staff his surgeon
or surgeons, to whom are committed the arrangement of
hospitals for the sick, and ambulances for those severely
wounded on the field. These constitute the staff surgeons
whose position is usually in the rear of the line of battle
where capital operations, &c, may be safely performed.
There are men enlisted as stewards and nurses for the spe-
cial purpose, in order that while the wounded may be pro-
perly cared for, at the same time, nothing, not even the
calls of humanity, may interrupt the conflict carried on by
the contending forces.
In the army of the United States as the wars have been-
few and no large assemblage of troops been required, the
appointment of medical officers has been restricted to r
il surgeons, and in it there are no staff surgeons. The
senior medical officer of a division or of an independent
command of a general sometimes has the the title of medi-
cal inspector or (/''rector ; and of a commodore's command at
1.] Health in the Gimp.
. that of fleet surgeon. The highest medical officer known
in our service is th< /v/, who, as the medical
purveyor, &c, lias the entire direction of this department
in the army. A requisition for medicines, lint, bandages,
other materials for any number of men, a battalion, or
division, is at once supplied by Lim. The acting surgeon-
Leral of the Confederate army said to me in Richmond,
had purchased 4000 ounces of quinine
at ^2 25, and could get as much more at $'2 50: and that
nor. ematized is the service, all lie required in for-
warding supplies to any given point, was the number of
ops to be stationed there.
In the organization of the volunteer forces in the sepa-
rate . that of the regular army is assumed as the
model. To insure well qualified medical officers, a hoard
of examiners is established to assemble once a year for a
iks, before which all applicants must undergo a
rigid examination to obtain an appointment. Tennessee,
however, lias three surgeon-generals, besides a medical
purveyor, who if . lull surgeon; and they, I under-
star - the medical board, which was no doubt design-
ed to i ated by her legislature.
Tin- \clusively employed in the army
and navy medical appointments, because it implies the
qualifications for the discharge of professional du-
p no one can be a good surgeon who is not capable
^of maki d physician, but one may be a good physi-
and yet never become a surgeon at all.
Hygiene in the tented field, or the preservation of health
in the military is just now of deep interest to our
pie. To array his forces in the best possible physical
- the grand object of every commander; and to
do this lie b lit, and must rely chiefly upon his
medical advisers. The prevention of d: is the nig]
ign and end of medical scien may
not cure, cannot under certain circumstances and in many
>. but from a kn icinghuman
rtainly indi-
cati . may I
camp, and
of habits and mode of living,
[j may do the recruit some
good to make known those thing-, the i oravoid-
:e of which may best pr arduous
588 Health in the Camp. [Ju ,
duties: and the maintenance of health and strength is now
the more necessary since in carrying on modern warfare
greater bodily activity is required than formerly. The
Zouave drill demands greater personal vigor, more rapid
movement and quicker evolution on the part of troops than
ever exhibited before. Battles are now decided by rifle
cannon and musket at long range, and then with the rush
of the bayonet. Our armies should therefore not only be
well equipped, but every man in them fully able to handle
his weapon in the most efficient manner, and each one
kept constantly vigilant and active.
Age, The first remark I make in regard to the physical
condition of the soldier is in reference to his age. To be
prepared to endure the fatigue and exposure of a campaign,
the human system should be fully developed. Males are
liable to military duty from eighteen to forty-five years of
age ; but no one under twenty-one, the period of maturity,
ought to be required to do full duty. The best soldiers
Napoleon ever had were those drilled two years at Bou-
logne in 1805. The youngest among them was twenty-two,
and when suddenly ordered to Austria, they traversed a
distance of over a thousand miles without scarcely leaving
a sick man on the route ; but when in 1809, this great
captain led his army again to Vienna from Strasburg, the
nearest point from France, his young conscripts of twenty
years filled numerous hospitals by the way. For the elan,
a desperate reckless charge, or the forlorn hope, the young
unmarried man, as he has fewer cares and everything to
gain might be best ; but for the regular service, the steady,
continuous hard work in the line, those between twenty-
five and forty will be found the most efficient. The life of
a soldier and sailor is undoubtedly the most trying to the
constitution of man, and no one ought to enter upon it be-
fore attaining a suitable age to sustain the hardship.
Habits. These of course ought to be regular and syste-
matic, and nothing indulged in to impair the full vigor of
the constitution or prevent the perfect development of the
system. Early hours are best that sleep may be obtained
at night. The^ instinct of nature in this respect is no doubt
right, approved as it is by reason and experience, that night
is the proper time for rest. To recover from the fatigue of
the day, for the system to recuperate from hard labor or a
long march, the soldier requires at least eight hours repose.
I know it is published, that Pichegru, one of the republican
186L] Uh in (he C 580
generals of France, passed through a campaign with only
one hours Bleep in the twenty- four, and that Napoleon slept
but four or live hours: these were, however, extraordinary
instances. Gen. Taylor ar the council of war held by the
field officers alter the battle of Palo Alto, made one general
reply to the many anxious inquiries what was to he done,
which was let the men sleep. The result at Resaca on the
morrow plainly demonstrated how he estimated the value
of rest to the weary soldier. To preserve health in the
camp plenty of sleep is required; and the opposite to this,
all irregular hours, sitting up late, excursions or exposures
during the night ; wet, uncomfortable places of repose are
obnoxious, and should be carefully avoided.
Dr. Winship, who lifts eleven hundred pounds, says one
condition to exert this immense power is plenty of sleep.
After the treaty of Tilsit, the French Emperor, who, we
have stated, was always so very wakeful, slept nine con-
secutive hours. It is not rest or repose alone, but to be
refreshing it must be quiet, undisturbed sleep.
Great cleanliness is essential to the preservation of health
at all times and particularly in crowded collections of men.
Daily ablution of the whole person, when at all convenient,
and throughout the year, is recommended. This greatly
fortifies the system and enables it to resist the impression
of cold, kc. The best time to bathe is in the morning,
rising from bed, or before dinner; and where water is not
abundant, a wetted sponge or towel freely applied to the
body, followed by friction, may be substituted. After great
fatigue or exposure the warm bath or bathing the feet in
warm water is best.
The nails, hair and beard, it scarcely need be observed,
so obvious are the reasons, ought to be worn quite short on
the tented field.
Habit may become second nature, so that man can accus-
tom himself to almost anything. The human will too is
almost omnipotent. The veriest poisons may not only be
daily used but even en; luxuries. I leel this is not
the time or place to offer arguments against tl;
ardent spirits and tobacco, or to attempt [fy them
with opium and arsenic in their effects upon man ; still the
almost universal and incessant practice of drinking, chew-
ifi unqualifiedly condemned. Wnafc
ojurious to " -'em, or weakens the power of its
-ce to disease, ought to be abandoned ; hence daily
590 Health in the Camp. [July,
rations of brandy or whiskey are no longer issued in the
army or navy, but very wisely coffee and tea substituted
instead. Chemistry in the nineteenth century has obtained
two essential elements extracted from coffee and tea, known
as caffeine and theine, having a remarkable affinity for the
human system ; thus confirming or legalizing as it were by
science these excellent beverages which had been employed
extensively for the three previous centuries. But the con-
stituent principle from tobacco, nieotine, is a deadly poison ;
so that the sickness produced in first using it, the habitual
furred tongue, loetid breath, tremor of muscles, nervous-
ness, &c, in all those who smoke or chew, but ratify the
truth revealed by the chemical analysis of it. The recent
demonstrations too in a school in France is mathematical
proof that the use of this article does obtund intellect and
diminishes the vigor of young persons. While I would not
curtail one comfort from the very small number enjoyed by
the soldier in the toil and privation of a campaign, but
would most willingly add to his pleasures and happiness ;
yet as a medical man I must denounce the constant habit
of smoking and chewing, as 1 do that of drinking, because
it renders him more liable to sickness, and when sick makes
him more difficult to be recovered. And I know full well
how such an unpalatable truth, for truth it is, will be re-
ceived and how little heeded. I have but done a duty in
pointing out how health may be secured by raising a warn-
ing voice, especially to the rising generation, against a
fashionable habit injurious to the constitution of man,
physically, mentally and morally. I would substitute coffee
for the tobacco offered by your general in a recent order,
and should not value the advice of your surgeon if found
interested in a practice so unprofessional.
Diet. The food of the soldier should be of the best mate-
rial and properly prepared for easy digestion. To prevent
exhaustion from the great and constant waste going on in the
system the supply ought to be good and abundant. The com-
missary department is one of the most important. Troops to
light well must be fully provided and cared for, well fed, and
well clothed. Without doubt the best organized army in the
world, in all its appointments, is that of France. The French
soldier has soup twice a day with vegetables and bread, he-
sides his coffee. I believe that it is no caricature to say that
ours are fed almost exclusively upon very fat bacon, poorly
cooked bread and strong coffee, three times a day. With the
I.] Health in the G . 591
very aterials on the earth, yet in no country is the pre-
paration for the table so lamentably deficient. Our mothers
who did know how to cook are last passing away; and alas!
the art is now ignored, and we are rapidly becoming a nation
of dyspeptics. The coffee drank in the camp is too strong,
much fat bacon is consumed, and the bread is not well
baked. No work should he done on an empty stomach ; the
breakfast may be made to consist of coffee or tea largely di-
luted, it possible, with milk, a little meat, fresh if obtainable,
and bread made ot' unbolted Hour, or corn or rye meal. AVj^
have sacrificed the host properties of the wheat in its fineness
mv\ whit^n^s Th. ancient Greeks and Romans, those re-
nowned warriors, used no bolting cloths. Soup, whenever
practicable, or stews with vegetables, some meat, bread, and
no coffee for dinner ; and for supper a light meal with tea, are
best. Ripe fruits and vegetables in seaaou, dried fruit cooked,
-. butter, sugar, molasses, vinegar, ecc, are all promotive
of health, and are by no means to be omitted in the supply
for the camp.
Clothing. ^Ye live in a climate ot great variability at all
seasons, and it becomes us to guard against the frequent, great
and sudden changes. Flannel next the skin at all times, when
it can be endured, should be worn. Silk or cotton is prefera-
ble to linen for this purpose. I can recommend the flannel
belt, particularly during the spring and summer months, as a
preventive to bowel affections. The military cap is unsuitable
to the Southern State- ; ought to be rejected entirely for the
warm weather, and the broad brim hat worn during this pe-
riod of the year. So too in regard to high collars, padded
coal stocks, and tight clothes : a soldier or an officer on
the battle field has no use for brass buttons, gold lace, cocked
hats; corded tassels or epaulettes. While I admit a uniform
roper in all military men, I would have it exceedingly
plain, presenting no contrasts in colors, and fitting easy about
the | perience has proven that a lighl less
frequently struck by balls in an engagement than any other,
and is t. suitable under the fire even of the
Minnie rifle.
In addition to the clothing, the thickness of which must
vary according to the weather, an overcoat and blanket, made
water-proof, and a knapsack secured too, against rain, are to
be provided. r] to have thick sole.-. ;
water-tight by being well oiled, ami the i to pre-
vent blistering or chafing.
The clothing should be frequently changed, washed and
592 Health in the Camp. [July,
dried, and no one ever allowed to go to sleep in them when
wet.
I would advise the soldier to avoid tampering with medi-
cines, indulging his appetites or passions, never to drink
spirituous liquors, but to live temperate in all things. Dis-
cipline iu the army implies a life of self-denial as well as of
great exposure and hard service ; and good health is an abso-
lute requisite to discharge its duties. Though sentence against
moral sin may not be speedily executed, yet every infraction
of hygienic rules is immediately visited with suffering. In
this respect be sure your sin will find you out, for it is an
inflexible law of nature, without variableness or shadow of
turning, that all her violators shall individually and peremp-
torily be punished.
All military men ought especially to be vaccinated.
Cheerfulness, too, is a great promoter of health, as a con-
sciousness of right is to courage.
As the camp is no place for the sick, the sanitary question
is the all important one with the surgeons. Five to ten per
cent more die from diseases contracted during a campaign
than in battle, and whenever possible, hospitals or barracks
should be provided for the sick, particularly during epidemics.
We are to recollect too that our volunteers are gentlemen, and
not drafted or mercenary troops ; and in their treatment, if a
distinction is made in favor of any class in the army, it should
be the soldier in the ranks, who, in every sense, bears the
heat and burden of the day. Nashville Journal of Medicine
and Surgery, July 18G1.
In view of the great want of some convenient work on Military Sur-
gery, we present in the present number the first portion of a valuable
little Treatise recently published by Dr. S. D. Gross, of Philadelphia,
*Thc book trade between the two sections of the continent having been
interrupted, it has rendered it impossible for the publishers to furnish
the work. We do not consider that their rights or those of the distin-
guished author are in the least violated by giving the work to the
Profession, serially, to the extent of the circulation of a single Medical
periodical.
M 5 trgery.
A Manual of Military &ur$ the Emergen
Camp, a . By B. D. Gross,
\[. J). Professor ot% Surgery in the Jefferson Medical
College of Philadelphia.
CHAPTER 1.
HISTORICAL SKETCH OF MILITARY SURGERY.
The duties and requirements of military are essentially
similar to those of civil surgery. It is founded upon the
same knowledge of anatomy, medicine, and the associate
sciences ; it demands the same qualifications, physical,
moral, and intellectual. The difference consists in the
application of our knowledge rather than in its range or
depth. The civil surgeon remains at home ; the military
follows the army, examines recruits for the public service,
and superintends the health of the troops. If the former
;- well educated, he will be quite as competent, at any
time, as the latter to perform these duties ; for the emer-
gencies of civil are often not less trying than those of mili-
tary practice, although they may not he on so large a scale.
The best civil have often also been the best military sur-
geons. In proof of th ion it is necessary only to
r to the names of Pare, Wiseman, Schmucker, Kern,
Larrey, Guthrie, Charles Bell, Alcoek, Thomson, Ballin-
gall, and Macleod, of Europe ; or to those of Rush, Jones,
icher, Mann, and Horner of our own country.
Military surgery occupies, at the present day, a deserved-
ly high rank in the estimation both of the profession and
of the public. The war in the Crimea, the mutiny in
India, and the recent convulsions in Italy, ail attended with
iUeh waste of blood and life, have attracted to it t\ic uui-
ud attention of the profession ; and the revolutionary
movements now in progress in our own country invest it
with a new and feartul interest to every American phj
ciau. Its praises have bee: by Homer, ami, in all
- of the world, governments have extended to it a fos-
and. As a distinct branch, however, of the heal-
ing art, it dates back no further than the early part of the
enth century, when it was inaugurated by Ambrose
Pare, by the publication of his treatise on "Gunshot
530 Military Surgery. [July?
Wound-." the fruits of his observations in the French army
in [taly. This man, who was surgeon to four successive
kings, was an eye-witness of the numerous French cam-
paigns, from L536, down to the battle of Moncontour, in
L569, a period of thirty-three years* His popularity, both
aa a civil and military surgeon, was, up to that time, with-
out a. parallel. The soldiers worshiped him ; and the suc-
cess of more than one siege, aswell as of one battle, wasdue
almosl exclusively to the wonderful influence of his pres-
ence. His treatise on "Gunshot Wounds" appeared to-
ward, the middle of the sixteenth century, and, after hav-
ing passed through various editions, was ultimately incor-
porated in his surgical writings, published nearly a quarter
of a century later.
In England, the earliest work on military surgery was
that of Thomas Gale, entitled a " Treatise on Gunshot
Wounds." designed chiefly to confute the errors of some
of his contemporaries, respecting the supposed poisonous
nature of these lesions. Gale was horn in 1507, and after
having served in the army of King Henry YIIL, at Mon-
trieul, and also in that of King Philip, at St. Quintin,
tin ally settled at London, where he acquired great distinc-
tion in his profession. In 1G39 appeared the work of J.
Woodall, "The Suigeon's Mate; or, Military and Domestic
Surgery."' lie was surgeon under Queen Elizabeth, by
whom he was sent to France, along with the troops that
were dispatched to the assistance of Henry IV. and Lord
Willoughby. In 1676, Richard "Wiseman, sergeant-surgeon
to King Charles 11., published his famous "Chirurgical
Treatises," one of which was expressly devoted to the con-
sideration of gunshot wounds. Two years after this a
treatise on gunshot wounds was published at London, by
John lb-own, also surgeon to Charles. He was a man of
eminence, and served with much credit in the Dutch war
of 1665. The next English work on military surgery ap-
peared in 1744, from the pen of John Ranby, sergeant-
surgeon to George li., under the title of "The Method of
r Gunshol Wounds." After Ranby came the im-
shable work of John Hunter, familiar to every reader
English surgical literature. The part relating to gun-
shot WOunds was founded upon his observations made
while serving as staff-surgeon at Belleisle and in Portugal,
and is one of the most precious legacies of the last cen-
tnrv, near the close of which if appeared.
L861.] MUitary Surgery. 631
The present century has supplied quite a number of
works on military surgery, as is shown by the valuable
publications of La r rev, Bennen, Becker, Angustin, Guth-
rie, Thomson, Hutchinson, Ballingall, Baudens, and others,
which have contributed BO much to the elevation of this
department of the healing art. Some of these works have
been re-issned in this country, and have acquired a wide
celebrity.
We must not forget, in this rapid enumeration of works
on military surgery, the "Manuel de Chirurgien d'Armee"
of Baron Percy, published at the commencement of the
revolutionary war in France. It is a model of what such
a treatise ought to be.
The ouly work on this department of science yet fur-
nished in this country, is that of the late Dr. James Mann,
published at Dedham, Massachusetts, in 181ri. It is enti-
tled " Medical Sketches of the Campaigns of 1812, '13, and
'14,'' and forms a closely-printed volume of upwards of
three hundred octavo pages.
The latest treatise on this subject in the English language
is that of Dr. George II. D. Macleod, now Professor of
Surgery at Glasgow, entitled "Notes on the Surgery of the
"War in the Crimea; with remarks on the Treatment of
Gunshot Wounds." Jt is a work of intense interest, writ-
ten with great ability by an accurate and diligent observer,
and is worthy of a place in every medical library. To this
work frequent reference will be made in the following pages.
To Dr. Lewis Stromeyer, Physician of the Royal Han-
overian Army, we are indebted for the most recent German
work on military surgery, it was issued in 18o8, under
the title of "Maximen der Krieg&heilkunst," in two duo-
imo volumes, to which a Supplement was added in the
early part of the present year. A more valuable contribu-
tion to this department of surgery could hardly be im-
agined.
Besides the above more recent work-, the reader should
carefully study the "Principle- of Military Surgery," by
the late Dr. John llennen, one of the m08l zealous and
distinguished military surgeons that Great Britain has yet
produced; a man of vast experience and of tin- most en-
lightened views upon everything he has touched with his
pen.
Perhaps the most systematic work on the subject in the
English language is that of Sir George Ballingall, entitled
,")3^ Military Surgery. [July,
"Outlines of Military Surgery," the last edition of which.
the fourth, appeared only recently at Edinburgh, where the
author held for many years the chair ot military surgery,
for a long time, we believe, the only one in Great Britain.
It is a production of much merit, and is destined to main-
tain a very high rank in this species of literature.
The works of the late Mr. George Guthrie also deserve
attentive study ; they are written with great clearness and
ability, and embody the results of an immense experience,
acquired during many years of arduous and faithful labor
and observation in the British army. I have always re-
garded the works of this great man as among the most
valuable contributions, not only to military surgery, but to
surgery in general, in the English language.
With these works before him, the student of military
surgery cannot tail to make himself in a short time per-
fectly familiar with everything pertaining to the subjects of
which they treat. He should also provide himself with a
ropy of the excellent little volume entitled " Hints on the
Medical Examination of Recruits for the Army," by the late
Dr. Thomas Henderson, formerly Professor of Medicine in
Columbia College, Washington City. A new edition of it
was published a few years ago by Br. Richard IT. Coolidge.
of the 'United States army.
Although we have long had one of the most respectable
and thoroughly organized army and navy medical staffs in
the world, our country has, neverlheloss, not produced one
great military surgeon ; simply, it may be presumed, be-
cause no opportunity has occurred since the establishment
of our government in which the men iu the public service
could distinguish themselves. Their aid has been required
in the duello and in skirmishes rather than in great battles,
such as have so often characterized the movements of the
armies of the Old World. We make no exception in this
remark in favor even of the battles that were fought during
the Revolution, and during our Late War, as it has usually
been designated, with Great Britain. Those engagements
were, for "the most part, comparatively bloodless. Happily
living under a Hag which, until recently, commanded alike
the respect and the admiration of all nations, belonging to
a government which was at peace with all foreign powers,
the medical and surgical staffs of the public service had
little else to do than to prescribe for such diseases as are
incident to civil practice. America has never witnessed.
1861.] MUtiary Surgery.
and we trust in Grod she never may witness, such ear naff c
as that which attended the footsteps of Napoleon at the
bridge of Lodi, at Leipzig, at Dresden, and at Waterloo ;
or which, more recently, characterized the exploits, of the
English, French, and Russian forces in the Crimea; or of
the French, Italian, and Austrian armies in Italy; or of the
English soldiers during ihe late rebellion in India. No**
has she ever been engaged in one great naval battle similar
to that of La Hogue, Toulon, Trafalgar, or Aboukir. A
number of highly respectable physicians accompanied our
army to Mexico, but they returned without any special
laurels, and without any substantial contributions to mili-
tary medicine and surgery.
CHAPTER II.
[IMPORTANCE OF MILITARY SUROERY.
It is impossible for any civilized nation to place too high
an estimate upon this branch of the public service. With-
out the aid of a properly organized medical staif, no army,
however well disciplined, could successfully carry on any
war, even when it is one, as that which is now impending
over us, of a civil character. Xo men of any sober reflection
would enlist in the service of their country, if they were
not positively certain that competent physicians and sur-
geons would accompany them in their marches and on the
tield of battle, ready to attend to their diseases and acci-
dents. Hence military surgery, or, more correctly speak-
ing, military medicine and surgery, has always occupied a
deservedly high rank in public estimation.
Dionis, a surgeon far in advance of his age, in referring
to the value of medical services to soldiers, exclaims, with
a burst of eloquence : k'Wo must then allow the necessity
of chirurgery, which daily raises many persons jrom the
brink of the grave. How many men has it cured in the.
army ! How many great commanders would have died of
their ghastly wounds without its assistance ! Chirurgery
triumphs in armies and in sieges. Tis true that its empire
is owned: 'tis there that its effects, and not words, cxpi
uloguim."
The confidence reposed by soldiers in the skill and hu-
manity o^ their sunreon ha? often been of signal service in
534 Military Surgery. [July,
supporting them, when exhausted by hunger and fatigue,
in their strugles to repel the advancing foe, or in success-
fully maintaining a siege when the prospect of speedy sur-
render was at hand. Who that is versed in the history of
our art does not remember with what enthusiasm and re-
solve Ambrose Pare, the father of French surgery, in-
spired the souls of the half-starved and desponding garri-
son at Metz, in 1552, when besieged by 100,000 men under
the personal command of Charles V. ? Sent thither by his
sovereign, he was introduced into the city during the night
by an Italian captain ; and the next morning, when he
showed himself upon the breach, he was received with
shouts of welcome. "We shall not die," the soldiers,
exclaimed, "even though wounded; Pare is among us."
The defense from this time was conducted with renewed
vigor, and the French army ultimately completely triumph-
ed, through the sole influence of this illustrious surgeon.
No man in the French army under Napoleon rendered
so many and such important services to the French nation
as Larrey, the illustrious surgeon who accompanied that
mighty warrior in his various campaigns, everywhere ani-
mating the troops and doing all in his power to save'them
from the destructive effects of disease and injury. His
humanity and tenderness was sublime ; and so highly was
his conduct, as an honest, brave, and skillful surgeon, ap-
preciated by Xapoleon, that he bequeathed him a large
sum, with the remark that "Larrey was the most virtuous
man he had ever known."
CIIAPTEPv HI.
QUALIFICATIONS AND DUTIES OF MILITARY SURGEONS.
It is of paramount importance that none but men of the
best talent and of the highest education should be received
into the public service. Rigid as the examination of the
army and navy medical boards already are, there is need of
increased rigor, in order that none may be admitted who
arc not thoroughly prepared for the discharge of their re-
sponsible duties. Equal vigilance should be exercised in
regard to the introduction of physicians and surgeons into
the volunteer service. Every regiment should be provided
with an able medical head, a man ready for every emer-
1 1. "] Military Surg* \ >''>
agency, however trying or unexpected ; a man skilled in the
diagnosis and treatment of diseases, and competent to
form any operation, whether small or largo, on the spin* of
the moment. To do this, he must be hiorc than a mete
physician; he must be both a physician and surgeon, in the
true sense of the terms, otherwise he will he unfit, totally
unlit, for his position. He must have heen educated in the
modern schools; be of undoubted courage, prompl
willing to assume responsibility, humane and sympathizing,
urbane and courteous in his manners ; in short, a medical
gentleman, as well as a medical philosopher, not hesitating,
if need be. to perform the most menial services, and to do
all he can to preserve the health and the lives of the sol-
diers committed to his. care. The white-gloved
such as figured in some of the regiments that went to
Mexico, have no business in the service; their time can be
much better spent in the discharge of their domestic du1
in the practice of their neighborhood, and in the contem-
plation, at a distance, of the miseries of war.
It i- much to be feared that, from the rapid man:
which our volunteers have been hurried together, many
medical men, old as well as young, have already been ad-
mitted into the g utterly unfit for the ofii fthis
be the case, let our authorities, warned by the past, bo
more circum gard to the future. Above all,
them sec that the medical staffs of the bin'/.- volunl
the country be notdefiled by charlatans and unworthy men,
between whom and the regular practitioners there
possibly be any professional, much less social intercourse,
cither in civil or military practice. Th< al men
should be on the b< ible terms with each other; all
f discord aud bickering among th< mid
studiously obviated, and speedily suppressed, if, unfor-
tunately, they should a> ' :t of action on the part
of the medi<-al corps is in<!: the
medical operations of an army.
Every regimental e mid have at lea
tants in time of peace, or during the inactivity of the troops
under his charge : when 01
the number should at Icasl be doubl ially in the face
of an anticipated bloody 1
should be selected solely to their c'ompc-
mould, bk' incipal, be eminently inl
ligent, and readyj in < nnv
o'Sij Military Surgery. [July*
operation that occasion may demand. Every brigade should
have its brigade surgeon, who should exercise a supervisory
control over the regimental surgeons, principals as well as
assistants, as every State should have its surgeon-general,
or medical-director, whose duty it should be to superintend
the whole medical arrangements, seeing that the candidates
Cor the medical department of the service be subjected to
a rigid examination, attending to the purchase of medicines
and instruments, providing suitable nurses, inspecting the
quarters, stores, and provisions, that nothing of an un-
wholesome character may find its way into the ranks, point-
ing out the proper location of camps, and the construction of
hospitals, and giving general instructions in regard to mili-
tary hygiene, or the best means of avoiding disease and
accident.
Trior to every engagement at all likely to be severe or
serious, a proper number of men should be detailed for the
purpose of rendering prompt assistance to the wounded,
and carrying them off the Held of battle to the hospitals,
or tents, erected for their accommodation and treatment.
Unless this be done as a preliminary step, much suffering
will inevitably be the consequence, if not great confusion,
highly prejudicial to the issue of the combat. So fully
aware are the leaders and sub-commanders of our armies
of this fact that they never permit any man to fall out of
the ranks, during an engagement, to perform this service.
While the battle is progressing it is the duty of the sur-
geon and of his assistants to remain in the rear of the com-
batants, as much as possible out of harm's way, but at the
same time ready and on the watch to render the promptest
possible aid. They must be Argus-eyed, and in the full
possession of their wits. One of the leading differences
between military and civil practice is the instantaneous ac-
tion so often demanded by the one and the delay so fre-
quently admitted by the other.
The first duty of every surgeon is to the officers and men
of his own corps ; but on the field of battle, or soon after
the battle is over, he is often brought in contact with the
members of other regiments, or even with the wounded of
the enemy; and under such circumstances the dictates of
humanity, not less than the usages of war, demand that he
should render his services wherever they may be likely to
be useful. The medical officers of the contending parties
-< mutinies meet upon such occasions, and, when this is the
L861.] Mildar
. their conduct should invariably be characterized 1>\
the courtesy of the gentleman, not the asperity of the
enemy. They should not forget that they are brethren of
the same noble profession, acting in the capacity of minis-
tering angels to the sick and dying. Country and cause
alike should be forgotten in generous deeds.
By the usages of war in all civilized countries, the sur-
qs are always respected by the enemy if, during an en-
ment, they happen to fall accidentally into their hands.
Their lives arc regarded as sacred, the more so, as they are
comparatively defenseless. They are not, however, during
the rage and smoke of the battle-field, always easily distin-
guishable from the other officers, or even the common sol-
diers. The green sash, their distinctive badges of office,
does not always afford them immunity, because it is not
always recognized ; and it is worthy of consideration
whether, as an additional safeguard, the word "surgeon'
should not be embroidered in legible characters upon a
piece of cloth, to be thrown across the chest in time of
battle. The significance of such a badge could not be mis-
taken by friend or foe, and would be the means of saving
many valuable lives.
I ilAPTEJi IV.
MEDICAL EQUIPMENT AND HOSPITALS.
Every regiment, or body of military men, should be am-
ply provided, in time of war, with the means of conveying
the wounded and disabled from the field of battle. For
this purpose suitable carriages and litters should constantly
be in readiness. The carriages should be built in the form
of light wagons, drawm each by two horses; with low
wheels, easy springs, and a large wide body, furnished with
a soft mattress and pillows, and capable of accommodating
not less than eight or ten persons, while arrangerm
might be made atti for seating a number more,
in the French A ;, I ;in>r
the sun and the rain, it should have a light cover of oil-
cloth or cam,
. reat number of Uttei'8, or bearers, will be found de-
scribed in ( on military surj at 1 am not ac-
quainted with any which combine so much simplicity and
Military Surgery. [July.
cheapness, with lightness and convenience, as one which,
after a good deal of reflection, I have just devised. It con-
sist of two equal parts, conducted at the ends hy stout
hinges, the arrangement being such as to permit of their
being folded for the more easy transportation on the held
of battle. Each part has a side piece of wood, three feet
four inches long, by two inches in depth, and an inch and
a half in thickness, the free extremity terminating in a
slightly curved handle. The side pieces are united by four
traverses, and the entire frame is covered with ducking,
twenty-four inches in width. Thus constructed, the'appa-
ratus is not only very light, so that any one may easily
carry it, or, indeed, even three or four at a time, but re-
markably convenient both for the transportation of patients,
and for lifting them in and out of the wagons, which should
always be at hand during and engagement. Moreover, by
means of side straps, provided with buckles, it will answer
extremely well for a bed-chair, so necessary in sickness and
during convalescence, the angle of flexion of the two
pieces thus admitting of ready regulation. In carrying the
wounded off the field, the labor may easily be performed
by two men, especially if they use shoulder-straps to diffuse
the weight of the burden. The body, in hot weather,
might be protected with an oil-cloth, while the face might
be shielded from the sun with a veil or handkerchief. A
pillow for the head can be made with the coat of one of
the carriers.
Besides these means, every regiment should be furnish-
ed with an ambulance, or, as the term literally implies, a
movable hospital, that is, a place for the temporary accom-
modation and treatment of the wounded on the held of
battle. It should be arranged in the form of a tent, and be
provided with all the means and appliances necessary for
the prompt succor of the sufferers. The materials of which
it consists should be as light as possible, possess every
facility for rapid packing and erection, and be conveyed
from point to point by a wagon sot apart for this object.
The ambulance, for the invention and improvement of
which we are indebted lo two emineul French military sur-
geons, Percy and Larrey, is indispensable in every well-
regulated army.
Tl lis temporary hospital should be placed in an open
pace, convenient to water, mid upon dry ground, with ar-
for the free admission of air and li^ht, which,
1861.] Military Surgery. 539
next to pure air. is one of the most powerful stimulants in
all eases of accident attended with excessive prostration.
The direct rays of the sun, in hot weather, must of course
be excluded, and it may even he necessary, as in injuries of
the head and eye, to wrap the patient in complete darkn<
A properly regulated temperature is also to be maintained,
a good average being about G8 of Fahrenheit's ther-
mometer.
As engagements are sometimes begun after dark, or are
continued into the night, an adequate supply of wax can-
dles should be provided, as the}' will be found indispensa-
ble both in fielc^and hospital practice, in performing opera-
tions and dressing wounds and fractures. Torches, too, will
frequently be needed, especially in collecting and trans-
porting the wounded. Bed-pans, feeding-cups, spoons,
syringes, and other appliances usually found in the sick
chamber, will form a necessary part of the furniture of
such an establishment.
The object of the ambulance is, as already stated, to
afford prompt succor to the wounded. Here their lighter
injuries are speedily dressed, and the more grave subjected
to the operations necessary for their cure. In due time,
the former are sent back to the ranks, while the rest are
conveyed to suitable lodgings or to permanent hospitals.
As soon as practicable, after the hurry and confusion
attendant upon a combat are over, the surgeon should clas-
sify the wounded and disabled, taking care that those
laboring under similar lesions are not brought in close con-
tact; lest, witnessing each other's sufferings, they should
be seized with fatal despondency.
Larrcy, in order to meet the exigencies of the grand
army in Italy, constructed a flying arnJndanct ; an immense,
and, at first sight, a very cumbersome establishment. It
listed of twelve light wagons, on easy springs, for the
transportation of the wounded ; some with two, others with
four wheels. The frame of the former, which wore design-
ed for flat, level countries, resembled an elongated cube.
curved on the top ; it had two small windows on each side,
with a folding door in front and behind. The floor of the
body, separable and movable on rollers, was covered with a
mattress and bolster. Uandl curedtoit laterally,
through which the sa-lie^ <t' the soldiers were passed in
lifting the sick in and ont of the carriage, when, on account
of the weather, their want conld no1 be relieved on the
540 Military Sun/cnj. [July,
ground. Each vehicle was thirty-two inches wide, and was
drawn by two horses ; it could conveniently accommodate
two patients at fall length, and was famished with several
side-pockets for such articles as might he needed for the
sufferers.
The large carriage, drawn by four horses, and designed
for rough and hilly roads, was constructed upon the same
principle as the small ; it had four wheels, and could ac-
commodate four persons. The left side of the body had
two long sliding-doors, extending almost its whole length.
so as to permit the wounded to be laid in a horizontal po-
sition. #
These carriages were used for conveying the wounded
from the field of battle to the hospitals of the lines, and
combined, it is said, solidity with lightness and elegance.
The number of men attached to the flying ambulance
was 113, embracing a soldier's guard with Lwelve men on
horseback, a quartermaster-general, a surgeon-major, with
his two assistants and twelve mates, a police officer, and a
number of servants. The Hying ambulance was, in fact, a
costly and imposing establishment, devised by the humani-
ty and ingenuity of the great and good Larrey, who could
never do too much for the wounded soldier, and whose
presence, like that of his illustrious countryman, Pare, al-
ways served to animate the French troops. At one time
three divisions of the flying ambulance, equipped upon
this grand scale, were upon the field in different parts of
Italy.
It is not deemed necessary in a work like this, to give
an account of the construction of hospitals, properly so
termed; for, with the railroad and steamboat facilities
which we now possess, there can be little difficulty in ob-
taining comfortable accommodations for the sick and
wounded soldiers. Lodgings can almost always be pro-
cured, in nearly every portion of the country where a battle
is likely to be fought, in houses, churches, and barns.
Temporary sheds might easily be erected in a few hours,
with such arrangements as would serve for the more press-
ing wants of the wounded. The chief points to be attended
to, in their construction, are sufficient elevation of the
ground floor for the free circulation of air, windows for
light and ventilation, and such a position of the fire-place
01 to annoy the inmates. i
The medical rtorcs of the military hospital, whether tern-
I.] M <,'/. ~A\
porary or permanent, include medicines, instruments, and
various kinds of apparatus, as bandages, oiled silk, and
splints.
It would far transcend my limits were I to enter fully
into all the details connected with these different topics.
A tew brief remarks under each head must suffice for my
purpose.
1st. In regard to inecii few articles only, well se-
lected and arranged for ready use, will be necessary. It is
bad enough, in all conscience, for a man to be severely shot
or stabbed, without physicking him to death. Let him by
all means have a chance for his life, especially when he has
already been prostrated by shock and hemorrhage. Food
and drink, with opium and fresh air, will then do him more
good than anything else. I shall enumerate the medicines
upon which, in my judgment, most reliance is to be placed
in this kind oi% practice, according to their known effects
upon the system.
1. Anodynes: opium, morphia, and black drop, or
acetated tincture of opium.
_. Purgatives : blue mass, calomel, rhubarb, jalap,
compound extract of colocynth. and sulphate of magn<
ie of these articles should be variously combined, and
put up in pill form for ready m
'>. Depressants : tartrate of antimony and i ipe-
cacuanha, and tincture of veratrum. viride.
4. Diaphoretics: antimony, ipecacuanha, nitrate ofpo-
. morphia, and Dover's powder.
>. Diuretics: nitrate and carbonate ofpotassa, and col-
chicum.
6. Antiperiodics : quinine and arsenic.
7. Anaesthetics: chloroform and ether.
Simulants : brandy, gin, wine, and aromatic spirits
of ammonia.
Astringents: acetate of lead, perchloride of iron and
alum, tannin, gallic acid, and nitrate of sih
10. Escharotics: nitric acid, acid nitrate of mercury,
(Bennett's formula,) and Vienna pa
2d. The surgical armamentarium should ah aple
as possible. It should embrace a small po with
tcw catheter; a full amputating case, with at least three
tourniquets, tw of different ,id several I;
bone-nippers ; and, lastly, a trephining i Several silver
'athoter- of different Bizes, a stomach pump, small rind
542 Military Surgery. [July,
large syringes, feeding-caps and bed-pans should also he
put up.
3d. Under the head of apparatus may he included "banda-
ges, lint, linen, adhesive plaster, splints, cushions, wadding,
and oiled Bilk.
The bandages, composed of tolerably stout muslin, should
be free from starch and selvage, well rolled, on an average,
from two inches and a quarter to two inches and a half in
width by eight yards in length. The bandage of Scultetus,
very serviceable in compound factures, can easily be made,
as occasion may require, out of pieces of the common roller.
Of lint, the patent, or apothecary's, as it is termed, is the
the best, as it is soft and easily adapted to the parts to which
it is intended to be applied. Old linen or muslin also an-
swers sufficiently well. Charpie is now seldom used.
An abundance of adhesive plaster, put up in small cases,
should be provided. Collodion will not be necessary.
Splints, of binders or trunk-maker's board, and ot light
wood, should find a place in every medical store, as fre
quent occasions occur for their use. In fractures of the
lower extremity special apparatus may be required, which,
however, as it is cumbrous and inconvenient to carry, may
generally be prepared as it is needed.
Cushions are made of muslin, sewed in the form of bags,
of variable size and shape, and filled with cotton, tow, saw-
dust or sand. They are designed to equalize and ward off
pressure in the treatment of fractures of the lower ex-
tremities.
Wadding is a most valuable article in surgical practice,
both for lining splints and making pads, as well as in the
treatment of burns and scalds, and cannot be dispensed
with.
Oiled Silk is a prominent article in the dressings of the
present day ; it preserves the heat and moisture of
poultices and of warm water-dressings, at the same time
that it protects the bed and body-clothes of the patient.
Oil-cloth, soft and smooth, is required in all cases of severe
wounds and fractures, attended with much discharge.
Air-cushions should be put up in considerable numbers,
as their use will be indispensable in all cases of disease and
injury involving protracted confinement.
Bran and saw-dust will be found of great value in the
treatment of compound fractures, ulcers, gangrene, and
L86L] Mil* l>i.i 548
suppurating wounds, as an easy support for the injured
limb and a means of excluding flies.
Medical t should be put up along with the other
articles, for the accurate registration of the names of the
sick and wounded, the nature ul' their lesions, and the re-
sults of treatment. The medical officers should also keep
a faithful record of the state of the weather, the tempera-
ture of the air, the nature oi' the climate, the products of
the soil, and the botany oi' the country through which they
or in which they sojourn, together with such matters as
may be of professional or scientific interest. The knowl-
edge thus acquired should he disseminated alter their re-
turn for the benefit of their professional brethren.
Finally, in order to complete hospital equipments, well-
trained nurses should be provided ; for good nursing is in-
dispensable in every case of serious disease, whatever may
be its character. The importance of this subject, however,
is now so well appreciated as not to require any special
comments here.
The question as to whether this duty should be perform-
ed by men or women is of no material consequence, pro-
vided it be well done. The eligibility of women for this
task was thoroughly tested in the Crimea, through the agen-
cy of that noble-hearted female, Florence Xightingale ; and
hundreds of the daughters of our land have already tendered
their services to the government for this object. Xo large
and well regulated hospital can get on without some male
nurses, and they are indispensable in camp and tield practice.
It is not my purpose here to point out the qualities which
constitute a good female nurse. It will suffice to say that
she should be keenly alive to her duties, and perform
them, however menial or distasteful, with promptness and
alacrity. She must be tidy in her appearance, with a
cheerful countenance, light in her step, noiseless, un-
der and thoughtful in tier manners, perfect mistress
her feelings, healthy, able to bear fatigue, and at l<
twenty-: f age. Neither the crinoline nor the
silk dress must enter into her wardrobe; the former is
too cumbrous, while the latter by its rustling is sure to fret
the patient and disturb his sleep. Whispering and wal king-
in on ti] has been truly observed by Florence X: a
ingale, are an abomination in the sick chamber. Finally,
a good nurse never fails to anticipate all, or nearly all, the
more important wants of the Bunerer.
Among other things t<> be specially attended to in nurs-
544
Military Surgery.
[July.
\S\s^r^r^/
ing is ventilation. Persons visiting the sick must at once be
struck with the difference of pure air in those chambers
where a proper ventilation exists and those where the re-
verse is the case. To insure this the fresh air should
always be admitted from a window not open directly on the
bed, or causing the patient to be in a draught. Even in
winter it is highly proper that fresh air should be admitted
some time during the day when there is a good fire and the
patient well protected by covering.
The pillows, bedding, and bedclothes should be well
aired and often changed, as also the flannel, under-gar-
mcnt8, and night-dress. To facilitate this, it is well, when
the patient is very ill and unable to help himself, to have the
shirt open all the way down in front, and buttoned up. The
patient often escapes great suffering and annoyance by this
simple method. Where there is a discharge from the sores,
or when water-dressing arc applied to a limb, it is advisa-
ble to place the latter upon a folded sheet with a thin, soft
oil-cloth underneath. Great tenderness and cleanliness
should be used in dressing wrounds or sores. Old linen,
muslin, and lint should always be had in readiness for this
purpose. A great prejudice exists against the use of mus-
lin, the preference being generally given to linen, but the
former is really quite as goed as the other, if it is soft and
old.
In regaid to the cleanliness of a sick-room, it is advisable
to use a mop occasionally for the removal of flue from un-
der the bed ; when, however, the patient is in too" critical a
situation for dampness, a few tea-leaves scattered over the
apartment will absorb the dust, and can be quietly taken
up with a hand-brush. A frequent change of bed linen is
very beneficial when practicable, and the clothes must al-
ways be folded smoothly under the patient. Great clean-
liness should be observed in all the surroundings of the
sick-room, and particular attention must be paid to the
glasses in which medicine is given, in order to render the
doses as palatable as possible. The patient should be
washed whenever able, and his teeth and hair w7ell attend-
ed to. The body seems infused with new vigor after such
ablutions.
A frequent change of posture is immensely conducive to
the comfort and well-being of a sick person, if performed
with a careful eye to his particular condition. Severe pain,
los of sleep, excessive constitutional irritation, and dread-
[861. | Military Surgery. 54o
tal bed-sores are Bure to follow, in all low states of the
jin, if this precaution be not duly heeded. No patient
must have his head suddenly raised, or be permitted to Lie
high, when he is exhausted from shock, hemorrhage, or
sickness. Many lives have been lost by this indiscretion.
The apartment must be free from noise, the light should
neither be too freely admitted nor too much excluded, ex-
cept in head and eye affections, and the temperature must
be regulated by the thermometer, from 65 to 68 of
Fahrenheit being a proper average.
As the patient acquires strength, he may gradually sit
up in bed, propped up at first by pillows, and afterward by
a bed-chair.
His food and drink, and also, at times, his medicine,
must be given from a feeding-cup during the height of his
and a good general rule is to administer them with
great regularity, provided this does not interfere too much
with his repose. If he is very weak, and sleeps very long,
it will be necessary to wake him in order to give him
nourishment ; but, in general, sleep is more refreshing
than food, and more beneficial than medicine. The bed-
pan and urinal of course find their appropriate sphere un-
der such circunistan*
As the appetite and strength increase, the patient is per-
mitted to resume, though very gradually, his accustomed
diet and to exercise about the room, if not in the open air.
After severe accidents and protracted sickness, a wise man
will not bestir himself too soon or too much, but court the
tickle goddess of health with becoming caution.
Dying patients >hould be carefully screened from their
neighbors, placed in the easiest posture, have free access
air, and be not disturbed by noise, loud talking, or the
presence of persons not needed for their comfort, A -
soon as the mortal struggle i< over, the body must he re-
ed.
should be removed a8 speedily as possible
from the apartment, and the vessels in which they are
ceived immediately well scalded, the air being at the same
tim< tly purified by ventilation, or ventilation and
disinfectants.
Finally, the nurse must tak '.'.'. She must,
have re.-,t, or she will soon break down. If she i obliged
to be up all night, .-ho should be spared in the daw
In' Military Surgery. [July,
OHAPTEB V.
WOUNPy AM nrin;i; | .\.| [' R \\'<.
The injuries inflicted in Avar are, in every respect, similar
to those received in civil life. The most common and impor-
tant are fractures, dislocations, bruises, sprains, hurnsand the
different kinds of wounds, as the incised, punctured, lacer-
ated, and gunshot! With the nature, diagnosis, and mode
of treatment of these lesions every army surgeon must, of
course, he supposed to be familiar; and I shall therefore
limit myself, in the remarks which J am about to offer
upon these subjects, to a few practical hints respecting their
management on the Held of battle and in the ambulance.
Most of the cases of fractures occurring on the field of
battle are the result of gunshot injury, and are frequently,
if not generally, attended by such an amount of injury to
the soft parts and also to the bone as to demand amputa-
tion. The bone is often dreadfully comminuted, and con-
sequently utterly unfit for preservation. The more simple
fractures, on the contrary, readily admit oi' the retention of
the limb, without risk to life.
In transporting persons affected with fractures, whether
simple or complicated, the utmost care should be used to
render them as comfortable as possible, by placing the in-
jured limb in an easy position, and applying, if need be, on
account of the distance to which they have to he carried.
of the mode of conveyance, short side splints of binders'
board, thin wood, as a shingle, or junks of straw, gently
confined by a roller. For want of due precaution the dan-
ger to limb and life may be materially augmented. Per-
manent dressings should be applied at the earliest moment
after the patient reaches the hospital. If the fracture be
attended with splintering of the bone, all loose or detached
pieces should at once be extracted ; a proceeding which
always wonderfully simplifies the case, inasmuch as it pre-
vents, in a great measure, the frightful irritation and sup-
puration which are sure to follow their retention. When
this point has been properly attended to, the parts should
be neatly brought together "by suture, and covered with a
compress wet with blood. As soon as inflammation arises
not before water-dressings are employed. A suitable
opening, or bracket, should bo made in the apparatus to
facilitate < Ira in age and dressing.
>61.] Military <>V/'7< /;>/. 547
HxUious, accidents by no moans common in military'
erations, arc treated according- to the general rules ot
actice; they should be speedily reduced, without the aid
' chloroform, if the patieni is faint or exhausted: with
doroform, it' he is strong or reaction has been fully estab-
ihed. The operation may generally l^e successfully per-
rmed by simple manipulation ; it, however, the case ih
>stinate, pulleys may he necessary, or extension and oonn-
r-extension made by judicious assistants.
or contusions, unless attended with pulpiticatiotn
soiganization, or destruction of the tissues, are best treat-
1, at first, until the pain subsides with tepid water impreg-
ited with laudanum and sugar of lead, or some tepid
urituous lotion, and afterward, especially if the patient )><>
rong and robust, with cold water, or cold astringent fluids,
the injury be deep seated, extensive, and attended with
sion ot very importaut structures, the case will be a seri-
is one, liable to be followed by the worst consequences,
squiring, perhaps, amputation.
are often accompanied with excessive pain and
re constitutional symptoms. They should be
gated with the free use of anodynes and with warnmvater-
-essings medicated with laudanum, or laudanum and lead,
he joint must be elevated and kept at rest in an easy
:>sition. Leeches may be applied, if they can be obtained ;
:her\vi>e. if plethora exisf, blood may be taken from the
le arm. By-and-by sorbefacient liniments and friction
jinein play. Passive motion should not be instituted too
on.
Among the accidents of Avar arc barns, and, occasionally,
ilds. The former may be produced by ordinary tire
by the explosion of gunpowder, either casual or from the
owing up of redoubts, bridge-, houses, or arsenals, and
rv irom the trivial to the mosl serious lesions, involving
peal extent of surface or of tissue, and liable to be follow-
by the worst consequences. Such injuries always re-
tire prompt attention ; for, apart from the excessive pain
A collapse which so often accompanv them, the longer
ev remain uneared for the more likely will they be to end
idly.
Various remedies have been proposetl for these injuries,
lave myself always found white-lead paint, such as that
nployed in the arts, mixed with linseed oil to the consist-
ice of very thick cream, and applied so ;t< t<> form ;< com-
.")4S Military Surgery. [July?
plete coating, the most soothing and efficient means. The
dressing is finished by enveloping the parts in wadding, con-
fined by a moderately tight roller. It should not be re-
moved, unless there is much discharge or swelling, foi
several days. If vesicles exist, they should previously be
opened with a needle or trie point of a bistoury. A lini-
ment or ointment of glycerin, lard or simple cerate, and
subnitrate of bismuth, as suggested by my friend, Profes-
sor T. (i. Richardson, of New Orleans, is also an excellent
remedy, and may be used in the same manner as the white
lead paint. In the milder cases, carded cotton, cold water,
and alcohol, water and laudanum, generally afford prompt
relief. Amputation will be necessary when there is exten-
sive destruction of the muscles, bones or joints. Reaction
must be promoted by the cautious use of stimulants;
while pain is allayed by morphia or laudanum given with
more than ordinary circumspection, lest it induce fatal op-
pression of the brain.
En burns from the explosion of gunpowder, particles of
this substance are often buried in the skin, where, if it be
not removed, they leave disfiguring marks. The best way
to get rid of them is to pick out grain after grain with the
point of a narrow-bladed bistoury or cataract needle.
The subject of wounds is a most important one in regard
to field practice, as these lesions are not only of frequent
occurrence, but present themselves in every variety of form
arid extent! Their gravity is influenced by numerous cir-
cumstances which our space does not permit us to specify
but which the intelligent reader can readily appreciate. 1
many cases death is instantaneous, owing to shock, or shoe
and hemorrhage ; in others it occurs gradually with or
without reaction, at a period of several hours, or, it may be,
not under several days. Sometimes men arc destroyed by
shock, by, apparently, the most insignificant wound 01
injury, owing, not to want of courage, butto some idiosynj
'v:\cy.
Tne indications presented in all wounds, of whatever na-
ture, are 1st, to relieve shock ; 2dly, to arrest hemorrhage:
;>dly, to remove foreign matter: 4thly, to approximate anc
retain the parts: and, ^pthly, to limit the resulting infiam
nmtion.
1. It is not necessary to describe minutely the symptoms
of shock', :\< the nature of the case is sufficiently obvious i
tiral sight, from the excessive pallor of the countenance, tin
I8t>l,] Military .w</. ///. o4f
weakened or absent pulse, the confused state of the mind,
the nausea, or nausea and vomiting, and th asivc
bodily prostration. The case must be treated promptly ; by
free access of fresh air and the use of the tan, by loosening
the dress or the removal of all sources of constriction, bv
dashing cold water into the face and upon the chest, by
recumbency of the head, and by draught of cold water, or
water ami spirits, wine <r hartshorn, ii" the patient can
>wallow; aided, it'tlie ease be urgent, by sinapisms t<> the
region of the heart, the inside of thighs and the spine, and
stimulating injections, as brandy, turpentine, mustard, or
ammonia, in a few ounces of water. Xo fluid must he put
into the mouth so long as the power of deglutition i- gone,
lest some of it should enter the windpipe, and bo occasion
suffocation. Whatever the cause of the shock may have
been, let the medical attendant not tail to encourage the
sufferer by a kind and soothing expression, whieh is often
of more value in recalling animation than the best cordials.
I hiring an actual engagement, the medical officers, as
well as their servants, should carry in their pockets such
articles as the wounded will be most likely to need on the
Held of battle, as brandy, aromatic spirits of hartshorn, and
morphia, put up in suitable doses.
-. The / /-: may he arterial or veiious. Or
both arterial and venous, -light or profuse, primary or
ndary, external or internal. The scarlet color and sal-
tatory jet will inform us when it is arterial: the purple hue
and steady flow, when it is venous. When the wound is
ire, or involving a large artery or vein, or even middle-
sized vessels, the bleeding may prove laud in a few minute-
unless immediate assistance is rendered. Hundreds of her-
etic on the Held of battle from 1 his cause. Tliey allow
their life current to run out. as water pours from a hydrant,
without an attempt to .-top it by thrusting the finger in tie
wound, or compressing the mam artery of the injured limb.
They perish simply from their ignorance, because the I
mental Burgeon has failed to give the proper instructibn. h
ary that the common soldier should carry a
Petit* s tourniquet, but every one may put into his pocke
stick ;. Bix inches lung, and a handkerchief orpieceof
r, with a thick com] id be advised how, where,
and when they arc to be used. By casting the handk
chief round the limb, and placing the compress over its
main artery, he can, by means or the stick, produce sncli
V<) Military Surgery. [July*
ail amount of compression as to put at once an effectual
stop to the hemorrhage. This simple contrivance, which
lias been instrumental in saving thousands of lives, consti-
tutes what is called the field tourniquet. A fife, drum-stick,
knife or ramrod may be used, if no special piece of wood
is at hand,
The most reliable means for arresting hemorrhage per-,
manentlv is the ligature, of strong, delicate, well-waxed silk,
well applied, with one end cut off close to the knot. Acu-
pressure is hardly a proper expedient upon the battle-field,
or in the ambulance, especially when the number of wound-
ed is considerable. The rule invariablyis to tie a wounded
artery both above and below the seat of injury, lest recur-
rent bleeding should arise. Another equally obligatory
precept is to ligature the vessels, if practicable, at the place
whence the blood issues, by enlarging, if need be, the
original wound. The main trunk ot the artery should be
secured on lv when it cannot be taken up at the point just
mentioned. Lastly, it is hardly requisite to add that the
operation should be performed, with the aid of the tourni-
quet, as early as possible, before the supervention of inflam-
mation and swelling, which must necessarily obscure the
parts and increase the surgeon's embarrassment, as well as
the patient's pain and risk.
Venous hemorrhage usually stops spontaneously, or readi-
ly yields to compression, even when a large vein is impli-
cated. The ligature should be employed only in the event
ofabsplute necessity, for fear of inducing undue inflaniraa-
tion.
Torsion is unworthy of confidence in field practice, and
the same is true of styptics, except when the hemorrhage is
capillary, or the blood oozes from numerous points. The
most approved articles of this kind are Monsel's salt, or the
persulphate of iron and the perchloride of iron ; the latter
deserving the preference, on account, of the superiority of
it hemostatic properties. Alum and lead are inferior styp-
tics.
Temporary compression may be made with the tourniquet,
M- ;i compress and a roller. It; may be direct, as when the
compress is applied to the orifice of the bleeding vessel, or
indirect, as when it is applied to the trunk of the vessel, at
some distance from the wound.
Constitutional treatment in hemorrhage i< of paramount
importance. It comprises perfect tranquility of mind and
L86L] MilUary Surgery. 551
body, cooling drinks, t mild, concenrated nourishing diet,
icially when there has been 9 loss of blood, ano-
dynea to allay pain, induce sleep, and allay the heart's inor-
dinate action, fresh air. and a properly regulated light,
internal hemorrhage in more dangerous than external.
ause it is generally inaeessible. The chief remedies arc
lous venesection, elevated position, opium and acetate ot
ol air, and eool drinks.
Exhaustion from hemorrhage should be treated accord-
ing to the principles which guide the practitioner in <
severe shock. Opium should be given freely as soon af
reaction begins to quiet the tremulous movements of the
heart and tranquilize the mind. When the bleeding is in-
ternal, the reaction should he brought about gradually, not
hurriedly, lest we thus become instrumental in promoting
Eciungthe hemorrhage.
clary hemorrhage comes on at a variable period,
from a few hours to a number oi days; if may depend
upon imperfect ligation of the arteries, ulceration, softening
a of these vessels, or upon undue
striction ^t' the tissues by tight bandage-. In some cases
it i- venous, and may then be owing to inadequate support
of the parts, Whatever the cause maybe, it should bo
promptly searched out, and removed.
The third indication is to remove alt fan
This should lc done at once and effectually; with spo
and water, pressed upon the parts, with linger, or finger
forceps. X<>t a particle of matter, not ahair, or the smallest
riot of blood must be let! behind, otherwise it will be sure
I-) produce and keep up irritation.
4. A- tin.' bleeding has been checked and
ii-aueous matter cleared away, the e4ges -i' the
tlyand even'; ximated and permanently retained
plaster,
bandage. The best suture, irritating, i-
silver wire ; but if this material i- not i
_. thiu, well-waxed silk is used. The adhe
applied in such a manner as to admit, ot five drains
required chiefly in injuries extending <!<
\\}i>'u this is the ease, it- use should
the
: the wound.
">. When the wound In next diitv of the Btir-
to moderate th<- resulting mfarmnation. For this
562 Military Surgery. [July,
purpose the ordinary antiphiogastic moans arc employed.
tn general, very little medicine mil be required, except a
full anodyne, as half a grain of morphia, immediately after
the patient hits sufficiently recovered from the effects of his
shock, and perhaps a mild aperient the ensuing morning,
especially if there be constipation with a tendency to exces-
sive reaction. The drinks must be cooling, and the diet
light and nutritious, or Otherwise, according to the amount
of depression and loss of blood. In the latter event, a rich
diet and milk-punch may be required from the beginning.
A diaphoretic draught will be needed if the skin is hot and
arid, aided by frequent sponging of the surface with cool or
tepid water. General bleeding will rarely, if ever, be re-
quired ; certainly not if the injury is at all severe, or if there
lias already been any considerable waste of blood and nerv-
ous power.
Much trouble is, at times, experienced both in civil and
military practice, especially in very hot weather, in prevent-
ing the access of flies to our dressing. The larvae which they
deposit are rapidly developed into immense maggots, which,
creeping over the wounds and sores of the patient, and gnaw-
ing the parts, cause the most horrible distress. The soldiers in
Syria, under Larrey, were greatly annoyed by these insects,
and our wounded in Mexico also suffered not a little from
them. The best prevention is bran, or light saw-dust, with
which the injured parts should be carefully covered. The
use of cotton must be avoided, inasmuch as it soon becomes
hot and wet ; two circumstances highly favorable to incuba-
tion.
The best local applications are the water-dressings, either
tepid, cool, or cold, according to the temperament of the
patient, the tolerance of the parts, and the season of the year.
Union by the first intention is, in all the more simple cases,
the thing aimed at and steadily kept in view, and hence the
less the parts are encumbered, moved or fretted, the more
likely shall we be to attain the object.
The medical attendant should have a constant eye to the
condition of the bladder after all severe injuries, of whatever
character, as retention of urine is an extremely common occur-
rence, and should always be promptly remedied. Attention
to this point is the more necessary, because the poor patient,
in his comatose or insensible condition, is frequently unable
to make known his wants.
Such, in a few words, are the general principles of treat-
1861.] MUUary Surgery,
ment to be followed in all wounds; but there are boiuo
wounds which are characterized by peculiarities, and these
peculiarities are of such practical importance as to require
separate consideration. Of tins nature are punctured, lacer-
ated, and gunshot wound-.
Puneturediooands are inflicted by various kinds of weapons,
as the lance, sabre, sword, or bayonet. In civil practice,
they are most generally met with as the result of injur-
ies inflicted by nails, needles, splinters, fragments of bone.
They often extend into the visceral cavities, joints, vessels,
and nerves; and are liable to be followed by excessive pain,
erysipelas, and tetanus; seldom heal by adhesive action;
and often cause death by shock or hemorrhage. When the
vulnerating body is broken off and buried, it may be difficult
to find and extract it, especially when small and deep seat-
ed. When this is the case, the wound must be freely di-
lated, an eye being had to the situation of the more import-
iant vessels and nerves. In other respects, the general prin-
ciples of treatment are similar to those of incised wounds.
( )pium should be administered largely ; and, if much ten-
sion supervene, or matter form, free, incisions will be neces-
sary;
In I wowulSj the edges should be tacked together
very gently, and large interspaces left for drainage. A
small portion will probably unite by the first intention; the
remainder, by the granulating process. Such wounds
nearly always suppurate more or less profusely, and some
of the torn andbruisedtissues not infrequently perish. The
same bad consequences are apt to follow them as in punc-
tured wounds. 'Warm water constitutes the best dressing,
either alone or with the addition of a little spirits of camphor,
opium should be used freely internally, and the diet must
be supporting.
mhot wounds, in their general character, partake
the nature of lacerated and contused wounds. They
are, of course, the most common and dangerous lesions met
with in military practice ; often killing instantly, or, at all
events, so mutilating the patient as to destroy him within
a few hours or days after their receipt. The most formid-
able wounds of the kind arc made by lie conical rifle and
musket balls and by cannon balls, the hitter often carrying
away the greater portion of a limb, or mashing and pulpiiy-
ingthei and viscera in the most frightful and -1
tractive manner ; while the former commit terrible ravai
556 Military Surgery. ['July,
violent inflammation in the soft parts, and caries or necro-
sis in the hone, ultimately necessitating amputation, if not
causing death.
Gunshot wounds of the knee-joint are among the most
dangerous of accidents, and no attempt should be made to
save the limb when the injury is at all extensive, especial 1 v
if it involves fracture of the head of the tibia or condyles of
the femur. Even extensive laceration of the ligament of
the patella should, I think, as a general rule, be regarded as
a sufficient cause of amputation. In 1854, Macleod saw up-
wards of forty cases of gunshot wounds of the knee in the
French hospitals in the Crimea, and all, except one, in
which an attempt was made to save the limb, proved fatal.
Of nine cases which occurred in India, not one was saved.
Guthrie never saw a patient recover from a gunshot wound
of the knee-joint; and'Esmarch, who served in the Schles-
wig-IIolstein wars, expressly declares that all lesions of this
kind demand immediate amputation of the thigh.
When, in bad cases of these articular injuries, an attempt
is made to save the limb, the patient often perishes within
the first three or four days, from the conjoined effects o!
shock, hemorrhage, and traumatic fever. If he survives for
any length of time, large abscesses are apt to form in and
around the joint, the matter burrowing extensively among
the muscles, and causing detachment of the periosteum with
caries and necrosis of the bones.
Muscles, badly injured by bullets, generally suppurate, and
are very apt to become permanently useless. Special pains
should therefore be taken to counteract this tendency during
the cure. Large shot and other foreign bodies sometimes
lodge among these structures, where their presence may re-
main for a long time unsuspected.
Cannon balls often do immense mischief by striking the
surface of the body obliquely, pulpifying the soft structures,
crushing the bones, lacerating the large vessels and nerves,
and tearing open the joints, without, perhaps, materially in-
juring the skin.
A very terrible form of contusion is often inflicted upon
the upper extremity of artillerymen- by the premature explo-
sion of the gun while in the act of loading ; causing excessive
commotion of the entire limb, laceration of the soft parts,
and most extensive infiltration of blood, accompanied, in
many cases, by comminuted fracture, and penetration of the
wrist and elbow joints. The constitutional shock is frequent-
1861.] Military Swrgerff. 567
ly great. If an attempt be made to save the parts, diffusive
suppuration, and more or less gangrene, will be sure to follow,
bringing life into imminent jeopardy. An attempt in such a
case to save the limb would be worse than useless, if, indeed,
not criminal ; amputation must be promptly performed, and
that at a considerable distance above the apparent seat of the
injury, otherwise mortification might seize upon the stump.
In the treatment oi this class of injuries, the first thing to
be done, after arresting the hemorrhage and relieving shock,
is to extract the ball and any other foreign substance that may
have entered along with it, the next being to guard against
inflammation and other bad consequences.
In order to ascertain where the ball is, the limb should be
placed as nearly as possible in the position it was supposed to
have been at the moment of the accident. A long, stout,
flexible, blunt-pointed probe, or a straight silver catheter, is
then passed along the track and gently moved about until it
strikes the ball. In many cases the best probe is the surgeon's
finger. Valuable information may often be obtained by the
process of pinching or digital compression, the ends of the fin-
gers being firmly and regularly pressed against the wounded
structures, bones as well as muscles, tendons, and aponeuroses.
Occasionally, again, as when a ball is lodged in an extremity,
its presence is easily detected by the patient, who may make
such an examination as he lies in bed.
The situation of the foreign body having been ascertained,
the bullet-forceps take the place of the probe, the blades,
which should be long and slender, being closed until they
come in contact with the ball, when they are expanded so as
to grasp it, care being taken not to include any of the soft
tissues. If there be any loose or detached splinters of bone,
wadding, or other foreign material, it should now also be re-
moved ; it being constantly borne in mind that, while a ball
may occasionally become encysted, and is at all times, if
smooth, a comparatively harmless tenant, such substances
always keep up irritation, and should, therefore, if possible,
be got rid of without delay.
Although preference is commonly given to the bullet-for-
ceps, properly so called, as an extractor, the polypus and dres-
sing-forceps, generally answer quite as well, especially the
former, the latter being adapted only to cases where the for-
eign body is situated a short distance below the surface, or
where the wound is of unusual dimensions, admitting of tin',
free play of the instrument.
I )urinir the extraction, the parts should bo properly sup
558 Military Surgery. [July.
ported, and if the wound is not large enough for the expan-
sion of the instrument, it must be suitably enlarged. When
the ball is lodged a short distance from the skin, it may often
be readily reached by a counter-opening.
When a bnllet is embedded in a bone, as in the head of the
tibia, or in the condyles of the femur, and the parts are not
so much injured as to demand amputation, extraction may bo
effected with the aid of the trephine and elevator. Sometimes
a bullet-worm, as it is termed, an instrument similar to that
usec{ in drawing a ball from a gnu. will be very convenient
lor its removal.
The operation being completed, the parts are placed in an
easy, elevated position, and enveloped in tepid, cool or cold
water-dressings, as may be most agreeable to them and to the
system. The best plan, almost always, is to leave the opening
or openings, made by the ball, free, to favor drainage ana
prevent pain and tension. If the track be very narrow, it
may heal by the first intention, but in general it will suppur-
ate, and portions of tissue may even mortify. Erysipelas,
pyemia, and secondary hemorrhage are some of the bad con
sequences after gunshot injuries, the latter usually coming on
between the fifth and ninth day, the period of the separation
of the sloughs.
GIIAPTEE VI.
AM CITATIONS AX1) EKSKCTIOjSs.
hi endeavoring to decide so important a question as the
loss of a limb, various circumstances are to be considered, a?
the age, habits and previous health of the patient, the kinds
of injury, and the number, nature, and importance of the tis-
sues involved.' In military practice amputation must often
be performed in cases where in civil practice it might be
avoided.
It may be assumed, as a rule, that young adults bear up
under severe accidents and operations, other things being
equal, much better than children and elderly subjects; the
strong than the feeble ; the temperate than the intemperate:
the residents of the country than the inhabitants of the
crowded city.
The following circumstances may be enumerated as justify-
ing, if not imperatively demanding, amputation in cases of
wounds, whatever may be their nature:
1861.] Military Surgery. 559
L-t. When a limb has been -truck by a cannon ball or run
over by a railroad car, fracturing the bones, and tearing open
the soft parts, amputation should, as a general rule, be per-
formed, even when the injury done to the skin and vessels is
apparently very slight, experience having shown that such
accidents seldom do well, it' an attempt is made to save the
limb, the patient soon dying of gangrene, pyemia, or typhoid
irritation. The danger of an unfavorable termination in such
a case is always greater when the lesion affects the lower ex-
tremity than when it involves the superior.
'2d. No attempt should be made to save a limb when, in
addition to serious injury done to the integuments, muscles or
bones, its principal artery, vein or nerve has been extensively
lacerated, or violently contused, as the re=nlt will be likely to
be gangrene, followed by death.
3d. A lacerated or gunshot wound penetrating a large joint.
as. that of the knee or ankle, and accompanied by comminu-
ted fracture, or extensive laceration of the ligaments of the
articulation, will, if left to itself, be very prone to terminate
in mortification, and is therefore a proper case for early am-
putation.
4th. Gunshot wounds attended with severe comminution of
the bones, the fragments being sent widely around among the
-oft parts, lacerating and bruising them severely, generally
require amputation, especially in naval and military practice.
5th. Extensive laceration, contusion, and stripping oft* of
the integuments, conjoined with fracture, dislocation, or com-
pression and publication of the muscles, will, in general, be
a proper cause for the removal of a limb,*
Amputation i^ not to be performed, in any case, until sufti-
eient reaction has taken place to enable the patient to bear
the additional shock and loss of blood. As long as he is dead-
ly pale, the puke small and thready, the surface cold, and the
thirst, restlessness, and jactitation exc it is obvious that
recourse to the knife must be wholly out of the question.
The proper treatment is recumbency, with mild stimulants,
dnapisms to the extremities, and other means calculated to
re-excite the action of the heart and brain. Power being re-
stored, the operation, if deemed necessary, is proceeded with,
due regard being had to the prevention of shock and hemorr-
hage, the two things now mainly to be dreaded.
One of the great obstacles about immediate amputation i-
the difficulty which the surgeon so often experiences in res-
\ vol. i. p. 895.
<~><i<> Military Burgqry. [July?
pect to the cases demanding the operation, and the uncertain-
ty that none of the internal organs have sustained fatal in-
jury; a circumstance which would, of course, contra-indicate
the propriety of such interference.
Cases occur, although rarely, where, notwithstanding the
most violent injury, or perhaps, even the loss of a limb, there
is hardly any appreciable shock, and, in such an event, the
operation should be performed on the spot.
The results of the military surgery in the Crimea show that
the success of amputations was very fair when performed ear-
ly, but most unfortunate when they were put off for any length
of time. This was the case, it would seem, both in the
English and French armies.
Should amputation ever be performed in spreading gan-
grene ? The answer to this question must depend upon cir-
cumstances. We may give our sanction when the disease,
although rapid, is still limited, and when the patient, compar-
atively stout and robust, has a good pulse, with no serious
lesion of a vital organ and no despair of his recovery, but a
cheerful, buoyant mind, hopeful of unfavorable issue. No op-
eration is to be done when the reverse is the case ; if it be, the
patient will either perish on the table, from shock and hem-
orrhage, or from a recurrence of mortification in the stum]).
Lacerated, contused and gunshot wounds are often of so
i rightful a nature as to render it perfectly certain, even at a
glance, that the limb wili be obliged to be sacrificed in order
that a better chance may be afforded for preserving the pa-
tient's life. At other times, the injury, although severe, may
yet, apparently, not be so desperate as to preclude, in tin1
opinion of the practitioner, the possibility ot saving the parts,
or, at all events, the propriety of making an attempt to that
effect. The cases which may reasonably require and those
which may not require interference with the knife, are not
always so clearly and distinctly defined as not to give rise, in
very many instances, to the most serious and unpleasant ap-
prehension, lest we should be guilty, on the one hand, of the
sin of commission, and, on the other, of that of omission ; or,
in other, and more comprehensive terms, that while the sur-
geon endeavors to avoid Scylla, he may not unwittingly run
into Charybdis, mutilating a limb that might have been saved,
and endangering life by the retention of one that should have1
been promptly "amputated. It is not every man, however
large his skill" and experience, that is always able to satisfy
himself, even after the most profound deliberation, what line
<>f conduct should be pursued in these trying circumstances :
1861.] Military Surycnj. 561
hence the safest plan for him generally is to procure the best
counsel that the emergencies of the case may admit of. But
in doing this, he must be careful to guard against procrastina-
tion ; the case must be met promptly and courageously ; de-
lay even o\' a few hours may be fatal, or at all events, place
limb and life in imminent jeopardy. Above all, let proper
caution be used if the patient is obliged to be transported to
some hospital, or to a distant home, that he may not be sub-
jected to unnecessary pain, exposed to loss of blood, or
carried in a position incompatible with his exhausted condi
tion. Vast injury is often done in this way, by ignorant per-
sons having charge of the case, and occasionally even by
practitioners whose education and common sense should be a
sufficient guarantee against such conduct.
Little need be said here about the methods of amputation.
In cases of emergency, where time is precious, and the num-
ber of surgeous inadequate, the flap operation deserves, in my
opinion, a decided preference over the circular, and, in fact,
every other. The rapidity with which it may be executed,
the abundant covering which it affords for. the bone, and the
facility with which the parts unite are qualities which strong-
ly recommend it to the judgment of the military surgeon.
The flaps should be long and well shaped, and care taken to
cut off the larger nerves on a level with the bone, in order to
guard against the occurrence of neuralgia after the wound is
healed. Whatever method be adopted, a long stump should
be aimed at, that it may afford a good leverage for the artifi-
ial substitute. No blood should be lost during or after the
operation, and hence the main artery of the limb should
always be thoroughly compressed by a tourniquet, not by the
fingers of assistants, who are seldom, if ever, trustworthy on
sucli occasions.
Anesthetics should be given only in the event of thorough
reaction ; so long as the vital powers are depressed and the
mind is bewildered by shock, or loss of blood, their adminis-
tration will hardly be safe, unless the greatest vigilance be
employed, and this is not always possible on the field of bat-
tle, or even in the hospital. Moreover, it is astonishing what
little suffering the patient generally experiences, when in this
condition, even from a severe wound or operation.
In the war in the Crimea, the British used chloroform al-
most universally in their operations; the French also exhibi-
ted it very extensively, and Baudens, one of their leading
military surgical authorities, declares that they did not meet
with one fatal accident from it, although it was given by
36
Military Surgery. [July*
them, during the Eastern campaign, thirty thousand times at
least. The administration of chloroform is stated by Macleod
to have contributed immensely to the success of primary am-
putations.
The dressings should be applied according to the principles
laid down under the head of wounds. The sutures, made
with silver wire or tine silk, should not be too numerous, and
the adhesive strips must be so arranged as to admit of thor-
ough drainage. A bandage should be applied from above
downward, to control muscular action and afford support to
the vessels ; the stump rest upon a pillow covered with oil-
cloth, and the water-dressing be used if there is danger of
overaction. Pain and spasm are allayed by anodynes ; trau-
matic fever, by mild diaphoretics. Copious purging is avoid-
ed ; the drink is cooling; and the diet must be in strict confor-
mity with the condition of the patient's system. The first
dressings are removed about the end of the third clay ; after
that once or even twice a day, according to the nature and
quantity of the discharges, accumulation and bagging being
faithfully guarded against.
The following statistics of amputations, both in the contin-
uity of the limbs and of the articulations, possess peculiar
interest for the military surgeon. They are derived chiefly
trom a review which I published of Mr. Macieod's "Notes of
the Surgery in the Crimea," in the North American Medico-
Chirurgical Review for January, 1860.
The number of cases given by Macleod is 732, with a mor-
tality of 201. Of these, 654 were primary, with 165 deaths,
or 26-22 per cent.; and 78 secondary, with 36 deaths, or in the
ratio of -6*1. The mortality of the greater amputations as
those of the shoulder, arm, and forearm, and the hip, thigh,
knee, and leg was 39*8 per cent, for the primary operations,
and 60 per cent, for the secondary.
The increase of mortality from amputations as we approach
the trunk, has long been familiar to surgeons, and the results
in the Crimea have not changed our previous knowledge.
Thus the ratio of mortality of amputations of the fingers was
>: ; of the forearm and wrist, 1*8; of the arm, 22'9 ; of the
phoulder, 27*2 ;' of the tarsus, 14*2; of the ankle-joint, 22*2;
of the leg, 30*3; of the knee-joint, 50-0; of the thigh, in iis
]>\ver third, 50'0, at its middle, 55*3, at the upper part, 86*8,
ami at the hip, lOO'O. The limb was removed at the latter
joint in LO^cases, all of which rapidly proved fatal. The
French had 13 cases, primary and secondary, with no better
luck.
1861.] Military Surgery. 568
Legouest has published u table of most of the recorded
Bof amputation at the hip-joint, for gunshot wounds. Of
these 80 were primary, and all ended fatally; of 11 interme-
diate, or early secondary, 3 recovered; and of 3 remote, 1 re-
covered, "thus," says Macleod, "if we sum up the whole,
we have -1 recoveries in 44 cases, or a mortality of 90*9 per
rent. " Some of the primary cases died on the table ; and
all the rest, except two, before the tenth day. In the Schles-
wig-IIolstein war, amputation at the hip joint was performed
seven times, with one cure. Mr. Sands Cox, recording the
experience of civil and military hospitals up to 1846, gives 84
cases, most of them for injury, with 26 recoveries. Dr.
Stephen Smith, of New York, has published tables of 98 cases
showing a ratio of mortality of 1 in 2 2-3. In 62 of these
cases, the operation was performed in 30 for injury, with a
mortality of 60 per cent.
Amputation in the upper third of the thigh was performed
39 times, with a fatal result in 34 Of these cases only one
was secondary, and that perished. Amputation of the mid-
dle third of the limb was performed in 65 cases, of which 3S
died. Of these cases 56 were primary, with 31 deaths, giving
thus a mortality of 53*3 per cent.; 9 cases were operated upon
at a later period, and of these, 7 died, or 77'7 per cent. Am-
putation of the lower third of the thigh was performed 60
times, 16 being primary, with a mortality of 50 per cent., and
11 secondary, with a mortality of 714 per cent. .
Amputation at the knee wras performed primarily in 6 cases
of which 3 died, and once secondarily, with a fatal result.
Chelius refers to 37 cases of amputation of the knee, collected
by Jreger, of which 22 were favorable ; and of 18 cases re-
corded by Dr. Markoe, of KewT York, as having occurred in
the practice of American surgeons, 13 got well. These cases
added together, afford an aggregate of 61, with a mortality
of 21, or 314 percent.
The leg was amputated 101 times, with 36 deaths, or a mor-
tality of 35'6 per cent. Of these cases 89 were primary,
with 28 deaths, and 12 secondary, with 8 deaths.
Amputation at the ankle-joint was performed in 12 cases,
death following in 2. Of these cases 3 were secondary, and
all favorable.
The arm was removed at the shoulder joint in 39 cases,
with a fatal issue in 13, or 33*3 per cent, 33 being primary,
with 9 deaths, and 6 secondary, with a fatal issue in 4. If we
couple these cases with 21 that occurred during the previous
period of the war, we shall have an aggregate f>f 60 <;.
with 19 deaths, or a mortality of 31.6 per cent. The advan-
oG4 Military Surgery. [July,
tage of primary over secondary amputation of the shoulder
has long been known to military surgeons. Thus, of 19 pri-
mary cases mentioned by Mr. Guthrie as having occurred be-
tween June and September, 1813, IS recovered, while of 10
secondary cases, 15 died. The experience of the late Dr.
Thomson, in Belgium, is equally decisive.
Amputation of the upper arm was performed 102 times,
with death in 25 cases, or a mortality of 24*5 ; 96 of the cases
being primary. Of the secondary cases one-half proved fatal.
The forearm was amputated primarily 52 times, and the
hand at the wrist once, with only 1 death ; while of 7 second-
ary operations upon the same parts, 2 died.
Resection is one of the aids of conservative surgery, and
military practice affords numerous occasions for its employ-
ment. " The operation, however, is not equally applicable to
all the articulations. Resection of the shoulder-joint has
hitherto afforded the most flattering results. It is more es-
pecially applicable in cases of gunshot injuries, unattended
by serious lesion of the vessels and nerves of the limb, or se-
vere laceration of the muscles and integuments. A portion
of the humerus, embracing, if necessary, from four to five
inches in length, together with a part or even the whole of
the glenoid cavity of the scapula, may be safely and expe-
ditiously removed under such' circumstances, and yet the pa-
tient have an excellent use of his arm.
Williams mentions 19 cases of gunshot wounds of the
shoulder-joint in which resection was performed, and of which
3 proved fatal. Eaudcns saved 13 out of 14 cases, and the
British surgeons in the Crimea lost 2 patients out of 27.
Resection of the elbow has of late engaged much attention
among military men, and although the results arc less flatter-
ing than in the operation upon the shoulder, they are, never-
theless, highly encouraging. Of 82 cases which occurred in
the Schleswig-Holstein and in the Crimean campaigns, only
10 died, or 1 in about 5.
The ivrist joint has seldom been the subject of excision ;
doubtless, cases not unfrcquently occur in which it might be
resorted to with advantage.
Dr. George "Williams has collected the history of 11 cases
oft excision of the hip-joint for gunshot injury, G of which oc-
curred in the Crimea. ' Of this number 10 died. Of 23 am-
putations at the hip joint by the English and French surgeons
in the East; all died.
Excision of the In ((-joint for gunshot injury holds out no
peel oj advantage, experience having shewn that, when
1.] .1/ ///.
the articulating extremities of the femur and tibia are true
tared by a ball, the proper remedy is amputation.
The ankle-joint has been resected in a tew instances only
i'or gunshot injuries, and the results have thus far been by no
means flattering. When the joint is seriously implicated, am-
putation will undoubtedly be the more judicious procedure.
Resection of the bones in their continuity is seldom prac-
ticed in this class of injuries, and experience has offered
nothing in its favor. The operation was performed several
times in the Crimea, but proved invariably fatal.
The after-treatment in resection must be conducted upon
the same principles as in amputation. The measures must,
for the most part, be of a corroborating nature. The limb
must be placed in an easy position, and be well supported by
a splint or fracture-box, to prevent motion. The operation is
liable to be followed by the same bad eilects as amputations.
CHAPTER VII.
ILL roxSLQUKXCES OF WOUNDS AND OPERATIONS.
The bad consequences to be apprehended after wounds,
amputations, and other operations, are traumatic fever, hem-
orrhage, excessive suppuration, spasms, erysipelas, gangrene,
pyemia, and tetanus.
a. Traumatic fever usually sets in within the first few hours
after the injury, or soon after reaction has been fairly estab-
lished. In camp practice its tendency generally is to assume
a low typhoid character, especially if there is much crowding
of the sick, with imperfect ventilation and want of cleanli;
Not unfrequently it displays an endemic or epidemic dispo-
sition.
The treatment must be exceedingly mild ; the patient will
not bear depletion, but will notwithstanding his fever, pi
bly require stimulants and tonics, with nutritious \'<">i\ and
drink from the very commencement. A gentle anodyne and
diaphoretic mixture, as morphia and antimony in camphor-
water, may be needful, in the early stage, to quell the ficti-
cious excitement or attempt at overaction. J
I. The likelihood of secondary hemorrhagt must be steadi-
ly kept in view in these cases ; much may be done to pre
it by the proper use of the ligature at the time of the o]
. but it is often unavoidable, especially in g
shot won Ing to the injury sustained by tho> coats of
sels by the grazing of the ball. However induced, it
566 Military Surgery. [July,
should receive the most prompt attention, inasmuch as the
loss even of a few ounces of blood may prove destructive to
the already exhausted system.
c. Spasms of the muscles is not peculiar to amputations ;
it often exists in a most severe degree in cases of fractures
and gunshot wounds. Anodynes in full doses, with a little
antimony, the use of a moderately-tight bandage, and warm
water-dressing, medicated with laudanum and acetate of lead,
arc the most appropriate measures.
d. Profuse suppuration may be looked for in nearly all bad
wounds, whatever their character, and also in many of the
amputations performed on the field of battle. The exhaust-
ing effects must be counteracted by supporting remedies, as
quinine, iron, cod-liver oil, and brandy, with frequent change
of dressing, cleanliness, and ventilation. Bagging is pre-
vented by counter-openings and careful bandaging.
e. Erysipelas usually manifests itself within the first thirty-
six hours after the injury or operation ; often assumes an en-
demic or epidemic character ; is easily distinguished by the
peculiar reddish blush rapidly spreading over the surface, to-
gether with the stinging or smarting pain and increased swel-
ling; and should be treated with dilute tincture of iodine,
or anodyne and saturnine lotions, quinine and tincture of iron,
with nutritious food and drinks.
f. Gangrene is sufficiently common after severe lesions on
the battle-field, especially that variety of it denominated hos-
pital gangrene. During the Crimean war, this form of gan-
grene raged with extraordinary virulence and fatality among
the French in the hospitals on the Bosphorus. It also pre-
vailed about the same period within some of the hospitals in
the south of France, and it is asserted that the "Euphrate," a
transport ship, in her voyage to the Mediterranean was
obliged, from this cause alone, to throw sixty of her men over-
board within thirty-six hours! After the taking of the
Quarries and the assault upon the Redan, during the heat of
summer, in 1855, the English surgeons lost a number of their
cases of amputation of the thigh from moist gangrene of a
most rapid character, the system having been literally over-
whelmed by the poison. When hospital gangrene is endemic,
it attacks not only open wounds and sores, but also the slight-
esl scratches, cicatrices, and stumps. Persons laboring under
diarrhoea, dysentery, and scurvy are most obnoxious to it.
The proper remedies are sequestration of the patients, the
free use of the nitric acid lotion, iodine to the inflamed skin,
charcoal, port wine, or yeast cataplasms, and frequent ablu-
1861.] Military Surgery. 567
tions with disinfecting fluids, aided by opium, quinine, tinc-
ture of iron, lemon-juice, and other supporting means. Mop
ping the affected surface lively with strong nitric acid often
answers an excellent purpose. The favorite remedy of Pou-
teau was the actual cautery.
;/. Pyemia, the purulent infection of the French writers. is
one o( the chief dangers after severe wounds and operations.
It was the great source of the mortality after amputation- .
pecially secondary, during the war in the Crimea. It usually
comes on within from three to eight days after the injury, and
is nearly always fatal. Its characteristic symptoms are rigors,
followed by copious sweats, rapid failure of the vital power.-,
delirium, and a withered appearance of the countenance, fre-
quently conjoined with an ictorode tinge of the eye and skin.
On dissection, 'the large veins leading from the stump or
wound are found tilled with pus, with redness of the lining
membrane: and abscesses, usually small and filled with un-
healthy fluid, are seen scattered through the lungs, muscles,
and cellular substance, matter also occasionally existing in the
joints. The treatment is essentially the same as in erysipelas.
h. Traumatic t tanus is not very common in military prac-
tice. It is most liable to show itself in tropical countries, in
hot, damp weather, and in persons of a nervous, irritable tem-
perament, occasionally supervening upon the most insignifi-
cant injuries, as, f<r example, a mere scratch. In India the
disease is often provoked by unextracted balls, and both in
that country and on the continent of Europe the operation
which was most frequently followed by it during the recent
wars, was amputation at the shoulder-joint.
The effects of sudden vicissitudes of temperature in devel-
oping tetanus, are well known. They are most striking in
tropical regions, when the change is i'rom hot to cold, or from
dry t<> wet. Larrey had repeated opportunities of observing
the development of the disease under such circumstan
both in Egypt and Germany. After the battle of Bautzen,
the exposure of the wounded to the cold night air produced
r a hundred cases of tetanus, and a largo number Buffered
from a similar cause after the battle of JDresden. Like
fects were witnessed at Ferozepore and Chillianwallah. Bau-
unehot wounds, states that the in-
fluence of cold and moisture in developing the disease, during
the French campaigns in Africa, was most striking. ( )f I
I men, placed in a gallery on >und
floor, during the prevalence of a northea
were speedily attacked with tetanus. Similar i
568 Military Surgery. [July*
several times been noticed in this country. Thus, after the
battle of Ticonderoga, in 1758, nine of the wounded who
were exposed the whole night after the action, in open boats
upon Lake George, died of lock-jaw ; and during our war
with Great Briiain, most of those who suffered on board the
Amazon, in the engagement before Charleston, were attacked
with this disease a fortnight after, in consequence of a very
sudden change of weather, the wind blowing cold and wet.
The extremes of heat and cold both favor the production
of tetanus. In the East and West Indies, the slightest prick
of the linger or toe is often sufficient to induce the disease,
and the inhabitants of the Arctic regions not unfrequently
suffer in a similar manner. Dr. Kane, in his memorable ex-
pedition, lost two of his men from this affection, and he adds
that all his dogs perished from a like cause.
The mortality from traumatic tetanus is notorious. Hardly
one recovers. Nearly all perish in two or three days from the
attack.
The most reliable remedies are opium, in the form of mor-
phia or acetated tincture, in large doses, in union with cam-
phor and antimony. The effects of Indian hemp arc uncer-
tain. Chloroform will mitigate pain and spasms. Amputa-
tion, except, perhaps, when the wound affects a finger or toe,
will be worse than useless, as will also be counter-irrita-
tion along the spine. To prevent the disease should be
our business, and to do this no wounded person should
ever be exposed to the cold night air, or to currents of
air at any time. After all amputations, however trifling,
special directions should he given upon this point
CHAPTER VIII.
INJURIES OF THE HEAD, CHEST, AND ABDOMEN.
The immediate effects of concussion of the brain are those
of fainting or collapse, and must be treated accordingly ; by
recumbency, access of cold air, the use of the fan, dashing
ot cold water upon the face and chest, and sinapisms to the
precordial region, thighs, feet, and spine, aided, in the more
severe cases, by stimulating injections. If the patient can
swallow, he may take a little wine or brandy. A smelling-
bottle may be held near, not to, the nose. Reaction is not
promoted too rapidly, for fear of secondary consequences.
18GL] Military Surgery. 509
The period of danger from collapse being over, the
patient is sedulously watched, that ovcraction may not oc-
cur, the risk now being from inflammation ; or, the stage of
excitement being happily passed, from the remote effects of
the injury, If the concussion was at all severe, all bodily
and mental excitement must be for a long time avoided.
Compression of the brain arises, surgically speaking, from
two causes only : effusion of blood and depressed bone. In
the former case, the characteristic symptoms insensibility
and coma, dilated and fixed pupil, stertorous breathing, and
paralysis frequently do not come until some time after the
receipt of the injury. The first symptoms will probably be
those of concussion, or exhaustion. By-and-by the patient
regains his strength, gets up, talks, or walks, and then sud-
denly drops down, as if he had been shot, in a state of ut-
ter unconsciousness. The effusion of blood, kept in abey-
ance during the collapse, has had full play, filling empty
places, and causing unmistakable effects. Such an occur-
rence will be most apt to happen when there has been ex-
tensive separation of the dura mater, or rupture of the
middle meningeal artery. If, on the other hand, the com-
pression is due to depression of the skull, the symptoms are
nearly always immediate.
When the case is one of sanguineous compressiou, it must
be treated very much as one of ordinary apoplexy ; at first,
by efforts at gradual reaction, and afterward by purgatives,
bleeding, and means to favor cerebral accommodation and
prevent inflammation. The trephine is not thought of
unless the unconsciousness obstinately persists, and there is
reason to believe, from the nature of the phenomena,
especially the existence of a wound or contusion on the
head, that the blood may be reached by the instrument.
Gunshot injuries of the skull, with or without lodgment
of the ball, may be productive merely of concussion of the
brain, or of concussion and compression. When the missile
penetrates the bone, and tears up the cerebral tissues and
membranes, death usually occurs instantly, or within a short
time after the receipt of the accident, without, perhaps, any
attempt at reaction. Nevertheless, a number of cases of
injury of this nature, in which the patient either partially or
completely recovered, have been recorded by military
surgeons. In some instances the ball merely penetrates the
skull, with no apparent depression, and in this event the
treatment should evidently be very simple, being limited,
570 Military Surgery. [July,
in great degree, after the occurrence of reaction, to the pre-
vention of inflammation of the brain. A similar course
should he adopted when the hone is broken and only slightly
depressed, especially if there be no urgent or obstinate
symptoms of compression. "When, on the contrary, the
bone is badly fractured, comminuted, or forced greatly
beyond the natural level, the proper plan is to trephine
whether there be any external wound or evidences of com-
pression or not. If the operation be neglected, loss of life
from inflammation will be sure to arise within the first six
or ten days after the receipt of the injury. In the punctur-
ed fracture, as it is named, the trephine is invariably em-
ployed at the earliest moment, however flattering, appar-
ently, the head symptoms may be. If the instrument be
withheld, fatal cerebritis or arachinitis will be no less cer-
tain than when the bone is shattered and driven down upon
the brain.
Fracture of the skull by contre-coup, so common in civil
practice, is seldom met with on the field of battle; doubt-
less for the reason that the injury is hardly ever inflicted
upon the top or the base of the cranium, as it is when a per-
son is struck upon the vertex or falls upon his nates. The
most frequent fracture among soldiers is the punctured. A
ball has been known to break the internal table of the
skull without the external.
The skull is sometimes frightfully injured without any
serious lesion of the scalp. Macleod refers to a case, which
occurred at the Alma, where it was completely destroyed
by a glancing shot, without any material implication of the
soft parts. A round shot ("en ricochet") struck the scale
from an officer's shoulder, and merely grazed his head as
it ascended. The result was instant death. The skull was
so completely mashed that its fragments rattled under its
scalp as if loose in a bag. The condition of the brain was,
unfortunately, not ascertained.
In the more simple forms of fractures of the skull, how-
ever induced, the practice of trephining is now much less
common than, formerly, and there is no doubt that the
patient often makes a good recovery, though it is by no
means certain that such a person may not suffer seriously,
at a more or less remote period from epileptic and other af-
fections. I am convinced from my own observation that
this happens not unfrequently. Dr. Stromeycr, surgeon-in-
chief in the Schleswig-Holstein campaign in 1849, express
1861.] MUitary Surgery 57]
strong opposition to the use of the trephine in gunshot and
other fractures of the skull, oven with depression, .on the
ground that, independently of the mischief inflicted in the
operation upon the tissues, admission of air to the contused
portion of the brain greatly augments the danger of inflam-
mation. Of 41 cases of gunshot fractures of the skull with
depression, reported by him, 34 were cured, and of these 1
only had been trephined.
When operative interference is deemed improper, the
most simple treatment should be enforced. Any probing
that may be necessary should, if practicable, be performed
with the finger, and the wound should not be enlarged, ex-
cept when we are compelled to elevate depressed or remove
loose bone.
"When trephining is required, it should be done as early as
rible, and without chloroform or ether, unless the patient
is very unruly, as the anaesthetic might tend to provoke in-
ilammation of the brain. Every particle of depressed bone
should be elevated, and such portions as are loose, detached,
or driven into the brain, and easily accessible, removed.
All bleeding vessels are tied, the edges of the wound arc
gently approximated with silver sutures, and the head, well
shaved and raised, wrapped in warm or cold water-dressing,
as may be most grateful to part and system. The great
danger after all severe injuries and operations upon the
skull is inflammtion of the brain and of its membranes, and
to the prevention of this, therefore, the surgeon should di-
rect his most zealous efforts. The patient must be frequent-
ly visited, and every untoward symptom promptly met by
appropriate measures, of which active purgation, loss of
blood by venesection, leeching or cupping, a restricted diet,
andjexclusion of light and noise from the apartment, with
perfect rest, are the most reliable.
Wounds of the brain must be managed upon general
principles; all foreign matter is at once removed, and the
parts being restored as nearly as may be to their normal
relations, the surgeon endeavors to keep the resulting in-
flammation within proper limits. Most of such lesions
prove fatal within the first week from their receipt. If the
patient survive for any length of time, death will generally
e at last from exhaustion, cerebritis, or fungus.
rtions of the 8hMy sliced off by the sabre or sword,
should be replaced and secured by wire sutures, even if
they are attached merely by small shreds of the scalp.
572 Military Surgery. [July,
Scalp wounds of every description, but in particular the
contused, lacerated, punctured, and gunshot, are extremely
prone to be followed by erysipelas ; death may also occur
from cerebritis, arachnitis, and pyemia. The slightest
lesion, then, of this region of the body should be zealously
watched.
Wounds of the face must be treated with an eye to the
avoidance of disfiguring scars, by wire sutures and cold
water-dressing. When a large portion of the lower jaw is
shot away, the tongue will be apt to fall back upon the
glottis, causing suffocation. The organ should be drawn
forward with the finger or tenaculum, and the patient ob-
serve the prone position until the tendency is lost.
One of the great sources of annoyance and danger, in
gunshot wounds of the face, is secondary hemorrhage. It
frequently appears soon after the accident, and, although it
often ceases spontaneously, it is sometimes controlled with
much difficulty. Paralysis, partial or complete, is not un-
common, owing to injury of the branches of the facial
nerve.
In the management of wounds about the mouth,
throat, and face, great care must be taken not to allow the
offensive mucous and salivary secretions to pass into the
stomach. The neglect of this precaution is apt to be follow-
ed by a low typhoid state of the system, very similar to
what occurs in pyemia, or blood poisoning. I have repeat-
edly witnessed these effects after operations upon the jaws,
mouth, and even the nose.
In fractures of the bones of the face from gunshot an ex-
ception should be made to the general rule of removing
fragments which are nearly detached, observation having
shown, says Mr. Macleod, that the large supply of blood in
this region will enable them to resume their connection with
the other tissues, in a way that would be fatal to similarly
placed portions in other situations.
Gunshot and other wounds of the chest are, as stated else-
where, extremely fatal ; death, if the lesion be at all severe,
being usually speedily caused by shock, hemorrhage, or
asphyxia ; or, at a more or less remote period, by inflam-
mation and effusion. When the lungs are wounded, the
characteristic symptoms will be hemoptysis, with suffocative
cough, great prostration, and excessive alarm. A copious
flow of blood may take place in the thoracic cavity from a
wound of one of the intercostal arteries.
1861.] Military Surgery. 573
Any foreign matter that is easily accessible is at once
removed, but officious probing is out of the question. The
wound, if small and unaccompanied by serious hemorrhage,
is closed in the usual manner, the chest being firmly en-
circled by a broad bandage, to compel diaphragmatic res-
piration. Under opposite circumstances, it is kept open, the
patient lying upon the affected side to favor the escape of blood
with as much elevation of the head as the case may admit of.
The main reliance for arresting pulmonary bleeding is upon
venesection, copious, and frequently repeated, unless the ex-
haustion amounts to absolute collapse. Sugarof lead, opium,
and veratrum viride are frequently exhibited, sinapisms are
applied to the extremities, and, in short, everything is done
to control cardiac action. Inflammatory symptoms are
counteracted in the usual manner, and effused fluids, caus-
ing oppression, and resisting ordinary measures, are, un-
hesitatingly, evacuated by puncture, as the only chance of
escape.
Wounds of the heart and aorta, of whatever nature, arc
usually fatal; now and then, however, an astonishing ex-
ception occurs.
Wounds of the abdomen, merely penetrating its walls, but
not its contents, are brought together by sutures, extending
down nearly to the peritoneum, otherwise they will be fol-
lowed by hernia. When they involve the intestine, and are
incised, they arc sewed up with a fine needle and silk
thread, either interruptedly or continuously, the ends ot the
ligature being cut oft" close.
Contusions of the walls of the abdomen by round shot
arc among the most dangerous injuries to which the body
is exposed, often rupturing both the hollow and solid
viscera, and rapidly causing death, without much apparent
sign of so severe an accident. The most important symp-
toms of these contusions arc vomiting, and pain in the
abdomen; and the great object of the treatment, in the
event the patient survives their immediate effects, is the
prevention of peritonitis, which often comes on in the most
stealthy manner. Laceration of an internal organ is near-
ly always promptly fatal. Shell wounds of the walls of
the abdomen are generally followed by extensive sloughing.
Abscesses among the muscles of the abdomen are not un-
common after gunshot injuries.
Balls often traverse the walla of the abdomen for a con-
siderable distance without entering its cavity, or they pass
in without injuring any of the contained viscera.
Military Surgery. [Julj'j
"The fatality of penetrating wounds of the belly," ob-
serves Macleod, "will depend much on the point of their
infliction. Balls entering the liver, kidneys, or spleen are
well known to be usually mortal, although exceptional cases
are not rare. "Wounds of the great gut are also always
recognized as much less formidable than those which im-
plicate the small. Thomson saw only two cases of wounds
of the small gut, after Waterloo, in the way of recovery ;
but Larrey reports several. Gunshot wounds of the stomach
are also exceedingly fatal. Baudens records a remarkable
case of recovery, although complicated with severe head
injuries. The syncope which followed the severe hemorr-
hage in this case lasted for ten hours, and doubtless assisted
along with the empty state of the* stomach at the moment
of injury, in preventing a fatal issue."
Gunshot wounds of the bladder occasionally occur ; the
ball may penetrate the organ in any direction, and at the
same time commit extensive havoc in the neighboring
parts, both soft and osseous. Such lesions are generally
fatal. Simple gunshot wounds, on the contrary, are some-
times recovered from, especially when they are treated by
the retention of the catheter, thus allowing the urine to flow
off as fast as it descends from the kidneys. The operation of
laying open the wounded viscus through the perineum, as
originally proposed by Dr. Walker, of Massachusetts, might
be performed in such a contingency. Such a procedure
would be much more likely to prevent urinary infiltration
than the catheter, however carefully retained, during the
detachment of the sloughs, as well as before the contiguous
structures have been glazed with lymph.
Balls, pieces of cloth, fragments of bone, and other foreign
bodies, if retained in the bladder, generally serve as nuclei
calculi, and should, therefore, be as speedily extracted as
possible, either through the perineum, or by means of the
forceps or lithotriptor. Quite a number of cases, in which
the operation of lithotomy was successfully performed for
the purpose of effecting the riddance of balls and other ex-
traneous substances, have been reported by different writers,
as Morand, Larrey, Baudens, Langenbeck, Guthrie, and
1 lutin.
CHAPTER IX.
DISEASES INCIDENT TO TROOPS.
The discuses which attend armies, or molest soldiers in
amps, garrisons, and hospitals, and which so often deci-
18G1.] Military Surgery, 5t5
mate their ranks, and even, at times, almost annihilate
whole regiments, are the different kinds of fever.-, especial-
ly typhus and typhoid, dysentery, diarrhoea, and scurvy.
These are. emphatically, the enemies of military life, doing
infinitely more execution than all the weapons of war, how-
ever adroitly or efficiently wielded, put together. Pneu-
monia, pleurisy, and hepatitis, of course, slay their thousands,
and various epidemics, especially cholera, not unfrcquently
commit the most frightful ravages. "War," says Johnson,
"has means of destruction more formidable than the cannon
and the sword. Of the thousands and tens of thousands
that have perished, how small a proportion ever felt the
stroke of an enemy I" Frederick the Great used to say that
fever cost him more men than seven pitched battles, and it
has long been a matter of history that more campaigns arc
decided by sickness than by the sword. The great mortal-
ity which attended our armies in Mexico was occasioned,
not by wounds received in battle, but by the diseases inci-
dent to men carrying on their military operations in an in-
hospitable climate, badly fed, subjected to fatiguing marches,
and obliged to use unwholesome water. Thousands perish-
ed, during their absence, from fever, dysentery, and
diarrhoea, and a still greater number from the effects of
these diseases, after the return of the troops to their native
soil. The latter affection, in particular, pursued many, like
a relentless foe, to their graves long after they had been
cheered by the sight of their homes and friends.
In the war in the Crimea disease destroyed incomparably
more soldiers than the sword, the musket, and the cannon.
Typhus and typhoid fever, dysentery, diarrhoea, scurvy, and,
lastly, malignant cholera, annihilated vast numbers, both in
the British, French, and Russian ranks. According to Dr.
leod, whose "Xotes on the Surgery of the War in the
Crimea," are so well known to the profession, the propor-
tion of those lost among the British by sickness to those
by gunshot and other injuries, was, during the entire
campaign, as 1G,211 to 1761, exclusive of those killed in
action. The difference he supposed to have been still
ater among the French and Russian forces. In Decem-
ber, 1*54, and in January, 1 *">">, not less than 14,000 French
soldiers were admitted into the Crimean ambulances on
'iint of disease, whereas, during the same period, only
I were admitted on account of wounds. Of the whole
number nearly 2000 died. During the lasl six month
576 Military Surgery. [July,
the campaign, in which the city was stormed and taken, the
French had 21,957 wounded as an offset against 101,128
cases of Disease.* At Walcheren, in 1809, the British lost
one-third of their troops by disease, and only 16 per cent,
by wounds^ In the Peninsular war, from January, 1811,
to May, 18l4, out of an effective force of 61,500 men only
42*4 per 1000, says Macleod, were lost by wounds, while
118-6 were lost by disease.
The number of sick that may be expected to be constant-
ly on hand during any given campaign is estimated, on an
average, at 10 per cent.; but this proportion must necessar-
ily be exceeded, especially in an invading army, with raw,
undisciplined, and unacclimated troops. This was eminent-
ly true even in the Crimea, in a climate comparatively
healthy, within a few miles of the sea. We may well im-
agine what would be the effects of the climate of the South
upon the Northern troops, if they were to pass far, during
the hot season, beyond Mason and Dixon's line. Disease
in its worst form, would be sure to invade and thin their
ranks at every step. Fever typhoid, typhous, remittent,
intermittent, and yellow dysentery, diarrhoea, scurvy, pneu-
monia, and inflammation of the liver would accomplish
more, infinitely more, for the Southern cause than all the
weapons of war that ceuld be placed in the hands of the
Southern people. Typhoid, typhus, and yellow fever, dys-
entery, diarrhoea, and scurvy would, in all human proba-
bility, soon become epidemic, and occasion a mortality truly
appalling. The Southern soldier, on the contrary, thor-
oughly acclimated as he is, would suffer comparatively little.
The British in the Crimean war lost 5,910 men from diar-
rhoea and dysentery, the whole number of cases having
been 52,442, affording thus a mortality of 11*26 per cent.
Cholera, of which there were 7,575 cases altogether, de-
stroyed 4,513 or in the ratio of 59-57 per cent. Typhus fever
killed 285 out of 828 cases ; fever not typhus, 3,161, out of
30,376. The French and Russian troops suffered in still
larger numbers from these diseases. Macleod asserts that
the former lost their men by typhus fever by thousands,
and the latter by tens of thousands. The British suffered
but little from intermittent fever, whereas this disease did
Macleod, op. fit,, p. C7
SOUTHERN
MEDICAL AND SURGICAL JOURNAL.
Vol Wll AUGUSTA, GEORGIA, AUGUST, ML NO.
ORIGINAL AND ECLECTIC.
ARTICLE XV F.
'hate of Quinia administered in small doses during
alth, the best means of preventing Chill and Fever, and
Bilious Fever, and Congestive Fever, in those exposed to the
unhealthy climate of the richlow lands and swamps of the
Southern Confederacy. By Joseph Jones, M. D., Professor
of Medical Chemistry in the Medical College of Georgia.
Chemist of the Cotton Planters' Convention of Georgia.
SUMMARY.
Importance of protecting the troops of the Southern Confederacy by
all passible means, from the effects of the climatorial fever of the South,
illustrated by the records of Midway Congregation, of Liberty Co..
Ga., situated in the low plain bordering the Atlantic ocean : by the
mortality of the Bcrmudans who emigrated to Snnbury on the coast of
Georgia ; by the groat mortality of Piice Plantations ; and by the mor-
tality of Savannah during the wet culture system in the lands surround-
ing the city; and by the sickness and mortality of Oglethorpe Barracks
and the Augusta Arsenal. Testimony to the value of Quinine in pre-
ing climate fever in the Southern States. The value of Quinine in
warding off climate lover, still farther demonstrated by the experience of
the Surgeons ol the British Navy on the ooastpf Africa. Facts proving
the unhealthy nature of the climate of Africa the malarial fever of
Africa similar in all respects to the malarial fever of the low-grounds,
swamps and rice fields of the Suuthern Confederacy. Comparison of
the mortality in the British Navy before and after tin1 use of Quinine as
a preventive of African fever.
38
594 Joseph Jones, on Quinine [August
The climate of the rich low plain, clothed with a luxuri-
ant sub-tropical vegetation, which forms a belt along the
Atlantic ocean and Gulf of Mexico, of varying width, from
30 to 100 miles, and which is intersected with numerous
swamps which discharge their waters into sluggish, muddy
streams, surrounded on all sides by extensive swamps and
marshes, is necessarily hostile to the white race. To the
pestilential exhalation of stagnant swamps and rich river
deposits, excited and disseminated by the burning rays of
the sun in this hot climate during the summer and fall
months, no process of acclimation has ever accustomed the
white man. In the early settlement of South Carolina and
Georgia, the inhabitants in most instances resided the
whole year upon their rich rice and Indigo plantations ;
many however soon fell victims to the climate, or dragged
out a miserable existence, with constitutions broken down
and rendered prematurely old, by repeated attacks of cli-
mate fever. The clearing of the forests, of the swamps and
rich low-lands, and the consequent exposure to the sun of
the vegetable matter which had been accumulating for ages,
rendered the climate so deleterious to the white race, that
the planters were compelled to seek health during the
summer and fall months, in sea island, or in pine barren,
or mountainous retreats ; and even with the most efficient
precautions, the mortality of these regions is far greater
than in the more elevated portions of the Southern Con-
federacy.
The following facts will illustrate the effects of the climate
of the swamps, rice fields and river bottoms, upon the mor-
tality of the white race.
In the Midway Congregational Church, of Liberty co.,
< la., (formerly St. John's Parish) the number of births from
1754 to 1804, was 600, whilst the number of deaths during
this period was (328, thus showing an actual decrease during
50 years of 28. In 1817 there were 49 deaths in this con-
gregation, which did not number more than 340 whites,
showing a mortality of one in every seven of the inhabi-
18G1.] Asa Preventative of Malarial Fed r.
tants (14-4 per cent. ;) of these 49 deaths, 34 occurred in
four mouths, 'July, August, September arid October, and
in almost every case the effects of climate fever : and
other years might be cited in which, if the mortality did
not rise to so high a figure, it still rose to such alarming
figures as from one in qvcvy ten, to one in every seventeen
inhabitants.
This heavy mortality was clearly referable to climate, ior
it is believed that no body of citizens in the Southern coun-
try excels this congregation in intelligence and virtue, or
in the careful regard for the substantial comfort and health
of its families.
Before the Revolutionary war, whilst Sunbury on the
coast of Georgia, was in a highly prosperous condition, TO
emigrants came from the Bermuda Islands : of this number
50 died the first year from climate fever.
Savannah, situated on a sandy plain, termini' ted on the
north by a turbid sluggish stream, and flanked on the cast
and west by extensive tide swamps, afforded during the
period that these low lands were cultivated in rice, a good
field for the determination of the probable mortality of
troops exposed to the climate of rich river-bottoms and
inland swamps. The dry culture system was commenced
with the lands surrounding Savannah, in 1818; we shall
therefore for our present purpose, deal with the mortuary
records of the city, and during the wet culture system, as
far as they extend back from 1818 : premising however,
that after the institution of the dry culture system, the
health of Savannah, excepting the years when the yellow
fever prevailed, has progressively improved, and will now
compare favorably with cities situated in the same latitudes,
and surrounded by similar alluvial deposits. After a c
ful examination of the records of the city, I have been able
to discover no record of deaths with a date earlier than
1804.
The deaths of the blacks are excluded from the following
statistics. The sum of the deaths of the foreigners and an
596
Joseph m.nks, on Quinine
[August,
tives, does not always c< *e ;pond with the total deaths from
climate fever, because in some instances, the nativities are
not given in the record.
Deaths amongst the
Whites
in Savannah from
1804 to
1818.
4
ft.* ?
srgl
ill
si
-
: *
: 2
: s
p
: S
o *
Eg"
Go
ii 2.
n
a S
^3
si
ri
*S
: =?
o
: 3
H
ft. 2.
ff
if
t
1804
118
77
63
14
207
1805
141
112
78
22
238
1806
120
52
43
9
159
1807
124
80
71
9
230
1808
103
77
67
8
219
1809
98
63
52
9
183
1810
79
46
38
8
163
1811
114
87
73
13
212
1812
132
120
92
24
226
1813
109
64
45
19
214
1814
185
166
138
23
300
1815
140
130
104
18
233
1816
161
146
91
38
272
1817
283
313
236
57
461
The population of Savannah in 1800 was 5,166 ; of these
2,799 were whites and 2,367 slaves. In 1808 the population
was 6,4C4; of these 3,010 were whites and 3,454 slaves.
In 1810, the entire population was 5,215 ; in 1820, entire
population 7,523.
Whilst the records of the population of Savannah at %
different periods are not as full and explicit as could be
wished, still from the data now presented we may institute
comparisons, and determine the average mortality for each
year with a very close approximation to the absolute num-
bers : thus in 1804, the proportion of deaths in round num-
bers of the whites to the white population, was 1 in 13
1805, 1 in 12; 1806, 1 in 18; 1807, 1 in 12; 1808, 1 in 13
1809, 1 in 16; 1810, 1 in 18 ; 1611, 1 in 14 ; 1812, 1 in 13
1813, 1 in 14; 1814, 1 in 10; 1815, 1 in 14; 1816, 1 in 18
1817, lin9.
1S61.] As a Preceitlativc of Jlahm'al Jfbk r. 597
It we compare the mortality from climate fever, of the
strangers ami foreigners, under which class we include the
seamen, who form a large part of the transient population
of Savannah, we will see that that the deaths amongst this
- wore more than four times as numerous as the deaths
of the natives. This fact illustrates still more strongly the
groat risks and siokness, if not heavy mortality, which
must attend the transportation of troops from Middle Geor-
gia, and from any part of the high mountainous tracts of
the Southern Confederacy to the swamps and rich rice
grounds, during the months of July, August, September
and October; for without doubt the observation was made
by the reader as he reviewed the preceding figures, that the
rate of mortality id Savannah during the wet culture sys-
tem, frequently rose to a figure which in healthy re-
gions would have been considered as the results of pes-
tilence ; and the correctness of this observation is placed in
the clearest light, when it is known that the annual mor-
tality in England (1) is one in every 45 of the living ; in
France, 1 in every 42; in the New England States, 1 in 64 ;
in the Middle States, 1 in 73 ; Coast planting States, 1 in
73 ; Northern States, 1 in 80. (2. |
Whilst we will readily grant that the improved method
of medical treatment of the present day would greatly di-
minish the rates of mortality, we would on the other hand
affirm that these improvements in practice would have lit-
tle to do with the prevention of disease. We have there-
fore presented these views of tin- rates of mortality in these
localities, rather to demonstra e the liability of men ex-
d in this climate to disease, and thus to establish the
importance of the present inn 'ry; for an army may be
rendered almost as ineffective ' siokness as by death.
1 Report of the I \ par General of Engl .
(2) Census of United States, 1 -
598L Joseph Jones, on Quinine [August,
Tho medical statistics of Oglethorpe Barracks during the
period they were situated one mile south of the city of
Savannah, just back of the present jail, illustrates still more
forcibly the sickness and mortality of troops encamped in
localities surrounded with rice fields and marshes. In 1828
during the months of July, August and September, there
occurred 23 deaths in a command of 95 men ; and during
the months of October, Xovember and December, 18 deaths
in a strength of 85 men : the total deaths for the year was
52, besides 19 women and children Remittent fever and
dysentery were the fatal diseases which caused the high
mortality. During 10 years, from 1829 to 1839, the annual
ratio of mortality was 5.5-10 per cent; the annual ratio of
Intermittent^ was 07 per cent, and that of Remittents 22
per cent ; and every man was on an average during this
period, reported sick in a little less than every five months.
So prevalent and fatal were the diseases in the summer and
fall seasons, that this post was finally abandoned.
The Medical statistics of the Augusta ArsenaL whilst it
was situated on the Savannah river, correspond with those
of the Oglethorpe Barracks ; disease prevailed to so great
an extent that it wan necessary to abandon the post in tho
summer season, and encamp on the Sand Hills.
These observations might be still farther strengthened by
\\\a presentation of the rates of mortality of rice planta-
tions, this subject however will be treated more fully, in
subsequent numbers of this journal, and we will merely
state the result of an extended personal examination of the
mortuary statistics of rice plantations ; the number of births
in proportion to inhabitants does not differ materially from
the number in the healthiest regions, but the mortality
Bcially amongst the young is for greater in fact so great
daring many years instead of an increase, there is
r a stationary condition, or an actual decrease.
The facts which have now been presented are sufficient
to justify the attempt to devise some means to ward off the
climate fever.
L] Asa Prevet
Duringthe study of the relatio i of climate and soil to
disease, the collection of the ry statistics and the
investigation of the causes of disease apon rice and cotton
plantations ; and during the discharge of the duties of
Chemist to the Cotton Planter's Convention of Georgia,
the author lias necessarily greatly exposed to the
agents which produce climate fev t, and the results of his
experience now presented, cannot there Tore be Baid to
be wanting the test of actual experiment.
Under these exposures I have found that Sulphate of
Qainia taken in from 3 to 5 grains twice during the day
would in most cases prevent the occurrence of Malarial
Fever, and if it failed to ward it off entirely, the attack
would be of a very slight character. I have still farther
observed that when the climate fever first appeared, with a
se of lassitude, headache and excitement of the pulse,
with alternate flushings, it might be arrested bv a dose of
from five to ten grains of Sulphate of Quinia, in combina-
tion with Bicarbonate of Potassa and Hoffman's Anodyne.
From 5 to 15 grains of the Sulphate of Quinia may be given
according to the urgency of the symptoms, united with 15
grains of Bicarbonate of Potassa and f 5ii of Hoffman's
Anodyne and 5 grains of Gum Camphor; the whole to be
dissolved in fjvi i I water. The feet should be placed in
hot water, immediately after, or before, the administration
of the remedies, and the patient after this bath Bhould
cove in bed. so as to promote free perspiration ami
induce quiet sleep. I have frequently gone to bed in
a feverish, restless -rate, with a severe h<
1 pulse, and pain in the limbs, and dry, warm
-kin. and under the action of these remedi in the
morning id and able to resume operati
Jarbonate oi
Ofthe I' i, (Salts of Tartar,) which is
fever, ii . be-
cause it is far less active in iqn. n the stomach,
and may be taken in much la:
600 Joseph Jones, on Quinine [August,
more effectually the neutralization of the acid which is so
oiten abundant in the stomach at the commencement of
malarial fever, and more effectually acts upon the liver and
the kidneys, and promotes the removal of all offending
matters from the blood.
The late lamented Dr. Charles West, of Savannah, in-
formed me that during his practice in Burke County, it
was his custom to arrest attacks of climate fever, at the
outstep, when the first symptoms were manifested, by Sul-
phate of Qumia; my respected colleague, Dr. Dugas, Pro-
fessor of Surgery in the Medical College of Georgia, informs
me that he has used this medicine in a similar manner; and
we have been informed that the energetic Superintendent
of the Savannah & Charleston Eoad which passes through
a most sickly region of country, preserved the health of his
white laborers by the daily use of small doses of Sulphate
of Quinia.
We would recommend the use of Quinia as a preventa-
tive of Climate fever, in the following manner :
If. Sulphate of Quinia, - - grains, iii.
Dilute Aromatic Sulphuric Acid, drops, v.
Brandy, - tablespoonful, 1.
Water, ----- wineglassfuls, ii.
Drop the diluted Aromatic Sulphuric Acid upon the
Sulphite of Quinia, and then add the brandy and water.
Administer twice during the day, after rising in the morn-
ing, and just before bed-time.
To render the value of this means of warding off climate
fever, still more evident, we will cite the practice and suc-
cess of the British Surgeons upon the coast of Africa, pre-
mising at the outset, that the endemic climate fever of
Africa does not differ in any essential manner, except, per-
haps, in its severity, either in its causes, symptoms or
effects, from the malarial fever of North America.
The value of Sulphate of Quinia in warding off the
climate I'cvw of Africa, can be determined only by insti-
tuting a comparison between the effects of the disease
I.] 601
before and after the use of this medicine as a prophyla*
Tho celebrated traveller, Mungo Park, suffered from two
pe attacks oi* lever, upon t tour through the
interior of Africa, and at the conclusion of his journey the
color of his skin was so altered by the disordered state of
his liver induced by Afri . that he could scarcely be
distinguished from a Moor; and upon his second visit to
Africa, not only was he brought to the borders of the grave
by climate fever, but 32 out of the 38 men who left witli
him the banks of the Gambia, fell victims to African fever
in less than two months.
The vi at out in 1G18, to relieve the English Ex-
plorer. Thompson, on the banks of the Gambia, lost almost
the entire crew with fever, and at the very outstep, failed
to accomplish the desired object.
The enterprising traveller, Ledyard, who had spent his
life in travelling, and had sailed around the world with
Captain Cook, had lived for several years with the Xorth
American Indians, and had travelled from Stockholm,
round the Gulf of Bothnia, and thence to the remotest
parts of Asiatic died of African fever, in the very
commencement of his journey to explore this continent.
Numerous other travellers might be mentioned, as
NTicholls. Morrison, Pearce, Clapperton, and the active,
athletic and temperate Frederic Horneman, who fell vic-
tims to the endemic climate fever of Africa.
The splendid expedition to the Congo, under command
. provided with a crew of fifty active
individuals, and with a Botanist, Zoologist, comparative
aost competent Physician, melted a.
under the influence of I id burning c and
Led with the loss of the Captain, all the officers and
. imilar termination closed the expedition
of Major Peddie, fur t; .cry of the Xiger.
The average mortality amongst the better i
ic, according to the testimony of Dr. Xichol,
Deputy Inspector of U rly about one in
twelve, or very nearly nine per cent.
002 Joseph Jonbs, on Quinine [August,
According to Mr. Tidlie, acting Staff Surgeon at Cape
Coast Castle in 1819, all the new-comers from England
were seized with fever, and one-half died, more than one-
third of the resident Europeans who had been there more
than one year were seized with the fever, and one eighth
died ; in 1820 all the new comers were saized with the
fever, and one half of them died, and of the older residents
one ninth died; in 1821 all the new comers were seized,
with fever, and one third died, whilst of the older residents
near one sixth died ; thus making an average of one death
out of every two and two thirds, of new comers during the
the first twelve months after their arrival, and one death
out of every eight of the resident Europeans who had been
there more than one year.
From the Report of Dr. Barry, Deputy Inspector of Hos-
pitals in 1822, we learn that twelve white sergeants from the
Isle of Wight, selected as good and healthy men of regular
habits, were attacked with fever, upon their arrival upon
the coast of Africa, and within a few months after their
arrival, eight paid the debt of nature, and the constitutions
of three of the remaining four were permanently injured,
whilst the sickness and mortality amongst their wives and
children were nearly in the same proportion.
According to Mr. William Ferguson surgeon to the Royal
African Colonial Corps, in the third quarter of 1824, the
mean strength of British soldiers at Sierra Leone, was 585,
of this number 38G were attacked with this African climate
fever; 161 died, showing one death to 3.63 of the strength,
and one death to 2-39 cases treated; at Gambia during
the same period, the strength was 108, cases of Malarial fever
02, deaths 7-4, giving a proportion of 1 death to 1-45 of the
original strength, and 1 death to 1-24 of the cases treated :
O CD J
at the Isles de Los, during the same period the mean
strength was 103, cases of Malarial fever 00, deaths 23,
showing 1 death in 4-47 of the strength, and 1 death in
4-3 of the cases treated. Captain W. F. Owen of the
al Navy, in his attempt in 1827 to found a settlement
1861.] As ''//(// Ft G03
at Fernando, Po., lost almost his entire colony from the
End f Africa ; and Colonel Nicholls who follow-
ed him in a similar attempt had one attack of Remittent
fever, and eleven attacks of Intermittent fever, and lost
twe: out of thirty individuals who composed the
.pany.
Numerous other examples might he brought forward to
show the dreadful effects of the climate of Africa upon
;-s, unprotected by the sulphate of quinia ; we will
however allude to but one more the expedition of H. B.
s AVilberforce, Albert and Soudan, during the year
1841 and 1*4:2. np the Niger with the leading object of pro-
moting the abolition of the slave trade. When the expedi-
tion entered the Nun branch of the Niger, on 13th of Au-
complement of men and officers consisted of, offi-
inelnding civilians and engineers 53, white seamen 63,
marines and Bappers 29, total number of whites 145 ; men
of color entered in England 25, Kroomen and liberated
African I on the coast 110 : blacks for model farm
total bL and total 303. The health of the
edition continued good until the ships had proceeded
two hundred and fifty miles from the mouth of the river,
ruber, when a most malignant fever ap-
red in all the v and spread with great rapidity.
The ath took place on the 9th; and on the 17th
there v. I of whom were whites ; and seven
whites had died. The expedition was now so disabled that
it v. . id advisable to send two of the .-hips back to
I the 19th the Soudan started for the mouth of the
r with forty eases of fever, and was followed by the
force, with nearly an equal number of sick, on the
. The Albert continued up the river, the officers be-
ing that the violence of the fever was in a measure
hansted, and that the climate of the more open country,
found I J thy. The
dt proved otherwise when the ship had arrived at
Egga, 340 miles from t: ban twenty more or
604 Joseph Jones, on Quinine [August,
the crew had been attacked, of whom two had died ; and
on the 3d of October there remained, capable of doing any
duty, only one white seaman, the sergeant and one private
of marines, the geologist, the mate, one hospital attendant,
and the surgeon Dr. Mc William: the entire enterprise was
now abandoned, and the Albert steamed down the river to
Fernando Po. Of the 145 whites who entered the Niger in
good health. 130 were attacked with fever, and 42 died ; of
the 158 blacks, only 11 had the fever, and that in its mildest
forms, and not one died.
The ratio of the men attacked by fever in the Albert
was 1 in 1.127, the ratio of deaths in total number
victualled was 1 in 2.606, and in the number of cases,
1 in 2.391 ; the ratio of the men attacked by fever in the
"Wilberforce was 1 in 1.666, ratio of deaihs in number
victualled, 1 in 8 ; ratio of deaths in number of cases, 1 in
6.857; the entire crew of the Soudan were attacked with
fever; the ratio of deaths in total number victualled
was 1 in 2.7.
We will now compare these facts and rates of mortality
with the health of the British Squadron, employed for the
suppression of the slave trade on the west coast of Africa,
since the systematic employment of the Sulphate of Quinia
as a prophylactic.
The observations which we will now present, are from the
most reliable of all sources : the "Statistical Report of the
Health of the Royal Navy," and we shall refer especially to
the reports for 1856 and 1857, printed by the House of
Commons, July, 1858, and August, 1859.
In 1856, the squadron employed for the suppression of
the slave trade on the west coast of Africa, consisted of
twenty-one vessels, with a mean force, including Kroomen
and African boys, of 1630 men of all ranks and ratings.
The number of men daily inefficient from wounds and sick-
ness on the west coast of Africa, averaged about 55 per
1,000 of mean force.
1 861.] As a Prmevtativc of Malarial Fever. 605
The following summary taken from the nosological re.
turns, will not only show that the great source of malarial
fever in the squadron is exposure to effluvia or miasmata,
while on shore, in boats near the shore, or by the entrance
of the cruisers into the large tidal rivers, but also that the
great means of warding off the endemic climate fever, and
of moderating its violence and duration, was the daily ad-
ministration of the Sulphate of Quinia to the men during
exposure to the noxious miasmata.
The Bloodhound remained during the entire year on the
northern division of the station. In March she steamed
about 300 miles up the Benin river; while in the river, and
for fourteen days afterwards, from three to six grains of
the disulphate of Quinine were given to each of the ship's
company as a preventative of fever, and although they were
exposed to the emanations from the mangrove swamps for
twenty-seven days, only six suffered slightly from fever.
Some time aiterwards they were again exposed to mias-
mata in the Bonny, New Calabar, and in the Sherhro, the
last, one of the most dangerous rivers for Europeans on the
whole station ; but Quinine in solution was invariably used,
as a prophylactic, and with good effect, as only one case
occurred after the vessel had been for a week in the Sherbro
and the patient was the only person who did not take the
quinine regularly. Xo death occurred in this vessel from
fever, but one man was invalided for its sequela.
The Guilders was employed almost constantly cruising,
for the first six months of the year off the coast, in the Gulf
of Guinea, and during the remaining months, off the coast,
between Loango and Benguela. With the exception of a
few unimportant cases, her crew entirely escaped fever, until
three hoats were sent on detached service up the Lagos
River ; in these there were twenty-seven white men and
five officers. They remained absent for two nights, one of
which was spent at anchor, off' the town of Lagos. The
surgeon accompanied the expedition and gave quinine-wine,
which was continued after they returned on board; still,
606 JosEPn Jones, on Quinine [August,
notwithstanding, nine of the thirty-two persons who formed,
the party, were attacked with fever; two in five days after
their return to the ship, one on the sixth day, one on the
eighth, one on the ninth, one on the thirteenth, two on the
sixteenth, and one on the seventeenth. The disease in all
was the same, differing only in its degree of intensity ;
some were convalescent on the eighth or ninth day, and
others not before the twenty-eighth ; one had a jaundiced
appearance. The surgeon thought the fever would have
assumed a worse form, but for the quinine-wine which had
been taken as a preventative. Xo other febrile disease of
any consequence occurred in the Guilders for several months
subsequently, nor in fact until she had been for some time
stationed on the southern division of the command, when
four cases took place, after she had been eight days at an-
chor in the river Congo. The Firefly did not arrive on the
station until August. Shortly afterwards she proceeded on
a' cruise off the river Pongas, while her boats, armed with
white men, were sent up the river. They took Quinine
wine night and morning while absent, and continued its use
for ten days after they returned, and all escaped fever.
Subsequently a few cases were contracted from long contin-
ued exposure to the miasmatous exhalations in the river
Lagos. Eighteen cases of remitting and fourteen of inter-
mitting fever occurred in the Hecate the majority of the
former were contracted on shore ; two ended in death.
The subject of one of the latter was a marine, who accident-
ally drifted away in the life-boat over the bar at Lagos ; he
slept one night on shore, and was not attacked until four-
teen days afterwards. In the other case, the patient, an
officer, slept two nights on shore, and exposed himself to
the full glare of the sun during the day time, by rowing
about in a boat, without an awning, in the lagoon off
Lagos ; he declined taking Quinine as a preventative, and
was attacked about fourteen days after he returned on
board.
1 .61.] As a Preventative of Malarial Fever, 607
The Merlin arrived on the station about the middle of
July, and after cruising a short while off the rivers Nunez
and Congas, proceeded to the Bight of Biafra. She was
then ordered on special service up the rivers Bonny, New
Calabar and Brass ; while thus employed, the following
autionary measures were adopted against fever : The
crew were turned up at ">.o0 a. m., and after dressing, took
half a wineglassfull of quinine wine ; they breakfasted at 6.
The decks were washed with water (warm) from the boilers
at 0.30 ; they took dinner at noon, and supped at 5 p. m.
No white men were sent away in the boats. Serge frocks
and white trousers were worn during the day, and blanket
dresses during the night. Xo water was allowed to be
drawn from alongside for any purpose whatever. Quinine
wine was administered to the whole crew for fourteen days
after leaving the rivers, in which they remained altogether
twelve days. Whether it was owing to the above measures
it is impossible to state, but no sickness of any kind follow-
ed the several expeditions into these notoriously unhealthy
localities. Although twenty-three cases occurred in this
j1, only one out of the whole number was of a severe
character, and it was the result of intemperance and expo-
sure on shore on the Isles de Los. The records of the
other vessels all substantiated the great value of Quinine as
a prophylactic.
It thus appears, that in all these vessels, with a mean
force of about 1,680 men, there were only seven deaths from
fever, being in the ratio of about a little more than four to
the thousand, a mortality so small, compared with that of
former ;. ems almost incredible, and might well lead
to the belief that the coast, like some of the cleared por-
tions of the North American Continent, is becoming more
healthy: but, with the exception of the non- appearand
yell p, which does not depend on terrestrial emana-
tions . the climate has undergone no salutary change.
The seemingly interminable forests which fringe the
estuari' iy tidal river, are still as prolific of the fever
608 Joseph Jones, on Quinine [August,
poison as i hey were in times gone by, when the death-rate
in the squadron was ten times greater. How then, it may
be asked, are we to account for this improvement ? Simply
by the change which has taken place in the mode of con-
ducting the duties of the station. By a wise and humane
regulation, the deadly practice of sending boats away on
detached service, to watch or intercept slavers, has been
interdicted, or at all events, greatly restricted. Prize
crews are no longer turned adrift to wander through the
streets of Sierra Leone, when the vessels they navigate from
distant parts of the station are delivered up to the authori-
ties of the Mixed Commission Court ; the orgies of " the
barn," which lowered the character of the white man in the
eyes of the black, have long since ceased; and last, though
not least, the introduction of quinine ivine as a preventative of
fever has not only reduced the number of febrile attacks, but has
lessened the severity of those which do occur, and thus the mor-
tality has also been reduced to a level ivhich does not materially
exceed the death-rate from fever on some of the more healthy
stations.
There has also been a great change in the medical treat-
ment of febrile disease: the so-called active measures which
were in vogue but a few years since, have given place to
others of a more rational character Blood-letting is no
longer carried to an extent which leaves the patient but
little chance of recovery when the fever terminates, and
the rash and empirical use of calomel in large and fre-
quently repeated doses, to produce ptyalism, has been
abandoned not only on account of the impossibility of
producing ptyalism white the fever lasts, but because mer-
cury, given to excess in any form, has a most injurious
effect on the constitution. If these changes have had no
effect in reducing the mortality, they, at all events, have
lessened the sufferings and misery entailed on patients, who
though they survived the fever, lingered long in a state of
debility from the effects of blood-letting and mercury.
Statistical Beport of the Health of the Royal Nov g for the year
1861.] Asa Preventative of Malarial Fe\ .
1856, ordered by the House of Commons to be printed 26th J
1858: pp. 110-116.
In 1857 there were nineteen vessels employed on the
African station, with a mean force, corrected for time, of
about 1620 men, including Kroomen and liberated Afri-
cans. The number daily ineffective from wounds and sick-
ness averaged 112, or in the ratio of 69.3 to the 1,000 of
mean force, which exceeds the ratio of the preceding ;.
seven. The total number of dead, exclusive of those
lost by shipwreck, amounted to thirty-six twenty-seven
from disease, one from poison and eight from accidental
on the whole, therefore, the mortality was some-
what greater than in 1856. Daring the year, eleven a
of endemic fever terminated in death: the ratio per 1,000,
6.7, and although nearly a third greater than in In-
still not greater than the mortality of some of the healthiest
ions, and incomparably less than the mortality upoiftlie
African station, before the use of Quinine wine.
The following summary, taken from the medical journals
of the squadron, affords additional proof of the useful:
of Quinine as a prophylactic.
In the Trident there were forty cases of lever, but no
death occurred : the greater number of these
contracted in the rivers which enter the sea in the Light of
Biafra. Quinine wine was freely used/as a preventative.
On two occasions when boats were sent up the . the
white men took quinine wine while in the river, and
fourteen days after they left it, and no fever of any
quencc followed.
Fourteen cases occurred in the Sappho: they were near-
ly all contracted in boating expeditions up the river Coi
Quinine wine was admii : to the men on these o
as, but several who did not take it regularly were
:ed. Twenty men were employed off and on between
the 30th of April and the 11th May, on this tell-
ing a sui el in the Congo. The medicated wine
administered carefully according to the printed circu-
39
610 Joseph Jones, on Quinine [August,
lar. Only four men were attacked by fever, the disease
Blowing itself about three weeks after they ceased taking
the wine. In the Myrmidon and Pluto there were but few
cases of lever, though they were employed on some of the
most unhealthy places on the station : the former was laid
on the beach at Sierra Leone, to be repaired, meanwhile
her crew took up their abode in an old hulk which lay in
the harbor. Some of the men, however, together with
several of the Pluto's crew, were employed, both by day and
nigl it, as their work depended on the tide, in patching up
the hull of the vessel. To these men quinine wine was ad-
ministered twice daily, and the executive officers took care
that they did not straggle into the town or bush ; conse-
quently no case of serious illness followed.
The gig and pinnace of the Alecto, manned by fourteen
white men and six Kroomen, were sent about 150 miles up
the Congo, late in December, with presents for one of the
petty chiefs ; they returned on the 6th of January, and be-
tween the 12th and the 18th every white man, with two
exceptions, was attacked with fever. The same boats were
again sent up the river to the same place, on the 14th, when
the two persons who had escaped fever formerly were now
attacked, though one of them was not taken ill until thirty
days afterwards. With the exception of these two persons
the boat's crew on the second expedition were made up of
Kroomen, who, as usual, entirely escaped. On these expe-
ditions, an ounce of quinine wine was given to the white
men daily during their absence from the ship ; but it ap-
pears to have been discontinued on their return. In Janu-
ary the boats of this vessel were again detached to cruise in
the Congo, but did not proceed more than 40 miles up the
river. Quinine was given to the men during their absence
and for 14 days after tbeir return. The same precaution
was adopted after any subsequent exposure to malaria in
the river, and no cases of fever followed. The Bloodhound
was employed in January in the River Benin, and during
July in the Congo; as long as she remained within these
1861.] I 611
rivers, and for ten days afterwards, lour grains of quinine
in a quarter of a gill of rum. was administered to every
white man on hoard. One case only resulted from th
two expeditions ; and in that Instance, the person attacked
had exposed himself in a most imprudent manner while
shooting wild fowl amidst the slimy ooze in the mangrove
thickets on the hanks of the Benin ; whether the patient
took quinine as a preventative is not mentioned.
Three boats from the Childers went up the Congo, as far
as Punto da Linha, and were absent for several days ; qui-
nine was administered to the white men, and no fever
resulted.
In May, two hoats were sent from the Ilecla up the river
Xunez, and returned on the following day. Quinine wine
was issued in the usual manner, and no febrile disease fol-
lowed.
In July, the same vessel entered the Sherbro, and subse-
quently her hoats, containing fifty-six seamen and marines,
with the usual number of officers, ascended the river to the
village Victoria they returned the same evening .
rejoined the vessel, which remained in the river for a few
days longer. Quinine in rum (the quinine wine having
been all used,) was given to the crew while she remained in
the river, and for fourteen days after she went to sea.
s of intermitting fever," the surgeon remarks,
"were added to the sick list a few days after our departure ;
they were, however, all mild, and terminated favorably, alter
an average of seven days' treatment. To the regular and
timely administration of quinine, I think our immunity
from fever may be fairly ascribed ; the cases that did occur
were no doubt modified by the prophylactic. That this was
the case, the mortality amongst the crews of tin* merchant
5 rrequenting the river, and by whom n<> i
tive is used, bears ample testimony
On the 23d of May, three officers landed at Lagos from
the Hecate, intending to return on board tin- following
reqm ntly happens on tliis coast, the surf
612 Joseph , ' oh es, on Quinine [August,
rose suddenly, and contimn d so long, that they could not
return to the vessel until the 29th. Again, on the 2d of
August, the pinnace, with e ..on white men in it, was de-
tached, to cruise in-shore between Little Popoe and Why-
dah, where she remained until the 8th. Quinine was
given on both these occasions, and no fever resulted. On
the evening of the 27th of November, the same boat and a
gig. with nine white men on board, were left off' Shark's
Point, to guard the entrance to the Congo. An ounce of
quinine wine was given to the men each morning. The
boats remained in the same position until the morning of
30th, when they took advantage of a sea breeze, and pro-
ceeded up the river to Punto da Linha. The gig, with one
officer and two white men, returned on the 2d, and the
other boat on the 5th of December. During their absence
they had fine weather, and all returned apparently in good
health. Quinine was now substituted for the quinine wine ;
four grains were given daily to each person at seven in the
morning ; but, notwithstanding this, nine out of the eleven
were attacked bv remitting fever.
The Merlin, between the 1st of January and the 30th of
September entered the rivers Oalebar and Cameroons, in the
Bight of Biafra ; she also entered the Nunez several times
while on the northern division of the station. During the
time she was in these rivers, and for some time after she
had left them, quinine wine was duly administered to the
white men on board, and no febrile disease of much impor-
tance took place ; but in November,'; after having entered
the Nunez and Pongas for the purpose of communicating
with the native chiefs, her crew suffered most severely from
remitting fever. Quinine wine was given to the crew for
some time, but the supply being exhausted, quinine in rum
was substituted. When the change took place is not speci-
fied ; but in connexion with the substitution of quinine
purchased on the coast, and :ssued in the same manner in
the llccla, the quality of the alkaloid in both instances may
he doubted. The Myrmidon was employed in the River
1861.] As a Preventative of Malarial Fcctr. 618
Bonny, and afterwards lay a long time in Clearance Cove,
Fernando Po ; during the entire period quinine wine was
given in the prescribed form : only one slight case of clima-
torial fever occurred. At Sierra Leone, while the vessel
was under repairs, the whole crew took quinine once a day,
and those who were engaged on shore, twice ; still, though
the latter were at work both night and day, only one case
of remitting fever resulted. In the same manner, the
Plato was laid in the beach at Sierra Leone early in March
tor repairs. The carpenters, together with the carpenters
of the Hecla, and a number of blue-jackets who were em-
ployed on her, took the prescribed measure of quinine wine
before going to work, and another on leaving off ; but the
men who remained on the hulk took one measure only
every morning until the 28th. Two men who had not
been out of the ship were subsequently attacked with fever,
but so long after the vessel had gone to sea, that the disease
can hardly be ascribed to miasmata from the land at Sierra
Leone.
It is worthy notice that in the preceding instances, when
quinine wine was administered according to the instruc-
tions issued with it, no fever of any consequence followed
exposure to land or swamp miasmata ; but on two occasions,
when quinine purchased on the coast was substituted, and
once when the wine was suddenly discontinued after the
exposure, a considerable number of the men were attacked,
owing, it is to be supposed, to the discontinuance of the qui-
nine wine in one instance, and to its bad quality in the other,
for it is well known that, like other high priced remedies, ir
does not escape adulteration when it falls into the hands of
dishonest traders. /Statistical He/port of the Health of the
Royal Navy ', for the year 185" Ordered by the Hou
to !> printed^ 2d Aug f, L859,^?. 7*
A comparison of these facl the great sickness and
mortality of the white explor and resident.-- and sailors of
the African coast and rivers, < inclusively:
6J4 Fobd. Bcport of Surgical Cascc. [August,
1st. Quinine taken during exposure to the exhalations of
miasmatic regions will, in most cases, ward off fever entirely
2d. If fever attacks those to whom the quinine has been
regularly administered, its severity and duration will be far
less than in those who have not taken the quinine; it therefore
not merely wards off disease but renders it less powerful and
destructive when present.
3d. To be entirely efficient the quinine must be administered
for some time, at least ten days, after exposure to the causes
of fever.
ARTICLE XVII.
Report of Surgical Cases from Case Boole. By DeSaussure
Ford, M. D., Demonstrator of Anatomy, &c, in Medical
College of Georgia.
March 4th, 1SG1, master C. aged 11, was kicked by a horse
on the posterior surface of the ulna, at the junction of its
middle with superior third, fracturing it obliquely upwards
and inwards, through its articlatiug surface, the sharp spicula
of the iipper end of the fracture destroying the continuity of
the soft parts, thus making the fracture compound. The same
force dislocated the radius, forwards and upwards, upon the
anterior face of the external condyle of the humerus.
With an assistant firmly grasping the arm above the con-
dyles, I made such extension as to reduce the dislocation, and,
at the same time, approximate the ends of the fractured bone ;
then applied an adhesive strip over the wound in the soft
parts and kept the arm extended by a splint upon the entire
anterior surface of the arm and forearm to the tips of the fin-
gers ; this splint confined with a many-tailed bandage cold
cloths were kept upon the joint, apprehending swelling, which
then was not extensive as the patient was seen immediately
p the injury.
March 5th. The swelling very extensive; loosened the
bandage; continuing the cold applications.
615 Ford. Report of & I Gases. [August,
March 6th. Swelling still very extensive ; find the arm
semiflexed, the bandage having been loosed during the night ;
removed the dressings and endeavored to extend the arm but
could not succeed ; very painful ; the wound in soft parts
healing ; applying the splint and tightening the bandage
around the elbow ; it was nearly extended.
March 19th. Since the 6th the swelling has subsided, the
arm, however, still remaining semi-flexed. Removing the
splint to make passive motion, I was surprised and disappointed
to discover the radius still dislocated. Jarvis' apparatus was
applied, pushing the force as far as safety to the recently uni-
ted fracture would permit ; failed in reducing the dislocation.
The splint was replaced and allowed to remain a week longer.
The young man has a partial stiffness of the elbow, caused by
the dislocated radius, and not the fracture, as extension is per-
fect. This stiffness does not incapacitate the arm for service,
and will, doubtless, be flexed more and more as the radius is
shortened by continually coming in forcible contact with the
external condyle. This result of the case compensates for the
oversight in allowing the dislocation to exist without discov-
ery, until too late to be reduced, which dislocation must have
been indicated by the semi-flexed condition of the arm the
second day after the injury.
It will be noted that the position most advantageous for the
treatment of such a fracture the extension of the arm is
most disadvantageous for such a dislocation, which explains
the tendency of the radius assuming the abnormal position,
so readily, after reduction.
March 12th, 1861. Was called in consultation with Drs.
Wm. Jones and Hatton to see Mr. B. aged 30, laborer, who
had been stricken upon the head by a rough stone, which
fractured both tables of the skull, wounding the soft parts im-
mediately above the left eye, the fractured bone depree
upon the dura mater. This was 12 o'clock at night, the acci-
dent occurred at 8 P. M. immediately after which lie walked
three squares, and soon after returning home, had a convul-
1SG1.]
Ford. Report of Surgical Cases.
GIG
sion ; up to my visit had bad three. It was deemed necessary
o trepan, as all efforts to elevate the bone were unavailing,
and as convulsions would recur from meningeal irritation.
I made a semi lunar incision with scalpel, the concavity
presenting upwards, then applied the trefine above the de-
pressed bone, cutting the sound bone about the middle of the
left lateral half of the frontal bone ; removing the piece em-
braced by the trefine, the fractured portion was elevated and
taken out. There was no hemorrhage, except from the inci-
sion of the soft parts. The flap was united with five sutures
and slight compress dipped in cold water applied. During
the operation the patient was partly conscious. Left at 2 A.
M.; perfectly conscious, with pulse 80, (soft.) He had taken
large doses of opium before my visit.
13th, 9 A. M. Pulse 80, skin moist, tongue soft and nat-
ural color, pupils much dilated, complains of pains through-
out the head and in the bowels. Bladder acted four or five
times last night ; rested comfortably ; conscious.
3 P. M. Pulse 85. Complains of pain in the head, though
not local and insomnia: pupil dilated; dressed the wound,
which discharged bloody serum; looking healthy ; conscious.
10 P.M. Pulse 80. Tongue more dry and coated. Com-
plains still of insomnia. Prescribed one-fourth grain mor-
phine, to be repeated every four hours, if restless; has had no
action from bowels since accident ; conscious.
14th, 10 A. M. Pulse 75. Pain in head better ; pupil a
little dilated ; eyes looking better in expression; took only 1
dose of morphine last night, resting four or five hours; con-
scious ; no operation from bowels; ordered light nourish-
ment.
4 P. M. Pulse 75. Not much pain ; dressed the wound;
removing sutures and applying adhesive strips ; it had healed
by primary union, except at one point, out of which dis-
charged a small quantity of bloody serum; wound looked
healthy and no tumefaction of the parts; ordered one soft
I egg with tea and (oast.
'> P. o\[. Having no watch did not count the pulse, which
617 Ford. Report of Sur< sea. [August,
ever is perceptibly Blower, say 60 ; speaks of getting up
in three or four days, he tods so comfortable; morphine to "be
repeated as usual; nourishment in the morning, an egg and
tea and t
15th, 9 A.M. Pulse CO. No urgent pain, either general
or local ; rested well last night, taking only one dose of mor-
phine ; nourishment the same.
8 P.M. Pulse 44. More feeble ; cannot interpret this
sudden change, with the healthy appearance of wound, which
I inspected, and the absence of any symptoms of compression)
complains of local pain, though not urgent ; ordered morphine
as usual ; has taken for nourishment to-day, two eggs, tea and
a little chicken broth,
10th, 9 A. ]\r. Pulse 41 ; not as feeble as last night ; soft
and natural in force ; removed adhesive strips from wound,
and it with simple cerate ; wound looking well ; did
not well last night ; took two doses morphine > local
pain; pupils very little dilated; nourishment only tea and
4 P. M. Had gotten up and walked across the room a few
moments before visit, but is comfortable.
10 P. M. Pulse 55. Pupils contract and dilate naturally;
more comfortable; same directions for the night; tea and
in the morning.
17th, (.i A. M. Pi,. Skin moist and pleasant ; re
well last night ; same diet, with addition of one <.
:; P. M. Pulse 60. Very comfortable.
5 P. M. Pulse 56. Suspect accumulation of pus beneath
flap; complains of slight, dull, local pain; same directions for
the night.
3th, 11 A. M. Pulse 50. Think there is pus beneath the
ilan, but have no instruments ; state comfortable; rested well
last night, without morphine p for dinner.
'. M. I' 1 the wound with a probe,
g up the recent adhesions; healthy pus discharged ;
put in a Bmall tent into the wound; same diel for the
morning.
1861.] Ford. Report of Surgical Cases. G18
19th, 12 M. Pulse 50. Skin warm, but moist and pleas-
ant ; the wound discharging, moderately, a healthy pus ; did
not rest well last night. Same diet.
0 P. M. Pulse 60. Comfortable ; same directions.
20th, 12 M. Pulse 50. The wound discharged very freely,
through the night, disturbing his rest ; comfortable.
10 P. M. Pulse 57. Wound discharging ; comfortable;
same diet.
21st, 11 A. M. Pulse 55. Rested well last night. Com-
fortable.
9 P. M. Pulse 60. Same uneasiness in bowels. Note
He has had no action since accident ; ordered an enema of
warm water in the morning, with same diet.
22d, 12 M. Pulse 57. Had an action after enema ; com-
fortable.
7 P. M. Pulse 60. Comfortable ; nourishing diet ; beef
steak in the morning.
23d, 12 H. Pulse 57. Some local pain, on account of the
formation of a scab, preventing the escape of pus from the
wound ; let out the pus ; comfortable ; no operation since
yesterday this hour.
24thj 12 M. Pulse Go. Had a comfortable night ; wound
discharging freely ; no operation from bowels.
7 P. M. Pulse 75. Applied a compress over the flap to
invite the union of the inner walls of the abscess ; no opera-
tion ; comfortable.
25th, 11 A. M. Pulse 45. Comfortable and wound not
discharging so freely; able to sit up in bed ; ordered enema
of warm water in the morning ; is taking strong, nourishing
food.
26th, 12 M. Pulse 15. Comfortable; dressed the wound ;
lias had a large operation.
27th, 12 M. Pulse 55. Had a restless night, with much
general pain in head. This probably was from over exertion
and excitement induced by smoking a pipe.
0 P. M. Pulse 60. Very comfortable ; not so much pain
as this morning; discharge has sensibly diminished since ap-
II.] Military Surgery. 619
plication of the compress ; is walking about the room and feels
perfectly well, except the Blight general pain in the head.
April 3d. Has been doing well since 27th of March ; dis-
charged the case as having recovered.
Remarks After the depressed fragment of hone was re-
moved, it was obvious why it could not have been elevated
and why the operation of trepanning was necessary. The
internal table of the bone was more extensively fractured
than the external, this internal surface being too large to pass
out of the opening made in the external plate, which inner
surface with its sharp spiculated edges caused the irritation of
the dura mater, which brought on the three convulsions which
the patient had before the operation. From the beginning
there were no symptoms of compression, as paralysis, &c. I
confess the slowness of the pulse, viz. 45 its minimum, embar-
1 my prognosis, nor can I now explain it, since the patient
in health, has the normal average pulse. In the treatment of
the case it will be noted that his bowels were not acted on for
fourteen daj enjoined and nature allowed
to take her course as much ible. After the abscess
formed beneath the flap had assumed a chronic form, the pus
becoming more thin and watery, compresses were used with
a happy effect, inducing the adhesion of its internal surfaces.
At this date July lGth, Mr. B. is well, but suffers dizziness
whenever exposed to the sun for any length of time.
MILITARY SURGERY.
[Continued from .July M
xtrcmely common among soldiers during the
cold, wet weather of winter. Thousands of the French
troo; bed from thi Russia, during Napole-
on's retreat from Moscow. Frost-bite was very prevalent
among the English during their first winter in the Crimea,
and the French suffered in ^till greater number . il as
mo; !v. The .habit which the men had aping
in their wet (most universal, contributed
G20 Military Surgery. [August,
greatly to its production, wet and cold combined diminish-
ing the circulation and vitality of the feet and toes. On
the 21st of January, 1855, when the thermometer stood at
5, not less than 2500 cases of frost-bite were admitted into
the French ambulance, and of these 800 died, death in
many having no doubt been expedited by the effects of
erysipelas, pyemia, and hospital gangrene. "Weak and in-
temperate persons are most apt to have frost-bite and to
perish from its effect*.
In the treatment, in incipient cases, cloths, wrung out of
cold water impregnated with a little spirits of camphor or
alcohol, should be applied, or the parts be covered for a few
minutes with snow, or immersed in cold water. On no
account must they be exposed to warmth, either moist or
dry. Excessive reaction is controlled by lead and lauda-
num lotions, or dilute tincture of iodine. If gangrene
occurs, the ordinary measures, local and general, are indi-
cated. All rude manipulation in dressing the injured part
greatly aggravates the disease. In general, spontaneous
amputation is waited for, experience having shown that
operative interference, even when the partis perfectly black,
and attached only by a few living shreds, is extremely prone
to be productive of excessive pain and constitutional irrita-
tion, often proceeding to an alarming extent.
Among the great evils, both of civil and military prac-
tice, are bed-sores, which, unless the greatest possible pre-
caution be used, are sure to arise during the progress of
acute diseases and of severe accidents, necessitating pro-
tracted recumbency. The hips and sacral region are their
most common sites, with the heel in cases of fractures of
the leg. The earlier symptoms are a sense of prickling,
as if the part were rubbed with coarse salt, or a burning,
itching or smarting pain, with a brownish or livkl discolo-
ration of the skin, and slight swelling. Then gangrene
ensues, followed by horrible suffering.
To prevent these sores, which otten prove destructive to
life, when there is already much exhaustion from previous
suffering, the posterior surface of the body should be fre-
quently examined, particularly if the patient is in a state
of mental torpor, and pains taken to ward off pressure by
tlie use of air cushions and other means. The parts should
be sponged several times a day with some alcoholic lotion
containing alum, or painted with a weak solution ot iodine.
If gangrene or ulceration occurs, a yeast or port wine poul-
1861.] MUUary Surgery. 621
tice is used, the separation of the slough is aided with the
knife, while the granulating process is promoted by the
usual remedies.
Ulcers of the leg are causea oi' disqualification in enlist-
ing, but they sometimes occur after the soldier has entered
the serviee. from fatigue, injury, or undue constriction of
the limb. However induced, they should be managed as
any other forms of inflammation, recumbency with eleva-
tion of the affected parts, tepid water-dressings, a restricted
diet, and cooling purgatives constituting the most import-
ant elements of the treatment. When the healing process
has fairly commenced, the leg should be supported with the
roller, or adhesive strii
Aa preventive of ulcers of the legs, the limbs should be
daily washed in cold water with Castile soap, and no soldier
ould be permitted to wear garters.
CHAPTER X.
MILITARY HYGIENE.
Much disease and suffering maybe prevented, and many
lives saved, by a careful observance of hygienic regulations.
There is no question whatever that immense numbers of
soldiers everywhere fall victims to their recklessness and
the indulgence of their appetites and passions. We would
not advocate too much restraint ; men are but men every-
where, and soldiers form no exception to the general law.
They, like civilians, must have their amusements and re-
creations. The bow cannot last long, if kept too constant-
ly and too tightly on the stretch. I ial relaxation is
indispensable to health.
Indolence, however, should never be countenanced in any
army. Its demoralizing effects, and its influence upon the
health of the soldier, have been noticed and commented
upon in all ages. "The efficacy," say- an eminent military
surgeon, in speaking on this subject, "of due attention to
the occupation of the mind mu rer be Lost sight of.
:y illustrations of its powerful inline!!'-", whether for
good or evil, whether in r< U rating the in-
roads of disease, may be found both in ancient and in
modern times, from the retreat of the ten thousand Greeks
022 Military Surgery. [August,
under Xenoplion down to the present day. It may be ob-
served that disease goes hand in hand with indolence and
inactivity, whether of body or of mind; and that, on the
contrary, where the minds of soldiers are agreeably occu-
pied, and their bodies energetically employed, as in the at-
tainment or pursuit of victory, disease is kept in abeyance."
It was the observation of another experienced authority in
military medical affairs, Mr. Alcock, that "the period of
the smallest loss to an army is a victorious and vigorously
prosecuted campaign, with frequent battles and much
marching;" an assertion corroborative of the facts, long
since so painfully realized, that sickness, however induced,
destroys incomparably more soldiers than the sword and
the musket.
Xo intemperance, either in eating or drinking, should be
tolerated in an army ; both are demoralizing, and both pre-
dispose to, if not actually provoke, disease. Alcoholic li-
quors should not be permitted to be used except as medi-
cine, and then only under the immediate direction of the
medical officer. The ordinary drink and food should be
selected with special reference to their healthful properties.
The use of bad water, even for a short time, is invariably
productive of mischief. The tea and coffee should be of
good quality, and well prepared, to preserve their agreeable
flavor and their soothing and refreshing effects. Lager
beer, ale, and porter, if sound, are both nourishing and
wholesome, if consumed within judicious limits.
The practice of allowing soldiers spiritous liquors, as a
portion of their daily rations, has, I believe, been pretty
generally, if not entirely, abandoned in the European ser-
vice. Its injurious effects upon the health and morals of
troops have long been deprecated. In the British army in
India, the use of alcoholic liquors was, at onetime, univer-
sal, on the supposition that it had a tendency to counteract
the depressing influences of a tropical climate ; the men
took their spirits regularly before breakfast, and not un-
frequently several times during the day, especially if on
active duty; but it was soon found that it produced quite a
contrary impression, causing instead of preventing debility,
and affording a temptation to general drunkenness, which
was followed by insubordination and crime. The result
was that the government abolished the alcoholic ration
tern altogether, substituting coffee and tea, which are now
regularly served once, and often twice a <\i\y.
1861.] Military Surgery. 02:5
The condition of the L3th Regiment of Light Infantry,
stationed at Jellalahad, during the late insurrection in India,
affords a happy illustration of the salutary effects of absti-
nence from spiritous liquors. While the siege was pro-
gressing, the men, during a period of five mouths, were
entirely debarred from drinking, and yet their health and
courage were most excellent. As soon, however, as the
garrison was relieved, and they began to indulge in spirits,
many of them in a short time became sick and riotous.
The experience of Major-General Wylie, of the Bombay
army, was precisely similar. When the soldiers under his
command were quartered in districts where no liquor could
be obtained, their health, discipline, and morals were all
that could be desired ; whereas, under opposite circumstan-
ces, insubordination and disease prevailed to a frightful
extent.
During the Crimean war, coffee and tea were found to be
eminently wnolcsome and invigorating, enabling the troops
to sustain fatigue and to resist disease. When the men
were in the trenches, and could not obtain their usual sup-
plies of these articles, they became languid, and suffered
trom dysentery and diarrhoea. To produce their peculiar
sustaining and exhilarating effects, coffee and tea should be
taken hot and moderately strong, with sugar, if not also
with cream.
Fresh meats are always preferable to salt, though good
ham and smoked beef may be taken once a day with ad-
vantage as an agreeable change. Fresh fish are always ac-
ceptable. Pickled pork and beef are fai from being good
articles as a portion of the daily rations. The frequent use
of fresh vegetables is indispensable to the health of the
soldiery. Pipe fruits are nearly equally so. Without a
proper admixture of this kind, d}\spepsia, bowel complaints,
and scurvy will, sooner or later, inevitably ensue ; and woe
to the man that is assailed by them! The acids and other
properties contained in these substances are indispensable
to the healthy condition of the blood and solid-, and the
importance of such a diet cannot be too deeply or too fre-
quently impressed upon the attention of every commi
riat. Potatoes, rice, hominy, bean spinach,
lettuce, asparagus, radishes, horse-radish, water-
dried peaches and apples, and the different kind- of fruits
as they come into season, should be constantly on hand.
Soups, both animal and vegetable, are generally grateful to
G2I Military Surgery. [August,
the palate, as well as useful to the system, and should be
used whenever the occasion is favorable for their prepara-
tion.
Eggs, butter, milk, and butter-milk should be freely in-
dulged in whenever they can be procured. Serious disease
is often engendered by bad bread and biscuit, and it should
therefore be made a part of the duty of every medical offi-
cer to see that no articles of this kind are brought into
camp.
When in the camp or barracks, the soldier should take
his meals with the same regularity as the ordinary citizen
at his home. Neglect of this precaution must necessarily
lead to great bodily inconvenience, and, if long persisted
in, may ultimately lead to serious disease, especially dys-
pepsia and other disorders of the digestive apparatus. He
should not disregard regularity even with respect to his
alvine evacuations ; for there are few tilings more conducive
to the preservation of the health.
The soldier's dress should be in strict conformity with the
season of the year and the vicissitudes of the weather. He
should, at no time, be either too hot or too cold, but always
comfortable, changing his apparel with the alterations of
the temperature. Flannel should be worn next the surface
both winter and summer. The shoes must be thick and
warm, with broad soles ; and woolen stockings will be more
comfortable, especially when the troops arc marching, than
cotton. A thin woolen cap-cover, found so useful in India,
will protect the neck from the hot sun, and an oil-silk cap-
cover, from the rain. In very wet weather the shoulders
might be defended with a cape of oil-cloth.
Frequent ablations will largely contribute to the comfort
of the soldier and the preservation of his health. They
should be performed at least once a day, the best time be-
ing late in the afternoon or in the evening just before re-
tiring. The feet, in particular, should be often washed,
especially in marching, for reasons which need not be dwelt
upon here. The under-shirt should be changed every night,
and frequently washed, to promote the healthy state of the
skin.
Exposure to the hot sun, to cold and wet, must alike be
avoided. Sojourning in malarious regions will be certain
to be punished by an attack of neuralgia or intermittent
fever.
All offals should be promptly removed from the camp,
1861.] Military Surgery. G25
and carried to a distance of several miles, or be well buried.
The privies should be in the most favorable location ;
respects ventilation, and be closed at least every three or
four davs ; or, what is worthy of consideration, every man
should be compelled to bury his alvine excretions, as was
the custom, in time of war, among the ancient Hebrews,
each man being obliged to carry a paddle for that purpose.
The emanations from these sources cannot receive too much
attention, especially when large masses of men are crowded
together, as they are then extremely prone to induce dis*
ease.
Finally the medical officer should make it his special
duty to see that every recruit is vaccinated, or, if the opera-
tion was performed prior to his enlistment, at a diatant
period, matter should again be inserted, experience having
shown that the effects of the virus are, in time, in many
instances, totally eradicated from the system. In most of
the European armies revaccination is extensively practiced;
and it is asserted by Stromeyer that during the Schleswig-
Holstein war, on an average, 38 operations out of 1000
were successful.
It is impossible to bestow too much care and attention
upon the selection of the camp ground, and the arrange-
ment of the tents, as a vast deal of the comfort and health
of the soldiers must necessarily depend upon them. The
following judicious remarks upon this subject arc from the
pen of an eminent military surgeon, the late Dr. Ballingall,
who served in various campaigns, and who was for many
years, as stated elsewhere, Piofessor of Military Surgery in
the University of Edinburgh.
"A camp," says Ballingall, "is most advantageously sit-
uated on a gentle declivity, on a dry soil, and in the vicinity
of a running stream. In order to ascertain the state of
ground it may sometimes be necessary to dig into it to some
extent ; for, although apparently dry on the surface, it may
be found sufficiently wet at the depth of a few feet ; and if
so, ought, if possible, to be changed, particularly if an en-
campment is to be stationary. A camp should never be
formed on ground recently occupied, nor on a field of bat-
tle where much carnage has itly occurred. Many fa-
vorable re to be found on the banks of rivers, which,
perhaps, upon the whole, afford the mosteligibl*
must yet bear in mind that, when the banks of tie' rivers
are low, or the country suhject to periodical rains or sudden
40
G2.Q Military Surgery. [August'
inundations from the melting of snow on contiguous moun-
tains, there may be a very serious danger from this cause.
Against the danger of such a position, we are cautioned in
Mezerey's 'Medecine d'Armce,' which states a casein which
the Austrian army lost 500 men and 200 horse from a sud-
den inundation of this kind."
When damp ground or a low situation is unavoidable, it
should be abandoned as soon as possible for a better, and,
in the meantime, the greatest care should be taken to pro-
tect the soldiers from damp or wet with straw or other suit-
able means.
An army has been known to suffer severely from disease
contracted in a malarious region. Against such a calamity
useful information may often be elicited from the people of
the neighborhood, especially physicians conversant with
insalubrious sites.
When an army is obliged to remain for a long time sta-
tionary, an occasional change of camp will be greatly con-
ducive to health, although such change should involve a
good deal of labor and temporary inconvenience. A camp
under such circumstances should, at all events, be frequently
ventilated, and kept constantly clean, a pure atmosphere
being of paramount importance to health and comfort. It
may often be difficult to do this, but it must, nevertheless,
be done; the welfare of the service absolutely demands it,
and no medical officer honestly performs his duty unless he
interests himself personally in these matters. "The most
obvious and perfect way," says Ballingall, uof thoroughly
airing the tents is by shifting them occasionally, and ex-
posing the straw, blankets, and soldier's clothing to the
open air; the necessity of frequently changing the straw,
and enforcing cleanliness in camp in every possible way,
are circumstances too obvious to require any effort of rea-^
soni ng to enforce. With this view the slaughtering of
cattle, and everything likely to create noxious or putrid
effluvia, ought to be conducted without the camp, and on
the side of it opposite to that from which the wind gene-
rally blows." The demoralizing influence of a campjife is
well known, and I am convinced that there is nothing so
well calculated to counteract this influence as rigid discip-
line, reasonable activity of mind and body, strict temper-
ance, both in eating and drinking, and- frequent religious
worship. Every regiment should have its chaplains, not
less than its medical officers, not only with a view of re-
straining vice and promoting morality, but of affording to
the poor soldier, away from Lome and friends, in the hour
of his morta mity, th< eolations which the min-
of the gospel alone know- how to impart. The miti-
;' the horrors and miseries of war, not less than the
tendencies of the age in which we live, absolutely dera
such a provision.
CHAPTER XI.
DISQt &XIFYIKG DISEASES.
Trocps, whether regulars or volunteers, should include
no men that are not perfectly qualified, both physically and
mentally, for the hardships of the public service. They
Bbould, in a word, he perfectly sound, or, what is the si
thing, free from all defects, congenital or acquired. It is
for this reason that the} are always subjected to a most
thorough examination by the recruiting or regimental e
geon. This examination is, as a generi I rule, a great d
more rigid in the regular than in the volunteer service. In
the former, the regulations are such that, if the recruit is
not found to be sound after he has be-
regular army surgeon, the at to hi
ment and transportation falls upon the
committed the oversight.
;i examination of th here mentioned <1
both time, patience, a. id skill In order to make it thorough,
the candidate must be completely stripped, so that if any
or delect in the exterior of the body exist it may he
nee rendered apparent The examination, 1.
must not be limited to the exterior: it mu
the interior. The disqualifying affections may be arrai
rding to the organs and regions in which
seated, under separate head-:
1. : and ear. 2. 1
lect. 8. The lungs and heart. 4. Th
ana
thra. 0. Tl 7. Th aen.
8. The limbs, including the join
The unlit a man for I e are
defi ught, of hearing, and of s]
iieet; ] ysi8; rnia; h ; -ai-i-
628 Military Surgery. [August,
cocele; imperfect development or absence of the testes;
hemorrhoid, anal fistule, and iissure of the anus; unusual
protuberance of the abdomen ; organic lesion of the internal
organs: large tumors; aneurism ; varix of the extremities;
ulcers, or large scars indicative of their former existence;
bad corns; bunions; overlapping toes ; flatfootedness ; de-
formity of the hands and lingers; contractions from burns
or other causes ; badly united fractures ; unreduced dislo-
cations ; diseased joints ; loss of the incisor and canine teeth;
serious disfigurement of the features; spinal curvature; ill-
formed shoulders; habits of intemperance; diminutive
stature or excessive overgrowth.
In the regular army no man is enlisted under the age of
eighteen or over that of forty-five. In the volunteer service,
similar regulations obtain, although they are not so rigidly
enforced.
Recruiting surgeons, after having examined a candidate
for enlistment, are obliged to certify, on honor, that they
consider him, in their opinion, to be free from all bodily
defects, and mental infirmity, which would, in any way,
disqualify him for performing the duties of a soldier.
When men become disqualified for service, in conse-
quence of disease or accident, a surgeon's certificate is also
required, in order to aid them afterward in procuring a pen-
sion and exemption from ordinary military duties. The
affections which may justify a soldier in applying for a re-
lease from further service are oiganic visceral lesions, deaf-
ness, blindness, mental imbecility, lameness, large hernia?,
and such mutilations as interfere with the proper handling
of the sword and musket.
CHAPTER XII.
FEIGNED DISEASES.
Soldiers, influenced by a desire to quit the service, to re-
visit their homes, or evade active duty, will not hesitate, at
times, to play the part of impostors, feigning diseases, or
even inflicting upon themselves more or less serious inju-
ries, with the" hope of accomplishing their designs. This
deception, technically called malingering, would be of
comparatively little consequence if it were always, or even
generally, confined to a few members of a regiment; but
1861.] Military Surgery. 629
when it is remembered that it is liable to become epidemic,
spreading from individual to individual, it assumes a d<
importance, well calculated to arouse the attention both of
the medical officer and of the military commander. Its
effects, then, become eminently demoralizing to the service,
which, if proper care be not employed to detect and punish
it, might seriously sutler, especially when such an outbreak
occurs on the eve of a battle. Great ingenuity is often
displayed by malingerers, requiring no little vigilance and
skill on the part of the surgeon for its successful exposure,
and yet it is not less necessary for his own credit than for
the honor of the service that he should not permit himself
to be deceived.
The number of diseases, imitated by this class of dis-
semblers, is surprisingly great, and there is also quite a list
of self-inflicted injuries. Among the former are various
mental diseases, as mania and. imbecility; deafness; amau-
rosis ; epilepsy; paralysis; hsematemesis ; haemoptysis;
tritis; dysentery and diarrhoea; affections of the heart;
rheumatism ; lumbago ; wry-neck ; contractions of the
joints ; incontinence of urine; bloody urine ; and stone in
the bladder : among the latter opthalmia, opacity of the
cornea, oedema of the limbs, wounds, and amputations of
the lingers.
Space will not permit me to enter into any details re-
specting this important subject. I shall, therefore, content
myself with a presentation of such facts as may be sup-
posed to be of special practical interest.
First of all, the medical officer should weigh well in his
own mind the nature of the disease for which a soldier ap-
plies for a certificate of discharge, or inability to perform
duty. If the case is one of recent standing, it will be well
not to come to too hasty a conclusion as to its diagnosis; it
should be examined and re-examined before any definite
opinion is given. Day by day facts may be developed,
revealing the true character of the affection. If the patient
affected with sonieserious chronic disor.
eral appearance will hardly fail to afford some evi-
dence of its existence. The pal tor of the countenance, the
functional disturbance of the Buffering organ, the bodily
atration, the want of appetite, and the gradual emacia-
tion will almost unerringly point to the nature and seat of
the .. on the other hand, the malady is
simulated, all, or nearly all, the usual phenomena of disi
630 Military Surgery. [August,
will be absent. Impostors, moreover, are generally very
zealous in talking about their disorders, or in obtruding
a upon tha notice of their surgeons, whereas those who
are really Bick and suffering fliake comparatively little com-
plaint. A malingerer may often be detected by carefully
watching his movements, coming suddenly upon him when
he is asleep, or when his attention is directed to some one
else, tickling his foot when he feigns paralysis, or pricking
his back when lie pretends to be laboring under lumbago.
Sometimes a determined threat will promptly restore him
to a sense of his duty, as the application of the actual
cautery in incontinence of urine, rheumatism of the joints,
or mental imbecility. Now and then the exhibition, in
rapidly repeated doses, of a nauseous draught, answers the
purpose. Whatever expedients be employed the surgeon
cannot exercise too much address, otherwise he will be
almost sure to be baffled.
Mental alienation, or mania, unless the result of inebria-
tion and of acute disease, generally comes on gradually,
being preceded by a marked change in the moral character
of the individual, loss of appetite and sleep, and other
evidences of general disorder.
Genuine deafness is also gradual in its approaches, and,
when fully established, is invariably attended by a peculiar
listless state of the countenance with more or less change
of the voice. Before a final decision is given, a careful
inspection of the ears should be made, to ascertain whether
there is any obstruction or appearance of matter. The un-
expected discharge of a pistol, in a case of feigned deafness,
might suddenly decide the diagnosis.
Amaurosis may be simulated by the internal use of bella-
donna, or by the direct application of this article to the eye,
causing dilatation and immobility of the pupil. These
effects are often accompanied by unnatural vascularity of
the conjunctiva, and they generally disappear spontaneously
in a few days. In genuine amaurosis, too, there is always
a dilated condition of the vessels of the eye.
Feigned epilepsy differs from the real in the absence of
lividity of the countenance', the want of froth at the mouth,
and t\\<> partial character of the convulsions. The pupil
does not contract, as in the genuine disease, the general
jibility is unimpaired, the tongue is not injured, the
nails are not discolored, the hand, if opened, is again firmly
.shut, and the individual often watches with, his eye the
II.] Military Surgery. 631
impression ; 3 making upon the by-standers. The
application of a boated case-knife, or of a cloth wrung out
of hot water, often speedily reveals the imposition.
frequently imitated, but is generally easily
detected, simply by watching the patient, tickling his feet
or threatening him with the hot iron.
The disease, when it attacks the lower extremity, is nearly
always caused by apoplexy, and is then generally associated
with mental weakness and difficulty of articulation. Partial
paralysis of the upper extremity is frequently induced by
lying upon the arm, by suppression of the cutaneous per-
spiration, and disease of the spinal cord.
s may be simulated by swallowing blood, or
an infusion of logwood, and ejecting the fluid afterward by
vomiting. It should be recollected that the real disease is
almost invariably connected with serious organic lesion, as
ulceration of the stomach, induration and enlargement of
the liver, or visceral obstruction, and that the patient, con-
sequently, will exhibit all the characteristic of a sick per-
son.
Soldiers sometimes counterfieit haemoptysis, by cutting the
gums, or chewing substances impregnated with coloring
matter. A case is related by Guthrie, in which a man, for
this purpose, swallowed a piece of cork full of pins. The
immediate effect was haemoptysis, and the remote one death
by wounding the carotid artery.
Gastritis may be simulated by spontaneous vomiting, a
faculty possessed by some persons, and by pretended pain
in the epigastric region. The attack in general speedily
yields to a large sinapism and a brisk emetic.
Dysentery and diarrhoea are occasionally leigned by ex-
citing, artificially, irritation of the rectum, by mixing blood
with the alvine evacuations, or by borrowing the discharges
of ] actually affected with these diseases. In gen-
uine dysentery and diarrhoea there arc always well-marked
constitutional phenomena, which are of course absent in
the spurious. Careful watching of the patient and com-
pelling him to use a close stool will soon remove any doubt
that may exist respecting the nature of the case.
Disease of the heart, in the form of palpitation, may, it is
Inced by the use of hellebore. Mr. Hutchinson,
of England, refers to an epidemic of this kind among th<i
members of the .Marine Artillery. Organic cardiac du
could easily qe detected with the stethoscope.
G32 Military Surgery. [August,
RTu umatism being a very common disease among soldiej'3,
is often counterfeited ; but the cheat is of easy detection
when it is recollected that the real affection, especially the
acute form, is attended with more or less swelling and
constitutional disturbance.
When lumbago is made the subject of deception, the at-
tack seldom long withstands the application of rash reme-
dies, or the threatened use, if speedy relief do not arise, or
the hot iron.
Contraction of the joints, a not unfrequent source of im-
position, is easily detected by the use of anaesthetics, or
simply by pricking the parts suddenly with a needle, when
the patient is off his guard.
When wry-neck is simulated, both the sterno-cleido-mas-
toid muscles are rendered rigid by ^the effort at deception ;
whereas in the real disease the contraction is confined to
one side.
Incontinence of urine, bloody urine, and stone in the blad-
der have all been simulated by designing soldiers. The
former is said to be at times epidemic, and then its detec-
tion is of course easy, as the ordinary disease never assumes
such a character. Harsh remedies are the best means of
relief. Ballingall states that fictitious cases of incontinence
have been successfully treated by the cold bath, by pre-
scribing a few lashes on the loins, wiih the avowed object
of strengthening the parts. In the Austrian army the
impostor is obliged to do duty with a urinal.
Bloody urine has been provoked by injecting blood into
the bladder, and by scarifying the urethra.
Calculus is almost unknown among soldiers; it is some-
times attempted to be counterfeited by scraping the walls
and throwing the lime into the urinal. When stone actually
exists, the sound will generally promptly detect it.
Self-inflicted injuries of various kinds are restored to for
the purpose of deception. Thus malingerers often provoke
inflammation of the eye and temporary opacity of the cor-
nea by means of corrosive sublimate, lime, tobacco, nitrate
of silver, and other irritants. A great number of men have
been known to sutler from this cause at the same time, as
if the disease was an epidemic. Ulcers of the legs are pro-
duced by pricking the skin with pins or needles, frictions
with sand, or caustic applications. (Edema of the limbs
may be excited by tight ligatures; disease of the scrotum
and testicle, by inflation of the parts with air* All such
I.] Military Surgery. G33
tricks are usually readily detected by the medical officer
and his assistants.
'/-/initiation sometimes amounts to the destruction ot
an eye, an entire finger, or even the greater portion of the
hand. Occasionally it is limited to slight wounds, and the
imposition may then he practiced on an extensive scale, as
was the case in the French army at the battles of Lutzen
and Bautzen, in which nearly 3000 soldiers were slightly
injured in the hand, causing the belief that the wounds had
been voluntarilv inflicted.
CHAPTER XIII.
MEDICAL, SURGICAL, AND DIETETIC FORMULAE.
Under this head I propose to notice such formulae, or medi-
cal, surgical, and dietetic preparations, as have been found
serviceable in my own practice, or in the practice of others.
1. General Remedies.
Among the more simple purgatives may be mentioned the
following: all drastic articles should, if possible, be excluded
from the prescriptions of the military surgeon:
R. Massse ex Ilydrargy. gr. x ;
Pulv. Ipecac, gr. i.
M. ft. pil. ii.
uld laxative in dyspepsia and disorders of the stomach and
liver.
Jy. Extr. Colocynth. c ;
Massie ex Ilydrargy.
Pulv. Rhei. v. Jalapae, aa gr. x ;
Ant. et Fotassce Tart. gr. }\.
M. i'r. pil. v.
An active, antihilioue purgative, from three to rive being an
imel may he substituted for the blue mass,
if there is much disorder ot' the liver and secretions.
'S are ipecacuanha, infusion of eupatorium
. and mustard and cominOD salt, an even table-
>nful ot' each to half a pint of tepid water, one-half to be
taken at once, the remainder, it* necessary, in fifteen mini
>per or zinc will afford the must prompt emetic
effect h at urgen ing.
The following formula will be found very BCrvicable in the
earlier stages of most inflammatory affections, especially the
634 Military Surgery. [August,
cutaneous, articular, and traumatic, unaccompanied "by dis-
ease of the alimentary canal :
1>\ Ant. et Potass. Tart. gr. iss ;
nesias Sulph. gi ;
Morphiee Sulph. gr. ss;
Sacch. Albi. 5ii.
Aquse Destil. gvi. M.
This is the antimonial and saline mixture, of which repeated
mention, ocenrs in the preceding pages, and which I am in the
daily habit of prescribing in my surgical as well as medical
practice. Lt may be rendered depressant by the addition, to
each dose, which is half an ounce, repeated every two or
three hours, of from three to eight drops of the tincture of
veratrum viride ; anodyne, or diaphoretic, by laudanum, or
morphia; anti-periodic, by quinine; anti-gonorrhceal, by
copaiba, gum-arabic being used, in the latter case, as one of
the ingredients ; and anti-rheumatic, by colchicum. If qui-
nine be used, the addition of aromatic sulphuric acid will be
required, which is also an excellent solvent of the salts.
IJ. Yini Colchici Sem. 5i ;
Morphias Sulph. gr. ss ;
Potassas Carbon, gr. x ;
Aquas Destil. gss. M.
In rheumatic and gouty affections, taken at bedtime, and fol-
lowed by a mild aperient next morning.
The following will be found to be pleasant and efficient
diaphoretics :
]J. Spirit, Mindereri, giv ;
Sp. ^Ether. Nitrici. 5ii ;
Morphias Acet. gr. i. M. S.
Tablespoonful every two or three hours. If there be much
heat of surface, we may add to each dose the eighth, twelfth
or fifteenth of a grain of tartar emetic.
IJ\ Potassas Carbon. 5i ;
Morphias Sulph. gr. i ;
Sacch. Albi. 5h ;
Sue. Limonis recent, gii ;
Aquas Menth. v. Destil. giiiss;
Sp. JEther. Nitrici. gss. M. S.
Tablespoonful every hour or two.
The effervescing draught, so valuable in irritability of the
stomach, is composed as follows :
]$. Sue. Limonis recent, gji:
Sacch. Albi. 5jiss;
11.] 7. G35
til. 5ji. M.
ft. P >n. ,li :
a. sji. m.
Pat two tabic ill of the lei of the alka-
line solution, ami lor the mixture be drunk while effervescing,
rig the dose at pleasure.
A- anti} , l di s quinine aud arsenic are the main reliance
lie modern practitioner. The former may be given by
itself, in pill or solution, in doses varying from two to ten
ins, according to the urgency of the case or the state of the
My usual dose is ten grains every eight ten, or twelve
hours, until the paroxysm is arrested. If the symptoms are
unusually violent, we need not hesitate to administer fifteen
or even twenty grains at a dose, being of course careful to
watch the effects, which will generally be more pleasant if a
little morphia be combined with the quinine.
In chronic, or frequently-recurring intermittent and neural-
gic affections, arsenic forms a valuable, and, indeed, in many
cases, an indispensable addition ; also iron, if there be evi-
deuces of anaemia. I prefer myself the arsenious acid to
Fowler's solution, convinced that it is much more efficacious
and at the same time less apt to cause nausea and anasarca.
The following formula will be found advantageous:
ft. Acid. Arseniosi, gr. iss ;
inioe S ul ph.
Ferri Sulph. aa 5i ;
Morphias Sulph. gr. i ;
Extr. Xucis Vomicae, 3i.
M. ft. pil. xxx.
S. One every live, six, or eight hours.
Quinine is also one of the best tomes, and it may always be
beneficially combined with other articles, as iron, gentian,
quassia, mix vomica, aud capsicum. The fluid extracts and
aromatic tinctures of bark and gentian will also be found
useful. One of the best chalybeate preparations is the tinc-
ture of the chloride of iron, in doses of from twenty to twenty-
five drops three or four times daily.
institute a large class of remedial agents, but
they nearly all derive their active principles from the admix-
ture of tartar emetic, ipecacuanha, or squills. They may
rally be usefully combined with potassa and anodynes,
being rendered palatable by Byrup or sugar.
Nurses should be familiar with the manner of administering
.idta or injections, as frequent occasions arise for their cm-
636 Military Surgery. [August,
ployment. They may be cathartic, as when they are designed
to empty the lower bowel, or to promote the action of oh er
remedies; stimulant, as in case of excessive exhaustion; nu-
tritive, as when food cannot be taken by the mouth; anodyne,
when it is wished to allay pain and induce sleep.
A cathartic effect may readily be induced by an injection
of a pint and a half of cold water, or water in which a little
ground mustard or common salt has been stirred, a mixture of
warm water and castor oil; or an infusion of senna, or senna
and Epsom salts. Turpentine is particularly indicated when
the bowels are distended with flatus.
Stimulating injections may be made of brandy, alcohol,
mustard, salt, or spirits of camphor or turpentine, mixed with
more or less water ; and they are often extremely serviceable
in promoting reaction.
Nutritive enemata may be necessary in the low stages of
fever, and in gunshot and other injuries attended with lesion
of the gullet. The best ingredients are essence of beef,
strong beef-tea, brandy, or brandy and milk, introduced in
Bmall quantity so as not to oppress and irritate the rectum.
Anodyne injections may consist of laudanum, black drop,
morphia, hyoscyamus, or belladonna, either alone, or various-
ly combined, and administered with about two ounces of tepid
water, or some demulcent fluid.
Tiie best syringe now in use is the gutta-percha, which is
not liable to be deranged, and which has the additional ad-
vantage of durability. It should be of various capacities,
from eight to sixteen ounces, according to the intention to be
fulfilled by it. The nozzle must be well oiled previously to
its introduction, and care taken that no air be pushed into the
bowel.
2. Topical Remedies.
JJ. Tinct. Ioclina?,
Sp. Vini Eectific. aa Sj. M.
To be applied with a large camel-hair pencil, or cloth mop.
I hardly ever use the pure tincture of iodine for local pur-
poses.
I\ Plumbi Subacet. 5j ;
Pulv. Opii, 5j. M.
To be put in half a gallon of hot water, and the solution to be
used warm or cold, as may be deemed best. Laudanum may
be substituted for the opium.
lv. Pulv. Ammonise Hydrochior. gj ;
" Potass Kit rat. 5'j ;
" Opii,5j. M.
1861.] MUHary Surgery. 637
To be used as the preceding; being particularly valuable in
inflammation of thejoints, on unbroken surfaces.
The warm water-aressing consists of warm water, simple
or medicated with laudanum, acetate of lead, or any other
ingredient that may he desired, applied upon flannel or mus-
lin cloths, properly folded, and covered with oiled silk, to
confine heat and moisture.
The cold water-dressing is composed of cold water, also
simple or medicated, applied with cloths, the parts being con-
.;ly exposed to the air to promote evaporation. The cloths
are to be wet whenever they become heated or dryish, the water
being pressed upon them from a sponge.
Water-dressings, if long continued, will occasionally cause
irritation, itching, and pustulation of the skin, rendering it
nec\ replace them with cataplasms, or other soothing
remedies.
Among poultices decidedly the best, for ordinary purposes,
are the flaxseed and slippery elm. The former is made by
mixing a suitable quantity of linseed meal with hot, or, what
is still better, boiling water, and rapidly stirring it into a thick
mush-like consistence. The mixture is then spread upon a
fold of cloth, in a layer a third of an inch thick, Avhen it is
covered with bobinet or gauze to prevent it from adhering to
the parts. A piece of oiled silk, larger than the poultice, is
placed upon its outer surface, to retain heat and moisture.
The elm, and, in fact, all other cataplasms, are prepared
and used upon the same principles as the linseed. Like water-
deessings, poultices may be simple or medicated, according
to the object proposed. They should be changed at least
twice, or, in warm weather, even three or four times in the
twenty-four hours.
J plaster is cut, in the direction of its length, into
strips of suitable length and breadth, warmed by holding the
backs against a smooth vessel, as a pitcher or tin case, and
.led in such a manner as to bring the middle of each piece
over the wound, the edges of which are, meanwhile, carefully
supported by an assistant. A suitable >p;iec is left between
the strip- for drainage. If things progress favorably, substi-
tution need not be made under three or four days. If the
wound be large, only a few of the strips are taken oft* at a
time, lest, all support being lost, the edges should be forcibly
separated.
re the soiled dressings are removed, everything intend-
ded for the new should be prepared, or put in its proper place.
The strips of plaster must be removed with great gentleness.
638 Military Surgery. [August,
If the injured parts are covered with hair, the surface must
always be shaved before the application of the dressings.
Proper material for sutures should always be kept on hand,
read}' for use. The silver wire is the best, as it is less :
ting than any other. Silk, however, answers exc
well; J(he thread should be rather thin, and be well waxed.
Saddler's silk is the article used for the ligation of large ar-
teries.
Among the more common and useful unguents for dressing
wounds, burns, abraded surfaces, or fissui es, are the follow-
ing:
B\ Fulv. Opii, oss ;
Pulv. Ehei, $i ;
ling. Cetacei, Si- M.
To these ingredients may advantageously be added, in many
cases of healing sores, or eruptions, requiring a mild stimulus,.
a drachm of the ointment of the nitrate of mercury, a few
drops of nitric acid, two drachms of ointment of acetate of
lead, a small quantity of myrrh, or of balsam of Peru, or
from six to eight grains of sulphate of quinine.
Jfc. Ung. Cetacei, i ;
Bismuth. Subnitr. ?ij. M.
Extremely soothing and valuable in superficial excoriations,
slight burns, and eczematous affections. Turner's cerate may
be employed for similar purposes, but should always be con-
siderably diluted.
The best disinfectants are the chloride of soda, chloride of
lime, Labarraque's solution, and the hypermanganate of po-
tassa, of which an abundant supply should always be on hand
in every hospital, free use of it being made, by sprinkling and
otherwise, upon the dressings, as well as upon the bedding and
the rooms.
The sponges about a hospital should be of the softest kind,
perfectly clean, and always ready for use. The same articles
should never be employed upon different persons, especially
where there are foul or specific sores, as contagion might thus
be communicated by direct inoculation, as has, for example,
so often happened during the prevalence of hospital gangrene,
3. DieU. tie Preparations.
The diet of the sick-room has slain its thousands and tens
of thousands. Broths, and Blops, and jollies, and custards,
and ptisans arc usually as disgusting as they are pernicious.
Men worn out by disease and injury must have nutritious and
concentrated food. The ordinary preparations for the sick are,
1.] Mitiiary Surgery. 039
meral, not only not nutritious, but insipid and flatulent
food is what is needed, even if the quantity taken
Buiall. Animal soups are among the most efficient
supporters of the exhausted system, and every medical man
should know how to give directions for their preparation. The
if a man is his food. Solid articles are of course with-
held in acute diseases, in their earlier stages, but when the
. nsto convalesce they are frequently borne with
impunity, and greatly promote recovery. All animal soups
should be made of lean meat ; and their nutritious properties,
well as their flavor, may be much increased by the addi-
tion of some vegetable substance, as rice or barley. If the
Btomach is very weak, they may be diluted, or seasoned with
pepper.
Est fe*fi so frequently given in the low stages of
iVxcv. and in the exhaustion consequent upon severe injuries
and operations, is prepared by cutting fro: l a quarter to half
a pound of lean beef into thin pieces, and putting it into a
wide-mouthed porter bottle, corked tightly, and placed in a
kettle of cold water, which is then heated till it bcils. After
it lias been digested in this way for a few hours, the juice is
decanted, and seasoned with salt and pepper, wine or brandy.
B ouch Jess nourishing than beef essence, is made
by putting a quarter of a pound of lean beef in a pint and a
of water, and boiling it for fifteen minutes, a few blades
of mace being added du:ing the process, and the fluid well
skimmed.
To make chicken broth requires half a young chicken and a
quart of cold water, with .. teaspoonful 01 rice or barley, tk
whole being slowly boiled for two hours under cover, with
proper skimming.
Oh Uy is prepared by putting a chicken, cut up and
all the bones broken, in a stone jur, closely covered, and re-
d in boiling water for three hours and a half. The liquor
is then strained, and seasoned with salt and mace.
composed of two Irish potatoes, one i
and a piece of bread, with a quart of water, boiled down to
a pint in a closely-covered vessel, a little celery or parsley
I near : of the operation. Salt and
at pleas
y a quarter of a pound of rice flour and
e that quantity of loaf sugar are boiled in a quart of
water, until the whole becomes a glutinous mafiSj when the
jelly is strained off and flavored.
Sago jetty is composed of four tablespoonful of sago, one
640 Military Surgery. [Angus
quart of water, juice and rind of one lemon, and enough sugar
to render it agreeable. After the mixture has stood half an
hour, it is boiled until all the particles are entirely dissolved,
the mass being constantly stirred.
Oatmeal gruel is composed of two large spoonsful of oat-
meal and half a pint of milk, stirred into one pint of boiling
water, and allowed to simmer for thirty minutes, when it is
strained through a hair sieve. Cornmeal gruel is prepared in
a similar manner. t
Arrow-root pcq) consists of a large tablespoonful of this
substance made into a paste with a little cold water, which is
then stirred into a pint of boiling water, and kept on the tire
for five minutes. The nourishing properties oi arrow-root
pap may be heightened by using milk instead of water in its
preparation.
Milk toast is often much relished by the sick ; and there h
a very excellent jelly for invalids made of a thinly sliced and
slightly toasted penny roll, boiled in a quart of water until it
becomes a glutinous mass, when it should be strained upon a
few shavings of lemon-peel.
The flavor and efficacy of the various dietetic preparations
here described may be greatly increased by the addition of
mace, lemon, wine, or brandy. When salt, or salt and pepper
are used, the patient's own taste should be consulted. Great
care should be employed in making these compounds that they
are not scorched. To prevent this a double boiler should be
used.
Milk-punch, an excellent article when a stimulant is re-
quired in conjunction with a nutrient, is made by mixinggood
brandy with cold, fresh milk, in the proportion of about one
ounce of the former to half a pint of the latter. Sugar and
nutmeg may be added to make the mixture palatable.
Wine-whey, well made, may be rendered of great service
to the sick. It is prepared by adding to a pint of fresh milk,
as soon as it reaches the boiling point, as much good Madeira
or Sherry as will coagulate it. The mixture is then strained,
and sweetened or flavored tor use.
The best wines for the sick are Madeira, port, and sherry.
Incases of gastric irritation, champagne sometimes produces
an excellent effect, quieting the stomach as well as the system
at large.
Jigg-nog consists of an egg, the white and yolk of which
are beaten up separately; half a pint of cold water with a
little loaf-sugar is then added, together with two tablespoons-
ful of brandy.
1.] Syphft* of New-Bmx ChM 641
Sqp' n Chikirca. By J. 13. Hughes, of M. D.,
' Kewbern, X. C.
To whateverepoch or circumstance the origin of Syphilis
may be assigned, it has probably existed, though in modi-
fied form, since the transgression of moral laws has been
nded by subsequent evil It was not till at the close of
the fifteenth century, however, that it assumed the charac-
ter, with which we have novi me so familiar, when it
exhibited itself in continentel Europe, and startled the
world with the terrors of its contagion, and ifs fearful rav-
ages. Much had been written on the subject, but Hunter
is the author who has given the first systematic treatise, to
which we usually refer for his own, and the previous ii
of its nature and treatment. lie availed himself of all the
information which three centuries had furnished, and made
great progress in the study of the disease gave an urimis-
takeable diagnosis of the indurated chancre, but arrived at
the conclusion that gonorrhea and syphilis proceeded from
the same virus.
It is to the French School with Ricord leading the avant
garde, that we owe so much for the light which has been
thrown upon this disease within the last fifty years. Ri-
cord, whose genius would rest with nothing less than ac-
tual experiment, inaugurated syphilography, and explo-
ded the dogma that gonorrhea and syphilis had th
origin, and established the contrary fact beyond the per-
nture of a doubt. With mathematical ] he
arranged the laws which govern syphilis; the domain and
feach kind of - . and apparently left no
tureofthe d unexamined; and us far as he could
can- [periments, established his doctrine in each par-
ticular*.
Inspired by the enthusiasm of their leader, some of his
ad former pupils, and especially M. Diday of
Lyons have pushed their investi still fip and
ubts in the minds of physicians in regard
dea of the unity of syphilitic \
confirmed by Ri . ' the non-contag
of the secondary manifestations of the di Ricord
himself proved, that the soft chancre was almost local in
*Lettres Sur la Sv;.liiiis. Ricord.
41
642 Syphilis of New-Born Children. [August,
its effects ; exciting bubo, but leaving the constitution im-
contaminated ; while the indurated chancre was followed,
as by fatality, with constitutional infection; but insisted
that both chancres had their origin in the same virus. M.
Diday at the head of the dual School, said on the contrary,
that the soft chancre always proceeds from the soft chancre,
and the indurated chancre had as invariably an indurated
chancre for its source. M. Fournier has given an ad-
mirable synopsisf of the actual state of knowledge on this
question, and of the result of the experimentation of MM.
Buzenet and Nadau. While the advocates of the dual
School seemed to be gaining ground in public belief, M.
Ricord announced the new idea, that all cephalic chan-
cres (of tongue, lips, face and scalp,)! were of the indurat-
ed kind, and consequently followed b}^ constitutional in-
fection. At the clinique of hopital du Midi, where Ricord
presided, the soft chancre of the body presented itself in
the preponderance in favor of the former variety, why
should these cephalic chancres always be of the latter ?
Unquestionably, M. Ricord has said, because the virus is
the same, but the cephalic region is the peculiar soil for
syphilis, and its anatomical characters convert the soft into
the indurated chancre. Those of the dual School on the
contrary, maintained that this region while it would resist
the contagion of the soft, had a peculiar election for the
indurated chancre, and that this election was not singular,
but an analogy could be found in other diseases ; as the
pericardium showing a great election for rheumatism,
while the peritoneum enjoyed almost an immunity from it;
the hands being peculiarly liable to itch, while the face,
back, &c, were almost never attacked by it, though it
could be forced into these regions ; and so on with other
diseases.
To settle the disputed points, MM. Buzenat and Xadau
had the courage to attempt inoculation on a great number
and variety of patients ; and their expeiiments are peculiar-
ly interesting, as they belonged to the opposite doctrinal
schools, and lead us inevitably to the same conclusion
M.Tnion Medicale Tonic xii. Nos. 19. 22. 25. 28. 35. 1:15.
(Lithe United States, these points are almost never visited by the
primary sore, hut the patients who present themselves at the hospitals o\'
Paris Beem to consider no points of the body sacred from its contact.
1861.] Syphilis of New-Born Chihlrca. 643
that the virus of syphilis is dual. The pus of a soft chancre
was inoculated upon the lip, and at the same time upon the
thigh of a healthy subject; in both places a soft chancre
resulted, and so on to each point of the disputed territory,
face, scalp and all. But in every instance the thigh was
similarly inoculated, with the uniform result of the re-pro-
duction of the soft chancre, thus establishing the fact that
a soft chancre could exist in these points as elsewhere. As
if in verification, however, of their pre-conceived ideas,
while the soft chancre was known generally to heal with
much greater difficulty than the indurated variety, it was
found uniformly that the soft of the head healed very rapid-
ly, while that of the thigh run the ordinary course where it
was not prematurely destroyed by caustic. Farther,
Ricord's idea that constitutional syphilis was like variola,
in thefact of one attack freeing its victims from a repetition of
it, has been strengthened by their experiments. Patients
who were suffering from constitutional syphilis from indu-
rated chancre, were inoculated with pus from a similar
chancre, and the result was uniformly negative. The same
individuals were inoculated with the pus of soft chancre,
with the invariable reproduction of soft chancre, which ran
the ordinary course without aggravating the constitutional
malady. The followers of the dual school, then offered as
their solution of the experiments, that the cephalic region
enjoys a peculiar immunity from the virus of soft chancre;
and that while a soft chancre will uniformly follow the in-
oculation of pus from asimilarsourse, this region will resist
the virus, so far as contagion is concerned. The experi-
ments would seem to justify this conclusion, and when we
have it more firmly established by additional investigations,
its announcement will excite no more surprise than we now
feel when gravely told that syphilis and gonorrhea have not
the same origin.
I have thought it necessary to introduce this expose of the
disputed points in syphilis, which have been fully discussed
in the French Medical Journals, as they affect to a gnat
extent, the transmission of syphilis by inheritance the soft
chancre not being transmissible, while the constitutional af-
fection resulting from indurated chancre is almost invari-
ably so conveyed. And also that while much is known in
regard to the syphilis of new-born children, it will require
some enthusiast with courage and hardihood to make actual
experiments to decide other points now in dispute. The
044: Syphilis of New-Born Children. [August,
following cases of syphilis in new-born children have, with-
in the past three years, come under the care of my father,
Dr. I. W. Hughes, and myself:
Case No. 1. June 11th, 1858. Bright mulatto child, girl,
four month old. The history given of it was, that it was
born at term, of full size, apparently healthy, nursed well,
and gave no indication of disease till it was two months old,
when its nose and mouth became sore, an eruption showed
itself on its body, and it began to lose flesh. When pre-
sented to us, it wa3 greatly emaciated, breathed with diffi-
culty through its nose ; its lips, mouth and nose filled with
condylomata (mucous papules) ; on its forehead and scalp
was an erythema of copperish color, while on the scalp there
were also several ulcers. Condylomata were in the vagina,
and associated with an ugly ulcer at anal orifice. The
string of lymphatics along the inner border of the thighs
was a series of abscesses. The hands and feet bore the
characteristic erythema, and several pustules ; while the
buttock was filled with pustules and tubercles, the spaces
intervening between the eruptions being of copperish-
brown color. The lymphatics at the back of the neck and
behind the ears were hard and swollen. Our inquiries
elicited no information of venereal taint from the mother,
but the child was put upon anti-syphilitic treatment witli
the happiest results. ! Hydrarg. Protiod. grs. ii to be
divided into 24 powders, one to be given each morning.
August 1st Child greatly improved the abscesses along
the thighs had been opened from day to day as necessity
required, some of them had healed entirely, and those
which had at first degenerated into ulcers, assumed a heal-
thy appearance with diminished discharge. The erythem-
atous eruption which had in a great measure disappeared,
left in many places a border of thin, whitish scales. A
slight iritis which had supervened soon after treatment wa3
commenced, giving great annoyance to the child, at this
time was entirely relieved. The Hydrarg. Protiod. which
had purged a little, was modified by the addition of a small
quantity of opium, and continued as before; a solution of
Nitrat Argent, gr. i. to Aqua f 5 i. was applied to the
ulcers. Nov. 1st. All signs of eruption disappeared, the
enlarged lymphatics were reduced to nearly their normal
size, &esh Increasing, skin clear and healthy, and the ulcer
;u ana! orifice, and one on the scalp were ail that remained
of the disease. Same treatment continued. Dec. 1. Child
I.J Syphilis of New-Born Children. 645
perfectly cured, and is at this time, three years old, vigor-
ous, intelligent, and in the enjoyment of perfect health,
having never exhibited any symptoms of the disease. As
a necessary explanation to this ease, I must mention that,
although the father of the child did not come under our
care, I saw him and he was suffering from constitutional
syphilis in the fullest sense of the phrase.
Case No. *2, Oft. 1859. Negro child, boy, three months
old. Born at term, with all the indications of health.
At the sixth week its mouth became sore, diarrhea set in,
lost flesh, and an eruption showed itself, which had been
treated by its mother without etfect. When presented to
us. its nose and mouth were filled with the condylomata ;
on its legs, feet and arms was an erythema, associated with
pustules in the accustomed crescentic order. The aspect of
the child was pinched and wearied, and its scalp bore a pap-
ular eruption of copperish color. We could get no fact
from the mother in regard to syphilitic infection. Pre-
scribed for child, Ilydrarg. Protiod. grs. ii. to be divided
24 powders, one to be given each morning. In four weeks
every symptom of syphilis had disappeared, it regained
flesh and was perfectly cured. It has not since had any
return of the disease in any form, and is a fine, healthy
child.
Ca&i No. 3, August 1860. Negro child, girl, two months
old. Born at Term, with somewhat pinched and aged fea-
tures, but otherwise exhibiting no evidence of disease. At
its fourth week Vuq inner border of legs and soles of the
feet showed a pustular eruption. When seen by us all the
natural orifices, nose, mouth, anus, &c. were covered with
condylomata, with the lymphatics of the neck, and behind
the ears hard and swollen ; its face bore patches of erythe-
ma mixed with pustules, which had, in some places, broke,
and been converted into ulcers, its scalp was foul with
scabs. The parents of this child had been under our care
in July, 1858, for gonorrhea, asscciated with indurated
- hancre. In September, the expected secondary symptoms
exhibited themselves, which were apparently entirely re-
l in May, 1
ime in": rwards, the mother became pregnant,
and in July, 1860, was delivered of the child above des-
cribed. The child was nut upon the same treatment as the
previous ca^es, hut gave us no symptom of decided im-
provement for two weeks. In this space of time, the dis-
646 Syphilis of New-Born Children. [August,
ease had reappeared upon the mother. Her occupations
had prevented her realising the necessity of taking medi-
cine anterior to the eruption. She was now given iodide
of potash, gr. v. three times a day, and the mecury contin-
ued with the child. Both mother and child soon began to
improve, and in November there was no vestige of the dis-
ease in either, and it has not since reappeared. The child
is healthy and growing rapidly.
Case No. 4, June, 1860. I was called accidentally to see
patient, mulatto child, eight months old. Had been sick
ever since it was two months old, when it began to lose
flesh, and an eruption commenced to spread itself over the
body. When seen, it was in the last stage of syphilitic
marasm. On its face and scalp was an erythematous erup-
tion with pustules and ulcers. The glands of neck and
behind the ears were swollen ; its body aud limbs well
marked with papules and pustules which assumed more or
less the crescentic form. The inguinal glands had degen-
erated into foul ulcers; its body wasted almost to a skele-
ton. The liver was much swollen, and alternate diarrhea
and constipation had prevailed ; its life was nearly worn
out. Prescribed Liq. Amon, Acet. in closes of ten drops
every two hours. Hyd. C. Mite, Pulv. Doveri, aa. grs. iv.
to be made into twelve powders, one to be taken morning,
noon and night. The child died two days afterwards .
could learn nothing of the history of the case, so far as re-
lated to syphilis of parents.
Case No. 5, December 1860. Negro child, girl, seven
months old. Had been born healthy and continued to
thrive till its third month, when its skin assumed a dryish',
scaly appearance, without characteristic eruption, and it lost
flesh rapidly. When seen by us, the skin presented this
dryish, scaly appearance very forcibly, and the expression
of face was like that of an old person, with muscles of the
body greatly wasted ; its bowels sometimes irritable, but
generally regular, the appetite generally good, the lymph-
atics of neck and groin, and the tonsils were swollen.
The symptoms presented gave no such unmistakable evi-
dence of syphilis, as the history of the mother. She had
borne three children previously by the same husband.
Neither he nor she confessed to a syyhilitic taint. Each of
the previous children had between the fourth and tenth
weeks, broken out with an eruption of nose, mouth, and
anus, and the limbs hfed become filled with erythema and
1861.] Syphilis in Xnc-Bom Children. 647
pustules. The iirst child had had large abscesses in the
groin, and though each succeeding child had manifested less
of the disease it was the same in all. Each child had
wasted and died before it was six months old. The child
rented to us, was placed upon the same mercurial treat-
ment as the cases mentioned above.
January, 18G1. While the child seemed to be improving
it at this time had an attack of measles, which greatly taxed
its strength, but left no bad symptom behind it, As soon as
it was better the mercurial treatment was resumed ; and at
this time although the child is not entirely cured, it bears
nearly the aspect of health its skin has become clear
appetite good swollen glands disappearing flesh increas-
ing and strength restored. The treatment is still continued
but will not be much longer necessary.
Case Xo. G, March 1, 1861. ^Tegro child, boy, three
months old. Born at term, good size and healthy. He
presented the following symptoms a papular squamous
eruption when it was five weeks old, existed on its scalp ;
at the inner border of limbs, and flexures of joints were
occasional patches of erythema which had given place ii\
some points to thin whitish scales; on the face and eyelids
were pustules, and the scrotum and anus were tilled with
condylomata, and at the anal orifice an ulcer. The buttock
was a mass of tubercles and pustules, some of which had
degenerated into ulcers. Every inquiry in regard to syph-
ilis was denied by parents ; but a few days before I saw the
child, the mother came to me for a sorethroat which was
palpably syphilitic, both nipples were sore and fissured, and
one of them had several mucous papules. She told me
that the throat had become sore one week after the birth of
infant, then the nipples in a few days afterwards. Soon the
mouth of the child was likewise affected, and then followed
the general eruption of the body. The mother was given
iodide of Potash, grs. v. three times a day, but no medicine
Was given to the child, letting it receive its cure through the
milk. This treatment is still pursued, and 1 saw both the
patients yesterday. They are already nearly well. The
throat of the mother gives her but little trouble, and the
eruption of the child is greatly improved, having disappear-
ed entirely from some parts of the body, and rapidly heal-
ing in the ret
The history of these cases illustrates the great difficulty
in deciding many doctrinal points in syphilis of new-born
648 Syphilis in New-Bom Children, [August,
children. The parents in some instances, from ignorance
or carelessness in noticing the primary sore, in others, from
an unwillingness to acknowledge any improper conduct,
deny every inquiry which would enlighten us in the ways
of diagnosis ; and if any confession is made, it is rather
through accident, or ignorance of the direction to which
our questions tend.
The cases presented for treatment constitute hut a small
proportion of those which have been infected, for a syphil-
itic mother may and generally does abort a great many
times, and at various periods of pregnancy, before a child
is delivered at term. Observers have detected external
manifestations of the disase as early as the second month
of intra-uterine life, and there are many observations of
this manifestation at the fifth and sixth months. This is a
feature of the force of the disease, when it seems to exhibit
itself with such violence as to prevent the foetus from arri-
ving at term, while in the cases reported in this article
which agree with other observation, the disease never exhibit
itself till the third, fourth and up to the tenth week of extra
uterine life. We may then say of syphilitic children born
at or near term, first, that some present a pinched cachectic
look, which ought to excite suspicion of the disease at time
of birth ; that this cachexia may constitute the only prom-
inent feature; while from mal-assimilation of nutritive
matter the muscles waste, the skin becomes dry, and the
child may die with or without any cutaneous eruption; or if
subjected to treatment may recover without the disease ever
having manifested itself externally. Second, that the ma-
jority of cases presented, are reported to have nursed and
looked wrell tiil the first or second month, when appetite
may or may not begin to fail, child grow feeble or emacia-
ted, and eruption show itself.
With regard to the period at which eruptions show them-
selves, we must say that pemphigus both in this particular and
in result makes a class of cases for itself. Sometimes at birth
generally a few days after, it manifests itself, and other things
ig equal, the victims of it die very rapidly. M. Bouchut
has quoted the investigations of MST. Paul Dubois, Deville
and -I liers in their autopsies of syphilitic children, which have
n made from the foetus of touv months up to child deliv-
ered at term. The thymus gland, the lungs, brain and liver,
have exhibited together or e 'y in each case, peculiar
changes. In the first stage there were mere points of conges-
L] en. G49
; farther bad degen-
erated into absc The thymus gland, especially, and
more aniformly has exhibited those changes. In the lungs,
1 Dubois has found many abscesses, nut in one case to which
da] value has been attached a child delivered at term
and tilled with pemphigus the Lungs were found without
-, but had disseminated all through them patches of
eruption which corresponded to that manifested externally.
The question which now pi tself is. what is the source
of syphilis in new horn children I M. Ricord says, u there
cannot be constitutional syphilis without a chancre or syphil-
itic mother or father." The first part of the proposition that
re is not C"HMl:!' us, as it will affect another
ich >f our subject, we will leave for the present, to revert
to it farther on. The second part means, that syphilis is
transmissible by inheritance, and I suppose there are fewper-
at the present day to contradict the fact. But the father
and mother seem to po>^-ss different powers in this agency.
In order to transmit syphilis to offspring, it is necessary that
one parents should be suffering from con itional sy-
phili unary sore not sufficient to cause such ..result.
In regard to the father j ir app rt that when suffering from
ititutional syphilis, the ovum is infected by him at the
moment of c Q, and though the foetus may be deliv-
ered, ut t 1 not exhibit the eight weeks
after birth, it has really from the very first moment been dis-
by father after conception, if
the mother does not become affec is harmless
ar as the offspring is concerned. But a child u crea-
ted syphilitic by the father can infect the mother during ges-
tation." The force of the disease is here brought in question
M to the relative power of father affecting the offspring.
Erichsen in his Surgery relates a case of Ids own, where a
leman suffering from constitutional syphilis, married and
a large family none of whom exhibited any symptom of
the disease But this case is exceptional, and although we may
beli- ffspring
than the mother, still when he is Buffering from constitutional
bilis the result will be, as a rule, t; iildren will
e world syphilitic. In n
>ther c from a con-
syphilis anterior I o to
an indurated chancre contracted daring on." Thus
the from mother ex* the period of preg-
nancy, except perhaps as M. Bouclmthas expressed a doubt
650 Syphilis in New- Bom Children. [August,
towards the eighth or ninth month. The only thing requi"
site is constitutional infection, for the mother to affect in
fants ; and we may now ask, is a constitutional syphilitic
mother who is carrying a syphilitic foetus apt to infect hus-
hand? The mass of evidence is against the supposition,
and M. Bouchut relates a case, where a woman who had
been under his care for indurated chancre, married in a few
months against his advice. She conceived, and a syphilitic
child was born at its sixth month, but the husband did not
contract the disease.
Here arises the important question of the power of con-
tagion of secondary syphilis. M. Ricord has asserted that
it is not contagious ; but that in those cases where this has
appeared to be the fact, there has been error in diagnosis,
and that what appeared to be a secondary manifestation
was really an indurated chancre transformed "in situ," into
an ecthymatous pustule or mucous papule. Melchior
Robert whose treatise (Maladies Veneriegnes,) is drawn
from the lessons >f Ricord says in relation to this point :
" It did not suffice to attribute to every primtive chancre
the property of infecting the economy ; it was necessary
still to multiply the propagating means of syphilis in ex-
tending this power to secondary accidents. The bodies of
unfortunate patients have been sown to profusion with the
secretion of every variety of syphilides ; they have inocu-
lated one patient from another, from patient to healthy in-
dividuals ; sometimes from mucous papule, sometimes from
ecthyma; again from tertiary manifestations, and finally
from the blood of syphilitica; and all that to arrive at the
means of contradicting an opinion, which experimentation
has a thousand times confirmed." There could be no more
positive assertion than this, and yet, in 1857, M. Ricord, in
his Oral lectures, expressed a doubt of this very point. The
frequency of reports of syphilitic child infecting healthy
nurse, and vice versa, and the medico-legal importance o:
the question have created much opposition to the belief oj
the non-contagion of the disease in this form. "Without
contradicting the theory entirely, it is certain that some
modification of it is necessary ; for a healthy mother car-
rying a foetus infected disease by the father, which has it in
secondary form, is in her turn affected, and perhaps in an
exaggerated degree, sometimes exhibiting it anterior, but
generally consecutive to accouchment. The question of
mother and child infecting each other when only secondary
61.] Syphilis -Born Children. 651
yjifestations have existed, have been the principal obsta-
to assent io this maxim of Ivicord, for the great major-
pf adults with constitutional syphilis have failed to com-
micate it by contact.
ran a syphilitic child infect a healthy nurse ? The pro-
bility is that it can ; hut to do so it is necessary that the
shall he developed into eruption. M. Bouchut re-
;es the case of an infant Baffle ring in this way, who cora-
Inicated the disease to three nurses consecutively, neither
whom had ever given any evidence of the disease ante-
>rly : of another nurse, who had a healthy child of her
jn but contracting syphilis from a child which she was
rsing, actually communicated it to her own child.
The means of transmission is generally thus : the child
s mucous papules or ulcers on the lips, in frequent con-
?t with the nipple of the nurse ; soon upon it a similar
aption, or it may be a fissure, is developed, and then fol-
vs constitutional infection. Aud in some instance, the
Dple is actually lost by the amount of fissure which sur-
.mds it. Can a syphilitic nurse impart the disease to a
althy child ? M. Ricord has denied this communication
In nurse to child, except when the former is suffering
mi primary syphilis, and she by accident inoculates the
.rsling with the pus from primary sore, when secondary
pptoms follow as a natural consequence. M. Bouchut
lile citing some cases to the contrary of this doctrine, is
clined to adopt somewhat the same views especially so
p as infection through the milk is concerned. In the dif-
rent analyses of the milk, it is pronounced " a perfect
Lment elaborated from the blood," and while the different
festa, excitement from rage, venereal desire, the men-
ual How, lVc. &c. may affect its character in the propor-
>n of fat globules, salts, &c. to a limited extent and
' affecting the nursling, yet there is no consistent
viation from the average standard from these causes. So
us with phthisis, scrofula, syphilis, cancer, rickets,
I the milk shows no consistent change so far as chem-
r will detect. Yet no one will rationally doubt
at the milk elaborated from the blood of such persons,
nourishes the blood, muscles, hoi, of nurs-
iu some wise differ from that of perfectly
Vo one would knowingly < ogage a 1
r their child who had syphili .iu>e her
ilk exhibited by chemical test no derangement. In re-
652 Syphilis in New Born Children. [Auguij
gard to syphilis, we sec that in the father the spermat
fluid is so contaminated that it infects the ovum at th
very moment of conception, and also, that a mother coi
trading syphilis after the child is conceived in health wi
infect it through the placental circulation. And why cai
not the milk of a syphilitic nurse, whose every secretion
affected b}T her syphilitic blood, convey the disease to
child which is nourished by it ? There may be such vigc
of constitution in some cases as to resist it, but in the gnl
majority of cases the infant must suffer. We ourselvc
know a gentleman, born of healthy parents, all of whos
brothers were healthy ; but he was "put to nurse" to
woman who was afterwards discovered to be syphilitic, an
he has all of his life suffered from rheumatism, and occ*
sional syphilitic eruption, which would disappear unfl
good health, but manifested itself again when attacked I)
any acute disease.
That the milk should give no evidence of the particul
malady, ought to excite no surprise when we reflect thi
the syphilitic pus differs so little from healthy pus, that v
have no certain means of distinguishing them, but by ii,
oculation ; and farther, that in the majority of cases wbH
the mother is put under treatment, and the milk is freigh
ed with the remedy for diseased child, chemical test wi
rai v detect any change in it. We have thus far conside
ed syphilis in its secondary form, and it will be necessai
now to examine its influence when passed into the tertiar
In. this 3tage, the sub-cutaneous, sub-mucous, fibro-osseoi
and muscular tissues, the testicle, liver, &c, have been i
vade<; ; that is, the poison has passed from the external
the deeper pai fca and taken firmer hold of the victim. II
its power of translation increased with its progress ? N
M. Ricord has said, that the disease passed into the tertiai
stage is not transmissible by inheritance, but whatev
manifestation may be made in a child born under such i
fluence will be scrofulous. M. Devil le has observed tli
children born of fathers suffering from tertiary syphilis c
not exhibit the disease, and while he believes the same
regard to mothers under similar circumstances, his obfll
vationa have not been so satisfactorv as to allow him to i
sert positive belief. The force of the disease is
brought in question here, and it must be confessed tli
grave doubts exist of the truthfulness of these observatioi
There is no doubt that secondary syphilis and scrofula
!61.] Dislocation of (he Crystalline Lens. G53
mewhat analogous in their manner of manifestation, and
ten extremely difficult to distinguish one from the
her; but their nature is bo different, that it will require
I much stronger proof to convince us, that though
rolulous parents do not give birth to syphilitic children,
I parents in the tertiary stage of syphilis will bring into
e world scrofulous children. This question is important
a therapeutical point of view, for a remedy which is of
eat benefit in a case of syphilis may be positively detri-
ental in one of scrofula.
With regard to the treatment, it has become an estab-
Hied fact, that however much the non-mercurial school
ay cavil about the use of mercury in this disease in the
pit, it is at least a specific in syphilis of new-born chil-
en. The iodide is the best preparation of mercury, and
ay be given to infants in doses from twelfth to twentieth
ain once a day ; if no benefit is derived in the course
the day. the dose maybe repeated twice a day. If ad-
pistered to mother, it is best to begin with one grain, to
\ increased if necessary to three grains per .Uem, this will
feet the mother, and through the milk, the child. Mer-
ry may also be used by inunction. Where it is not de-
to give mercury, the iodide of p< tash may be used
9 of five grains three times a day. if the disease is
ken in time, when the child is not worn out, the proguo-
i is always favorable, but when it is in an advanced stage
marasm, its exhaustion and not the disease is the first
combat. It this can be overcome, the syphilis will
:i age able.
iry Dislocation of the Crystalline Lens.
exhibited a patient to the Paris So<
'Surgery who had the power ol producing a dislocation
voluntarily. Paralysis of the iria . and the
oabled to cause the passage of the Lens from one
lamber to the oth< ransparency being completely re-
ined. Some ace M. Larrey also presented & child
pibiting a similar peculiarity the lens in that in-
did not become opaque until three or four years af-
654 Hemorrhage. [Angus
On the Arrest of Venous Haemorrhage. By Professor Lah
gf.xeeck. (Archiv fur Klinische Chirurgie, Band i. p. M3
In the course of an interesting paper by Professor LangeE
beck on the " Surgical Pathology of Veins," illustrated by nn
nierous cases, he observes that styptics are not suitable forth
arrest of venous haemorrhage. The best of these, the liquk
ferri sesquichlorati, is dangerous, owing to the extensive
thrombus formations and subsequent irritating effects it g
rise to. In all cases, when obstinate venous bleeding proceec
from several small veins, he gives decided preference to the
actual cautery, as most certainly guarding against the break
ing up thrombi and pyaemia. When the bleeding proceec
from a large vessel, compression, ligature of the vein, or liga
ture of the corresponding artery, should be resorted to.
wounds of the large veins of the extremities, compression o1
the peripheric ends by means of the finger will usually suffice
and in wounds of the jugulars, we should at once apply the
finger to the central end to prevent the entrance of air, anc
then to the peripheric end to arrest the bleeding. In the cast
of a large wound of the jugular, the finger can only act pro
visionally, and the best means of proceeding consists in closing
the lips of the outward wound by strips of plaster, (which must
not extend to the uninjured side of the neck, where they would
compress the opposite jugular), so applied as to exert the most
equable compression around the wound without impeding the
circulation. In the case of the veins of the extremities, band-
ages may also be exactly applied, commencing at the toes or
fingers. When the injured vein is at the bottom of the wound,
the author places somecerated linen in contact with it, fills the
wound with charpie, and then brings its edges together with
plaster.
Ligature of the Vein. In general, tying the peripheric end
of a wounded vein of the extremities suffices; but a ligature
both above and below the wound may be required when a
considerable branch enters just above the central end. To
avoid the loss of blood during the removal of large tumors, the
provisional ligature of several large subcutaneous veins, which
sometimes acquire the size of the finger, may be requisite ;
and in such cases the author always applies a double ligature,
and divides the vein between, removing the ligatures after the
completion of the operation. The practice is the more to be
recommended from our ignorance of the conditions under which
air gains entrance by dilated subcutaneous veins. In woun
of the external jugular, the central end should always be tie
as it should be prior to operations likely to lead to its bein
.801.] Dislocation of the Shoulder. 655
pened. Under other circumstances, the ligature of large
eins should be avoided as much as possible, especially in hos-
itals, where the danger from thrombosis and pyaemia is in-
roased. The internal coat of a large vein is not divided by
be ligature, as in the case of an artery; and the inner walls
pproximated by the ligature may unite before the separa-
ion of the latter the vessel remaining pervious, though some-
what narrower, up to the very seat of the ligature. "When in-
lammation follows a wound or a ligature, more or less exten-
ive thrombosis may succeed, which may lead to detachment
I coagula or pyeemia. When this is not the case, the vein
gradually becomes pervious again ; and so great is the regen-
irative capacity of veins, that, even when large portions have
men removed, these may be reproduced, effecting a junction
etween the separated ends of the still pervious vessel.
hi the Diagnosis of Dislocations of the Shoulder. By AT.
Maisonneuve.
It very often happens, M. Maissonneuve observed in a re-
ent clinical lecture, that even experienced surgeons may
lesitate respecting the existence of a luxation of the shoulder ;
,nd you are aware of the learned dissertations to which the
lilfercntial diagnosis of these luxations, fractures of the neck
tf the humerus, and even simple contusion, has given rise to.
Numerous are the pages, even in the most recent works, de-
roted to this important discussion; and certainly after reading
rad meditating upon them, one can be persuaded that this
-is is one of the most delicate and difficult in surgery.
cs not arise from the enumeration of the characteristic
ymptoms of each lesion being incomplete. Far from it ; for
:eal and doubttul symptoms, vague and precise symptoms,
ire bo accumulated that even the most skilful can scarcely
pake them out, while the simple practitioner is utterly at a
WL Still there is a simple and easily-discovered symptom,
jdiieh will always enable you to recognize with certainty not
nly this but any other dislocation, whatever swelling of the
rounding soft parts may exist. This symptom is based
ipon the fact that in all dislocations the normal movements
peded or abolished, while in simple contusion these
rients persist, and in fractures others of an unusual na-
ure are added to them. Take hold of the arm, and endeavor
to make it execute the movements proper to the articulation,
f these are found to be impossible, or very limited, there is
G56 Prominent Eyeballs. [August
without doubt dislocation ; while if these remain intact, no
luxation exists, and the presence or absence of shortening
and crepitation will determine whether the accident is a
fracture or a mere contusion. This sign alone will enable
the diagnosis of the dislocation to be^ made. The at idy
of the symptoms may be carried further, and analyzed in le-
tail. We may verity the flattening and the depressibility of
the shoulder, the projection of the head of the humerus, the
elongation of the limb, and the various circumstances which
determine the variety of the dislocation. But the mere fact
of the abolition of the movements of the joint had already
placed the fact of the dislocation beyond doubt. Moniteur
des Sciences Medicate.
Prominent Eyeballs. " Exophthalmic Goitre."
At a recent meeting of the Academy of Medicine, in Paris,
M. Aran, Physician to the Saint Antoine Hospital, read a
paper upon the nature and treatment of the affection known
under the name of exophthalmic goitre, exophthalmic cac-
hexia, &c. The conclusions at which that writer has arrived
are the following: That the disease known under the various
names referred to above is not essentially constituted either
by exophthalmos (protrusion of the eyeball) or by a swelling
of the thyroid body, but rather by an irrirable condition of
the heart and the arteries of the neck, with which it is, at
times, closely connected; it is impossible to fix definitely, the
interval wl ich separates the production of these two series of
facto, a dilatation with hypertrophy of heart, and of the large
vessels of the neck. Neither this dilatation with hyperthrophy
nor the increased irritability cf the circulatory system, which
would appear to govern it, can be considered as the base or
point of origin of the malady. Preceding these phenomena,
or coin< dent with them, there exists various derangements iu
the digestive system, the secretory apparatus, and the n-rvous
system, which do not leave any doubts concerning the com
Dion tie which unites, and which generalizes them; this lie
would seem to be a morbid condition of the great sympa-
thetic system. The existence of this morbid condition of the
sympathetic nerves is further shown by the production of ex
ophthalmos which, although inexplicable on the ground ot
vascular dilatation, and equally inexplicable by the hypo-
1S61.] Epileptiform Convulsions. 657
thesis of an hypertrophy of the cellulo-fatty tissue 6ontained
in the orbit, (au hypothesis which is itself irreconcilable with
the rapid production of this phenomenon in certain ca
with it- ;: in others, and with its inure striking mani-
ition in one eye than the other), is, on the contrary, fully
explained by the influence of the sympathetic system, as
demonstrated by the investigations of Claude Bernard and
Muller.
The nervous affection which we have described is curable
by a plan of treatment continued for a sufficient length of
time, which has for its object to excite the contractibility
of the walls y^t' the heart and of the arteries, to lessen the
exaggerated irritability of the heart and of the vessels of
the neck, and to combat the general neuropahtic condition,
which serves as a base for it, at the same time as the al-
l condition of the blood when its exists. Amongst the
therapeutic measures, those upon which we can place most
reliance are the application of cold to the region of the
heart, the administration of increasing doses of veratria, or
of digitalis, repeated affusion with water, removal of the
:nt into the country, and, at a certain stage of the
malady, ferruginous prepan .ions, especially the perchloride
of iron. London Medical Review.
and Origin of Epileptiform Convulsions caused by
I 1 Epilepsy. By
lolf Kussmaul and Adolf Tenner, M. J). Translated
by Edward Bronner, M. D.
The chief results obtained from these careful researches
may be con- ouped under the following beads:
1. The convulsions appearing in profuse hemorrhage of
a blooded animals (including man,) resemble those ob-
served in epileps
2. When the brain i- suddenly deprived of its red blood,
fconvulsi cription as those occur-
ent to ligature of the great i of the neck.
Epileptic convulsions are likewise brought on when
arterial blood rapidly as3um rioua color, as for ex-
knpli . a ligature is applied to the trachea.
4. It i- highly probable that in these cases the attack of
4J
658 Epileptiform Convulsions. [August,
spasms depends upon the suddenly-interrupted nutrition of
the brain. It is not caused by the altered pressure which
the brain undergoes.
5. Epileptic convulsions in hemorrhage do not proceed
from the spinal cord, nor from the cerebrum ; tbeir central
seat is to be sought for in the excitable districts of the brain
lying behind the thalami optici.
6. Ancemia of those parts of the brain situated before
the crura cerebri produces unconsciousness, insensibility,
and paralysis in human beings ; if spasms occur with these
symptoms, some excitable parts behind the thalami optici
must have likewise undergone some change.
7. Anaemia of the spinal cord produces paralysis of the
limbs, of the muscles, of the trunk, and of respiration.
When the anaemia suddenly attains its greatest intensity,
then only, and even then but rarely, do slight trembling
movements of the limbs precede paralysis. The sphincter
ani acts analogously to the constrictor muscles of the face
in anaemia of the brain, that is, it contracts spasmodically
before it relaxes.
8. Convulsions from hemorrhage are neither physical nor
reflective ; they do not ensue
a. In cold-blood animals, at least not in the frog.
b. When the hemorrhage is slow, so that the vital power
is only gradually consumed.
c. When the animals are very much debilitated.
d. When the nutrition of the spinal cord has suffered.
e. When large pieces of the excitable districts of the brain
have been removed.
/. In animals subject to etherization.
g. Doubtless, also, when excitable districis of the brain
have undergone certain pathological alterations.
9. As suffocation brings on convulsions, and etherization
averts them, it is evident that etherization and asphyxia
are two different conditions.
10. The brain of warm-blooded animals can only be de-
prived ot red blood for a short time ; otherwise it loses its
capability of resuming its functions when again supplied
with the nutritive fluid, and the appearance of death he-
comes a reality. The brain of some rabbits presented this
capability for two minutes.
11. It is sometimes observed, after the arteries of the
neck have been tied, that the muscles of the trunk perish
and take on the rigor mortis before the action of the left
1861.] Epileptiform Convulsions. G59
heart is extinct Hence the left heart is not always the
im moriens among the muscular organs.
12. Contraction and subsequent extreme dilatation of the
pupils in the agonies of death is no certain sign of real
death, and of the incapability of being revived, as main-
tained by Bouchut.
13. To cure epileptic attacks caused by anaemia, there is
no better method than that of renewing the supply of red
blood. The debilitating method of treating epilepsy, espe-
cially by abstracting blood, should almost always be re-
jected.
14. The, quantity of blood in the cranial cavity can, by
way of experiment on the living subject, be considerably
increased or diminished. Hyperemia in the cranial cavity
used by releasing the stoppage of circulation in the
cervical arteries, by tying the cervical veins, especially by
simultaneously dividing the cervical branches of the symp-
athetic nerve, and lastly by tying the trachea, during inspi-
ration. Anremia in the cranial cavity is produced by hem-
orrhage and by tying the cervical arteries, as well as by
electric excitation of the vaso-motor nerves of the head.
15. The quantity of bloocFcontained in the cranial cavity
after the application of a ligature to the arteries is greater
Kan after hemorrhage: the amemia as regards small arte-
ries, the capillaries, and the smallest veins being always
nt to a greater extent.
16. From the quantity of blood contained in the skull
after death, it is seldom possible to draw certain conclusions
with respect to the quantity contained during life. The
death-struggle brings on numerous conditions altering the
circulation of the blood in the skull, and even in the corpse
the quantity of blood may still undergo alterations.
17. The phenomena of the incomplete epileptic attack
be explained by alterations occurring in the cerebrum
: while the phenomena of the complete attack presup-
)ose an alteration of the whole brain. Convulsions in epi-
epsy are justly styled cerebral ones, and the spinal cord
wobably plays only the part of a conductor, transferring
ives from the brain to the muscles.
18. Circumscribed anatomical alterations of the brain, or
ilterationa of protracted duration, cannot be regarded as the
proximate cause of epileptic attacks, but may cause epileptic
19. Pathological anatomy cannot give any explanation
660 On Vrcemic Intoxication. [ August
as to the nature of epilepsy. Suddenly-withheld nutrition
i3 only one of the causes by which the brain is brought in-
to that peculiar internal condition which is manifested in
the form of an epileptic attack. Arterial congestion of the
brain does not seem to be capable of producing any other
symptom than those of paralysis. Venous congestion of
the brain, as well as arterio-venous congestion, brings about
conditions which belong more to those of apoplexy than
to those of epilepsy and are characterized by paralysis of
the glottis, together with a slower respiration and slight
spasmodic symptoms.
20. Marshall Hall's sphagiamus and trachelismus are not
to be regarded as a source of epileptic attacks, but the latter
will produce them. All theories are false which assert the
epileptic attack to be derived from a sudden determination
of blood, whether active, passive or mixed. It is probable
that certain forms of epilepsy result from a spasm of the
muscular coats of the cerebral arteries.
21. The epileptic affection which disposes to the attacks
occupies either the whole of the brain or some districts on-
ly, and by it the brain is brought into that altered state on
which the epileptic attack is based. The medulla oblongata
as being the part whence the nerves causing the constriction
of the glottis and the vaso-motor nerves take their rise,
seems frequently to be the spot from which eclamptic and
epileptic attacks proceed. N. A. Med. Chir. Rev.
On Urocmic Intoxication. By m, A. Hammond, M. D.
Professor of Physiology and Anatomy in the University
of Maryland.
In the memoir entitled as above, Dr. Hammond relates "
an elaborate series of experimental researches designed to
clear up some of the unsettled questions as to the effect of
the accumulation of certain of the urinary elements in the
blood. Dr. Hammond considers that the most important
of these mooted points is, whether carbonate of ammonia
from the decomposing urea, as Frerich has urged, is the
cause of the condition now known as nrremia. After cri-
ticising French's views, by means of a succession of well
planned and ingenious experiments, Dr. Hammond exam-
1861. "I mic Into (361
inod the whole subject anew, in an additional series of ex-
periments, and by their aid, arrives at the following eon-
elusions :
1. That the injection of urea, in limited quantity, into
the blood of animals produces a certain amount of disturb-
ance in the nervous system, similar in its symptoms to the
first stages of uremia, but that this condition disappears, if
the kidneys arc capable of so depurating the blood as to
eliminate the toxic substance.
-. That urea when introduced into the circulation in
larger quantity than can in a limited period be excreted by
kidneys, induces death by uremia.
& That by ligature of the renal arteries, or removal of
the kidneys, the elemeets of the urine being retained in the
blood, render this fluid unsuitable to the requirements of
the organism, and consequently induce a condition of sys-
tem not essentially distinguishable from the uremic intoxi-
cation of Bright's disease, or that caused by the direct in-
troduction of the blood. As, however, was pointed out by
Bernard and Barreswil, so long as the urea or the products
of its metamorphosis are discharged by the stomach or in-
testines, uremia does not take place, but that when these
channels become closed, convulsions and coma are produced
and deatlr soon follows ;
4. That the introduction of urea or urine into the circu
lation of animals, the kidneys of which have been ablated,
shortens the life of such animals as Frcrichs and others
have already shown.
There is reason to believe that the urine, as a whole,
;ore poisonous than a simple solution of urea, for in
:i which urine was injected into the blood, the
int of urea thus introduced was much smaller than that
sly thrown in, in a pure state, and yet symptoms of
at intensity followed.
That urea or the elements of urine, as a whole, induce
such a condition of the nervous agly to pre-
i and inflammation of the viscera, e
cially the lun_ ardium and spleen.
That urea, when directly injected into the blood.
red to accumulate in this fluid bj ition of I
kidn _ some manner the
) as to disturb the normal relation of t rpportion
bite and red corpuscles, and either
to hasten the de< these latter, or t 0 iuterfi
662 Placenta Prcevia. [August,
with the due removal from the blood of such as are broken
down and effete.
8. That there is no reason to suppose that, under the cir-
cumstances specified, urea undergoes conversion into carbo-
nate of ammonia, but that on the contrary, there is suffi-
cient evidence to warrant the conclusion that no such pro-
cess ensues. The fact that in the foregoing experiments a
larger amount of urea was generally found in the blood
taken from the body after death than in that abstracted
daring life is, of itself, conclusive against any such hypo-
thesis. Ibid.
Placenta Prcevia; Treatment by the Caoutchouc Water Pessary.
By E. J. Fountain, M. D. Davenport, Iowa.
Mrs. I\ aged twenty, at seven and a half months of her
pregnancy, began to have hemorrhage, but without labor
pains or dilatation of the os. This ceased partly under the
use of rest, cold water, enemata, opium, and acetate of lead.
At the end of two weeks, it recurred with greater violence
and some pain. Dilatation was sufficient to allow the finger
to enter, and the placenta was ascertained to be in front.
To check the alarming discharge, a caoutchouc bag was in-
troduced and filled full of cold water, which at once arrested
the flow. In half an hour it again commenced moderately
the water now quite warm was allowed to escape and the
bag refilled. By the continuance of this process through
the day and night, the patient was kept safe. "When the
contents were changed, an examination could be made with
out removing the instrument. After twenty-four hours, as
the os was becoming well dilated, and the pains more regu-
lar, turning was thought of, but finally rejected, and the
former plan continued." Finally, the head pressed down on
the placenta, thus perfectly controlling the hemorrhage, and
the child was soon born in good condition about thirty
hours after the commencement of the treatment. Thevda*
cent a was found loose in the vagina,
Therapeutic uth.
On the Therapeutic Acli '/A. By J. i>. M'Caw,
M. D.
Having concluded my remarks on bismuth and its com-
binations, I call your attention for a few moments to their
value in the treatment of disease. I think you will
how much the curative virtues of these compounds depend
upon the physical and chemical properties, already explain-
ed to you.
First, then, remember the physical properties of the bis-
muth compounds and especially of the basic Bubnitrate, the
usual form in which this agent is administered by the phy-
Bician. This Bait, as I have told you, is the result of the
action of water on the ternitrate, causing a white, almost
insoluble semi-unctuous precipitate, which is the subnifrate
of the pharmacopoeia.
Known as the magistery of bismuth, this powder was
much prized by the ladies, long ago, as a cosmetic, because
of its emollient influence on the skin, concealing pimples,
freckles and other deformities to which even the fair sex is
sometimes liable, and leaving a beautiful white gloss much
to be admired. Xot only did its external applieation act
soothingly to the excoriated or irritated integument, but it
was also used as a drying powder, checking a too profuse
perspiration, by coating over, with its delicate varnish, the
exuding membrane.
then, you have a patient with dyspepsia, an
irritable mucous membrane, painfully excited during the
act of digestion, by the excessive flow of the gastric juice
and the mechanical efforts of the muscular coat, can you
not, with great propriety, appeal to the inocuous and emol-
lient subnitrate of bismuth, which coats over the angry
membrane with its soft white precipitate, shields it from all
-os of irritation, and gives to the digestive function a
great amount of comfort ?
Recollecting, also, its mechanical effect upon the trans-
piration of the skin, you can see why the subnitrate should
be i: of in the treatment of serous diarrheal
cially those not the result of organic disease ; in the "sum-
" of teething children, and in the irritable form
of disordered b< 'lowing measles ai i fever.
Here, as we have to act upon ;i great extent of surface, it is
give the remedy in large pi , and
in such one ounce in twenty-!
hours with great advantage.
G64 Therapeutic Action of Bismuth. [August,
So much for the mechanical influences of this agent on
the mucous membrane, explaining, to some extent, its the-
rapeutic action; but I think by observing its chemical at-
tributes you may also derive some hints of practical impor-
tance.
I have shown you that the presence of bismuth or any of
its compounds can be detected by the agency of sulphuret-
ted hydrogen, when a precipitate of the brown-black sul-
phide of bismuth will at once appear. So sensitive is the
subnitrate to the presence of this agent that its use as a
cosmetic has also been abandoned since the iutrod action of
the coal gas as an illuminating agent, which, when impure,
often sets sulphuretted hydrogen free. The pearly cheeks
of a cluster of beauties decked for the ball would soon,
under the action of this unerring detector, even rival the
sootty complexion of Christy's Minstrels.
If you have to treat hereafter cases of gastric or enteric
disorder accompanied by disengagements of sulphuretted
hydrogen, as, for instance that distressing condition of sto-
mach called ue^g belch," or the windy colic of defective
digestion and torpid liver, remember that subnitrate of bis-
muth may be relied on to neutralize the offending and of-
fensive gas, by the formation of a sulphide which is entirely
innocuous, if not positively curative. The dark color of
the stools after the administration of this remedy proves
the truth of this statement, as there is not always sulphu-
retted hydrogen to give the characteristic precipitate.
The surgeon as well as the physician may gain some use-
ful ideas from a study of the physical and chemical proper-
ties of bismuth. As an application to burns, or diseases of
the skin, such as erysipelas, the subnitrate, with its soothing
influence, will be found very valuable; also in excoriations
of the skin, and the chafing of infants, the result of acrid
discharges. As a disinfectant, I would advise you to use
this harmless salt freely, being equally effective and greatly
more convenient than the tar and plaster of Velpeau, or the
permanganates of Girdwood a foetid ulcer, a sinus con-
nected with a carious bone, or a malignant sore, pouring
out its putrid odors, will be greatly unproved under the
Iree application of the agent under discussion.
Before closing these remarks, which arc not intended to-
infringe upon the prerogatives of our colleagues of surgery
and the practice, but rather to show you the value of chem-
istry even in the mote practical departments of medicine,
1861.] Chronic G G65
I will mention that as arsenic is not unfrequently found in
. with biamuth in a native state it would be well
re using the aubnitrate, in the Large quantities I have
.amended, to make aure that your preparation is pure.
The usual mode of manufacturing the article, I should
think, would preclude the poaaibility of much danger from
this source, hue we have the high authority of Prof. R. E.
of Philadelphia, to justify ua in giving you this
caution. In experiments made by him some years ago, he
3 of ar enic in many of the samples of subnitrate
of bismuth collected by him from the druggists of Phila-
,ia. Aa far as my own observations go, however, I
have never detected arsenic in the subnitrate in any appre-
ciable quantity, and never heard, after an experience of
many years, of its producing the symptoms of arsenical
poisoning in a single instance. Maryland Yirg. 2IaL Jour.
On Ghr \ Post-Mortem Appearance, Inflammation
of I By X. S. Davis, M. D.
Gentlemen : At the last clinic hour, your attention was
occupied chiefly with a case of chronic inflammation of the
mucoufl membrane of the stomach, coupled with indications
of incipient tuberculosis. "We then not only stated the
ptoms of the as illustrated in the patient brought
you, but we alluded also, briefly, to the diagnosis
between it and the different varieties of cancer on the one
hand, a: functional derangement of the stomach on
the other. We reminded you that chronic gastritis is S
iterized by a distinct burning, Bmarting pain,
inci >d ; frequently the rejection of the latter by
vui:. : a sour or acrid condition, or mixed with mu-
ration of the pulse; some tenderness of the
; the tong mooth and
;) its 8ui ared and tender; the
bowels gene sometimes relaxed, with
urine ia in most cases
.ty and emaciation dve.
m those
'.rnple functional dci. :it of the .stomach in several
666 Chronic Gastritis. [August
respects. They are more constant or uniform from day to
day, while functional derangement is seldom accompanied
by either redness of the tongue, acceleration of the pulse,
or any considerable emaciation : and it tenderness of the
epigastrium exists, it is only for a day at a time, while the
distress from food is rather a load or weight with gaseous
eructations, instead of burning, smarting and vomiting, as
in inflammation. The differential diagnosis between
chronic inflammation of the stomach and cancer was ad-
mitted to be more obscure and difficult to define ; so diffi-
cult indeed that the experienced arc sometimes left in
doubt. We reminded you, however, that the symptoms of
cancel usually commence much more gradually and ob-
scurely than those of chronic inflammation.
There is for a long time less alteration of the pulse, less
redness of the tongue, less thirst, while the emaciation is
accompanied by that mixture of the sallow and anaemic hue
of the skin peculiar to the cancer cachexia ; and the abdo-
men is almost constantly sunken or empty, and the bowels
costive. We have briefly recalled these symptoms which
were dwelt upon much more minutely in the preceding
lecture, for the purpose of introducing to your notice some
pathological specimens obtained by a recent post mortem
examination. We were called directly from the clinic, to
which we have alluded, to the bedside of a patient whom
we found dying. He had the appearance of one decidedly
anaemic, but was only moderately emaciated, with some
anasarcous swelling of the extremities.
His pulse was feeble and thread-like, extremities cold,
breathing oppressed, in fact he seemed apparently in articulo
mortis.
From his wife and friends we learned that about one
year since he had an attack of fever, and during his treat-
ment, he was severely salivated with mercurials. His gen-
eral health had not been good since that time. He had
been constantly more or less anaemic and troubled with in-
digestion. Still he had continued to attend to his ordinary
duties until about six weeks since, when his food began to
give him more distress, and much of it was rejected by
vomiting. His strength, of course, rapidly failed, and du-
ring the last three weeks he retained neither food nor
drink. He had some pains in his back and head, and
oedema of the extremities. The condition of the urine
could not be ascertained as no attention had been paid to
1861.] Chronic Gastritis. 667
that subject The medical attendant, who was not a regu-
lar member of the profession, had pronounced the disease
to b< ' of the stomach. But its evident beginning
after the attack of fever and salivation, the persistent and
active vomiting during the last three weeks, together with
the oedema of the extremities and paroxysms of headache,
led us to doubt the existence of cancer, and to express the
opinion that the disease was chronic gastritis, complicated
with some morbid condition of the kidneys. In about an
hour after this visit the patient died, and the next day we
were requested to make a post-mortem examination. We
complied with this request, assisted by Dr. M. O. Hey clock
of this city. The cavity of the abdomen was opened in the
usual manner, and its viscera carefully examined. The
liver was perfectly natural in size, color and structure, and
the gall-bladder was moderately full of yellow bile.
The spleen was natural in color, but about one-third
larger than the normal size, unusually firm and dense in its
structure, and on its outer or costal surface there was a spot
about one inch in diameter, where, on cutting into it, the
investing membrane was found to contain a true bony de-
posit, so firm as to resist the scalpel. Here is a portion of
that part of the spleen, and by passing it from one to the
m can see the change of stricture, and you
will observe also that the hard or bony deposit is limited
strictly to the surface. The whole exterior of the intestines
and mesentery appeared healthy. The only evidences of
found in these organs were in the mucous mem-
brane of the stomach, which is here exhibited for your ex-
amination. That part lining the lesser curvature of the
stomach is intensely red, with here and there a dark spot,
moderat id'; and on close examination two or
thiv ;ill be ^Qon abraded or deprived of epithelium.
An unnatural degree of redness is also seen over that part
lining the left portion and larger curvature of the stomach,
but less than in the part just described.
A- we approach the pylorus the membrane appears more
natural, and the pylorus tly healthy.
Thus, all the morbid appearances in the stomach are such
idicate the existence of simple chronic or sub-acute
infls nofthemucou8mem.br! it the l<
pliant o The bladder
was found moderately d ith urine, and the left
kidney entirely natural. On Lifting the right kidney from
668 Chronic Gastritis. [August,
its place, it was found slightly larger and a darker red than
the left; and on laying it open, its whole texture was in-
tensely injected with blood, forming a strong contrast when
compared with the other. The specimen is here before yon,
and though faded some by maceraticn during the last forty-
eight hours, yet the morbid redness is still easily recog-
nized. The further progress of the post-mortem revealed
no other evidences of disease. It is thus seen that the
opinion expressed by the attending physician, that the pa-
tient was laboring under cancer of the stomach was entirely
erroneous.
The morbid condition of the spleen had undoubtedly
existed a considerable length of time, probably since the
attack of fever one year since. As the function of the
spleen evidently exerts some influence, either direct or in-
direct, over the formation of red corpuscles of the blood, its
morbid condition might explain the anaemic appearance
exhibited by the patient during the last six or eight months.
This was also accompanied by sufficient gastric derange-
ment to occasion imperfect and sometimes painful digestion.
These embarrassments, however, were not sufficient to
prevent him from attending to his duties: in an active out-
door occupation until four or live weeks since, when the
active and persistent vomiting commenced and continued
until death. This symptom doubtless marked the com-
mencement of the inflammation which you have seen in
the mucous membrane of the stomach, and the parenchyma
of the right kidney. Whether the inflammation in these
localities commenced simultaneously from the same general
causes or not cannot be determined with certainty by the
post-mortem appearances. But I wish to remind 3*011 that
there is a close relation in many cases between a morbid
condition of the kidneys and gastric irritation. A case
came under our care a year or two since, in which the uri-
nary secretion was very scanty, amounting to not more than
four ounces in the twenty-four hours, and highly albumi-
nous, with general anasarca, and a profuse watery diarrhoea.
These symptoms had supervened during the period of con-
valescence from an attack of remittent fever.
Fearing the occurrence of extreme exhaustion from the
continuance of diarrhoea, remedies were administered for
the purpose of restraining it. and at the same time favoring
the increased secretion of urine; But it was soon found
that whenever the intestinal discharges were restrained for
1881.] Ma *< I Icterus. 669
twenty-four hours, either active vomiting ensued or symp-
shing coma. This led to the suspicion that
the diarrhoea was purely vicarious or the result of urcemic
irritation ; and on applying the teste, area was readily de-
ed in the intestinal discharges. The patient ultimately
ivered under the influence of treatment for inflamma-
tory congestion of the kidne
If you make the necessary inquiries yen will find many
> in practice, illustrating the effects of urinary disorder
on the gastric and cerebral functions. It is now well
known that a large proportion of the convulsive affections,
not only of puerperal women, but of children also, arise
from the retention of urea in the blood.
We have found many cases of that distressing affection
called '-sick headache," which had recurred again and again
for a long period of time, permanently relieved by estab-
lishing and maintaining a full healthy action of the kidneys.
In the case immediately before us, whether the inflamma-
tion of the kidney preceded that of the stomach, or merely
accompanied it, there canhe no doubt but that it contributed
much to increase the gastric irritability and advance the
patient towards a 1 suit. Yet its existence appears
not to have been suspected during life. Such cases should
admonish you to acquire the habit of examining all patients
carefully in reference to every important function, instead
of allowing the attention to be wholly engrossed with the
more prominent symptoms, as is too often the case.
We shall allow you to occupy the remainder of the pre-
sent clinic hour in examining the physical signs of pneu-
monia com] tlicating a case of extensive tuberculosis. Chi-
cago j
ked Icterus villi Fatty Ik 'on of the Liver >
hieys. By Dr. Yon Plazer.
Marie St. -, ag< I tv an unmarried servant
union, cume m in Octo-
had sufl two ot three months with
ition and digestive disorder, panied with col-
lick in the abdomen, particularly in rium
they earnc on in periodical accessions. Two days before
applied for medical advice she had observed thai she
G70 Marked Icterus. [August,
was jaundiced, and began to be troubled with malaise.
headache, heat and vertigo, obliging her to give up work.
Her skin and conjunctive were moderately tinged yellow;
her tongue foul, and her abdomen slightly meteoric ; the
spleen was swollen, the skin hot and dry, pulse and respi-
ration a little quick, the urine scanty, brownish yellow,
cloudy and albuminous ; stools pale brown and pasty. The
chief subjective symptoms present wTere somnolence, dull-
ness, vertigo, sensitiveness of the liver and stomach upon
pressure, nausea, thirst, and loss of appetite.
All these symptoms were aggravated on the next day,
when she passed into a state of alternating coma and
delirium. On the third day of the treatment she died.
Autopsy. The skin was tinged yellow, and the abdomen
meteoric. The cerebral meninges were edematous, the
brain swollen, congested, infiltrated with serum ; at its base
were about two ounces of bloody serum. The lungs wrere
somewhat edematous ; the heart was flaccid, and numerous
ecchymoses existed beneath the endocardium and peri-
cardium.
The liver was swollen and heavy, its left lobe and the left
half of its right lobe colored deep yellow, the remainder of
it pale brown ; its substance was soft and friable, anemic,
greasy to the knife ; the lobuli were indistinct. The gall-
bladder was small, containing a little clear yellow bile, the
ducts pervious.
The spleen was enlarged one-half, its capsule tense, its
parenchyma soft and deep red. The stomach and intestines
were a good deal distended with gas, the mucous membrane
puny, dotted with ecchymoses of the size of a pin's head,
and covered with deep brown thick mucus. The kidneys
were large, flaccid, somewhat yellow, moderately injected ;
the cortical part pale yellow, here and there streaked with
red, the medullary part brownish red. The urinary bladder
was small, and contained three or four ounces of cloudy,
icteric urine.
On microscopical examination, the liver was found in a
state of extreme fatty degeneration. The kidneys were in
a less advanced stage of a similar condition.
M. Yon Plazer is disposed to regard this case as one of
acute atrophy, the fatty change becoming rapidly developed.
lie quotes similar cases published by Rokitansky in the
Zeitechrift der Wiener Aerzte for I860, but objects to an idea
suggested by this observer, that uremic poisoning may be
the proximate cause of death. Gazette Hebdomaaaire, Dec.
1861.] Miscellaneous. 671
EDITORIAL AND MISCELLANEOUS.
The editor being at the seat of war, will account for the lack of matter
under the editorial head.
We are requested to call attention to the following announcement :
In consequence of the existing war between the governments of the
Confederate States of America and the United States of America the
proximity of this point to the territorial lino dividing the combatants
the possibility that this vicinity may, in the course of the ensuing six or
twelve months, become the theatre of hostile operations, the excited
condition of the public mind generally, and especially among that class
of the community yielding pupils to institutions of medical learning
the unfitness for receiving instruction, either satisfactory or profitable,
which necessarily results from this state of mind, the large number of
the youth of the country who are already in the military service the
gency everywhere prevailing in regard to pecuniary matters caused
be posture of affairs above described, and the fact that four of our
corps of teachers are employed in professional positions connected with
the army, the Faculty of Shelby Medical College have doomed it pro-
per to announce that the winter course of Lectures for 18Gl-'G2 will
not be opened, and that this suspension of exercises will be continued
until further notice.
John II. Callender, M.D. Prof. Therapeutics, etc.
Thomas L. Maddin, M.D. Prof. Surgery,
Daniel IS. Ciiffe, M.D. Prof. Anatomy,
J. J. Abernathy, M D. Prof. Theory and Practice,
Daniel F. Wright, M.D. Prof. Physiology and Pathology,
Henri Erni, M.D. Prof. Chemistry,
John P. Ford, M.D. Prof. Obstetrics, and Dean of Faculty
U, M. Compton, M.D. Demonstrator of Anatomy.
shvillc, August 22, 1861.
ClILOROFORMIC SOLUTION OF GuTTA PERCHA. TaliC of GuttB
Percha, in Bma and a half; Chloroform, twelve fluid
ounces ; Carbonate of Lead, in 1 r, two ounces.
To eight fluid ounces of the chloroform contained in a bottle, add the
gutta percha. and shale occasionally till it is dissolved, then add thecar-
: lead, previously mixed smoothly with the remainder of the
672 Miscellaneous.
chloroform, and Laving shaken the whole thoroughly together, several
times, at intervals of half an hour, set the mixture aside and let it stand
for ten days, or until the insoluble matter has subsided, and the solution
has become limpid, and either colorless or of a light straw color. Lastly
decant, and keep the solution in a glass stopped bottle .-Am.Jour.Phar
Prescription for Irritable Stomach. By Dr. Blackwell, of New
Jersey. Creasoti, gtt. j.
Aq. calcis f.zj. M.
S. Five drops every ten minutes; failing with this, one drop every
three minutes.
Stomach irritation, transmitted from the pelvic viscera, in pregnant
women, being paroxysmal, may be successfully treated in the interval by
medicines which strengthen the stomach and general system to resist its
attacks.
11. Ferri, lactatis, vel.
Ferri et strychnise citratis,
Quinias sulph. aa gr. xii. . M.
Divide into twelve powders giving one every four hours. M.fyS.Rep.
A Pathognomonic Sign of Scarlatina. For some years past, M.
Bouehut (Journal Practical Medicine and Surgery) has been in (he
habit of pointing out in his wards a curious sign which assists in the dis-
crimination of scarlatina from measles, erythema, erysipelas, etc. It
consists in a vascular phenomenon, proportionate ir. intensity to the ex-
treme contra ctibility of the capillaries ; we refer to the enduring while
stripe produced at will by drawing the back of the nail over the part of
the skin in which the eruption exists. Pressure with the nail or any
other hard substance upon the exanthematous surface, produces a white
streak, which lasts one or two minutes, and sometimes more. Figures
may thus be traced upon the skin, the lines of which are conspicuous
from their whiteness. With a blunt probe or pen-holder, the diagnosis
of the disease may be distinctly inscribed on the integument, and after a
minute Or two the word scarlatina disappears, when the uniform tinge of
the eruption again invades the written surface.
This phenomenon is observable in scarlatina only. The scarlet hue
of measles id not uniform, the eruption consisting of mottled patches,
with very slight elevations separated by interstices of healthy skin In
measles the procedure we have described would produce an alternately
red and white streak, enduring a much shorter time than in scarlatina.
in erysipelas, in the redness induced by a mustard poultice, in solar
erythema, the white line we allude to is not visible ; and without attribu-
ting to this sign an undue degree of importance, it may be said to supply
one more element in the determination of the characters of the eruption
of scarlatina. Ibid.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
Vol. XVII. AUGLSTA, GEORGIA, SEI'IEPER, ISM. NO. 9
ORIGINAL AND ECLECTIC.
ARTICLE XVIII.
Indigenous Remedies of the Southern Confederacy which may
be Employed in the Treatment of Malarial Fever. By
Joseph Jones, M. D., Professor of Medical Chemistry in
the Medical College of Georgia, and Chemist to the Cotton
Planters' Convention of Georgia.
No. 1.
Summary. Necessity for the use of indigenous remedies at the pre-
sent time. Georgia Bark, (Pinckneya puoens) its affinities with
Peruvian Bark geographical distribution active alkaloid principle
medicinal properties use of by the inhabitants of Georgia in the treat-
ment of Intermittent Fever Testimony of Dr, John Stevens Law, of
Sunbury, to its efficacy as an an anti-periodic : method of using it.
Dogwood, (Comas Florida) botanical description geographical
distribution chemical composition examination of Dr. Walker, of
Virginia, 180-'] ; Dr. "Walker's receipt for making ink from the bark
examination of Mr. Carpenter, of Philadelphia Cornine examination
of Drs. Staple^, S. Jackson, James Cockburn and D. C. O'Keeffe medi-
cinal properties and uses testimony of Dr. Walkt.-r, of Yirgiuia, to the
medicinal properties of Dogwood ; of Dr. Gregg, cf Bristol; of Dr.-.
Jacob Bigslow, 8. G. Morton, R, Coates, D. (J. O'Keeffe and others- -
niethd of preparing the extract dose.
Cornus Circinata (Round-leaved Dogwood) testimony of Mori m
and Ives to its medicinal value.
Poplar or Tulip Tree, (Lirwdcndron Tulipifera) Botanical
character examination by Dr. Roger*, 1802 ; by Dr. J. P.Emmet,
1832 discovery of Liriodendrine chemical and physical properties
medical properties and uses of Poplar Bark testimony of Michaux, of
43
GT4 Joseph Jones, on the Indigenous [September,
Dr. Benjamin Rush, of Dr. I. T. Young, of Governor Clayton, of Drs.
Barton, Bigelow arid Bberlie great value as an antipcriodic.
Small Magnolia or Sivect Bay {Magnolia glauca) botanical
characters geographical distribution chemical composition examina-
tion of Dr. Jacob Bigelow medical properties and uses known to the
Indians testimony of Dr. Bigelow a domestic remedy in chill and
fever dose.
Cucumber Tree, (Magnolia acuminata,)
Big Laurel, (Magnolia grandiflora.)
Umbrella Tree (Magnolia tripetala.)
Persimmon, (Diospyros Virginiana.)
Catalpa, (Bignonia Catalpa.)
Virginia Sna/celioot, ( Aristolochia serpentaria) Botanical descrip-
tion geographical distribution chemical constitution analyses of Bu-
cholz, Chevallier, Dr. Jacob Bigelow, Conwell medical properties and
uses experiments of Jorg on Virginia Snake Root used by the Indians
and early settlers of America employed and extolled by numerous
physicians testimony of Dr. Nathaniel Chapman, of Sydenham, of Dr.
John Eberle, of Dr. Jacob Bigelow, of Dr. George B. Wood, and others.
Dose, and mode of administration.
Indian Quinine or Ague Weed, (Gentiana quinquifolia.)
Thorough Wort. (Eupatorium perforatum) Botanical description
geographical distribution chemical composition examination of Drs.
Anderson and Bigelow discovery of a salifiable base in, by Mr. J.
Scattergood. Medical properties and uses the Indians acquainted with
its uses use of by early settlers testimony of Drs. Chapman, Wood,
Anderson, Hosack, Baird, Eberle, Ives, Bigelow and others. Dose,
and mode of administration.
With our ports blockaded, and all commercial intercourse
cut off with those foreign countries and American States from
whence the South has received her supplies of medicine, it is
important, and we may say absolutely necessary that the in-
digenous remedies of the Southern Confederacy should be
carefully examined and employed. This examination and
employment of Southern remedies should be commenced by
the physicians not as a temporary expedient, but as a perma-
nent advance in the establishment of our absolute indepen-
dence. To facilitate this important object, we propose to
pass in review the various remedies which may be employed
in the treatment of the most common and important of South-
ern i . reserving the chemical analyses, physiological
and therapeutic experiments, with these and other remedies,
for subsequent papers.
1861.] Remedies of ih </. 675
GEORGIA BASK (FIX CXNEYA* PUBENS.) Michaux.
Bota?iical diameters. Capsule two celled, bearing the partition in
the middle of the valves. Corolla Tubular. Calyx, with one or two seg-
ments resembling braeteaa. Filaments inserted at the base of the tube.
Seed winged.
A large shrub, 15-20 feet high, with many stems from each root ;
branches branchiate ; the younger tomentose. Leaves opposite, large,
lanceolate, entire, slightly acuminate, shining on the upper surface,
though sprinkled with hairs, tomentose on the lower ; petiole about an
inch long, tomentose. Panicles terminal and axillary, composed of fas-
cicles, commonly 5 nWered. Calyx superior, 5 parted; persistent,
slightly colon I _ Qta sometimes equal, hmceclate and acuminate ;
:ently one and sometimes two segments dilate into a larg<-. ovate,
veiny, rose-colored leaf; when twe segments dilate, they ar.. never equal
ia size Corolla tubular ; the tube of an obscure green coior, tomentose ;
border 5 parted ; segments oval, obtuse, purple. Filaments inserted
into the base of the the corolla, longer than the tube. Anthers incum-
bent, two celled. Germ turbinate. Syle shorter than the stamens.
Stigma obtuse. Capsule nearly globose, opening at the summit across
the dissepiment. Seeds flat, orbicular, attached to a central receptacle
This geuu? is very nearly allied to cinchona. It differs in it3 calyx, but
principally by the transverse partition of its capsule. Flowers May and
June. Elliott. A Sketch of the Botany of South Carolina and
Georgia, vol. 1, p. 268.
Geographical Distribution. This small tree, interesting not
only for the elegance of its flowers and foliage, but also for its
close affinity to the celebrated genus Cinchona, which yields
the Peruvian bark, and for the valuable medicinal properties
of its bark, is indigenous and confined to the most southern
parts of the Southern Confederacy. It grows in wet and
boggy soils, along the small streams which intersect the pine
barrens, from New River, South Carolina, along the sea coast
into Florida. I have found it in greatest abundance in
Consecrated by the Elder Michanx, in testimony of his gratitude and
respect, to Charles Cotesworth Pinckney, of South Carolina, an enlight-
ened patron of the arts and sciences, from whom Michaux received mul-
tiplied proofs r.f benevolence m during hi- South
Carolina. First discovered by Bart ram, who considered it a
nda. Found for the first time by the elder IGohanx, in 1701, on the
banks of the St. M;.
376 J "osepii Jones, on the Indigenous [September,
the "branches" ofWalthourville in Liberty County, where it
is found in company with the elegant Buckwheat Tree (Mylo-
carium ligustrinum Pnrsh,) several species of Andromeda,
[Andromeda angustifolia Pursh, A. Catesbsei, Walt. A.
acuminata,) Hypericum fasiculatum, Poison bush, (Rhus ver-
nix,) Tupelo (Nyssa aquatica and ISr. grandidentata), Black
Gum, (Nyssa sylvatica), Red Maple, (Acer rubrunr), Cypress
(Cupressus desticha,) Small Magnolia or White Bay, (Magno-
lia glauca), Loblolly Bay, (Gordonia lasyanthus), Red Bay,
(Laurus Caroliniensis,) Sweet Gum, (Liquidambar styraciflua)
and Water Oak, (Quercus aquatica.) The branches which in-
tersect the Pine-barrens of Georgia are capable of supplying
large quantities of this important medicinal plant, and with
care, and the assistance of cultivation, tiiey might be made to
yield sufficient bark to supply the entire Confederacy. If this
plant fulfils its high promise, these barren and now valueless
regions of country, will yield one of the most valuable
remedies.
Chemical and; Therapeutic Properties. The inner bark of
the Pinckheya pubens is extremely bitter and appears to par-
take of the febrifuge virtues of iha Peruvian bark. Mr. Farr,
au able chemist of Philadelphia, many years ago instituted an
analysis of this bark, which although by unforseen accidents
was not as satisfactory as he would have wished it, still led to
the discovery of a crystallized substance which resembled
Cinchona. Previous to the extensive introduction of Bark
and Quinine, the inhabitants of Georgia and Carolina em-
ployed it successfully in the treatment of intermittent fevers.
Mr. John Stevens Law," ofSunbury, Georgia, in his Thesis
for the Degree of Doctor of Medicine, presented to the Faculty
of the University of Pennsylvania in the spring of 1825, states
that he was induced, to try it in intermittent fever, from the
estimation in which it was held by some of the inhabitants in
the neighborhood where he resided.
*Tho American]' tv, by John Redman Coxe, M. D: Philad.
1630, p. 4 'JO.
1861. Remedies of the Southern Confederacy. 077
Mr. Law nsed it in seven cases of intermitt( ix of
which were \ sedily cored by it. He affirms that in no
did it distress much the stomach, though in two cases it
was given in the quantity of i uv a dose, after the custom ot
the West Indian physichi
This bark may be administered in powder, in doses varying
from 5' to Si, accordiug to the severity 01 the it may
also be administered, in infusion or decoction. Michaux*
states that the inhabitants were accustomed to boil a
handful of the bark in a quart of water till the liquid was re-
duced one half, and to administer this decoction to the sick.
The tacts now presented with reference to this interesting
vegetable, which so closely resembles the celebrated Peruvian
Barks, that it has by several distinguished botanists been re-
d to the same genus, are sufficient to excite, but by no
means to satisfy, inquiry; and we sincerely hope that physi-
3 will make extensive examinations and trials, in practice,
with this Georgia Bark, which., aside from the reputation
h it formerly held in the cure of malarial fever, promises
so much from its botanical connections.
IK)GY\T>OD, (CORPUS FLORIDA.) L1X
Botanical Characters. Arborescent ; leaves ovate, acuminate ;
involucrum large, cbcordate ; drupes ovate.
A tree 15-25 feet high, the trunk 8-10 inches diameter, with expand-
ing brandies, the smaller crowded at the extremities of the older.
Wood fine grained, hard, durable. Leaves opposite^deciduaus, c
lanceolate, acuminate, entire, ribbed ; the younger oi ; tibcscent,
almost villous en the under surface. Flowers in terminal beads. Invol-
ucrum four-leaved ; leaves large, oboordate, nerved, white : the
callous, sessile s o? each ; efore the time
of flowering. Calyx one-leaved, small, tubular, left; seg-
ments erect, obtuse-,, shorter than the. tube. Petals 4, linear-lanceolate,
inserted into the summit of the germ, yellowish. Filaments 4, as long
corolla, alternating with the petal rs incumbent, two-1
Germ inferior, slightly angled. Style shorter than the stamens, sur-
rounded at has- by a glandular ring, around which the petals and fila-
"Xorth American, Sylvo, vol 1. ]>. 181, PhOad.
678 Joseph Jones, on the Indigenous [September,
merits are inserted. Stigma capitate. Drupe red. Flowers March.
April. Elliott. Sketch of Botany of South-Carolina and Georgia, vol
1, pp. 207-208.
Geographical Distribution. The Cornus Florida is first
seen in Massachusetts, between the 42d and 43d degiees of
latitude, and extends uninterruptedly throughout the east-
ern, southern and western states to the banks of the Missis-
sippi. Although abounding especially in the Middle States,
it is, nevertheless, one of the most common trees over this
vast extent of country. In New-Jersey, Pennsylvania, Ma-
ryland and Virginia, it abounds upon moist, gravelly, and
uneven soil ; in North Carolina, South Carolina, Georgia,
Florida and Alabama, it is generally found most abundant
and most luxuriant on the borders of swamps and low-
grounds, and scarcely ever in the pine barrens, where the
soil is too dry and sandy to sustain any trees but the long
leaf Pine, (Pinus Australis,) the Barrens Scrub Oak (Quer-
cus Catesbiei,) Upland Willow Oak, (Quercus cinerea,)
Black Jack Oak, (Quercus ferruginea,) and Running Oak,
(Quercus pumila.)
In the most fertile districts of West Tennessee and Ken-
tucky it is said not to appear in the forests, except where
the soil is gravelly and of middling quality.
Chemical Composition. The bark of the root, stem and
branches of the Comas Florida is a powerful bitter, posses-
sing a bitter astringent and slightly aromatic tae^a. The
chemical composition of this ba^k appears to have been
first investigated by Dr. Walker, of Virginia, who publish-
ed his observations in 1303 in Philadelphia.* He found
that water distilled from the bark in powder had a transpa-
rent, whitish appearance, with a slight aromatic odor, and
Experimental inquiry into the similarity in nature between the Cornus
ad Sericea, and the Cinchona Officinalis of Linncous, &c. &c. by
U. Walker. Philadelphia, 1803.
1861.] Remedies of the Southern Confederacy, 679
no perceptible taste ; when the heat was. increased the fluid
a lemon color, with an unpleasant smell, and an acerb
taste^ effects which were probably produced by the volatil-
ization and partial decomposition of portions of the bark
in consequence of the continuance of the heat until the
mixture was evaporated nearly to dryness.
Dr. Walker also endeavored to ascertain the effects of dif-
ferent menstrua upon the extract furnished by evaporating
a decoction of the root of Cornus Florida. Strong alcohol
tlved from the extract, three-fourths of the entire quan-
tity : the part which remained undissolved was destitute of
. and underwent no change of color on adding the test
of iron ; the alcohol which contained the dissolved portion
of the extract possessed an intensely hitter taste with as-
tringency, presented a clear red color, and turned to a deep
black on the addition of a salt of iron. When the alcoho-
xtract was macerated in repeated portions ot sulphuric
r, with a view to ascertain the quantity of resin, the
uired a dark color and a bitter taste, and dissolved
quarters of the extract. When tested with iron, it
found that the remaining quarter, only, waa changed
to a black coJ'
Upon this examination Dr. Walker announced that the
Dogwood contained gum, resin, tannin and gallic acid.
Mr. G. W. Carpenter, of Philadelphia, t subsequently
announced the discovery of a peculiar bitter principle for
which he proposed the name Cornine, and which he assert-
ed to he the active alkaloid principle of the Cornus Florida,
*Dr. Walker gives t for makii client ink, in which
bark of gall nuts.
* halt an ounce of Dogwood bark, two Bcruples of Su] hon
and two scrupl
the inlV,
tK- of the mos
By G. w. Carpenter. Philadelp] p. 202.
680 Joseph Jones, on the Indigenous [September,
and to be fully equal, if not superior to Quinine in its tonic
and febrifuge properties.
In consequence, however, of yielding this salt in so very
minute comparative proportion to what the Quinine is
yielded by the Cinchona, it is even more expensive than
the latter. It is greatly to be regretted that Mr. Carpenter
did not publish the method by which he extracted the alka-
loid principle. Some nave gone so far as to affirm that he
did not discover any alkaloid principle at all, because sub-
sequent investigations have failed to detect Cornine. "We
consider this criticism severe, for three reasons.
1st. ISiO absolutely accurate and complete examination of
the bark of the Cornus Florida has yet been made.
2d. As Mr. Carpenter did not state his method of obtain-
ing the active principle, it might be supposed that the
agents used exerted some influence in the transformation
as well as the separation of the alkaloid principle.
3d. Mr. Carpenter affirms that he submitted Cor-
nine to the examination of several physicians. This
subject is of so much interest and importance that we quote
the entire passage from the work of Mr. Carpenter :
"It gives me much pleasure to announce the discovery
which I made of an alkaline base in the Cornus Florida,
which I have denominated Cornine, and which with acids,
forms neutral salts, the sulphate of which has proved a
highly valuable tonic and febrifuge. This article has been
very carefully and accurately described by Dr. Samuel G.
Morton, of this city, in the Philadelphia Journal of the
Medical and Physical Sciences, and from the most respect-
able sources in the medical profession, from various parts
of the United States, where this article has been sent, the
most corroborating evidences have been received of the un-
equivocal success of the Cornine in the treatment of remit-
tent and intermittent fevers, in the same doses as the Qui-
nine, and the only circumstance which precludes its com-
petition with that substance, is the minute comparative
1861.] Remedies of the Southern Confederacy. 681
proportion of Cornine yielded by the Cornus Florida. If,
however, at any time, we should fail in our supplies of Cin-
chona, which is not impossible, or even improbable, we
shall then be able to supply its place by this principle of the
Cornus Florida/' Essays on the most important articles of
the Materia Medica, kc. p. 203.
Dr. S. G. Morton,* of Philadelphia, described Cornine
as a greyish-white powder, extremely bitter and deliquesent
when exposed to the air, and affirmed that he had exhibit-
ed it in some cases of intermittent fever with much success.
Dr. Morton considered it to be in no respect inferior to
Quinine. Dr. K. Coates, and several other practitioners,
exhibited this salt in the same cases in which Quinine is
employed, and with decided success.
Cornia, according to Mr. Carpenter, does not crystallize
but forms on evaporation a viscid mass. It is of a pale,
straw color, attracts the moisture of the atmosphere, and
dissolves in alcohol, and in sulphuric, acetic and muriatic
acids, with which it forms crystallizable, neutral salts. The
Sulphate crystallizes in acicular or needle-like cystals, deli-
quescent, and consequently soluble in water, of a greyish-
white color, and its taste is intensely bitter. According to
the testimony of Joseph Tongo,f M.D. and E. Durand. of
Philadelphia, Dr. Staples obtained it by digesting the bark
of the root of the Cornus Florida in alcohol of 30 deg. of
Baume's areometer. After several days had elapsed, the
latter was filtered and concentrated by distillation in a water
bath. On cooling, a granular extract was obtained, of a
light pink color, of a very bitter and astringent taste ; when
treated with diluted sulphuric acid, afforded a very small
* Philadelphia. Journal Medical and Physical Sciences, xl.
+ A Manual of Materia Medica and Pharmacy, comprising a concise
description of the articles used in Medicine by II. M. Edwards M. D. and
P. V M. J), "translated from the French by Joseph Tongo, M.
D. and E. Durand. I' 399.
G82 Joseph Jones, on the Indigenous [September,
quantity of cystals of Sulphate of Cornia, without having
been exhausted of all its bitterness and astringency.
Mr. Ellis states that Dr. S. Jackson, lately of Northum-
berland, Pa. informed him that he had subjected the bark
to Henri's process for obtaining Quinia from Cinchona, and
that without carrying the process so far as to obtain a cys-
talline salt, he used the concentrated alcoholic solution with
the most decisive results, and was satisfied that it contained
a principle analogous to Quinia.
Mr. James Cockburn examined the Cornus Florida in
1835, with the following results :
The decoction, which was of a bright red color, and slight
mucilaginous appearance, formed a precipitate with a solu-
tion of subacetate of lead, which consisted of gum, color-
ing matter, and other foreign substances. A precipitate
was also formed with pure alcohol.
Upon the addition of water to the tincture, concentrated
by evaporation, it threw down a curdy precipitate, which
upon examination, was found to be resin.
The decoction and tincture, redden litmus paper, and
cause a yellowish precipitate in a solution of gelatine, and
one of a dark olive green in a solution of sulphate of iron.
They also afford precipitates with sulphuric and muriatic
acids, lime water, alumina, the carbonates of ammonia and
potassa tartrate of antimony and potassa. The color be-
comes lighter on the addition of nitric acid ; milky by the
corrosive chloride of mercury, and has its color deepened
by ammonia.
A portion of the bark was digested in sulphuric ether for
a few days and filtered.
The etherial tincture was of a lemon color and reddened
litmus paper, and on evaporation deposited on the sides of
the vessel a fatty matter, insoluble in water, but soluble in
alcohol, leaving a greasy stain on paper; besides this there
was a compound of oil and resin combined with colouring
matter, and a substance of a light brown color, very bitter
taste, friable and very regular appearance, supposed to be a
1861.] s of the Southern Confederacy. 683
compound of a peculiar bitter principle, mixed with tannin
and other mutters. This was dissolved in alcohol and
formed a beautiful red colored tincture, which reddened
litmus paper. Lime was then added, boiled, filtered and
evaporated ; a substance resembling the etherial residue,
remained interspersed with small, shining acicular crystals
of a bitter taste, which property I am disposed to believe
they owed to the bitter extract with which they were asso-
ciated. The bark used in the last experiment was submit-
ted to the action of boiling ether, which on cooling depos-
ited a substance of the consistence of wax, which it resem-
bled in all its properties.
Two ounces of the bark coarsely powdered were intro-
duced into Jviij of alcohol and exposed to a temperature of
from 105 to 120 decrees F. The alcohol was then decanted
and a fresh portion added and treated as before. The liq-
uors were then united and a solution of sub-acetate of lead
added to separate the coloring matter ; after the insoluble
portion subsided, the clear liquor was separated, a little
sulphuric acid was then added to the solution to separate
any excess of sub-acetate of lead. This was filtered, and
the alcohol distilled off. There remained in the retort an
oily like substance, together with a principle of a dirty,
white color, curdled appearance, resembling the residue of
the etherial tincture. Ammonia was then added to the
liquor to precipitate any principle remaining in solution.
residue was then treated with a little sulphuric acid,
water and animal charcoal, (previously treated with muri-
atic acid,) which, upon evaporation, deposited an abuudant
ralline mas* of a flaky appearance, resembling at first
sulphate of quinine, but on coolin;:, assumed a feathery ap-
pearance, with a sharp saline taste, soluble in hot and cold
water, insoluble in alcohol and ether, soluble in nitric acid,
and resembled sulphate of ammonia in all its properties.
One pound of coarsely | 1 bark was boiled for
half an hour in one gallon of water, acidulated with 5iss
sulphuric acid. The tincture was poured oil', and treated
684 Joseph Jones, on the Indigenous [September,
with animal charcoal, and when evaporated, left a brown
extract of a resinous, waxy appearance, and very bitter taste,
which appeared to have very much the flavor of Peruvian
bark ; this was again treated with animal charcoal, and left
on evaporation, a crystalline mass in an impure form, which
was slightly soluble in alcohol, almost insoluble in ether,
but voiy soluble in nitric acid. The alcoholic solution was
evaporated, and left crystals of a very line, long, flexible
and silky appearance: which crystals decomposed when
thrown upon red coals, and did not form a precipitate with
oxalate of ammonia, but were without taste.
The bitterness was entirely owing to the bitter extract,
which was slightly soluble in water; soluble in alcohol, but
nearly insoluble in ether. This I propose to call bitter ex-
tractive, and in this I am inclined to believe the active
principle resides.
A concentrated tincture yielded by evaporation a dark
brown extract, slightly soluble in water, soluble in alcohol
and ether, bitter aromatic taste, possessing the properties of
resin. Both this and the watery extract possess the sensi-
ble properties of the bark in a concentrated form.
There is a red coloring principle in this bark, taken up
very feebly by alcohol and ether, but less so by water, and
has its color rendered deeper by an alkali.
One thousand grains of the bark yielded by incineration
a product weighing sixty-five grains : this residue was sub-
mitted to the action of boiling water, and concentrated by
evaporation; it then had an alkaline taste, effervesced
strongly with acids, and restored the blue color to litmus,
previously reddened by an acid ; it was then neutralized
with nitric acid, and upon evaporation yielded cystals of
nitrate of potassa.
The insoluble residue of the preceding experiment was
dissolved by nitric acid, (with the exception of a minute
portion of carbonaceous matter) with violent effervescence ;
the colorless solution thus obtained, threw down a white
precipitate, on the addition of oxalate of ammonia, and a
1861.] Remedies of the Southern. Confederacy. 685
deep blue one with ferrocyanate of potassa. It produced
also a dark green or black, with tincture of galls. Carbon-
ate of soda when added to the solution, caused a white
flocculent precipitate. On adding a solution of phosphate
of soda, no change was immediately produced, which led to
the belief that a salt of magnesia was present.
From the result of these few and imperfect experiments,
we may venture to enumerate the following as among the
principal constituents of the Cornus Florida.
1, Gum; 2, Resin; 3, Tannin; 4, Gallic Acid; 5, Oil
6, Fatty Matter ; T, a Crstalline substance ; 8, Bitter Ex
tractive; 9, AVax; 10, red coloring matter; 11, Lignin
12, Potassa; 13, lion. To which may be added, Salts of
Lime and Magnesia. Cornus Florida, by James Cock
burn, Jr. Extract from Thesis. Phil. Coll. of Pharm
American Journal of Pharmacy, July 1835, new series, vol
1, pp. 109-114.
Dr. D. C. O'KeefTe, whilst a student of medicine in the
Medical College of Georgia, published a valuable article on
the chemical constitution and febrifuge properties of Dog-
wood Bark ; in which he states that with the assistance of
Dr. Robert Campbell, he had determined upon and con-
ducted the following process for obtaining Comine:
Pulverize two lbs. of the well-dried bark of the root;
separate its tannin with sulphuric ether, and filter. Mace-
rate the separated bark in alcohol for two days, to extract
its resin and comine. Pour off the alcohol, and precipitate
the resin with water. Filter off the resin, and precipitate
the comine from the liquor with a solution of sub-acetate of
lead. Separate the sub-acetate of lead from the solution
by passing a current of sulphuretted-hydrogen gas through
it. Filter and evaporate the fluid down to the comine.
This substance is possessed of decided acid properties,
having a well-marked acid reaction ; it is of a dark straw
color, very bitter and astringent. Southern Medical and
Surgical Journal, January, 1849, p. 0-7.
Dr. O'Keeffe cites the testimony of Prof. Geiger, of Hei-
686 Joseph Jonfs, on the Indigenous [September,
dleberg, as confirmatory of the results of his examination
of the acid properties of comma.
It is evident from the discrepancies in the statements and
views of these various observers, that the analyses of Dog-
wood, thus far published, are not sufficiently thorough and
accurate, and that the profession needs more extended and
definite information with reference to the chemical and
physical properties of this valuable indigenous plant.
Medical Properties and Uses. The bark of the Dogwood
has been known and successfully used in the treatment of
intermittent fever for more than one hundred years.
Upon the human body the bark of the Cornus Florida
acts as atonic, astringent and antiperiodic, and resembles in
its general effects Peruvian Bark. Dr. Walker, by nume-
rous experiments with it upon the healthy system, deter-
mined that it uniformly increased the force and frequency
of the pulse, and augmented the heat of the body. He in-
stituted collateral experiments with the Peruvian bark, and
found that both its internal and external effects agreed with
those of the Cornus.
Dr. Gregg, of Bristol, Pennsylvania, states that after em-
ploying the Cornus Florida for nearly twenty-three years in
the treatment of intermittents, he was satisfied that it was
not inferior to Peruvian bark ; and that he had found it
uniformly beneficial as a tonic in cases of debility. Among
the number of cures by this medicine was that of his own
case. Dr. Gregg estimated thirty-five grains of it equal to
thirty grains of Peruvian bark; and observed that the only
inconvenience accompanying its use was, that if taken
within a year after being stripped from the tree, it some-
times occasioned acute pains in the bowels ; but this evil
was remedied by adding to it five grains of Virginia Snake
Root, (Aristolochia serpentaria.) He recommends the bark
as being in the best state after it has been dried a year.
In an intermittent fever which prevailed many years ago
in West Jersey, it is said to have proved, generally speak-
ing, more beneficial than Peruvian bark.
1861.] s of the Southern Confederacy . 687
Drs. Jacob Bigelow, S. G. Morton, R. Coatcs and many
other medical men have employed this bark with advantage
in intennittents and in debilitated states of the system, ac-
companied with loss of appetite and indigestion.
I have myself used it with good success in the treatment
of our climate fevers.
In the southern part of Georgia I have known the
planters to employ it extensively amongst their people in
combination with Wild Cherry bark and Wild Horehound,
(Eupatorium pilosum,) not only in the treatment of inter-
mittent fever, but also in colds and dropsies, and in all
cases of debility, accompanied with loss of appetite and
indigestion.
Dr. B. S. Barton states that a decoction of the Dogwood
bark was found very useful in a malignant disorder of
horses, called "yellow water."
Dr. D. C. O'Keeffe, in the article previously referred to,
gives an interesting account of the physiological as well as
the therapeutic action of the extract of dogwood, and sup-
ports his views by fifteen accurately detailed cases of inter-
mittent fever.
In order to ascertain with precision the effects of large
doses of the extract on the system in a physiological state,
Dr. O'Keefe instituted the following experiment upon him-
self
10 A. M. First dose 30 grains ext.; pulse previous to
taking it, * 2.
II A. M. Second dose, 30 grains ; pulse intermittent,
72-76; temperature ef surface somewhat augmented; gen-
eral perspiration ; a sense of fullness and slight dull pain
over the frontal eminences, much increased on flexing the
head forward and downward; uneasy feelings in the stom-
ach and bow
12 M. Third dose 30 grains; pulse 76, not intermittent
but somewhat depressed ; sensation in the head uniform
On taking this dose a Bense of warmth was felt in the sto-
mach, and radiated over the surface of the trunk.
688 Joseph Jones, on the Indigenous [September,
1 P. M. Fourth dose 30 grains ; pulse 7G and regular ;
pain in the head augmented, and extended clown the fore-
head to the eye-lids, with a disposition to sleep; slight op-
pression in the precordia.
Eating dinner, neither mitigated nor heightened the dull
headache, which continued the same throughout the day;
at night, tendency to sleep much more urgent retired early
slept well during the night, and arose in the morning free
from any uneasy sensations whatever. Southern Med. &
Sur. Jour. Jan. 1849 pp. 10-11.
The discrepancies between the effects observed by Dr.
O'Keeffe and Dr. Walker may have been due to the fact that
the former used the extract and the latter the bark ; be this
as it may, it is nevertheless true that the profession needs
an extended series of experiments upon the action of the
various preparations and constituents of the Cornus Flor-
ida. Until these data are supplied it would be worse than
useless to attempt any critical analysis and description of its
physiological effects.
Dr. O'Keeffe not only substantiates the testimony of va-
rious physicians to the great value of Dogwood in the treat-
ment of malarial fever, but he also establishes the fact that
the extract has no tendency whatever to disturb the stomach
and bowels. This is important, for the alleged tendency of
the Cornus to disturb the stomach and bowels mentioned
by so many writers, has exerted no little influence in causing
this valuable remedy to remain ueglected.
According to Mr. Carpenter the Cornus Florida yields a
beautiful extract resembling very closely that of Cinchona,
differing, however, in its sensible character, from the extract
of the superior species of Peruvian bark, by being less bit-
ter and more astringent.
The following is the most eligible mode for preparing!
this extract: Evaporate in a sand or water-bath a tincture
of the bark made by digesting it in proof-spirits in thef
proportion of two ounces of the former to a pint of thc|
latter, suffering it to stand for at least a week before strain-
i 1 .] Remedies of the Southern Confederacy* 089
ing; occasionally during this time submitting it for a few
hours to a moderated heat, an J thereby facilitating the so-
lution. This extract, from its most prominent and sensible
characters, is unquestionably much more active than the
common extract, of Carthagena bark, and is a preparation
admirably adapted, in all cases, where the Cornus may be
employed with advantage; and in consequence of being a
concentrated preparation, separated from the ligneous and
Luble portions, and containing less gum and mucus
matter, (which constitutes so large a portion,) is certainly
much preferable to the crude substance, and no doubt will
be resorted to by many country practitioners as a useful
expedient, particularly in those places where this article is
in profusion, and where bark of a good quality is frequent-
scarce, and sometimes even unknown. Essays on
Materia. Medica, &c. by W. P. Carpenter, pp. 203-204.
The extract thus prepared has been exhibited with suc-
cess by several practitioners in the same doses as the alco-
holic extract of Cinchona.
Dose of Extract of Cornus Florida from gr. x. to -Su-
ited as often as the case demands.
Dose in powder from 20 to 30 grains, to be repeated
according to circumstances. It may also be given in
decoction, made with an ounce of the bark to the pint of
water, of which the dose is from an ounce to two ounces.
In some parts of the country the ripe berries infused in
brandy, have been used as bitters; and the infusion of the
flowers are said to form a good substitute for chamomile
tea. A decoction of the buds and twigs has been thought
to agree better with weak stomachs than the other prepara-
tions.
CORNUS CIRCINATA. WILLD. (ROUND LEAVED
DOGWOOD,) and CORNUS SERICEA. AVILLD.
(SWAMP DOGWOOD.)
The ten species of Cornus, indigenous to the United
States and Southern Confederacy, are all supposed to |
44
690 Joseph Jones, on the Indigenous [September,
sess similar medicinal properties. With the exception of
the Cornus Florida the two under consideration have been
most carefully investigated. Our knowledge, however, of
both their chemical and medicinal properties is not only
more imperfect than that of the Cornus Florida, but is
vague and meagre. Professor Morson and Dr. Ives appear to
have been the first to introduce the Cornus Circinata into
medical practice. They recommend it very highly for its
astringent and tonic properties, and affirm that they have
successfully used it in intermittent fevers and dysentery.
Mr. Carpenter announced that the alkaloid principle, Cor-
nine, exists also in this species of Cornus.
The alcoholic extract appears to be the most eligible
mode of using this article. The extract is prepared in the
same manner with that of the Cornus Florida, it possesses
more astringency and is therefore better adapted to the
treatment of dysentery. As this plant appears to be rare in
most of the Southern States, it is not likely that it will ever
be extensively employed, espescially as the Cornus Florida
is not only more abundant but also fully as efficient. The
bark of the Cornus Sericea (Swamp Dogwood,) was found
by Dr. Walker to be equal to that of the Cornus Florida,
and but little inferior to the common pale Peruvian bark, in
the treatment of intermittents. It forms a beautiful tinc-
ture with proof spirits.
As the Swamp Dogwood inhabits the North American
continent from Canada to Florida, growing in moist woods,
in swamps, and on the borders of streams, especially in the
mountains, it is well worth the attention of the physicians
of the Southern Confederacy.
The doses and modes of preparation and administration
are the same with those of the Cornus Florida.
POPLAR OR TULIP TREE. (LIRIODENDRON TU-
LIPIFERA.) LINN.
Botanical Characters. Calyx three-leaved. Petals 6. Capsules
(Samara) imbricated, forming a strobilus, 1-1 seeded, not opening.
Leaves truncated, pnemorse, four-lobed ; calx three-leaved. This is
1861.] Remedies of the Southern Confederacy. 691
one of the largest trees of the American forests. In the low country of
Carolina and Georgia, it is somewhat rare and seldom exceeds three
feet in diameter, but in the fertile soils of the western country in Ken-
tucky, Tennessee and Alabama, it is sometimes found seven to nine feet,
and one hundred and twenty to one hundred and forty feet in height.
The wood of this tree though soft is durable. The leaves are alternate,
three-lobed, with the middle lobe truncate, and varying with the angles
of the lobe obtuse, acute and accuminate, glabrous, on petioles two to
three inches long. Flowers solitary, terminal. Leaves of the calyx
concave. Petals obovate, lanceolate, of a dull, yellow colour tinged
with red. Stamens numerous, disposed in a simple series shorter than
the petals. Germs numerous on a conical receptacle, Grows in most
fertile soils. Flowers May and June. Elliott. Sketch of Botany So.
Ca. and Georgia, vol. 2. pp. 40-41.
Geographical Distribution. According to Michaux, the
southern extremity of Lake Champlain in latitude 45, may
be considered as the northern limit, and the Connecticut
river, in the longitude of 72 as the eastern limit of the
Tulip tree. It is only beyond the Hudson which flows two
degrees further west, and below 43 of latitude, that it is
frequently met with and fully developed. It is multiplied
in the middle states and in the upper parts of the Carolinas
and Georgia, and still more abundantly in the western
country, particularly Iventucky. Its comparative rare
in the maritime parts of the Carolinas and of Georgia, in
Florida, Alabama and lower Louisiana, is owing less to the
heat of the summer than to the nature of the soil, which in
some parts is too dry, as in the pine-barrens, and in others
too wet, a- in the swamps which border the rivers.
The western states appear to be the natural soil of this
magnificent tree, where they have been found 23 feet in
circumference and from 120 to 140 feet in height. Forest
trees of America, vol. 2, p. 35.
Chemical Composition. The first chemical examination of
the bark of the Liriodendron Tulipifera, appears to have
been made in 1802, by Dr. Rogers. From the state of
Organic chemistry at that time this examination was almost
necessarily imperfect and resulted m the determination of
nothing more than gum resin, an acid supposed to be mu-
692 Joseph Jones, on the Indigenous [September,
riatic, iron, calcareous salt, mucus and fecula, as its chief
constituents.
In 1832 Dr. J. P. Emmet,* of the University of Virginia
announced the discovery of a peculiar principle in the Pop-
lar bark, which he called Liriodendrine ; and which he de-
scribed in the pure state, to be solid, white, crystallizable,
brittle, inodorous at 40p, fusible at 180 and volatile and
decomposed at 270, and of a slightly aromatic odor, and a
bitter, warm, pungent taste ; insoluble in water, soluble in
alcohol and ether ; water precipitates it from its alcoholic
solution ; incapable of uniting with alkalies and acids ; al-
kalies precipitate it tfrom the infusion or decoction of the
bark by combining with the matter which rendered it solu-
ble in the water. It is obtained by mascerating the root in
alcohol, boiling the tincture with magnesia till it assumes
an olive green color, then filtering concentrating by distil-
lation till the liquid becomes turbid and finally precipitating
the Liriodendrine by the addition of cold water. When
carefully heated in a glass tube closed at one end it gives
off a white vapor which condenses again without any signs
of crystallization. Prof. Emmet regarded it as analogous to
Camphor.
The fact that the bark of the Liriodendron is weakened
by age and so far loses its bitter and aromatic taste, as to
become almost insipid, gives force to the opinion that its
peculiar properties reside in this volatile principle, Lirio-
dendrine.
Medical Properties and Uses. Formerly this bark was
employed in the United States, both in domestic and regu-
lar practice, and from the testimony which was then pub-
lished in favor of its decided value as an aromatic, stimu-
lating tonic, diaphoretic and anti-periodic, it appears to be
well worthy of the careful examination of physicians at the
present time.
* Journal of the Philadelphia College of Pharmacy, iii. 5.
1361.] Remedies of Southern Confederacy. 693
Michauxf in his splendid work on the Forest Trees of
America, states that in some parts of Virginia the inhab-
itants were accustomed to steep the bark of the roots, with
an equal portion of Dogwood bark in brandy during eight
days; two glasses of this tincture, taken every day, some-
times cures intermittent fevers.
Dr. Benjamin Rush* states that he employed the Poplar
bark in the treatment of intermittent fever "with as much
satisfaction as any of the common bitters of the shops."
The testimony of Dr. J. T. Young, of Philadelphia, to
its value is decided and well worthy of consideration at the
present time, when we are liable to be deprived of our most
powerful and valuable remedies.
In a letter* addressed to Gov. Clayton, of Delaware, in
1792, he thus states the results of his experience :
" The Liriodendron Tulipifera, (Tulip or Poplar tree,)
grows throughout the United States of America. The best
time to procure the bark for medicinal purposes is in the
month of February, as the sap at this time being more con-
fined to the root increases its virtue.
It possesses the qualities of an aromatic, a bitter and an
astringent. The bitter quality is greater, the astringent
less than in the Peruvian bark. It likewise posseses an
aromatic acrimony, hence I infer it is highly antiseptic and
powerfully tonic. I have prescribed the Poplar bark in a
variety of cases of intermittent fever, and can declare from
experience, it is equally efficacious with the Peruvian bark,
if properly administered.
In the phthisis pulmonalis attended with hectic fever,
night sweats and diarrhoea, when combined with laudanum
it has frequently abated these alarming and trouble?'
iptoms. I effectually cured a Mr. Kiser, fifty years of
t Vol. ii. p. 40.
Transactions of the College of Physicians of Philad. 1798.
\ Carey's American Museum, vol. 12.
694 JosEni Jones, on the Indigenous [September?
age, who was afflicted with a catarrh and dyspeptic symp-
toms for five years, which baffled the attempts of many
physicians, and the most celebrated remedies, by persever-
ing in the use of the Poplar bark for two weeks.
I can assert from experience there is not in all the Mate-
ria Medica, a more certain, speedy, and effectual remedy
in hysteria than the Poplar bark, combined with a small
quantity of laudanum. I have used no remedy in the
cholera infantum but the Poplar, after cleansing the primse
via;, for these two years. It appears to be an excellent ver-
mifuge. I have never known it to fail in a single case of
worms which has come under my observation. I prescribed
it to a child when convulsions had taken place. After ta-
king a few doses, several hundreds of dead ascarides were
discharged with the stools. The dose of the powder for an
adult is from a scruple to two drachms; it may likewise be
used in tincture, infusion, or decoction, but its virtues are
always greatest when given in substance."
Gov. Clayton in his reply observes : " During the late
war the Peruvian bark was very scarce and dear. I was at
the time engaged in considerable practice, and was under
the necessity of seeking a substitute for the Peruvian bark.
I conceived that the Poplar had more aromatic and bitter
than the Peruvian, and less astringency. To correct and
amend these qualities I added to it nearly an equal quan-
tity of the bark of the root of dogwood, (Cornus Florida or
Boxwood,) and half the quantity of the inside bark of the
White Oak tree. This remedy I prescribed for several
years in every case in which I conceived the Peruvian bark
necessary or proper, with at least equal if not superior suc-
cess. I used it in every species of intermittent, gangre-
nes, mortifications, and, in short, in every case of debility.
It remains to determine whether the addition of those barks
to the Poplar increases its virtues or not. This can only be
done by accurate experiments in practice."
Dr. Barton* recommended the bark of the Poplar in
larton's Collections.
1861.] Remedies of the Southern Confederacy. G95
chronic rheumatism and in gout ; and from its tendency to
produce diaphoresis, together with its tonic powers, there can
be little doubt of its value in certain conditions of these dis-
eases. Dr. Eberle* employed it repeatedly in conjunction
with the Ulmus Aspera, in the form of decoction, in the treat-
ment of advanced stages of dysentery with satisfactory re-
sults.
Dr. Bigelowf used it with success as a stomachic.
The powdered bark in union with steel dust has been pre-
scribed with great advantage in debilitated states of the
stomach.;}:
The most efficacious form of administering the bark of the
Liriodendrum Tulipifera is in substance in the form of pow-
der, 5ss to oij. The infusion i.5 of powdered bark to one pint
of water, may be administered fji to fij., and the saturated
tincture in the dose of f5i.
The infusion and the tincture are not as efficient as the
powder.
No use that we are aware of has as yet been made of the
Liriodendrine.
The seeds are said by Rafinesque to be laxative ; this fact,
however, has been noticed by no other writer, and needs con-
firmation.
The leaves have been used as an external application in
headache ; and an ointment prepared with them lias been
. with good effects in ulcers.
In the administration of the bark in powder the bowels
should be first opened by a cathartic ; and if the bark pro-
duces pain in the bowels, it should be combined with small
quantities of laudanum.
* A Treatise on Materia Mediea and Therapeutics, by John E
biladelphia, 1830. Vol. 1, p.
t American Medical Botany, fro. Philadelphia, by
I>. B !1. H2.
| Thacher's ]' :y.
G9(j Joseph Jones, on the Indigenous [September,
SMALL MAGNOLIA OR SWEET BAY, (MAGNOLIA
GLATTUA.) LINN.
Botanical Characters. Leaves oval lanceolate, glaucous under*
ncath ; petal? obovate, tapering at the base. A shrub frequently be-
coming a small tree, remarkable for its white or somewhat glaucous bark.
Leaves alternate, on petioles abont an inch long, acute, shining, and
when young, pubescent, underneath glaucous, pubescence when young
having a silken lustre. Flowers solitary, terminal. Leaves of the
calvx oval, glabrous, membranaceous, sprinkled with pellucid dots as
long as the corolla. Petals generally nine, obovate, white, as long as
the receptacle. Filaments very numerous, compressed, with the point
acuminate, and extending beyond the anthers. Anthers attached to the
inner side of the filaments This is probably the most fragrant plant
in our forests. It grows in great profusion along the margin of the
rich swamps which border our rivers, and in the morning and evening,
during the period of its flowering, the atmosphere of our streams is often
literally perfumed with its fragrance. Flowers April and May.
We have a variety with perennial leaves, which sometimes becomes a
tree 50-GO feet high. I have been able to discover no other distinction
between these two plants than this difference of habit. Elliott. Sketch
of the Botany of South Carolina and Georgia, vol ii, p 37.
Geographical Distribution. The Sweet Bay lias the most
extensive range, especially near the seaboard, of any of the
species of the Magnolias. According to Professor Bigelow*
its most northern* boundary appears to be in a sheltered
sAvamp in Manchester, Cape Ann, about thirty miles north of
Boston. It here attains to but small size, and is frequently
killed to the ground by severe winters.
It is common in the Middle States, and abounds in the
maratime parts of the Southern States.
In North Carolina and South Carolina it is found in great-
est abundance within the limits of the pine-barrens, growing
abundantly in the brandies, marshes or swamps traversing
the pine-barrens. It is not abundant in the large swamps
bordering the rivers, and is very rarely found upon the islands
which border the sea coa
mical Composition. As far as our information extends,
mplete chemical analysis lias been made of the bark of
ibis tree ; it is highly probable that its constituents will be
* American Medical Botany, vol ii, p. 68.
1861.] JR of (he Southern C ?/. 697
found to resemble closely those of the Magnolia grandiflora,
which, bccot if Dr. Procter-, contains
ven resin, a volatile oil, and a peculiar crystallizable prin-
ciple analogous to Liriodendrine, which, as we have previously
liscovered by Dr. J. P. Emmet in the bark of the
Tulip Tree. Dr. Bigelow gives in his most valuable Ameri-
can Medical Botany the fullest account of the chemical con-
stitution of the bark of the Magnolia Glauea with which we
are acquainted. The following are the results of his exami-
nation.
The bark of the Magnolia Glauea has a bitter taste, com-
bined with a strong aromatic pungency, which approaches
that ifras and of the Acorns Calamus. The aroma
resides in a volatile portion, which is probably an essential
oil or a variety of camphor. It is lost from the *b ark in the
dry state, after it has been kept some time. Water distilled
from the green bark has its peculiar flavor, with an empyreu-
matic smell. Xo oil appears on the surface when the experi-
ment is conducted in the usual way. The dried bark affords
a little resin, and more of a bitter extractive substance. Cha-
lybt 3 produce a very slight darkening of the green
color of the decoction, but gelatine occasions no change.
rht be anticipated from the little taste of astringency
in the bark. American Medical Botany, vol. ii, p TO.
The Indians used the bark
he Magnolia Glauea as a remedy for autumnal fever and
rheumatism, and in many parts of this country it has been
used with si the treatment of malarial fever, both in
regular prac
Dr. J. -low thus testifies nedicinai properties
and value : . lal article, the Magnolia is to be
sidered an aromatic tonic, approaching in its character to
' :es of their class. Considered
sim; is t'.;.:" powers, it is probably of a
rjdary order, though from the additional properties which
* American Journal ofPharmacv, vol. xiv, p. Oo.
698 Joseph Jones, on the Indigenous [September,
it possesses of a warm stimulant and a diaphoretic, is found
useful in certain disorders.
Chronic rheumatism is one of the diseases in which it ex-
hibits most efficacy. Not only the bark, but the seeds and
cones which are strongly imbued with the sensible qualities
of the tree, are employed in tincture with very good success
in this disease.
In intermittent and remittent fevers the Magnolia is one of
the many tonics which have been resorted to for cure by the
inhabitants of the marshy countries where they prevail. Suf-
ficient testimony has been given in favor of the bark of this
tree, to warrant a belief that it is fully adequate to the remo-
val of fever and ague, when administered like the Cinchona,
in liberal quantities between the paroxysms. In the more
continuous forms of fever, of the typhoid type, it has also re-
ceived the commendations of physicians. American Medical
Botany, vol. ii, p 70-71.
The dose of the powdered bark is from half a drachm to a
drachm, repeated according to the character of the case. A
decoction may be made in the proportion of one ounce of the
powdered bark to the pint of water this may be administer-
ed in doses of from fS to fSij, and repeated every one, two or
three hours, according to circumstances.
An extract has been made from it, but its powers have not
been sufficiently tested. An infusion of the bark in brandy
has been employed in rheumatism.
The cones and seeds have likewise been employed to make
a tincture, which has been a popular remody in the treatment
of chronic rheumatism, and as a prophylactic against inter-
mittent fever.
CUCUMBER TREE, (MAGNOLIA ACUMINATA MICH.)
and BIG LAUREL, (MAGNOLIA GRANDIFLORA
MICH.) and UMBRELLA TREE, (MAGNOLIA TRIPE-
TALA,) WILLD.
Our information with reference to those three species of
Magnolia, although less definite and far more meagre than
that which we have presented concerning the Magnolia
1861.] i?' f the Southern Confederacy. 699
Glauoa. still as far as it extends, tends to establish their value
in the treatment of malarial fever.
The Cucumber tree, m)agn<>lia acuminata) which extends
from the Falls of Niagara along the whole mountainous tract
of the Alleghanies to their termination in Georgia, and also
along the Cumberland mountains in Tennessee, has been em-
ployed by the inhabitants of the country bordering on the
Alleghanies as a preventative of intermittent fever. Michaux*
states that they gather the cones about midsummer when half
ripe, and steep them in whiskey ; a glass or two of this liquor,
which is extremely bitter, they habitually take in the morning,
as a preventative against autumnal fevers.
AVe are not aware that there are any recorded observations
of the results of these attempts to ward off malarial fever ; it
would therefore be highly important that physicians living
in the regions where this tree is found, should carefully deter-
mine the value of the cones as a prophylactic. The discovery
of a native prophylactic against malarial fever would be of
incalculable value to our planters in the rich low-lands of the
Southern Confederacy, and especially to bodies of white men
exposed during marches, and in the defence of our coast, to
the destructive exhalations of marshes and rice fields.
We have before alluded to the discovery by Dr. Stephen
Procter, of a principle in the bark of the Magnolia grandi-
flora, analogous to the principle Liriodendrine of the Tulip
tree. In addition to this he found a volatile oil, and resin.
The medicinal properties of these different species appear, as
far as our very limited information extends, to be almost iden-
tical, and it is probable that they may be substituted one for
the other without inconvenience in the same doses recom-
mended for Magnolia Glauca. AYe need, however, accurate
analyses and extended medical observations.
PEBSIMMON (DIOSPYEOS V1RGIXIAXA.) MICH.
Ereckel in his "History of North Carolina," says that the
inner bark has been used with success in intermittent fever.
*Fore<t Trees of America, vol. ii. p. 10.
700 Joseph Jones, on the Indigenous [September,
As tar a? our information extends, this interesting statement
remains to be verified. It is well known that its tonic and
astringent powers have proved exceedingly valuable in the
treatment of affections of the bowels,* hemorrhage and ulcer-
ated sore throatf ; there are many stages and complications
of the different forms of malarial fever, where these tonic
and astringent properties would fill most important indica-
tions; tor malarial fever, as is almost always the case in
China, is frequently accompanied with derangements of the
bowels.
CATALPA. (BIGNOXIA CATALPA.) LINN.
In a thesis supported at the Medical Department of the
University of Pennsylvania, the bark of the Catalpa was
maintained to be t:>nic, stimulant and more powerfully anti-
periodic than the Peruvian bark. I have been unable, after
careful research with the best authorities to find any facts
which bear either upon the chemical constitution, or the tonic,
stimulant and antiperiodic properties of the bark of the
Catalpa. Physicians should exercise caution in their experi-
ments with it, because it is generally believed to be poisonous.
When the bark is wounded a very unpleasant, and according
to the testimony of some, a poisonous gas is emitted ; and it
lias been stated, on good authority, that the honey collected
from its flowers is poisonous, producing effects analogous,
though less alarming, than those produced by the honey col-
lected from the Yellow Jasmine of Carolina.
The seeds have been employed by several practitioners of
continental Europe in asthma.
M. Automarchi recommends for this purpose a decoction
made by boiling twelve ounces of water with three or four
ounces of the seeds down to six ounces, the whole to be given
morning and night.
I u the use of the unripe fruit of the Diospyros Virginiana, as a thera-
peutic a cut. By JohnP. Mettauer, At. I)., of Virginia. The American
Journal of Med. Soi October, L842, p297. Amer. Jour. Pharm. xii, p
161. "Wood house, Inaug. Diss.
+ Dr. B. S. Barton^ Collections. 11.
1SG1.] Remedies of the Southern Confederacy . 701
VIRGINIA SXAXEROOT, (ARISTOLOCI1IA
SERPENTAKIA.) LIXX.
Botanical Description. Loaves cordate, oblong, acuminate ; stem
flexuons; peduncles radical ; lip of the corolla lanceolate. Root pe-
rennial, composed of many filiform fibres, pungent and aromatic. Stem
i eight inches high, herbaceous, pubescent, erect, geniculate and
knotty at base, as if formed of the remains of older stems. LcAves few,
oblong, lanceolate, slightly acuminate, a little hairy, cordate at base.
Flowers few at the base of the stem, laying on or sometimes under the
surface of the earth. Peduncles one-flowered. Corolla ventricose at
base, slightly three cleft at summit ; one lobe extended, lanceolate.
Grows in drv soils. Flowers in summer. Elliott. Sketch of Botany
of S. C. and Ga. vol. 2, pp 511-512.
Geographical Distribution. Middle and Southern States.
The most northern situation from which Dr. Bigeldw received
specimens was from the vicinity of Xew Haven. There are
many varieties, and according to some botanists, several
species confounded in the market, under the common name
of A. Serpentaria. In a medical point of view, this confusion
of species is of no consequence, as they are almost entirely
identical in properties and remedial action.
Chemical Constitution. According to Bucholz, who ana-
lyzed the root in 1807, 100 parts contain :
Volatile Gil, 0.50
Greenish-yellow soft resin, - - - 2.85
Extractive matter, - - - - 1.70
Gummy Extractive, - - - 18.10
Lignin, 62.40
Water, 14.45
100.00
It was again examined by Chevaliier in 1820, and fonnd to
consist of volatile oil, resin, extractive, starch, ligneous fibre,
albumen, malate and phosphate of lime, oxide of iron and
silica,
Grassman obtained only half an ounce of volatile oil from
100 1!js. of the root, which he describes of a yellowish color,
strong odor and moderately strong taste, and compares the
odor and taste to those of valerian and camphor combined.
702 Joseph Jones, on the Indigenous [September,
The bitter principle termed Extractive by Bucholz and
Chevallier is very bitter, slightly acrid, soluble in both water
and spirit ; its solution which is yellow, is rendered brown by
alkalis, but is unchanged by ferruginous salts. The root com-
municates its qualities both to spirit and water, but most to
the former.
Dr. Jacob Bigelow, subjected a quantity of the root to dis-
tillation for one hour, and obtained in the receiver a wetish,
pearly fluid, very strongly impregnated with aroma, but less
bitter than the root. On standing twenty -four hours, this fluid
deposited round the edges of the surface a considerable num-
ber of small white cystals, which proved to be pure camphor.
They were inflammable, fusible with a suddeu, and volatile
with a gradual heat. American Medical Botany, p 85.
Dr. C. Conwell,* more than thirty years ago announced the
discovery in this root of a new alkaloid principle for which he
proposed the name of Serpen taria. It forms in a defined
cystallized mass of a bitter taste, and possesses all the alkaline
properties. The sulphate cystallizes in quadrangular prisms,
terminated in inclined facets. The hydrochlorate of Serpen-
taria forms brilliant plumose fibrils. Both these salts are'in-
soluble, except in an excess of acid. The preparation is the
same as that by which quassa is obtained.
This principle may be the same as the yellow bitter princi-
ple of Chevallier, which he considered as analogous to the
bitter principle of quassa.
Medical Properties and Uses. The experiments of Jorg
and his pupils, established that in small doses it promotes
appetite ; in large doses, it causes nausea, uneasy sensations
in the stomach, flatulence and more frequent but not liquid
stools : after absorption, it increases the frequency and fulness
of the pulse, augments the heat of the skin, and promotes se-
cretion and excretion, and in very large doses causes disturb-
Manual of Materia Mcdioa, by II. M. Edwards and P. Vavasseur, M.
D. Translated by J. Tongo, M. D., and E. Durand, p 1S3. Philad. 1829.
1861. Remedies of the Southern Confederacy. 703
ance of the cerebral functions, producing headache, sense of
oppression within the skull, and disturbed sleep.
root is said to have been in common use among the
Indians at the time of the arrival of the first settlers, and was
much esteemed by them as a remedy in snake-bites. The
early colonists soon adopted it as an excellent tonic and
stimulant, and it is to this day extensively employed as a do-
mestic remedy in levers and in debilitated states of the system.
It has been employed and extolled by numerous physicians,
and it will be profitable for us to review the testimony of
several of the most intelligent and extensive American practi-
tioners. Dr. Chapman considered the Serpentaria as possess-
ing the mixed qualities of a stimulant and tonic, with active
diaphoretic and diuretic properties. "Among the more early
- of the medicine was its application in the cure of inter-
mittent fever. Whether it is adequate alone to the purpose
does not clearly appear. But it certainly proves an important
adjuvant. It was used by Sydenham, in conjunction with
wine, to prevent the recurrence of the paroxysm, and, from
his account, not without advantage. As a general rule, he
. that in all cases where it is expedient to combine wine
with bark, the effect will be much increased by adding ser-
pentaria. The correctness of this observation lias been fully
confirmed by subsequent experience, and it is now very much
the practice to unite these articles in the low states of disease.
"To remittent fever, serpentaria seems to me to be best
adapted. It has here, in many oases, an indisputable supe-
riority over the bark, inasmuch as it is rarely offensive to the
stomach, and maybe given, without injury, in those obscure
states of the disease where the remission is not readily dis-
cernible. As a popular remedy, more particularly, it is much
employed in the secondary stages of pleurisy. After bleed-
ing, it is the practice in many parts of our country, to resort
to a strong infusion of this article, with a view to exciting
piration, and the result is said to be generally favorable.
Catarrhs, rheumatisms, and other winter affections incident to
rustic life, are managed in the same way. It is also a noted
704 Joseph Jones, on the Indigenous [September,
remedy in dropsy, to which, I should presume, it is adapted,
and especially if the ease be of an intermittent type.
"In that species of pleurisy which is properly enough desig-
nated by the epithet bilious, I have repeatedly had occasion
to recur to the serpentaria, and always with more or less
utility. I know not, indeed, any modification of disease in
which it displays its power more advantageously. The bilious
pleurisy has all the characteristics of pneumonic inflammation,
with the addition of some of the symptoms incident to autum-
nal fever. There is considerable headache, much gastric dis-
tress, and almost always violent vomitings of bile. It differs
also from ordinary pleurisy in having less activity of inflam-
mation, and consequently in not bearing the same extent of
depletion. The system, indeed, will often be very evidently
depressed by one or two bleedings. In this case, the practice
which lias been commonly pursued, is after the removal of a
comparatively small portion of blood, and the thorough evac-
uation of the alimentary canal, to administer draughts of the
infusion of serpentaria, in order to excite diaphoresis. As an
epidemic, the bilious pleurisy prevailed in the neighborhood
of this city many years ago, and I am informed, was managed
most successfully by the practice which I have detailed. It
is not, however, one of the ordinary complaints of the climate
of the middle States. The cases which I have seen of it have
for the most part occurred in persons coming from districts of
country exposed to marsh exhalation, and who have previously
had autumnal fever. I have only one more remark to make
on the properties of this article, which is, that it is admirably
suited to check vomitings, and to tranquilize the stomach, par-
ticularly in bilious cases. It is given for the purpose in infu-
sion, in the small dose of half an ounce or less at a time, and
f req uen tly re pea ted. " *
* Elements of Therapeutics and Materia Medica. By N. Chapman, M.
D. &c. Philad. 1S22, vol. ii, pp. 432-433.
1861.] es of the Southern I racy. 705
Dr. John Eb eric thus testifies to the action and medicinal
value of Virginia Snake*
When taken into the stomach it increases the force and fre-
quency of the pulse, exc! low of heat throughout the
system, and produces pretty copious diaphoresis. It is not,
however, simply stimulant and diaphoretic in its effects, for
along with these qualities, it possesses very important tonic
powers.
Possessing, along with its tonic, pretty powerful stimulant
properties, the snakeroot is peculiarly suited to fevers of a
low grade of excitement ; on the other hand, however, it can
never be employed without danger, when blood-letting is
indicated.
In every variety of fever, however, when the system is
sinking into a typhoid state, the snakeroot is a remedy of un-
questionable utility. It is especially serviceable in the latter
stages of febrile diseases, when the skin and tongue remain
dry and hot, and the pulse is feeble and frequent. When
given in this state, it commonly excites a general diaphoresis ;
the tongue becomes moist, and the pulse and the general
powers of the system are invigorated.
A good deal 1. . said in favor of the powers of the
serpentaria in putrid fevers, and from the general properties
of this remedy, there can be little doubt of its applicability to
the treatment of fevers of this kind.
The snakeroot was formerly much employed in intermit-
tents. Of its efficacy, however, in the cure of thie
when administered by itself, not a great deal can be said. I
have employed it in some instances, but always without buc-
. and I am inclined to believe that it is not often capable
of arresting the disease. When united, however, with bark,
me of the bitter tonics, it seems to increase their efficacy,
and it is in this way thai it is now commonly employed in in
mittent and remittee It is particularly useful, with
Peruvian bark, in those intermittents wher n is
depressed and sluggish during the intermission, with a small
45
706 Joseph Joxes, on the Indigenous [September,
and feeble pulse, and a cold and dry state of the surface of
the body.
During the prevalence of the late epidemic, pneumonia
typhoides, in this country, the serpentaria was much pre-
scribed by some physicians. Being at once stimulant, dia-
phoretic and roberant, it was particularly calculated to pro-
duce beneficial effects in this disease by equalising the circu-
lation and imparting vigor to the vital powers.
Dr. Dyckman states that he has prescribed the snakeroot in
combination with seneka, with marked advantage in this
disease. It may also be employed with advantage in the
latter stages of pneumonia and bronchial affections, being
useful not only by its tonic operation, but chiefly, perhaps, by
exciting the cutaneous emunctories, and thereby relieving the
pulmonic system. The infusion of snakeroot may be used
with advantage as a gargle, in ill-conditioned ulcers of the
throat. Treatise on Materia Medica and Therapeutics by
John Eberle, M. D. &c. Philadelphia, 1S3G, vol. i, pp.
258-259.
The following is the testimony of Dr. Jacob Bigelow :
Medically considered, serpentaria is a tonic, diaphoretic and
in certain cases an antispasmodic and anodyne. It has been
abundantly used in fevers of various descriptions, and has
been commended by a host of medical writers. There is no
doubt that it has been injudiciously employed in many cases,
in fever attended with an active pulse and inflammatory
diathesis.
The early stages, also, of febrile diseases rarely admit the
exhibition of so decided a stimulant without injury. But in
the advanced stnges of fever, and those attended with
typhoid al symptoms, this medicine is resorted to with groat
advantage, both alone and in combination with other tonics
and stimulants. It is peculiarly useful in supporting the
strength and in allaying the irregular actions which attend
; febrile debility, such as subsultus tendinum, delirium,
watchfulness, &c. Its bitter ingredients, and the camphor
which it contains, no doubt contribute to their eflects. It is
1861.] Remedies of the Southern Confederacy. 707
most advantageously given in combination with bark, or witL
wine and opium. American Medical Botany, vol. 3, p
Dr. George B. Wood in his valuable work on Therapeutics
and Pharmacology, considers Virginia Snakeroot as simply
tonic and stimulant to the circulation, with a tendency to pro-
duce perspiration, generally acceptable to the stomach in
moderate doses, and probably without special influence on the
brain or nervous system. "It may be employed injure dys-
pepsia, attended with a degree of debility calling for some-
thing more stimulating than the simple bitters, and especially
when there is a disposition to dryness of the surface ; but its
most appropriate application continues to be that for which
it was early recommended, to the treatment, namely, of f<
of a low or typhoid character. Whenever any febrile disease
begins to exhibit this tendency, and stimulation is demanded,
serpentaria is one of the first medicines to which we may
have recourse, provided the stomach be wholly free from in-
flammation or vascular irritation. It may be used, therefore,
with the condition of stomach mentioned, in typhus or typhoid
fever, when passing from the first stage of excitement into
that of debility, in protracted remittent fever assuming a low
character, in typhoid pneumonia, and in small-pox, scarlatina,
malignant sore throat and erysipelas, under similar circum-
stances. But it should be understood, that in none of these
affections, does it possess any specific curative powers, that it
can act merely as a tonic and gentle stimulant, and that it
should be used only as an adjuvant in very serious cases, being
alone wholly incompetent to the support of the system under
powerful depressing influences. In many of these
may be very properly associated with Peruvian bark or
Quinia.
"From my own observations, I should infer that serpen-
taria pot do peculiar antiperiodic power, and that it
cannot, therefore, be relied on for breaking the course of an
intermittent or remittent fever; but in either it may be con-
joined with sulphate of quinia when the system is feeble, and
the stomach somewhat insusceptible. The association of Pe-
ruvian bark has long been a habit among practitioners. It ex-
708 Joseph Jones, on the Indigenous [September,
ists in the compound tincture of Peruvian lark of the British
and American Pharmacopoeias, better known under the name
of Huxhams Tincture of Bark"*
I have employed Yirginia Snakeroot in conjunction with
quinia and brandy, in the treatment of numerous cases of the
various forms of malarial fever ; as the results of these obser-
vations have been laid before the profession,f we shall merely
state that while it has proved a valuable stimulant, diuretic
and diaphoretic, we do not believe that it is by itself capable
of arresting, as a general rule, the more violent forms of
malarial fever.
Administered in conjunction with sulphate of quinia, bran-
dy and carbonate of ammonia, I have derived great benefit
from it, as well as from the other remedies, in the severe forms
of malarial fever, when the pulse is rapid and feeble, beating
from 120 to 160 times in a minute, and feeling like the vibra-
tions of a delicate silver thread ; when the heart thumps
feebly, and spasmodically and rapidly against the walls of the
thorax ; when the respiration is full, panting, labored, vary-
ing from 30 to 50 in the minute ; when the skin is hot, and
parched, and rough, or bathed in a cold, clammy sweat;
when the temperature of the extremities is far below that of
the trunk, which by no means corresponds with the increased
efforts at the introduction of oxygen; when the circulation of
the blood in the capillaries of the extremities is almost entirely
checked ; when the chemical changes of the solids and fluids
are in a great measure arrested and perverted, and the devel-
opment of the nervous and physical forces arrested, and their
correlation disturbed ; when the altered blood stagnates in
the capillaries of the brain, and the intellect is either abnor-
*A Treatise on Therapeutics and Pharmacology, or Materia Medica, by
George B. Wood, M. D., &c. Philadelphia, 1856, vol. 1, p 302.
tObservationa on some of the Physical, Chemical, Physiological and
Pathological Phenomena of Malarial Fever; by Joseph Jones, M. D.
Transactions of the American Medical Association, vol. 12, 1859. South-
ern Medical and Surgical Journal, 1858.
1S61.] Remedies of the Southern Confederacy. TOO
mall v excited or depressed ; when the altered "blood stagnates
in the capillaries of the tongue and stomach, and the brilliant
red, dry, rough tongue, is but a fit index of the consuming
thirst of the restless patient tossing from side to side and plead-
ing for a drop of water. In such cases, if brandy and snake-
root be used alone, the beneficial effects will be only tempo-
rary. To be permanent, some powerful antiperiodic, as
sulphate of quinia, should be combined with the stimulants.
The effects of carbonate of ammonia in such cases, although
powerful, are in like manner evanescent, unless combined
with large doses of the sulphate of quinia. If we should at
any time be deprived of quinine, and be compelled to rely
wholly upon the indigenous remedies, I should recommend in
such cases the combination of large doses of brandy, carbon-
ate of ammonia, Virginia Snakeroot, Georgia Bark, Poplar
and Magnolia Bark. We would thus obtain the stimulant,
diuretic, diaphoretic and antiperiodic virtues of several reme-
dies, in a condition of the system where we need not merely
active stimulation, but the excitation of the process of excre-
tion, in all the structures and organs, by which the morbific
agents and offending products may be eliminated. I have
also derived much benefit from the tincture of snakeroot in
the debilitated state of the system succeeding remittent fever.
In such cases it is most beneficial when administered in con-
junction with citrate of potassa, or carbonate of soda. These
latter remedies act in conjunction with the diuretic properties
of the snake-root.
Dose of the powder 10 to 40 grains. The infusion made
in the proportion of half an ounce to a pint of boiling wa-
ter, may be administered in the dose of one to two fluid
ounces, repeated in chronic cases ; and where we wish more
especially a tonic effect, three or four times a day ; in fe .
when we wish a more decided effect, it may be adminis-
tered every half hour, or at longer intervals, according to
The tincture, prepared by macerating for fourteen days
three ounces of powdered snake-root in two pints of dilu-
710 JosEPn Jones, on the Indigenous [September,
ted alcohol, and filtering, or more rapidly in two days by
the use of the displacement apparatus, maybe administered
in the dose of one to three fluid drachms.
In the treatment of malarial fever the properties may be
conveniently obtained and combined with a suitable stimu-
lant, by pouring one pint of brandy on one ounce of the
roots. One tablespoonful of this may be administered
every hour, or more seldom, according to the urgency of
the symptoms. In congestive fever it may be administered
every half hour until reaction takes place ; of course the
maximum dose of stimulants here stated would be used only
to meet special indications and not as a general rule in pro-
longed treatment.
Dr. Eberle recommends the following mixture as very
useful in the dyspeptic affections of infants ;
]$. Pulv. serpentaria3 ;
Magnes. albi aa gr. xvi;
Pulv. Rha^i, gr. xij. M.
Divide into six equal parts.
Iluxham's Tincture of Bark, (compound tincture of Pe-
ruvian bark,) is prepared by macerating two ounces of Red
bark in powder, one ounce and a half of bruised Orange
peel, three drachms of bruised Virginia snake-root, cut Saf-
fron one drachm, and rasped red Saunders one drachm, in
twenty fluid ounces of diluted alcohol for fourteen days ;
then expressing and filtering : or more rapidly with the
same formula, in two days by the use of the displacement
apparatus.
(M-:XTIA^A QUINQITEFLORA. EsTDIA^ QUININE
AGUE WEED.
Dr. E. P. A\rood, of Wisconsin, has given this plant with
success in a number of cases of intermittent fever, and he
states that it is used extensively in domestic practice.
Trans. Illinois State Med. Soc. 1857.
acy. 711
THOKOTJGB WORT. (ETJPATOKIUM PERFO-
LIATUM.)
lied also Thorough "Wax, CrossT^ort, Boneset, Indian
. The Herb, &c.
Botanical Description. Loaves connatc-perfoliatc, rugose, to"
mentose underneath ; stem villous, Stem three to six feet high, striate*
villous, almost tomentose, and with the leaves and involucrum hoary and
sprinkled with glandular dots. Lower leaves connate, the upper distinct,
abruptly truncated at base, all tapering gradually to the summit, serrate,
rugose, slightly pubescent on the upper surface, tomentose underneath.
Involucrum many-leaved, (fourteen to sixteen,) eight to ten-flowered,
leaves linear-lanceolate, acute, pubescent, imbricate. Corolla small,
white, glabrous. Style nearly twice as long as the Corolla, two cleft,
mple. Seed angular, pappus scabrous. A decoction of this
plant is much used and recommended in fevers it acts as an emetic or
sudorific, according to the constitution of the patient.
Grows in wet soils. Flowers in September October, Elliott.
Sketch of Botany of South Carolina and Georgia. Vol. ii. p. 302.
G< '<m. Inhabits meadows and boggy
soils in all latitudes from Nova Scotia to Florida.
CI Hon. According to the experiments of
Dr. A. Anderson of Hew- York this plant contains. 1. A
free acid. 2. Tannin. 3. Entractive matter. 4. Gummy
matter. 5. Resin. 6. Azote. 7. Lime, probably the i
tate of Lime. 8. Gallic acid, probably modified. 9. A re-
siform matter, soluble in water and alcohol, and which
seems to contain a bitter principle.
Dr. Anderson concluded from the results of this examin-
ation that this plant jx active medicinal properties,
and that many of its constituents and properties arc similar
..ose which characterise the cinchona officinalis, the an-
themis nobilis,*and other valuable articles of the Materia
hat these virtues resided chiefly in
the I
Dr. Js
ry part of the Eupatorium has an 1 bit-
ter, combined with a fh iliar to the plant, but with*
712 JosEPn Joxes, on the Indigenous [September,
out astringency or acrimony; the leaves and flowers abound
in a bitter extractive matter, in which the important quali-
ties of the plant seem to reside. This bitter principle is
alike soluble in water and alcohol, imparting its sensible
qualities to both, and neither solution being rendered tur-
bid, at least for some time, by the addition of the other
solvent. It forms copious precipitates with many of the
metallic salts, such a3 muriate of tin, nitrate of mercury,
nitrate of silver, and acetate of lead. Of the mineral
acids, the muriatic and sulphuric form .slight precipitates
with the aqueous decoction the muriatic a more copious
one, and the nitric no precipitate, but changed the color
red in the alcoholic solution the muriatic acid alone form-
ed an immediate precipitate. Tannin exists very sparingly
in this plant ; a solution of isinglass produced a slight pre-
cipitate from the tincture, and a hardly perceptible turbi-
ncss in separate decoctions of the leaves and flowers ; Sul-
phate of tin gave a dark green precipitate, which partially
subsided in a short time. In distillation water came over
very slightly affected with the sensible qualities of the plant
and not alterable by sulphate of Iron. American Medical
Botany, vol. i. p. 35.
According to the testimony of Dr. Joseph Tongo* and
Mr. E. Durand, Mr. J. Scattergood obtained from this
plant a salifiable base which forms, with sulphuric acid,
tasteless, prismatic crystals, and which he calls Eupatoria.
Medical Properties and Uses. The effects of Eupatorium
vary according to the dose and mode in which it is admin-
istered ; in cold infusion, and in the form of powder, in
moderate doses, it acts as a tonic, producing effects very
similar to those of the simple bitters. Larger quantities
and in warm effusion it sometimes proves emetic and laxa-
tive, and most commonly produces a decided diaphoretic
action. So decided and uniform is this action upon the
* Edwards Manna! of Materia Medica, p. 139.
18G1.] Remedies of the Southern Confederaq/. 713
skm, that it has been called ''vegetable antimony," and it
lias been, with propriety, termed a tonic sudorific.
The Indians appear to have been acquainted with the
medicinal properties of this plant, and they are said to have
instructed the first settlers in its use who used it as a feb-
rifuge long before it was introduced into the regular prac-
tice. From the settlement of the country to the present
time it has been in use in various parts of the Xorth and
South as a tonic and febrifuge, to accomplish the same pur-
poses for which gentian, chamomile, peruvian bark and
other febrifuge tonics are employed, and many physicians
have testified to its great value. Dr. Nathaniel Chapman*
of Philadelphia, in his notice of this article states that
"many years ago, we had throughout the United States a
ies of influenza, which in consequence of the seat of
pain attending it, came to be denominated break bone fever.
The eupatorium, acting as a diaphoretic, so promptly re-
lieved this peculiar symptom that it acquired the popular
title of bone-set, which it retains to the present moment."
Dr. George B. AVood,f of Philadelphia, supposes that the
epidemic alluded to by Dr. Chapman was that described by
Dr. Rush as having occurred in Philadelphia in the summer
and autumn of 1780, called break-bone fever, from the vio-
lence of its pains, but which there is every reason to sup-
pose was the disease since better known under the name oi
dengue. Dr. Wood, from this fact, suggests a trial of eupa-
torium in that very painful epidemic disease.
Various practitioners in the Middle and Southern States
have testified to the great value Eupatorium perfoliatum in
the treatment and cure of intermittent fever.
Dr. Andrew Anderson,J of Few-York, has borne une-
quivocal testimony to the value of this remedy in malarial
* Elements of Therapeutics, vol. i. p. 383.
t Treatise on Therapeutics and Pharmacy, vol. i. \<.
X Inaugural Dissertation, 1813.
714 Joseph Jones, on the Indigenous [September,
fever. He states that this remedy was used in nearly every
case of intermittent fever that occurred in the New- York
Alms-house in 1812, to the exclusion of the Peruvian bark,
with uniform success. It was given either in decoction or
in powder from 20 to 30 grains every second hour during
the intermission.
Out of this large number which had been successfully
treated with the Eupatorium, Dr. Anderson detailed six
cases of intermittent, quotidian, tertian, and quartan; in
these cases the cures appeared to have been as expeditious
as could have been expected from Peruvian bark. In re-
mitting fever he found that as a sudorific it produced the
most salutary effects.
Dr. Anderson supports his own experience by the testi-
mony of several distinguished practitioners.
Dr. Hosack and Dr. Baird in the treatment of Yellow
fever, after proper evacuations, placed almost exclusive de-
pendence on sudorifics, and amongst this class of remedies
they considered the Eupatorium, administered in the form
of decoction, of great value.
The disease called by some petechial or spotted fever, and
by others the malignant pleurisy or typhoid periphneumony
has been more successfully treated by the class of remedies
denominated sudorifics than by an other, and in many cases
of this epidemic which occurred in the city of New- York
in the winter of 1812-13 after the proper evacuations had
been employed, the Eupatorium was resorted to, and its
sudorific, its tonic and its cordial properties were clearly
demonstrated and much benefit was derived from its use.
The testimony of Dr. Eberlc to its use in intermittent
fever is not so favorable as that of Dr. Anderson ; in his
notice of the medical effects of this plant in his Therapeu-
tics, he says : " Dr. Anderson states that this remedy
v-;:s used in nearly every case of intermittent fever that
o-vun-ed in the New-York Almshouse in 1812 instead of
Peruvian bark, and that it uniformly proved successful. I
do not doubt that it has sometimes proved successful in this
1861.] Remedies of the Southern Confederacy. 715
disease, but the result of my own experience with it does
not lead me to form a very high opinion of it in this respect.
I have known it to remove the disease, in a tew instances,
by vomiting and copious perspiration. But in the great
majority of cases in which I have tried it no manifest ad-
vantage was obtained." Therapeutics, vol. ii. p. 194.
The testimeny of Dr. Wood agrees with that of Dr.
Eberle. "From the Inaugural Dissertation of Dr. Ander-
son, (Xew-York, 1813,) it would appear to have been em-
ployed with very great success in the treatment of inter-
mittents in one of the Xew-York Hospitals. Subsequent
observation of its effects has proved less favorable; and em-
ployed as a mere anti-periodic, in the ordinary mode of
prescribing bark or quinia in the intermissions, it cannot be
relied on. But I have known it to supersede the parox-
ysms of intermittent fever, when given in emetic doses, in
the state of strong tepid infusion, shortly before the period
for the return of the chills ; and if jointly with this method
of exhibition it be administered in moderate doses at short
intervals during the apyrexia, there is little doubt that it
will often prove successful. Still it is greatly inferior to
Sulphate of Quinia in certainty, while in its effects as thus
used, it is much more disagreeable. It may be very appro-
priately tried in obstinate and frequently recurring attacks
of intermittent fever, in which Quinia has become offensive
to the patient, or inoperative from repetition. The same
remarks are applicable to its comparative efficacy in remit-
tents; in which, however, its tendency to produce perspira-
tion is somewhat in its favor." Therapeutics and Pharma-
cology, vol. i. p, 298.
Dr. Chapman, on the other hand, whose experience was
certainly equal to, if not larger than that of Drs. Kberle
and AVood sustains fully the statements of Dr. Ander
"I have had lately put into my hands a very well written
t, in which the properties and medicinal applications of
this article are fully i d.*
on on the Eupatorinm, &C
716 Joseph Jones, on the Indigenous [September,
By the reports of the writer it appears that in the public
institutions of New- York it has been extensively employed
in intermittent, remittent and yellow fever, in typhus pneu-
monia and catarrhal fevers, in several cutaneous affections,
in dropsies, and for the removal of mere debility. By
properly regulating the administration of the medicine, it
has, according to him, fulfilled successfully all these diver-
sified indications. After making due abatement for the
confidence in which new and favorite remedies are always
announced, I entertain little suspicion of the accuracy.of
these accounts. My own observations, together with com-
munications which I have received from highly respectable
sources, would, indeed, nearly confirm every part of the
preceding statement relative to the efficacy of this medicine,
and especially in intermittent and remittent fever. To
these affections it seems particularly adapted, inasmuch as
having the united properties of a diaphoretic and tonic, its
use may be continued in the successive stages of the parox-
ysm, as well as the apyrexia." Elements of Therapeutics
and Materia Medica, by JS\ Chapman, vol. ii. p. 445.
Dr. Ansel W. Ives, of New-York, the editor of the
Pharmacologia of Dr. J. A. Paris, adds his testimony to the
correctness of Dr. Andersons observations : "It was long
ago used as a tonic by the aborigines of this country, but
its properties were not fully investigated, and its remedial
character appreciated by the profession till the publication
Of Dr. Andrew Anderson's excellent inaugural dissertation
on the Eupatorium Perfoliatum in 1813. From that time
to the present its reputation has been increasing. It is pe-
culiarly valuable from the diversified effects that may be
produced by it by varying the preparation and the dose.
These may be so modified as to secure its operation as a
tonic, emetic, laxative and sudorific ; and from its effects in
opening the secretions of the whole system, there is, per-
haps, no other bitter or tonic, of equal activity, that can be
exhibited in febrile affections with so little danger of hi-
ring excitement or producing congestion. In the year
1861.] Remedies of (he Southern Confederacy. 717
1S14, while resident physician to the New-York Almshouse,
I had frequent opportunities of testing- its tonic powers, as
it was enjoined from motives of economy upon the medical
department of the institution to substitute this article for
the Peruvian bark when it could be done with safety to the
patient. In many instances it proved an efficacious substi-
tute. It is a valuable emetic in the early stage of autum-
nal intermittents." Pharmacologia, &c. by J. A. Paris, M.
D. with additions by Ansel W. Ives, M. D. Xew-York,
1823, vol. ii. p. 143.
"Dr. Bigelow has prescribed an infusion of the Eupatori-
um, in various instances, to patients in the low stages of
fever, when it has appeared instrumental in supporting the
strength and promoting a moisture of the skin, without
materially increasing the heat of the body. He has also
found the cold infusion Or decoction a serviceable tonic in
loss of appetite, and other symptoms of dyspepsia, as well
as in general debility of the system. Am. Med. Botany,
vol. i. p. 37.
AVe hope that we will be excused for multiplying testimo-
ny to the medicinal value of this plant. We believed
that at the present time such an examination of its merits
as embraced the views of distinguished and reliable
writers, would prove valuable as well as interesting. At
some future time we hope to be able to present an extended
chemical analysis of its constituents, together with numer-
ous experiments upon its physiological and therapeutic
action.
When employed as a tonic from twrenty to thirty grains'-
of the powder may be taken three times a day ; the cold
infusion, made in the proportion of ?y to Oj of water, may-
be taken as a tonic in doses of one to two fluidounces.
When intended to act as an emetic, an ounce of the pla
iled in a quart of water, down to one pint, and thi
taken in the dose of two fluid ounces every ten or twenty 3
minutes until the emetic effect is produced.
718 rl he dire of Phthisis. [September,
The warm infusion is said by Dr. Bigelow to be a conve-
nient substitute for that of chamomile flowers in facilita-
ting the operation of an emetic. Dr. Anderson gave the
powder in the treatment of intermittent fever in doses of
from twenty to thirty grains every second hour during the
intermission.
In the treatment of both intermittent and remittent fever
the warm decoction prepared m the proportion of one ounce
of the leaves boiled in a quart of water, may be adminis-
tered in the dose of a wineglassful every two hours, or oft-
ener, according to circumstances. Of course the amount
administered will be regulated, in a great measure, by its
emetic and cathartic effects.
[Concluded in our next number.]
The Cure of Phthisis.
At a late meeting of the Harveian Society of London, Dr.
Pollock read a paper on this subject:
"Dr. Pollock first spoke of the various stages of phthisis,
which disease he did not regard as necessarily making a
steady progress to decay, but frequently exhibiting a suc-
cession of attacks, and susceptible of local repair. Such
cases he had seen the system sometimes opposing itself to
morbid action in so marked a manner as to cause very con-
siderable prolongation of life. In referring to the cure of
phthisis, Dr. Pollock said he had no specific to offer, and
thought that no cure, in the popular sense, would be disco-
vered. He was of opinion that the average duration of life
since the use of cod-liver oil, as stated by some authorities
at four years was too low an estimate. Tubercle might be
absorbed, leaving the lung sound, by excavation and cica-
trization, or a cavity sometimes remains circumscribed, the
patient living for years. Waste of tissue might be
retarded by stimulants when first going under treatment,
and those taken at long intervals of time were exhibited to
the society, which last gave evidence of favorable results. '
Med. Times Gaz.
1861.] Typhoid ]<\ 719
Clin ' Jic< Mi asun b of Tn stnu nt i >
' Typhoid Fever. By Austin Flint, M. J)., Professor of
inical Medicine, etc., in the New Orleans School of
Medicine.
GentloTnon I have chosen as the subject of my lecture to-
day, a renewal of the eases of typhoid fever which have been
under our observations during the winter, with reference es-
pecially to abortive measure.- of treatment. >
Abortive measures of treatment are those employed to
arrest the pr f the disease either by cutting it short,
jugulating it as the French writers say, or by abridging ma-
terially its career. Up to a late period measures for these
ends were employed habitually by physicians, and, as was
Bupposed, with considerable success. Blood-letting, cathar-
tics, emetics, mercurialization, and other means have been
advocated as possessing the power of arresting the common
continued or typhoid fever. But since the natural history of
the disease has been more acurately studied, and its diagnos-
tic characters better understood than they were but a few
years ago, it has come to be considered very generally that it
cannot be controlled by any measures at present known. The
measures just mentioned have mostly gone out of use in the
treatment of the disease; at all events, few, if any, now resort
to them with the expectation of arresting the disease. The
doctrine taught by the most approved writers at the present
time is, that the typhoid and other forms of continued fever
must have their course, and that the power of the physician
is limited to palliating symptoms, sustaining the vital forces
and guiding the disease to a favorable termination. This doc-
trine, however, is not accepted by all. Son: "nee, Dr.
Henry, of Illinois, communicated for the medical journals
ral papers in which he asserted that opium in large di
Combined with calomej, succeeds in arresting alike remitting
and continued fevers. More recently, Dr. Dundas, of Liver-
pool, has claimed in behalf of large doses of quinia a poti
great in continued as in periodical fevers. My di
hed friend and colleague, the Professor of Practice in this
Prof. Fenner, advocates the use of quinia in large
imbined with opium, as successful, if resorted to early
and efficiently, in often cutting short continued fever, and in
abridging its duration and modifying its intensity when the
t at once 1. 1 have made some observa-
abortive treatment of typhoid l\:\\r,
and been led to think that opium in large,* doi the wet
sheet employed often, after the manner of the hydropathists,
720 lyphoid Fever. [September,
sometimes may succeed in arresting the disease.
Now you will, perhaps, ask why this matter is not settled
to the satisfaction of all candid minds? It may seem to you
that the question as to the efficacy of any particular measure
could ho very easily answered by an appeal to facts ; but it is
more difficult to bring facts to bear on this question than at
first appears. The difficulty arises mainly from two sources.
In the first place there is a liability to error in diagnosis
during the early part of the course of typhoid fever, and this
creates a distrust in the minds of others, and in the mind of
the observer, also, when the disease appears to be arrested.
In the second place, the disease appears sometimes to abort
of itself ; in other words, we meet with cases in which the
phenomena attending the forming stage of typhoid fever are
present, but the disease does not become fully developed, or
if developed, it abruptly ceases and does not go on, irrespec-
tive of any measures of treatment.
To obviate the first of these difficulties it has been proposed
to wait until the eruption appears, and not consider the diag-
nosis as positive until this event occurs. This plan was pur-
sued by Prof. Bennett, of Edinburgh, in testing the views of
Dr. Dundas, and he found that the quinia failed in several
cases in which he intended to give this remedy a fair trial.
But the eruption in typhoid fever does not usually appear
until the seventh day after the patient takes to the bed, and
by this time the disease has advanced nearly half-way through
its career. This plan involves too much delay to secure for
any measure a fair trial. We must, theretore, base the diag-
nosis on other circumstances, and make due allowance for a
liability to error. In like manner, allowance is to be made
for the natural abortion of the disease.
You see, gentlemen, that the question as to the efficacy of
any abortive measure is not very easily settled. Great cau-
tion is requisite in the collection of facts. The observer must
be competent for observation, and be careful as regards the
diagnostic characters, exclusive of the eruption. His mind
must not be warped by undue enthusiasm or credulity, and,
unfortunately, we find that not a few persons, who are not
wanting in conscientiousness, are apt to see precisely what
they desire or expect to witness. If in a considerable number
of cases correctly observed, the disease abruptly ends or fails
to run its accustomed course in a larger proportion, when cer-
tain abortive measures are employed, than when no such
measures are employed, we must attribute to these measures
more or less efficacy. Now, with regard to the efficacy of any
i.] 7/// TlM
particular remedies [ shall not express an opinion in general*
terms, for I have not formed any opinion on the subj<
I regard the subject as a legitimate one for clinical ol>
ration, and that the accumulation of more facts than we at
lary before we arc prepared to come
to anv positive conclusions.
Without further preliminary remarks, let us direct atten-
tion to the cases of typhoid fever which have heen treated
in my wards this winter. The cases are few, for this dis-
has not pTevailed to much extent in this city during
the present season. I have recorded all the cases in nay
wards, and they are only lour in number.
The first ease proved fatal in about two weeks after the
admission of the patient. In this case abortive measures
were not employed. The characteristic intestinal lesions
were found after death, and exhibited to the class ; tuber-
culous ulceration from another body being exhibited at the
same time, in order to illustrate the points of contrast. In
this case, unexpectedly, extensive cystoid degeneration of
the kidney was found, these organs being full of cysts, va-
rying in size from a pea to a hickory nut.
2 was admitted Nov. 14th^ The patient had
been ill for six or eight days, but he was not confined to
the bed before he came to the hospital. His age was
twenty-eight. He had lived in this city for two years.
On his admission he took to the bed. His expression was
dull and the mind acted slowly. He had moderate diar-
rhcea which had existed for several days. Before coming
to the hospital he had had epistaxis, pains in the head and
limbs, lassitude, loss of appetite and some nausea. Ten-
derness was marked in the iliac region and gurgling. The
abdomen was meteorized but not distended. There was
Lerate febrile movement Xo eruption.
On the day after his admission, when I first examined
I ')) I prescribed fifteen grains of the sulphate
of quinia.
On the loth, at my morning visit, he was <: and
sitting up. but he was evidently too ill to keep np, and he
returned to the bed. He reported better than on tie'
.-. but the symptoms were about the same. 1
quinia on this day.
On the 17th he was in bed and reported not a- well. The
diarrhoea had been troublesome during the night. The
dullness of expression and slowness of mind continued. The
46
722 Typhoid Fever. [September,
febrile movement was moderate. Tenderness in the iliac
region continued. The chest was everywhere resonant,
and some sibilant rales existed on both sides. I counted
two or three sore spots on the chest. I prescribed on this
day \'ov the diarrhoea, opium, gr. i, and tannic acid, grs. iii,
throe times, discontinuing the quinia.
On the 18th the daily record is as follows:' "He reports
no better; says that he did not sleep last night, owing to
had dreams. He had two dejections during the night and
has had one this morning. The pulse is eighty ; the respi-
rations sixteen. He dozes but is easily aroused. The skin
is warm and moist. Slight capillar}- congestion exists on
the face and upper limbs. Tenderness in the iliac region
continues. Three or four sore spots are found on the chest
and abdomen. He has no appetite, but complains of thirst.
There have been no manifestations of delirium. Treat-
ment opium, grs. ii, three times."
On the 19th the symptoms were the same, and some in-
coherent talking during the night was observed by the ward
nurse.
The treatment on this day had reference to an abortive
effect, the case being now regarded as clearly one of typhoid
fever. Five grains of the sulphate of quinia and three grs.
of opium were directed to be given three times.
Nov. 20th, the patient was dressed and sitting up, but
was evidently quite feeble. Moderate diarrhoea continued.
The pulse, while sitting up was eighty-four, but on return-
ing to the bed it fell to sixty-four. No man testations of
delirium. Tenderness in the iliac region, with gurgling,
continued. The sore spots, previously observed, had dis-
appeared. Treatment opium, grs. iii, and the sulphate of
quinia, grs. vii, three times.
Nov. 21. The patient sat up a portion of the previous
day, and on this day he reported quite well. Xo dejection
since the previous evening. ' Pulse sixty-four.
Xo medicine was prescribed ; a diet of essence of beef,
milk and bread was directed.
Nov. '1-. Reported not so well. Did not sit up on the
previous day. Several dejections occurred during the night.
The pulse was seventy-two. The countenance was more
dull. Treatment opium, grs. iii, and the sulphate of
quinia, grs. v, three times.
Nov. 23. The patient reported better, and the aspect
was brighter. One dejection only. Pulse seventy-six. The
1861.] Typhoid F\ 723
patient sat up a portion of the previous day. Treatment
continued.
Nov. 24th. The patient remained the same. Opium,
grains iii, and the sulphate of quinia, grains vii, were pre-
scribed.
Nov. 25th. The patient Bitting up a little daily ; the
mind clear: slight diarrhoea ; no febrile movement. Treat-
ment continued.
Under this date I have noted in the record of the ease the
following remark: "The remedies have appeared to exert
some controlling influence over the disease in this case, as
shown by the change for the worse on the 22d, when the
remedies had been withdrawn tor a day, and the improve-
ment when the remedies were resumed."
Nov. i!ijth. Xo material change. The treatment was
continued.
Nov. 27th. Patient dressed and sitting up. Reported
much better. The opium ami quinia were suspended on
this date, and a drachm of the compound tincture of cin-
chona, three times, was prescribed.
. B. Xo medicine and full diet.
Dec. 2. The patient reported well enough to leave the
hospital, and was discharged.
Dating from the time when this patient took to the bed,
and com _ convalescence as distinctly existing when
the medicine was discontinued and full diet allowed, the
duration of the disc; fourteen days. The disease was
not cut short, hut it i- to he remarked that the amount of
quinia prescribed fell considerably short of that given by
those who claim for this remedy an abortive efficacy in ty-
phoid fever.
The question m the case is whether the disease was short-
1 or modified by the treatment. I am not prepared to
:vc answer to th tion, for, undoubtedly,
. typhoid fever in which the disease U
mild and shorter in duration than in this case. But, as
d in the note which has been quoted, the change for
the wore when the treatment i 'tided for a day, and
the immediate improvement when it was resumed, render
it probable that some controlling influence was ex< rted.
i. we may be permitted to conclude
that the opium and quinia given in the case did not exert
an unfav t}|(. progress of the dise:
No. -J 1 -ball read from my records, as it will not
occupy much time.
724 Typhoid Fever. [September,
James Ellis, aged seventeen, admitted January 17th, was
first seen by me on the morning of the 18th, and the record
is commenced on the 20th.
lie stated that he had resided in this city since August
last ; that he had been ill for eight or ten days, but took to
the bed only two days before his admission. His ailments
before admission were cephalagia, loss of appetite and
nausea, moderate diarrhoea and pain imthe abdomen, lassi-
tude and debility. Epistaxis occurred on the day after his
admission. The symptoms on the 18th were, moderate fe-
brile movement, capillary congestion of the face, moderate
diarrhoea, tenderness over the abdomen and resonance
without distension, want of appetite, thirst and debility.
The treatment on the 18th was Dover's powders, grs. v.
and the sulphate of quinia, grs. v. three times.
On the 19th his condition was about the same. ~No
eruption was discoverable. The pulse was one hundred and
four. The treatment on this day was, opium, grs. ii, and
the sulphate of quinia, grs. x, twice.
On the day of the first record (20th) I learned that he had
been delirious during the night, talking incoherently, and
getting out of bed, saying that he wished to go home. At
the time of my visit in the morning, he seemed rational.
At the present time (2 p. m.) he lies dozing, and frequently
talking incoherently. He is readily aroused and replies to
questions promptly and rationally. The abdomen is reso-
nant and moderately distended. Tenderness in the iliac
region, and over the abdomen generally continues. He
relapses into a dozing state immediately after being aroused,
and begins to mutter. The skin is warm and dry. The
pulse is one hundred and four, and the respirations twenty-
four. There is no eruption. Physical exploration of the
chest yields a negative result.
This morning I prescribed opium, grs. ii, and the sul-
phate of quinia, grs. x, three times, with half an ounce of
wine every four hours, and sustaining diet.
Jan. 21. He has passed a quiet night, without muttering
or any manifestations of delirium, He states that he has
had a little buzzing in the ears. The pulse is ninety-six;
respirations twenty-four. Diarrhoea continues with abdomi-
nal tenderness. He continues to dose most of the time, but
asily aroused. Treatment opium, grs. iii, and the sul-
phate of quinia, grs. x, three times, with wine and diet as
before.
II.] 7 rpkoid F
Jan. 22. The /aspect m much brighter. Some muttering
during the night, but no other manifestation a of delirium.
The pulse is eighty-four; the respiration- are twenty.
Abdomen not dsitended, and the tenderness is Blight
diarrhoBa.
To-day no medicine is prescribed, but wine and diet
re.
Jan. 23. Aspect bright Pulse seventy-six ; respirations
twenty. Slight abdominal tenderness. He seems to be dis-
tinctly convalescent. Xo medicine.
Jan. 24. Continues bright. Pulse seventy-two ; respira-
tions twenty. Xo diarrhoea and no abdominal tender
nor distension. lie has appetite, but complains of o
sional vomiting after taking food, for which a scruple of the
sub-nitrate of bismuth, three times, was prescribed.
Jan. 25. Reports perfectly well, excepting want of his
usual strength. Tli3 bismuth has been discontinued.
Jan. 30. The patient reported well enough to leave the
hospital and was discharged.
In this case, gentlemen, we have the career of the fever
ending on the eighth day, dating from the time of taking
to the bed. The diagnostic characters of typhoid fever, ex-
clusive of the eruption, were well marked. Xow, it is un-
deniable that this disease sometimes ends, of its own ac-
cord, with as brief a career as eight days, and I am not
prepared to affirm positively that the quinia and opium con-
tributed to the short duration. That these remedies exerted
a controlling influence, however, I cannot but con
probable.
Admitting the need of an accumulation of ca-es before a
more positive opinion is admissible, the case shows, to say
the least, that there is no hazard in repeating e Intal
observations of this kind.
Case Xo. 4 is also brief, and the reading of the notes will
not occupy much time. It is proper to state that the greater
portion of this case was made by Mr. Profilet, the hi
student assigned to my wards.
Robert Pricely, aged 19, was admitted February 1"
and the record is commenced on the 10th.
If that he was il! four days before his admission and
confined to the bed three day-. lie has now diarrhsea, which
has existed from the commencement of his illness, The
abdomen is tympanitic, and tenderness in the iliac region is
726 Typhoid Fever. [September,
marked. The mind is dull. The tongue is dry. The face
is congested. The pulse is one hundred.
On exploration of the chest, dullness on percussion,
broncho-vesicular respiration and bronchophonic voice are
found over a small space of the upper portion of the poste-
rior lobe of the right lung. Treatment opium, grs. iv.
three times.
Feb. 17. He reports better. Pulse eighty. All the
symptoms are improved. The physical signs of solidifica-
tion continue within the circumscribed space in which they
existed yesterday. Treatment continued.
Feb. 18. The patient's mind is still sluggish ; he answers
questions coherently, but after considerable hesitation. He
is now sweating profuselv. Pulse sixty ; respirations
twelve. The abdomen is still somewhat tympanitic, and
tenderness in the iliac region continues, but is diminished.
Six sore spots, with all the characters of the typhoid erup-
tion, are counted upon the abdomen and chest.
The solidification of lung has not extended, and the signs
show that its degree is less. Treatment continued, with an
ounce of brandy three times and sustaining diet.
Feb. 19. Improvement is manifest. Pulse fifty-six ;
respiration twelve. The eruption has disappeared. Xo
diarrhoea. The mind is bright.
No extension of the pneumonia, and the solidification is
diappearing. Treatment the opium is discontinued;, the
brandy continued and diet as before.
Feb. 20. Convalescence continues and the patient de-
sires to sit up.
Feb. 25. The patient reported well enough to leave the
hospital and was discharged.
The career of the fever ended in this case on the seventh
day from the time of taking to the bed, the treatment con-
sisting of twelve grains of opium per day,- and this treat-
ment continued for three days. The diagnostic characters
of typhoid fever wore marked, and one day the character-
istic eruption was observed. Did the disease end from an
intrinsic limitation, or was it arrested by opium. In answer
to this question, I have only to repeat the remarks which
were made in connection with the preceding case.
The last case is interesting from the existence of pneu-
monia as a complication, which, like the fever, seemed to
be arrested, not extending over the lobe, and rapidly disap-
pearing.
1861.] Perineal Section. 7:27
We have thus, gentlemen^ reviewed our experienc
the management of tpphoid fever during the past winter.
Throe out of four cases have recovered. In the fatal i
no abortive measures were employed. In one of the re-
mainiog three cases opium and quinia were given in pretty
full doses. The duration was fourteen days, and the dis-
was extremely mild. In the second of these three
cases the abortive treatment was commenced on the sixth
day of the disease, dating from the time of taking to the
bed ; in the second and third of the cases the treatment was
commenced on the fifth day. In the first case the duration
of the disease was eight days after the treatment with quinia
and opium was commenced ; in the second case the disease
continued for three .days after the treatment with quinia
and opium was commenced, and in the third case the
disease ended on the second day after opium was prescribed
in large doses.
These three cases, considered alone, are not of great
value ; hut they are valuable in encouraging* experimental
researches in the same direction, and as a small contribu-
tion towards the stock of recorded facts, by means of which
it is to be determined whether typhoid fever be amenable to
abortive measures of treatment. N. 0. Med. Times.
On Perineal Section. By J. Mason Warren, M. D. one of
the Surgeons to the Massachusetts General Hospital.
The distinguished surgeon, Mr. Syme, of Edinboro, lias
of late years brought more particularly to the notice of the
profession the incision of the urethra in the perineum for
the purpose of relieving strictures of a had character.
Some confusion seems to exist as to the cases for which this
operation is more particularly applicable. So far as we can
understand Mr. Syme, his operation appears to he directed
to tbos< which are permeable to the instrument, yet
ritable and intractable as to he a permanent Bburee of
irritation to the patient. Mr. Syme considers that every
stricture, with patience, is capable of being penetrated.
Other gentlemen, and particularly Mr. Bryant, in an excel-
lent paper in Guy's Hospital Reports, think there are certain
728 Perineal Section. [September?
cases of stricture admitted to exist by most surgeons which
no patience will overcome, and which the use of the knife
alone will remedy. In these he advises that an instru-
ment should be introduced into the urethra as far as
allowed by the obstruction ; the finger of the left hand is
then introduced into the rectum as a guide to the prostate
or neck of the bladder. The integuments now being divi-
ded, the knife is introduced with its back towards the rec-
tum so as to strike the urethra in front of the prostate, and
a cut is made forwards till it meets the instrument in the
urethra.
Mr. Bryant after mentioning the different forms of stric-
ture requiring this operation, rejects that in which with
retention of urine the urethra is impermeable to an instru-
ment for which case he advises as the only proper operation
the puncture of the bladder through the rectum. Without
entering upon a discussion as to the merits of the operation
we would simply state, that in our experience this is the
very case whfch most frequently calls for the active inter-
ference of of the surgeon ; and there seems to be no good
reason, if the history indicate a callous and incurable stric-
ture as the cause of the retention, why the operation should
not be so extended as to divide the stricture at the same
time, and give the patient a chance of permanent instead of
temporary relief.
In order to illustrate this subject and bring it more fully
before the profession I propose by the exhibition of two or
three cases, to show the advantage of the operation in these
extreme cases which we are so often obliged to deal with ;
as it is well known that in permeable strictures, to which
Mr. Syme's operation would be applicable, the patient, so
long as he could obtain relief otherwise, would be unlikely
to submit to a cutting operation. One of these is a casein
point with those mentioned by Mr. Bryant, viz: a case of
organic stricture of long standing gradually diminishing the
calibre of the urethra, and finally terminating in complete
retention. In this case, it will be perceived, that instead of
puncturing the bladder through the rectum, as would have
been the practice of Mr."l>. the urethra was cut down upon
in the perineum, opened near the neck of the bladder, and
then the whole portion of the strictured urethra divided ;
and a large instrument being introduced the urethra was
moulded upon it until a complete cure was produced. The
other two cases are those in which the operationof Mr. Syme
1861;] Perineal Section. 729
must have been rejected ; as, after much patient treatment
in one of them, no instrument could be made to enter the
bladder, and in the other, although for a time an instru-
ment could pass through the stricture, ultimately this be-
came impracticable, and the patient's life was gradually
being exhausted by pain, confinement, and the irritation
and discharge from the numerous fistulous openings in the
scrotum and perineum. To Mr. Symc undoubtedly belongs
the credit of having fully brought this subject before the
profession, and shown the great relief that might be ex-
tended to a class of cases allowed to linger on in torment
through many years.
In his very valuable paper Mr. Bryant has indicated yet
other cases, a class to which the attention of hospital sur-
geons is much more likely to be called, and of which the
preceding are an illustration. We take the liberty of copy-
ing Mr. Bryant's conclusions, to which we fully agree, with
the exception of the first, upon which we have commented
above.
" Conclusions. 1. In uncomplicated retention of urine
from organic stricture, the operation of opening the urethra
in the perineum is not required, the more simple and safe
one of puncturing the bladder through the rectum being
preferable.
2. When complicated from extravasation of urine from
an}* cause it should be performed at once, and the stricture
when present divided if possible.
3. In laceration of the urethra from injury, when a ca-
theter cannot be passed, the urethra should be opened.
4. And also when the above injury is associated with pel-
vic mischief.
5. Strictures are occosionally met with which arc imper-
meable, and urethras which are obliterated.
6. That in cases of organic stricture, when the passage of
a catheter is possible and not difficult ; where it does not
produce either any injurious, or painful constitutional or
local disturbance, and where, after dilatation of the stricture
an occasional passage only of the instrument is required to
maintain an open channel, no other surgical means can be
called for.
7. T! of stricture do occur occasionally, which
o exquisitely sensitive, and in which the | of a
heter, however skillfully performed, is followed by such
ere constitutional and local disturbance as to produce
730 Perineal Section. [September,
more harm than good ; and others, which are relieved by
means of a catheter, and are even fully dilated, but which
have a tendency to contract immediately upon the omis-
sion of the treatment; in such cases the operation of "ex-
terna] division" is most valuable.
8. That the majority of cases of what are called imper-
meable strictures may be rendered permeable by constitu-
tional treatment but that some are undoubtedly impermea-
ble; in such cases the operation "perineal section " is of
value.
9. When the urethra is obliterated the operation of "pe-
rineal section" may occasionally be demanded, particularly
when associated with perineal fistula.
10. That the worst and most intractable forms of stric-
ture are the result of injury, and in those cases the opera-
tion either of "external division," or "perineal section," is
of great value.
11. That in boys the operation is not so successful as in
adults, although no better can be suggested."
Case 1. Organic Stricture of the Urethra of Ten Years'
Standing; The Urine finally passed in Drops ; Retention; Pe-
rineal Section ; Division of the Stricture ; Complete Recovery.
A. L. Foydt, about 30 years of age, entered the Hospital on
April 30, 1860, with a stricture of the urethra of ten years'
duration. The water, when he entered, passed in a very
small stream, and urine was constantly dribbling away from
him during the night accompanied with a purulent dis-
charge. He complained of pain in the renal region, though
not of a severe character. After very careful attempts to
pass a bougie of the smallest description, it was finally de-
cided to attempt to cut the stricture from within, which was
done from a canula with a concealed blade, on May 15, and
which, although it cut but partially through the stricture,
seemed to afford him temporary relief.
On May 26, the urine became less free ; there was consi-
derable dulness in the pubic region, and the patient com-
plained of pain about the bladder, with general uneasiness.
I had already made up my mind to perform the perineal
section in this case, and ordered the preparations for the
operation to be made for the following day.
On visiting him the next day, 1 found he had a complete
retention of urine, and therefore proceeded at once to the
operation. The patient was placed on a table, on his back,
:i
I
1861.]- 'ncal Section. 7-U
and after being thoroughly etherized, so that his joints v.
\illy relaxed, he was tied as in the operation for lithotomy,
~ lave found it much better to confine the limbs in this way
than to intrust them to the care ot assistants, who are apt
to be worn out during an operation so likely to be long and
tedious. A small staff was introduced, and it seemed to
penetrate the first stricture, which as stated above, had been
noised about a couple of weeks before, and brought up
against a second stricture, apparently just behind the scro-
tum. The forefinger of the left hand was now introduced
the rectum, and the situation of the prostate ascer-
d. The perineum was then divided, and a careful dis-
>n made, to ascertain the site of the urethra. This
rendered very tedious from the constant discharge of
d at the bottom of the deep wound from the bulb of
the urethra, which in tills ease was more than ordinarily
troublesome. The urethra, however, was finally opened
directly in front of the prostate, and a gum clastic catheter
Dassed into the bladder; giving exit to a very large collec-
[on of urine. The canal was u/nv opened forwards, and
the callosities freely divided, until the staff was reached.
A s mi-elastic catheter was now passed downwards
ugh the penis until it appeared in the wound ; and the
ivory end of the first having been cut off, the point of the
second was insinuated into it and firmly fixed. In this
manner it was dragged up through the whole extent of the
urethra, It might be here mentioned, as a hint for finding
the urethra, which I have before practiced upon, without
the -tail* for a guide, and where other means have failed, to
was done in the present case viz, allowing the pa-
tient partially to recover from the ether, stimulate him to
make an effort to urinate, and when the urethra behind the
stricture became dilated, a minute stream of urine
indicating the spot for the introduction of the probe, and
the urethra was found. Xo unpleasant symptoms followed
the operation. On the next day the patient expressed him-
elfin great comfort, more so than he had experienced for
many year.-. The sense of fulness, arising from probable
disi -f the bladder, ureters and pelves of the kid]
having entirely passed away. At the end af a week the
firv ! at once replaced by an-
other which had been piepared the day ame
and curve. The catheter was found to have been par-
tially acted upon by the urine, and its calibre hat
obstructed.
732 Perineal Section. [September.
At the end of a month the patient was able to introduce
the instrument himself; and at the end of two months, tin
wound in the perineum having nearly healed, he kept it up>
at night, leaving it out during- the da}T.
He shortly after left the hospital, well, with the exceptioi
of a small aperture not larger than a pin hole, and soim
weeks subsequently presented himself there on the eve ojf
a voyage to the sea.
I
n
Case II. Stricture of the Urethra of Twenty-five Year&fi}
Duration ; numerous ZJrinaay Fistulas in the Scrotum am
Perineum ; Perineal Section ; Cure. E. O. B., shipmaster
entered the Massachusetts General Hospital on April 24 lei
1860, and gave the following history ot himself. He ha<
suffered from gonorrhoea twenty-five years previously, an
was treated by his captains at sea by strong injections
The gonorrhoea terminated in gleet, which was treated b
bougies for two years, when it was increased on account c s
increased obstruction. He then remained pretty well unt pv
eight years since, when tle stricture became so tight as t U
give him a great deal of inconvenience, for which he entei od
ed the hospital, under my care, and the stricture ws )\
divided by internal incision. This relieved the urinar
trouble, and for a time he enjoyed gocd health. Two yeai
since a fistulous opening appeared in the perineum ; fou
months later, another in the scrotum ; five months since
third ; through these openings parulent matter with urin
was freely discharged. The whole of the scrotum wa
tense, indurated and barred by sinuses. Two months pre
vious to his admission, a ~No. 1 bougie was passed into th
bladder, after much effort; his symptoms have been aggrf
vated by it.
1 passed a 'No. 1 bougie down to the stricture, and ke]
it applied for two or three hours daily) exerting a gent
pressure against the stricture. After treatment for about
week in this way, the stricture gave way, and the instn
ment passed into the bladder.
On May 1, I made an incision into one of the scrotal opei
ings, and gave vent to a quantity of purulent matter, mixe
with urine. Notwithstanding the passage of the bougu
the symptoms of trouble about the scrotum increased, an
towards the 1st of June, the stricture having again closec
so that it was quite impossible to pass any instrument, th
operation was done, at his request, on June 4.
161.] Perineal Section. 733
The patient being etherized, and confined in the position
or lithotomy, Syme's sound w;> I through one stric-
ture and encountered a second. An incision was now
nade in the median line of the perineum, and dissection
performed until the point of the staff was reached. The
<3i issues were much hardened, and infiltrated by a deposit,
no vhieh greatly opposed the progress of the knife. The flow
0 )f blood from these diseased parts interfered much with the
>peration : the perineum also was uncommonly deep. In
>rder the better to bring the continuation of the urethra
i leyond the stricture into view, the end of the staff was
1 turned out through the incision, and served to hook up and
[i ;hus bring the deeper parts more fully in sight. The wound
i Iteing freely sponged with iced water, a puncture was made
il jito the supposed urethra, in the neighborhood of the neck
B)f the bladder, which allowed the passage of a probe into
>ai ;hat organ; and the urine having escaped, showing it had
b jone in the right direction, a large gum elastic catheter
'( vas substituted for the probe, A sharp-pointed knife was
it low passed up by the side of a small Syme's sound, and the
I irst stricture, which lay behind the middle of the scrotum,
I ind which would not allow anything larger than the sound
;i to pass, freely divided.
i A second gum- elastic catheter was now introduced
}] through the glans and urethra, insinuated into the mouth
of the first, which remained in the bladder, and was thus
drawn upwards as in the former case.
Xo great constitutional irritation followed the operation,
and the patient on the following day described the comfort
of. freeing the bladder by a large stream, after having suf-
fered for so many years in his efforts to do so, as beyond
relief. The first bougie was left in place a week, then be-
coming obstructed, it was replaced by another, and this was
done weekly through the course of the treatment. The
wound in the perineum, on account of the diseased state of
was very slow in healing, and the patient re-
mained in the hospital for two months afterwards.
A communication was received from him in Nov. 1SG0,
hich he states that he was well.
, I E. Traumatic Stri im of the I V. thr
. G. U.,3Gyear80 r, came into the
ital under my care in the early part of the spring of
.dd that live years before he had been jammed
734 Perineal Section. [September,
K
leu
elii
L
1
(
1
against a wall by the buffer of a freight car with such force
as to produce a rupture of the urethra He remained in a
critical situation for a time, and had never since been able
to pass his water, except in a very small stream. Two
years previous to his admission, a fistula appeared near the
tuber ischii of the left side, between that and the rectum.
] lis water has passed by drops through this fistula, and f
another in the rectum, ever since. Various attempts have
been made to perforate the stricture, but all of them without
avail.
On examination by the rectum I found that the bladder,
intestine and surrounding parts were glued together and
involved in an indurated mass, und the calibre of the in-
testine was very much diminished. A probe being intro-
duced into the fistula by the side of the rectum, passed up
by the side of the gut through these indurated tissues, and
apparently entered the interior of the bladder. Having
made very careful attempts for a time to get through the
stricture by gentle means, I finally advised him, unless
willing to have the perineal section performed, to desist
from any further efforts, for fear of producing irritation and
complete retention, especially as he did not suffer much
from his disease.
In June, having heard of the success of two of the above
operations, he came back to the hospital for the purpose of \m
having one performed upon himself.
Operation. A sound was passed down as far as the stric
ture, an incision made upon it, and its point reached deep
in the perineum. ~No traces of the urethra beyond could
be discovered by the most careful manipulation. He was,
therefore, allowed to recover partially from the effects of
the ether, and to make an effort to void his urine. An in-
cision was now made in the direction of the neck of the
bladder, and a female catheter introduced as a guide, which
was replaced by a ISTo. 8 elastic catheter. The parts were
very vascular, and the steps of the operation, which lasted
over an hour, much obscured by blood.
jSTot the slightest unfavorable symptom followed ; but at
the end of the week, when it was necessary to replace the
catheter, it was found to be a matter of much difficulty to
do so, the end of the instrument escaping into the rectum.
This was, however, finally effected both at that time, and
afterwards, bp hooking the beak of the instrument against
the pubes, and then, instead of trying to force it forwards,
ill!
1861.] Nvy 735
the handle was suddenly depressed, and it slipped into the
gladder. Carried forwards in the ordinary way, it always
went into the rectum.
On the 27th, it was recorded that all the urine was dis-
charged by the catheter, although there was purulent dis-
charge through the fistulous opening near the rectum, and
occasionally from the rectum itself. The patient remained
in the hospital rather more than two mdhths, when he left,
and has since been seen well. Am. Jour. Med. Sciences.
A Paper 0/1 the Treatment of Constitutional Syphilis by repeated
Inoculation* with the virus of Chancres, Bead before the
German Medical Society of Paris, by Dr. Mansuroff, of
Moscow.
Syphilization, instituted by Auzias-Turenne, proposed by
him in the first stage as a prophylactic means for syphilis,
and applied to the tteatment of constitutional syphilis first
by M. Sperino, and then by MM. Boeck, Sigmund, Stein-
berg. Danielsen, Hebra and others, is a great fact, whose
importance has attracted the attention of the learned world;
but in the present state of science, ought this discovery to
idopted ? or, ought it to be rejected even as a method
of treatment for constitutional syphilis ':' This is an impor-
tant question for science and humanity, which will be very
soon settled in a definite manner by the learned of all coun-
. The large number of cases which have been carefully
studied for several years at Turin, Christiana, Stockholm,
ma, Berguen, Pesth and elsewhere, the scientific au-
thority and the well known honorable positioirof the phy-
sicians who have studied this question, and the attention
which I have given it for five months at Vienna and eleven
months at Turin, authorize me to give in this paper a short
; int of my convictions and my observations, which will
I some time hence in an extended work, and
Which, I will say in advance, will be favorable to syphiliza-
tion as a curative method for constitutional syphilis.
1. MM. Sperino and Boeck, who have observed and pub-
it number of cases, have established the three
following propositions: (".) The repeated inoculation of
736 Syphilis. [September,
chancroufl virus produces immunity ; (b.) The symptoms of
constitutional syphilis disappear under the influence of the
inoculation ; (c.) Syphilization acts in a beneficial manner
on the health of the patients. These three propositions
form the basis of syphilization; and a certain number of
observed cases have convinced me that they cannot be .con-
tested whenever syphilization has been practiced regularly.
Thus, I have seen that in general after twenty or thirty
days the symptoms of constitutional syphilis began to dis-
appear; and that after two, three, or four months, and rare-
ly more, the cure of the patient takes place. The time
varies according to the individuals, the gravity of the dis-
ease, and the previous mercurial treatment which they have
submitted to, etc.
2. As to syphilization as a prophylactic means in a
healthy man, it has never been practiced by MM. Sperino
and Boeck ; and since the year 1852, it has even been
abandoned by M. Auzias-Turenne, who practiced it in
some cases affected with chancres. The absolute immuni-
ty procured by the inoculations is, besides, very transient.
After some years, and even in some exceptional cases, after
some months, the patient loses in part this immunity, al-
though the cure of the constitutional syphilis continues ;
and the relapses, or rather the cases of incomplete cure,
have been cured easily by a small number of new inocula-
tions, although these individuals are with difficulty inocu-
lated. Consequently, if time proves that syphilization pre-
vents the relapse of constitutional syphilis, as my observa-
tions lead me to hope, it is easy to foresee the future of this
new treatment.
3. If after some inoculations we interrupt the treatment
for several days, wre see new syphilitic accidents supervene,
or those which already exist to become aggravated ; but
both disappear very soon, if we resume the inoculations
and repeat tmSm until immunity is established. The pro-
duction of chancre being the essential condition of syphili-
zation, we may favor its evolution in mercurialized persons
by a small dose of iodide of potas., which, however, may
be replaced by other means.
4. Before and during the treatment, we must remove all
causes susceptible of producing an inflammatory complica-
tion. If these supervene, the artificial chancres may be-
come inflamed and assume a certain gravity, especially with
persona who have already been treated with mercurials.
1861.] SypkUis. HI
Hence it is sometimes necessary to give a purgative, some
baths ami mucilaginous drinks before or during the syphiliza-
tion.
jervation has demonstrated that the more recent and
the oldest forms of constitutional syphilis may be cured by
syphilization. Among these forms I can count several c;
of affection of the bones of the cranium and extremities,
affections of the nails and cellular tissue, etc. In these grave
cases, when the organism presents but a feeble reaction to the
inoculations, ye employ sometimes the iodide of potas., which
we know is a go>tl remedy in mercurialism, and favors the
development of the inoculated ulcers. In less grave cases
the syphilid?-?, for example the effect of the iodide potas.
was ineffective or injurious, because it favored the explosion
of affections of the skin.
6. From all the facts known at the present time, it results
that the relapses after syphilization do not exceed five in one
hundred, whilst the relapses after the mercurial treatment
have been observed in one-third or one-half of the patients
(Boeck. The relapses after syphilization ordinarily present
themselves in light forms, which are cured in a very short
time by some inoculations.
7. The age and sex of the patients do not constitute any
coutra-indication for the treatment of constitutional syphilis
by means of inoculation. Prof. Boeck cured children of
eight weeks as well as old persons of sixty-seven years of age.
The experiments of Prof. Sperino were made almost exclu-
sively on women, and demonstrate that the uterine functions
were not disturbed by the treatment. On the contrary, with
the improvement of the general condition the patients were
cured of the syphilitic anaemia and of amenorrhcea. As to
children affected with hereditary syphilis, they died often in
spite of the syphilization and every other treatment (Boeck).
8. The health of the patients, improved during the treat-
ment, continued after the cure, which encouraged MM. Spe-
rino and Boeck to continue their studies. The patients are
neither exposed to the dangers of mercurial or iodic intoxica-
tion, nor to their consequences ; they do not carry mercury
in their bodies or viscera (luring four months, or even longer,
after the treatment (Gorup-Bezanez, Michaelis, Schroder van
der Kolk, Kletzinsky, etc.
9. It is only the practical study which can convince a
'urative value. It is also the general opinion of the cele-
brated Professors MM. Oppolzer, Hebra and Sigmund, that
hilization ought to be studied practically before judging
47
i
738 Syphilis. [September,
of its therapeutical value, and its applicability to the different
itituticmal syphilis. Besides the opinions emitted
id Italy on syphilization, we have read also the
5, more or less differing, of MM. Behrend, Huron, Yon
prang, Michaelis, Simon, Sigrnund, Uerrman, Kalis*
cher, and others ; we have also read the classical works of the
>cck and Sperino. These works, and the
r of cases observed clinically in the hospitals of
Turin and Vienna, as also in the private practice of M. Speri-
no. have afforded me advantages to study Syphilization, and
to form a decided opinion of this new method of treatment.
And when we think that there are physicians who never em-
mercury, and apply syphilization at all times when they
judge it necessary (MM. Boeck, at Christiana, Baumann, at
Lillehammel and Wildagen, at Drammen), we can conceive
then that this treatment has solid basis, although its practical
importance has not yet undergone all the improvements of
which it is susceptible.
10. It is useless to say that syphilization has inaugurated a
reform in syphilology. and that this reform has been accom-
plished by the study of pathological physiology. '-Syphiliza-
tion proves to us by evidence/' says Michaelis (Compend.
en, 1859, p. 345) "that syphilis is a disease which is cured
alone by the powers of nature ; and if the physician succeeds
in transforming the chronic syphilitic affection into an acute
i; hematic affection, Byphilization becomes a benefit to the
patient ; for it places him in the way of a natural cure (natur-
heibung). and spares him any depressing treatment whatever."
* words were written by a learned man who defends
mercury, and who judges severely syphilization after having
d it with success. His opinion differs, then, from the in-
dulgent opinions of the recent anti-mercurialists.
As the results and the facts of these observations cannot be
I a -mere detailed manner in this paper, I will con-
seli to name only the programme which I will follow
later in ii iption. I will describe the methods of syphi-
fche indications and the contra-indications, its process,
the local effects of indurated chancrous inoculations, non-indu-
s (or pustules), abortive, negative inoculations,
the immunity, the effects of syphilization on the organism at-
ihilis, but not suffering from concomitant dis-
. m chancre bubo, and the Byphiiization ; upon nutrition,
] [ien will tbliow the effects of constitutional syphilis on
the I ed with syphilis, and suffering from acci-
ases as fevers, catarrh, rheumatism, anaemia*
1861.] nabis Indira. 739
mereurialism, etc. I believe that the study of syphilization,
in all its aspects, being made at the bedside of the patient, is
Ined much sooner to throw a light on its practical bear-
ings as a method of treatment As it is supported now by
numerous facts which prove its power of curing constitutional
syphilis, even in its grave forms, 1 feel myself authorized to
say, with M. Herrman, that the period of experiment is passed,
and that it is no longer a question of judging from a large
number of facts, but from a small number well observed.
Hehdomadaire. Cincinnati Lancet cf' Observer.
On the Action of Cannabis Indica.
On the action of the Cannabis Indica, (Indian Hemp,)
Dr. Charles A. Lee uses the folio wins.1: language in the
Journal of Materia Medica.
-The action of hemp on man is so various that when we
oral descriptions given, (littering so widely, we
viv considering the same agent;
but it is, perhaps, no less remarkable than the every day
exhibitions we witness of alcohol, with which, being more
familiar, we give less attention. The great variety of phe-
nomena presented in the use of the latter, according to the
natural disposition or temperament of the person, and the
lition of the mind, as well as to the quantity, alternately
clew depressing in its effect, or producing the ex-
treme of kind or brutal emotions, can, to a certain extent,
be observed in the other.
The mental phenomenon upon a subject possessing an
aginative faculty in a high degree, when fully developed
One writer de-
ows: 'When it first begins to act, the ef-
chisch may be considerably diminished, or
becked by a firm exertion of the will. By de-
the power of controlling at will and direet-
the thoughts diminishes, till finally all power of fixing
. and the mind b the sport of ev-
ery idea which arises within itself or is forced upon it from
740 ( armabis Indica. [September
without. "We become the sport of impressions of every
kind. The course of our ideas may be broken by the
slightest cause. We are turned, so to speak, 1)}' every wind.
By a word or a gesture our thoughts may be successfully
directed to a multitude of different subjects with a rapidity
and lucidity which are truly marvelous. The mind becomes
possessed with a feeling of pride corresponding to the ex-
altation of its faculties, which it is conscious it had increas-
ed in energy and power. The slightest impulse carries it
along.
" The errors of perception in regard to time and place,
to which the person is liable during the period of fantasia,
are remarkable. Minutes seem hours and hours are pro-
longed into years, till at last all idea of time seems oblitera-
ted, and the past and present are confounded together.
"M. Aubert describes the influence upon him in the fol-
lowing language : 'I was engaged in conversation when I
felt a prickling sensation in my feet, and in my head a
stricture which gave way suddenly and my skull seemed
empty. Every object wore a new aspect ; my companion's
face assumed a grotesque expression ; I burst out laughing
and continued to laugh for almost an hour. The merest
trifle renewed my mirth. Meanwhile the most varied and
whimsical ideas coursed swiftly through my mind. I expe-
rienced the most perfect sense of comfort. For me there
was no longer past, present or future ; the fleeting moment
limited my whole existence. Then followed a calm, and
sleep stole over me. The whole night was but one long,
delightful dream. On awaking, I remembered perfectly
all that had taken place, and my head was not heavy nor
my mouth dry, as it would have been after a debauch in
opium or wine.'
" Dr. Christian relates the following concerning hemp :
'On trying Mr. Robertson's extract once for toothache, I
found that about four grains taken about 3 a. m. caused in
an hour cessation of pain, a pleasant numbness of the limbs,
giddiness, a rapid succession of unassociatefl ideas, and im-
possibility to follow a train of thought, frequent interval
of sleep, and slight increase in the force of the pulse. Xext
morning there was an ordinary appetite, much torpidity,
and shortness of memory, extreme apparent;
protraction of time, but no peculiarity of articulation or
other effect ; and these Bymptoms lasted until 2 P. M. when
they ceased entirely in a lew minutes alter taking lemon-
1.] nabislnd 741
ade. On anotb ion I took one grain of the extract
olved in spirit. I felt a peculiar numbness creeping
through my body and limbs. On lying down the numb-
continued but in fifteen minutes my sensations became
eable. J laughed heartily several times, answered
is incoherently, and immediately forgot what they
about and what I bad answered. Delightful reveries
came over me, and whatever I looked at became lost, as it
wore, in amaze; the lamp appeared to be slowly turning
round, and when I lost eight of this the red lines on the
paper of the room appeared to intertwine in a most beauti-
ful manner. The most remarkable effect was the constant
succession of new ideas, each of which was almost instantly
2 >tten. When roused to tea I ate ravenously without
feeling satisfied. I slept soundly at night, afterwards, and
the night day was stupid and forgetful, but was much im-
proved by drinking lemon juice. * * * *
" Dr. O'Shaughnessy describes a singular form of insan-
ity occasioned by an incautious use of the hemp, and which
- singular as the delirium tremens by the prolonged use
3pirituous liquors. He says it is at once recognised by
balancing gait of the patient, a constant rub-
the bands, perpetual giggling, and a propensity to
rid chafe the feet of all bystanders, of whatever
:. The re an expression of cunning and mer-
riment which can scarcely be mistaken. In a few cases the
patients are violent; in many highly aphrodistie. in all that
n voraciously hungry: there is no increased
l circulation, or any appearance of inflamma-
tion 'ii. and the skin ami general functions are
in ;
"Dr. Hooke in hi-; paper upon Indian hemp in 16*89, no-
3 the various odd tricks shown by persons while under
influence of this plant, and says that when this condi-
3 the patient finds himself mightily refreshed
and exceedingly hungry.
- pain, and may be employed
Mr. Donovan found that under its influ-
>uch and feeling gradually became ob-
. until al length he !<>-t all i tnlesa he pinched his
ly.
ataleptic condition, in
whic are moderately contracted, but flexible
the limbs retain any position or attitude
742 Cannabis Indica. [September,
in which they may he placed. Dr. O'Shaugnessy gives an
interesting case of this kind.
" It does not appear to affect the secretions mnch. The
testimony is strongly in favor of its increasing the appetite
and very little that it causes nausea. It neither causes dry-
ness of the tongue nor constipation of the bowels; and its
effect upon the bronchial secretions is beneficial than other-
wise.
"Its habitual use is said, by Di. Stille, to produce conse-
quences no less mischievous than are produced by alcohol,
and opium ; the face becomes bloated, the eyes injected,
the limbs weak and tremulous, the mind sinks into a state
of imbecility, and death by marasmus is the ultimate pen-
alty for the overstrained pleasure it imparts. We are not
acquainted with any case of death directly resulting from
the poisonous action of cannabis ; but several are recorded
which illustrate its effects in excessive doses.
u We shall now consider as briefly as possible the disea-
ses for which it has been employed, under their several
heads.
" Tetanus. Dr. Christian states that Dr. O'Shaughnessy
treated several cases of tetanus with apparent success. In
one, ascribed to cauterization of the hand by a quack mix-
ture of incandescent charcoal and tobacco, a state of in-
toxication was excited by large doses of the extract of
hemp, and the spasms were gradually put an end to ; but
death ensued in the end from mortification of the hand.
Another patient consumed one hundred and thirty-four
graius of the extract, and was ultimately discharged from
the hospital cured. A third case with similar results is
detail eel. At the Native Hospital in Calcutta, Mr. O'Brien
treated seven cases of tetanus, and in four of them he em-
ployed ten grain doses. The result wa3 almost immediate
relaxation of the muscles, and interruption of the convul-
sive tendency. Four of these cases recovered. A case in
the practice of Mr. Richard O'Shaughnessy is also detailed,
where the disease was connected with suppurating wounds
of the scrotum. The hemp had no effect for four days,
and then the patient became tranquil, with fewer paroxysms
and the appetite good. When the hemp was intermitted
the symptoms became aggravated : latterly the hemp caused
much excitement and was therefore discontinued. The last
is one of infantile convulsions, where very large doses
were given, and where the narcotic action greatly relieved
1861.] 743
ms. The child recovered. This gentlemai
confident that the rosin rig the |
of te - in a lar portion or" eases, it will
cure the disease.
It would certainly app hat In-
dian hemp has : >f service in the treatment of t
nn8, as it India. How far tl
ined in Europe I shall now describe.
That I may not extend my observations to too gre
limit my remarks to the treatm
in private practice, and in the
loyal Infirmary.
Pj Miller hi Med me with the following
marl
"My own experience speaks loudly in favor of the hemp.
I can now record three fortunate cases under its use all
traumatic tetanus and a case which proved fatal, but
where great alleviation of &u was produced.
" The first of these was a girl, even, admitted to
the Royal Infirmary, Oct. IE SShe had received an
extensive injury of the mid er of the right hand a
. Infko yelling a be-
a tendency to lex-
ion of the fi]
e to tak< becoming
: in the j ieit she
ell. A "brisk pi, L, and lest the
re tetanus tincture of hemp v
taken every four hours. Next d
ptoms ^ ! marked without any influent
hemp. The
: died to the wound. The dose of hemp \va-
creased to twenty drops, and after five <: hut
the following day the symptoms were aggravated, lurpen-
ordered and ice to the spine thin
of cam ahis to b hourly. In tha
the hemp to be givou
.
Aconite
eke became mor
er, the d
lually re<
744 Cannabis Indica. [September,
drowsiness or calm sleep ; it was soon discontinued, as it
then seemed to excite the circulation. Throughout the
whole period of its use, its effect was most obvious, the
craving for food being at times absolutely voracious. After
this no more medicine was given and recovery was complete.
" The second case, occurring in private practice was that
of a boy, about the same age, who had simple fracture of
the thigh, with compound and comminuted fracture of the
great toe. The treatment and result were the same.
The third was a boy rather old, who had compound frac-
ture of the bones of the arm. Treatment again resulted in
cure.
In these cases a few doses generally induced sleep, with
marked mitigation of the spasms. The period of narcot-
ism did not exceed two or three hours, the sleep was deep,
and unbroken, and seemed to be refreshing. It was fol-
lowed by no headache, or other apparent inconvenience.
The most remarkable effect observed was the tolerance of
the remedy, whereby a girl, aged seven, took every half
hour, and sometimes many hours in succession, doses of
hemp sufficient to narcotise an adult.
" In these cases Mr. Miller is inclined to give the hemp
credit for a chief share in the cure.
In 1846 the virtues of hemp were tested in a case of tet-
anus in the Royal Infirmary, in the wards of Mr. Duncan.
In 1847 another case presented itself where hemp was ad-
ministered. At that time sulphuric ether was much used
as an anaesthetic, and it was thought probable that it would
be of service in this case. The patient inhaled it at fre-
quent intervals during a whole afternoon, with decided but
only temporary relief. After this cannabis was given,
without its physiological action being attained by nearly
an ounce and a half of the tincture ; it was not persevered
with. Ether was again tried, and also opiates with some
benefit. The patient died on the thirteenth day.
" The first of these cases was very accurately observed,
and the following report of the case from the journal will
be found to have considerable interest.
" James Mackay, a railway laborer, was admitted under
the care of Dr. Duncan, October 20, 1846. He had received
a slight lacerated wound of the hand a week before, and
tetanus had commenced on his admission. The wound ap-
peared to be healing. He complained of great uneasiness
particularly about the neck and spine, of some rigidity of
1861.] Cannabis Indlea. 745
the jaws, winch could only be separated three quarters of
an inch, of inability to protrude the tongue, and of com-
mencing spasm of the neck and upper part of the back.
He complained also of a burning about the heart. His
expression was anxious with but little 'risus.' His thirst
was great but swallowing difficult. He perspired profusely.
The spasms of short duration, recurred once or twice every
minute ; pulse, one hundred and fifteen to one hundred
and twenty, soft. Opening medicines were ordered, and at
11 o'clock tincture of hemp was given, repeated in doses
of fifteen to twenty drops with appreciable effect. On the
21st the bowels were not opened, though a turpentine ene-
ma was administered. The spasms were more violent and
general, and a touch caused general spasm. He had not
slept. One hundred and twenty to one hundred and forty
drops had no effect. The doses were increased to sixty or
eighty drops every three quarters of an hour, and croton
oil was given producing free action of the bowels, and in
the evening the spasms abated, but the hemp caused only
slight dozing at intervals. The tincture was ordered to be
continued and strong beef tea to be drunk.
" On the 22d swallowing was easier, the spasms less vio-
lent, but not less frequent ; one hundred drops were given
at half past eleven, and continued about every half hour
till four o'clock, when drowsiness was quite decided, he was
not easily roused, even by the spasms, which though as fre-
quent, were not so intense. At nine o'clock drowsiness
was passing off; copious stools, colored as by the medicine,
were brought away by injection ; one hundred and thirty
drops were given, and repeated at midnight, at which time
he was much relieved, but suffered from cough. On the
23d the spasms were again gaining strength, no hemp hav-
ing been given for nine hours. A drachm of the tincture
was given and repeated at eleven, when he became quiet.
The doses were continued till evening, when he took mince
collops and beef-tea without difficulty, and the bowels were
copiously relieved.
" On the 24th, at visit, the spasms were absent, but the
chest symptoms were worse, with general mucous rale, and
frothy sputa mixed with blood. Drowsiness had been kept
up by doses of a drachm to a drachm and a half. In the
evening he was much weaker, but quite sensible, with a
ire for food. On the 25tD he was from
spasm, but was evidently dying from accumulation of ma-
74 G Amputation through the Foot [September'
ens in the chest. Very little hemp was given. lie died at
8 P. M.
"In this case six ounces of O'Shaughnessy's tincture of
Indian hemp wore given in all, being equal to one hundred
and forty grains of the extract. The extract for the tinct-
ure was reputed the best in Edinburgh. The doses at first
were evidently too small. The examination of the body
was not permitted.
"It is a safe conclusion from these facts, that Indian
hemp deserves further trial in the tetanus of Europe, as
well as in that of hot climates. 1 would particularly urge
however the necessity in all such trials of making certain
by experiment on healthy persons, that the preparation to
be used is good. For the present there is no other satisfac*
tory test of quality." Med. Surg. Reporter.
Conservative Amputations through the Jhootand Ankle
The probability of the occurrence, to military surgeons, of
frequent occasions for amputations through the foot and ankle,
gives the following appreciation of the operations of Sym
and Pirigoii, an importance at this time.
The correspondent of the Medical Times and Gazette from
Bonn, Switzerland, says, "that Professor Weber has recently
given us a statistical comparison of the different amputations
which are performed in the neighborhood -of the ankle joint,
and which may be of some interest to your readers. The
cases brought together have been collected from the German,
English and French Hospital Reports. As regards Symc's
operation, much preparatory work to this had been done in
the valuable work of Professor Gunther, of Leipzig : t Lehre
von den Bmtigen Operationen,' (A Treatise on Bloody Opera-
tions,^ to which numerous plates are added ; and there is also
a well written these on the results of Pirigoff's amputation by
Dr. IT. Kestncr, of Strasburg, which appeared in 1857, and in
which twenty-tv. i been collected. Altogether,' 216
;en published. Of these, 3 i were made
e above il : mall< bli, LOJ : /me, with ai
rior flap, 40 accordii w the astragalus, at
by Textor, later by ' me, 21 according to Ohopart.
From these returns, it that the amputation, close
e the malleoli and Chopart's method give the most favor-
1.] <h tlu Foot, fc. 747
results as to mortality. In the first only throe per cent.
died ; the amputations according to Syme and Pirigoff gave
equal results, as 15 per cent died by each of these methods.
In the operation according to Baudens, S3 per cent, died,
while the operation of Textor and Malgaigne, below the astra-
gal:,- only one death in S ouefi. This seems certainly
m favor of the amputation above the malleoli, to
h s<> m- ; but, perhaj
larger numl ses might give a different result. In the
: cases operated upon according to Syme and Pirigoff,
death was mostly due to gangrene of the heel having super-
vened ; this is still more frequent if the nap is formed from
the thin skin at the back of the foot, as is done in Bauden's
Operation. In FirigoiFs amputation, the number of cases in
whi induced, amounted to 12, in Syme's to
in Bauden's to 25 per cent. Independently of this, how-
ever, the first mentioned operations yield exceedingly favora-
ble results; the stumps are always useful, and there is only
case known of Syme's operation in winch t}m stump was
rinful as to prevent walking ; and only one case of Piri-
"s in which caries recurred, and a subsequent amputation
became necessary. In this respect, the results are much more
unfavorable in the amputation above the malleoli. The cir-
cular incision, even if a large cuff should be formed, is not
is the formation of a flap, especially if the
made posteriorly and suiiiciently large. The com-
:t that a e<nical .slump is generally the result of this ope-
ration, is of less moment than the continuous exulceration of
the cicatrix which is apt to ensue; and in some cases it has
d been necessary, in consequence of such an occurrence,
imputate the stump again. Some time ago, a patient who
ler the care of sh, of this University, and
i both legs had been amputated close above the i
undergo amputation at the place of elec-
on that account, which was successfully done. Amputa-
tion above the malleoli shows about 25 percent, of anfavora-
. and the number of such is just as great after Cho-
iOUgh in of BUCC
;- to Chopart, have lal
drawing op of the
er <m the ba 1 \\ hich is,
f the niche i the
748 Amputations through the Foot, c. [September,
malleoli; but the mere retraction of the -tendon of Achilles
does not Beem to be a sufficient reason, as M. Yerneuil has in
Beveral cases, in which he made an anatomical examination
of the stump, found this tendon quite relaxed. The best
means to prevent the drawing up of the heel, seems to be a
union of the tendons of the back of the foot and the plantar
flap ; and in order to effect this, the latter ought to be made
as large as possible, and the tendons ought to be left as long
as possible.
"As the time which is required for the cure has, in many
cases, some influence upon the choice of the method, and is
especially to be considered in amputations made during war,
I may mention that Professor Weber has found that the cases
of Syrne's and PirogofFs operation in which the cure took
less than a month, were far more numerous than such of am-
putation above the malleoli. Of this latter and of Chopart's
operation, only 27 per cent, were cured in less than a month ;
but of Pirigoff 's and Syme's more than 40 per cent. This
circumstance, of course, does not absolutely decide the ques-
tion ; and the most important point will always be the com-
plete removal of all diseased and the preservation of all
healthy parts a principle the correctness of which cannot be
denied by even the most conservative surgeons.
"I conclude with a few remarks upon the method of opera-
ting in ~ Pirigoff 's amputation During the last year a contro-
versy took place in the columns of one of your London con-
temporaries, between Professor Pirrie, of Aberdeen, and Mr.
Watson, as to which of them had first made this amputation
without previous disarticulation of the astragulus. I believe
that both these gentlemen were led to the idea of simplifying
the operation independently of each other ; but I may remark
that before either of them, Dr. Schultz, formerly assistant to
Professor Pirigoff, had, in 1854, recommended that the calca-
neus should be sawn through from below, to avoid disarticu-
lation. No doubt it is more difficult in this operation to pre-
serve the A tibialis postica, which is of the greatest import-
ance, as the nutrition of the flap depends upon it; and I may
also say that, in case the calcaneus should, contrary to what
had been expected, prove to be entirely diseased, a subse-
quent disarticulation of the process would be attended with
great difficulties ; and it is always advisable that the surgeon
ild reserve to himself the possibility of eventually perform-
ing Syme's operation. The modification alluded to lias, there-
, not met with much encouragement in Germany.
Whether the tendon of Achilles ought to be cut through, and
1861.] Treatment of Tetanus.
whether the sawing should be more or less obliaue, must
depend upon the rigidity or softness of the surrounding parts,
which are often much infiltrated. If such is not the i
not difficult to put the sawed surfaces together ; otherwise, the
means just alluded to must be employed; That the bones
aawed through should be closely adapted to each other, is of
the utmost importance for a rapid union; and this is the rea-
iie surgeons (for instance. Professor Langenbeck,
of Berlin) have even united the hones by means of silver
wires. But this is not often necessary. I hope thatthiscom-
munication may assist in setting aside some of the prejudices
which still prevail with many surgeons in your country re-
garding Syme's and Pirigoff s amputations, which yet have
not been so extensively tried as they deserve." Medical &
Surgical Report r.
The Treatment of Tetanus.
Dr. Hutchinson, of London, after the consideration of a
statistical table of a large number of cases of tetanus, oc-
curring in the London hospitals, concludes with the follow-
ing memoranda as to the management of the disease. We
quote from the Medical Times and Gazette ;
1. The chief objects in view arc three to mitigate the
force of the local irritation to which the disease is due ; to
tain the patient's strength by food ; and lastly, by pro-
curing sleep, to allow the nervous system the opportunity
of regaining its wasted powers.
2. If the case be seen in the very onset, and if the in-
jured part be a finger or toe, it is desirable at once to am-
putate, whatever may be the local condition. If the injury
been severe, and the part have passed into a state in
in which, whether from sloughing or oi: . its reco^
is doubtful, it is desirable to amputate at any stage of the
disease, or even if one of the extremities he the part in-
volved.
3. The injured part should be poull id the limb
ive it wrapped in lint soaked in laudanum and chloro-
form.
4. The patient should be put in a room with but one
and the strictest quietude should be insisted on.
750 Fomentations. [September,
5. If the patient has been accustomed to it, he should be
allowed to smoke.
i). The bowels should be well cleared out by croton oil,
or other efficient purgative.
7. If the skin be very hot, the pulse jerking, and the
tongue red and dryish, the surgeon maybe justified in com-
bining small doses of calomel with the narcotic he may
have selected for employment.
8. A free allowance of beef tea, milk, eggs, and similar
articles of concentrated fluid nutriment should be given,
more especially in the later stages of the complaint.
9. As long as the patient is able to take food and to ob-
tain periods of comparative quiet and freedom from pain,
the use of anaesthetic inhalations is not desirable. Great
advantages may, however, be obtained from them if he be
unable to open the jaw sufficiently to permit of taking food
or if the tetanic spasms are without remission. Ether ap-
pears to have stronger facts in its recommendation than
chloroform.
10. One or other form of narcotic opium, indiari hemp,
belladonna, or woorara should be used. There is no very
decisive evidence as to the advantage of any one of these
over the others. Respecting the Indian hemp and the
woorara, the difficulty often encountered in obtaining them
in a state of reliable activity will often be an obstacle to
their employment.
11. Excepting, possibly, in the per-acute cases, the free
use of quinine appears to be desirable. If given in large
doses it generally reduces the frequency of the pulse, and
in some cases a mitigation of the tendency to spasm has
attended its influence. The rapid induction of cinchonism
is a measure well worthy of a fair trial. Ibid.
On the Use of Warm or Luke-warm Fomentations in certain
Ophthalmia?.
Von Graefe reaches the following conclusions on the
above subject. We quote from the" London Ophthalmic
Hospital Reports :
" To sum up. l The methodical application of warm fo-
mentations assists materially in bringing about the desired
1801.] Fomentations. 751
demarcation in all the non-irritative purulent infiltrati
of the cornea, which shows a tendency to spread circum-
ferential ly.'
u Warm fomentations are most serviceable in those cases
in which, after an accident or ai tion, a circumscribed
corneal infiltration shows itself where very violent pain
Id to one or two .tions of leeches, where
the customary cold applicati ther do not alleviate at
all or only temporarily, and where finally a circumscribed
portion in the infiltration becomes yellowishly discolored.
After the fomentations have been applied for twelve to
twenty-four hours, there will generally be a diminution in
the irritation, and the process on the cornea begin to be
circumscribed ; when the desired effect has been attained,
we must cease their application.
' In those cases of malignant ulcers of the cornea, in
which there is but little tendency to formation of pus, but
at to progressive destruction of the cornea, not
only in depth but in circumference.
[n the diffuse suppurations of the cornea, which some-
times unfortunately threaten or occur after extraction, Yon
.'mud them here of great advantage, particular-
ly in old decrepid people, in whom, after passing eighteen
ur hours without the slightest pain, we notice
much swelling of the upper lid and a too great conjuncli-
-ecretion. If these symptoms are not clue to an inaccu-
adaptation of the corneal flap, (for which compresses
are the best remedy,) he applies warm fomentations period-
ically, and paints tincture of iodine on the lids.
"But although we cannot expect much good even from
their application, when there is a plentiful thin secretion
from the conjunctiva, serous chemosis, yellow hue of the
whole of the cornea, and a more or less circumscribed ab-
- find that they will limit these processes to the
anterior portion of the eye-ball, and thus spare the patient
the frightful sufferings of panophthalmitis.
efnl in :; .'mate cases of granula-
tions, wi it pannns, for it is a Well known fact
under these circumstances, a ce tount of conjuncti-
val swelling propitious. Von Graefe thinks that the
ability of acute granulations (which often
kittle, if any, therapeutic aid) d< n this.
A V i i : band, we find that the less conjunc-
tival In : . a there is, particularly during the stage of
752 Miscellaneous,
development, the more do the granulations develope them-
selves and attain the type of the so-called trachom granules.
It has been lately shown, particularly in Belgium, that the
development of a diffuse hyperemia of the conjunctiva
brought about by inoculation, not only exerts a most bene-
ficial i nil nonce upon secondary pannus, but also upon the
acute granulations. The curative effect of the periodical
application of sulphate of copper is similar in nature. And
the same is the case with warm fomentations, which reme-
dy links itself on to the treatment by inoculation, and
although it cannot supplant this remedy in all cases, it yet
has the great advantage of being free from any danger.
This is of the more importance in Berlin, where, owing
most likely to the climate, diptheritic inflammation often
supervenes on the inoculation of blenorrhea.
"Finally, having observed that patients suffering from
the very obstinate diffuse non-vascular form of keratitis,
have been surprisingly quickly cured, if they, perchance,
have been infected with conjunctivitis, Yon Graefe has
tried the warm fomentations in some of the cases with good
effect. At present, however, his observations have been
too few to warrant any very decisive opinion on their
efficacy." Ibid.
Dr. Win. V. Keating has been elected to fill the chair
recently vacated by the resignation of Dr. Ch. D. Meigs, in
the Jefferson Medical College at Philadelphia.
The Legislature of Louisiana has enacted that no one
shall hereafter be permitted to practice Medicine in that
State unless he be a graduate of some respectable Medical
Institution.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
ML AUGUSTA, GEORGIA, OCTOBER, 1861. NO. Ill
ORIGINAL AND ECLECTIC.
ARTICLE XVIII.
[Conci :iber number.]
Indi - -of tic Southern Oonfedei%acywhichmay
ill In in: 7 U of Mala/rial Fever. By
Joskpu Jones, M. D., Professor of Medical Chemistry m
the Medical College of Georgia, and Chemist to the Cotton
Ranters' Convention of Georgia.
No. 2.
SUMMARY:
Wild Uorehound, (Eupatorium rotundifolium.) Botanical descrip-
tion ; geographical distribution ; medical operation and uses ; extensively
employed in domestic practice in the treatment of intermittent fever :
medical properties first brought prominently to the notice of the profes-
sion, by George Jones, President of the Georgia Medical Society ; tes-
timony of Dr. Jones, showing that it serves as an excellent substitute
for Peruvian bark ; testimony of Dr. Nathaniel Chapman, of Philadel-
phia, to its value in intermittent fever.
BUvk Willow, (Salix nigra.) Testimony of Michaux to its value
in intermittent fever.
Vhite Willow of "Europe, (Salix alba.) Chemical composition :
analysis of M. M. Pelleticx and Caventou ; discovery of the principle
icin by Buchner, of Germany ; investigations of M. Font an a,
telli, M. Leroux, upon'the different species of Willow ; properties
salicin : medical properties and uses of Willow bark ; use of, by the
ancients, brought to the notice of the profession in 17<>.'). by Rev. Mr.
of Mr. Stone to its value; testimony of Fames
White and Wilkin- of by Elaller : testimony of European phy-
sicians to the value of Salicin,
48
754 i;i'Ji J'oXes, on the Indigenous [October,
Yellow Jessamine, (Gclseminum sempervirins.) Accidental disco-
very of its value in malarial fever ; use of in Western States ; testimony
of Drs. Cleveland, Nash, J. A, Mayes and others, to its medicinal proper-
ties and uses; dose and mode of administration.
Milk Weed, or Root of Man, (Asclepias syriaca.) Testimony of
Dr. Richard S. Oauthorn, of Richmond, Va., to its value in intermittent
fever.
Common Salt, (Chloride of Sodium.) Dr. Scclle Montdezert the
first to call i he attention of the profession to the value of Chloride of
Sodium in the treatment of intermittent fever ; testimony of Dr. W. P.
Lattiinorc to the success of M. Piory with common salt in the treat-
ment of intermittent fever ; testimony of Drs. Moroschkin and Dr. Hut-
chinson ; dose and mode of administration.
Sal Ammqniac, (Ilydrochlorate of Ammonia.) Testimony of Dr.
Felix Jacquot to its value in intermittent fever.
Nitric Acid. Testimony of Drs. George Mendenhall, Bailey, J. C.
Thompson, and Dr. William A. Hammond.
Arsenic. Testimony, experiments and investigations of Drs. Felix
Jacquot upon its relative value in the treatment of malarial fever ; testi-
mony of M. Boudin.
Ligature oj r the Extremities in 1/an miiient Fever. Testimony
of J. PeDrauw and others to the effects ci ligature of the extremities in
intermittent fever.
Cold Water in tJteTreatment of Malarial Fever. V^e of by Dr.
Wright in 1786 : practical rules for its use, by Dr. J. Currie, of Eng-
land; testimony of M. Fleury to the value of cold douches in the treat-
ment of intermittent fever.
WILD IIOEEHOUND1 (EUPATOIUUM EOTUXDI-
FOLIUM. Eli..
Botanical Description. Leaves sessile, distinct, deltoid, nearly
round, obtusely serrate, veined, somewhat glaucous; scales of the involu-
crum acute, Stem two to three feet high, very pubescent. Leaves
opposite, decussate, triplinerved, dotted, slightly scabrous, with a some-
what glaucous, or perhaps more correctly, hoary hue. Flowers in a fas-
tigiate corymb. Involucrum ten leaved, five flowered ; leaves lanceolate,
acute, very pubescent. Corolla white. Stamens very short. Style
much longer than the Corolla. Seeds angled, Pappus scabrous, longer
than the corolla. Decoctions of this, as well as of the preceding species,
used with much success as a tonic febrifuge. I have always sus-
pected this plant te be the E, Marrbium of Walter. It is commonly
known through our low country as the Wild Ilorehound, and its leaves
bear more to the Garden Ilorehound, (inarrubiuin vulgare,) than
those of an)- other of our species.
Grows in dry pine barrens.
Flower.- from .July to September. Elliott. Sketch cf Botany of
South Carolina and Georgia, vol. 2, p 300.
w England to Geor-
gia : very abundant in the South examina
that I am aware of, has Qver b< eterinihc the
chemical constitution of this plant.
M This plant has been exten-
sively employed in domestic practice, in the treatment of in-
termittent fever, colds, and in debilitated states of the system;
The medicinal properties of this plant appear to have been
first brought prominently to the notice of the profession, by
the Honorable G [., President of the Georgia
. who thus describes its medical virtues : "It
- an excellent substitute for the Peruvian bark, and
amoifg the planters in or near the sea-board, it
lie bark in the cure of fevers. It is tonic, dial
c and mildly cathartic, and does not oppress the
the bark is apt to do hence it may often he e.\
hihited where the cinchona is inadmissable. It is usually
given .: of infusion : one ounce of the dried lea*
d into a quart of water, may he taken daily, in
Four ounces every hour or two. It may he ad-
van; ; mbined with Peruvian bark, and. thougl
may sometimes fail of producing the desired effect, I think
the articles of the mate-
ria n Dr. Chapman in his Therapeutics, nt'^v quoting
the : the President of the Georgia Medical :
: "In this sentiment I entire! own prac-
tice has not afforded me many opportuniti it, but 1
- tate, ir wj
in the cases which have
catarrhal
a hitter tunic, in
ich. [1 lee'H, in
apd
made ii nip or candy/'
p 437.
756 Joseph Jones, on the Indigenous [October,
I have employed the wild horehound both by itself and in
conjunction with Cornus Florida, in the treatment of inter-
mittent fever, colds, and debilitated states of the system, with
very good success. In my native county, Liberty, it has for
many years, (as far as I can ascertain from the oldest inhabi-
tants, probably from the first settlement of this portion of
Georgia,) been employed extensively as a domestic remedy in
fevers and colds.
It may be administered in somewhat larger doses than the
preceding species.
BLACK WILLOW. (SALIX NIGRA.)
This willow, which is the most common of the American
willows, and the most analogous to the White willow, (Salix
alba) of Europe, is found in all the States from New England
to Florida, and wesr, nearly to the foot of the Rocky Moun-
tains.
According to the younger Michaux, the roots of this small
tree afford an intensely bitter decoction, which is considered
in some parts of the country as a purifier of the blood, and as
a preventative and remedy for intermittent fever. The ex-
tensive genus of willow, which comprises not less than one
hundred and thirty species, which, with a few exceptions, are
natives of Europe and North Americo, is especially worthy of
the attention of Southern physicians, since in several of the
European species, a principle resembling quinia, has been
extracted, and upon a fair trial has been found to possess the
properties of quinia. With the exception of the testimony of
the younger Michaux, which I have just brought forward, I
am not aware that any experiments or medical investigations
with reference to the American species have ever been laid
before the profession.
WHITE WILLOW OF EUROPE, (SALIX ALBA.)
Although not indigenous to the Southern Confederacv, the
White Willow of Europe has been so extensively introduced,
that it is worthy of the consideration of physicians as tho
source of salicin.
1861.] Remedies of the Southern Confederacy. 757
Chemical Composition. According to MM. Pelletier and
Caventou, the bark of Salix alba contains bitter yellow color-
ing matter, green fatty matter, similar to that found in cin-
chona, tannin, resinous extract, gum, wax, woody fibre, and a
magnesian salt containing an organic acid.
These chemists failed to isolate the most important of all its
ingredients, salicin, which was most probably mixed with the
bitter yellow coloring matter. Subsequently, in 1828,
Buchnei, of Germany, discovered a peculiar principle,
which has since been discovered in fourteen species of salix,
and eight species of populus. M. Fontana and Ttigatelli, of
Italy, discovered this principle shortly after Buchner. M.
Leroux, of France, appears to have been the first to accurately
investigate its properties. When pure, salicin presents itself
as white, shining, slender, inodorous, very bitter cystals, in-
soluble in ether and oil of turpentine, soluble in alcohol,
much more soluble in boiling than in cold water.
According to Merck,- it may be prepared in the following
manner :
Dried or fresh willow bark is cut small, and exhausted by
repeated boiling with water. The decoctions are concentra-
ted, and, while boiling, treated with litharge till the liquor
appears nearly colorless. The dissolved oxide of lead is
removed, first by sulphuric acid, afterward- by Biilphuret of
barium, and after the separation of sulphuret of lead, evapo-
rated, when salicin crystallizes ; and is purified by repeated
solution and cystallization. From willow bark which is fresh
and rich in salicin, it may be obtained by cautious evapora-
tion of the cold aqueous infusion. The oxide of lead rem
from the solution gum, tannin and extractive matter which
would impede the crystallization of the salicin. It also com-
bines with the salicin, forming a kind of salt, which is decoin-
d by the sulphuric acid and sulphuret of barium. I:
latter be carefully added, neither sulphuric acid nor baryta
'Turn- I istryj 7th ed. p
7 58 Joseph J ones, on the Indigenous [October,
remain in the solution ; and the sulphuret of lead which sepa-
rates, acts as a decolorizing agent.
I'wal Properties and Uses. The ancients arc said to
have employed the Lark of the willow in the treatment of
disease ; it fell into disuse, however, until 1703, when it was
brought into hottce by Rev. Mr. Stone, who published in the
Philosophical Transactions of the Royal Society of London,
an article entitled "On the Success of the Bark of the Willow
in the cure of Agues by the Rev. Edm. Stone, of Clipping-
Norton, Oxfordshire:"' Dated April, 25th, 1763."
As his observations are exceedingly interesting at the pre-
sent time, we shall present a full account of them :
About six years prior to 1TG3, Mr. Stone tasted the willow
bark, and was surprised at its extraordinary bitterness, which
immediately raised in him a suspicion of its having the pro-
perties of Peruvian bark. As this tree delights in a moist,
wet soil, where agues chiefly abound, the general maxim that
many natural maladies carry their cures along with them, or
that their remedies lie not far from their causes, was so very
apposite to this particular case, that he could not help apply-
ing it ; and that this might be the intention of Providence,
he owns had some weight with him. The plenty of this bark
furnished him, in his speculative disquisitions on it, with an
argument both for and against these imaginary qualities of it ;
for on one hand, as intermittents are very common, it was
reasonable to suppose, that what was designed for their cure,
should be as common and as easy to be procured. But then,
on the other hand, it seemed probable, that if there was any
considerable virtue in this bark, it must have been discovered
from its plenty. His curiosity prompted him to look into the
dispensatories and books of botany, and examine what they
said concerning it ; but there it existed only byname. He
could not find that it ever had any place in pharmacy, or any
suc'i qualities as ho Bnspected, ascribed to it by botanists.
However, he determined to make some experiments with it;
au! for the purpose he gathered that summer near 1 lb.
weight of it, which lie dried in a bag, on the outside of a
baker'.- oven, re than three mon
reduced to a powder by pounding and sifting, at'
manner that d.
It was not long b( fore he had an opportunity of making a
trial of il : bn1 being an nature, he gave
it in is, he thinks it was abon :.sof
the powder at very tour hoars be-
tween the tits, but with great caution and the strictest atten-
tion to its effects : the tits were considerably abated, but did
not entirely ceae perceiving the least ill e< ices,
he became bolder with it, and in a few days increased the I
to two Bcruples, and the ague was soon removed. It was then
n to several others with the same success, but he foun
better answered the intention when one drachm of it
n every four ;rvals of the paroxysi
lie bad continued to use il with success, as a remedy
agues and ii r five years successively.
It bad been ailed in the
cure, anal and quartan ague
which the \ . u long and severely afflict
then reduced, in 2 ree,but did not wholly tal
oft*. The patient, at the usual time for the return of
n't, felt some smattering of his distemper, v
saut repetition of tl could not
seemed as if th< ' v could reach thus far and
tber, and he ed it would not have continued to r<
nd that would have so<
with its pristine violence, but be did no
Tie added one-fifth part of the Peruvian bark t
and with this small auxiliary it totally rout
It was found necessary also in one 1
-her time- of the year, to mix tl
bark with it. but th<
abroad imprudently, an L caught cold,
did. who being alm< an in vet'
as:u he not
760 Joseph Jones, on the Indigenous [October,
only neglected his powders, but meeting with bad weather
renewed his distemper.
One-fifth part was the largest and, indeed, the only pro-
portion of the quinquinia made use of in this composition,
and this only on extraordinary occasions ; the patient was
never prepared cither by vomiting, bleeding, purging, or
any medicines of a similar intention, for the reception of
this bark, but he entered upon it abruptly and immediately
and it was always given in powders, with any common ve-
hicle, as water, tea, small beer, and such like. This was
done purely to ascertain its effects, and that he might be
assured the changes wrought in the patient could not be
attributed to any other thing, though, had there been a due
preparation, the most obstinate intermittents would, proba-
bly, have yielded to this bark without any foreign assist-
ance ; and by all he could judge from five years' experience
of it on a number of persons, it appeared to be a powerful
absorbent, astringent, and febrifuge in intermitting cases, of
the same nature and kind with the Peruvian barks, and to
have all its properties, though perhaps not always in the
same degree. It seemed, likewise, to have this additional
quality, viz : to be a safe medicine, for he never could per-
ceive the least ill effects from it, though it had been always
given without any preparation of the patient. The tree
from which this bark was taken, is styled by Ray, in his sy-
nopsis, Salix Alba Vulgaris, the common white willow.
Philosophical Transactions of the Royal Society of London,
abridged bv Ilutton, Shaw and Pearson, vol. xii. 1763-1769,
p. 1-3.
Messrs. James White, and Wilkinson published strong
evidence in favor of the use of the broad-leaved willow in
intermittents, foul ulcers and other affections. Dr. Cullen
recommends the willow-bark in his Materia Medica, as a
substitute for Cinchona. I taller was in the habit of using,
with success, a decoction of the bark as a bath to dip infants
in. Dr. Closs affirms that the bark of the willow, given in
1861.] Remedies of '1 7*51
the do>e of a scruple every three hours, has cured many
eases o intermittent and bad scorbutic ulcers; numerous
other English physicians have testitied to its value in inter-
mittents; and its great value as a substitute for Peruvian
bark is established beyond all doubt.
The testimony of numerous European physicians shows
that the active principle of Willow bark, Salicin, is capa-
ble of arresting and curing intermittent fever, and stands
next to Quinine as an anti-periodic remedy.
According to Buchner, twelve grains, in divided doses,
will irenerallv arrest a<me, and Magendie affirms that he
has seen fevers cut short in one day by three doses of six
grains each.
The dose of the bark in powder is 5ss to 5ij. The infu-
sion or decoction prepared with one ounce of the bark to
one pint of water, may be administered in doses of from
one to fouriiuid ounces.
Salicin should be administered in the same manner and
to accomplish the same objects as Quinine, but in larger
r'rom ten to forty grains may be administered every
three hours.
YELLOW JESSAMIXE. (GELSEMDTUM SEMEER-
VIKEXS.)
According to Dr. Cleveland, of Cincinnati, the value of
the Yellow Jessamine in malarial fever was accidentally
discovered by a planter suffering under bilious fever, who
took by mistake, an infusion of the root of this plant, and
was cured, although for a time he lost all muscular power.
It has been announced as a speedy cure for intermittent
fever, and has been largely used in this disease in the west-
ern Stafo
Dr. Nash, of Norfolk, who has employed it in many cm
of fever, affirms that it lias produced the most desirable ef-
fects, neither age nor .-ex interfering with its exhibition; and
whilst he does not rely solely upon it, in all specially
762 3EPflJoKfis, bn the Indigenous [October,
those of a high gra-de, lie still thinks that it is entitled to
rank as a coefficient with Quinine in fevers.
It has been chiefly used in the form of tincture. Dr. J.
\. Mayes, who has published a most valuable paper upon
the Gelseminum in the Charleston Medical Journal and
Review for March, 1857, recommends the following form-
ula for the tincture: " Four ounces of the fresh root clipped
small to one pint of diluted alcohol, macerate for fourteen
days." Dose for adults from twenty to fifty drops, repeat-
ed as frequently as circumstances may require. Dr. Bach-
elor thus prepares the tincture : " A bottle is loosely filled
with the bark of the fresh root, equal parts of whiskey and
water are added, and the bark is macerated for fourteen
days ; twenty to sixty drops of this infusion may be used at
a dose, alone or combined with Quinine."
"Whether or not the Yellow Jessamine possesses any an-""
tiperiodic properties, it certainly possesses valuable sedative
properties, and is capable by controlling irregular nervous
action,, of aiding greatly the powers of nature in fever, and
also the action of other remedies. The testimony to its se-
dative power is unequivocal.
Dr. Mayes affirms that he has never been disappointed
in a single instance in obtaining a direct sedative action
from the use of the gelseminum ; the patient being speed-
ily quieted, although he may have been excessively agita-
ted previous to its administration. Under its influence rest-
lessness is soon succeeded by calm repose, and the excited,
frequent pulse tempers down to tranquility. These favora-
ble impressions must bo secured, however, by a frequent
repetition of the dose, as its effects arc not very durable,
wearing off in two or throe hours. It will be found neces-
sary to administer the medicine in doses of from twenty to
fifty dro i'ding to the severity of the symptoms, cv-
cry two until under the influense of more
radical remedies, the di has boon permanently con-
1. And his ctesire by the |strong advocacy of this
I .] Confederacy.
medicine, is U) bring it into no1 an admirable agent
rolling irregular nervous action and bringing about
iii 1 1 i a state of i favorable for obtaining the
full action of other and more radical treatment. Drs.
reland, Branch, Nash, Douglas, and others, have, in like
manner testified to its nn antispasmodic and sedative
effects.
A6CLEPIAS SYRIACA. THE ROOT OF MAX. T.
PLANT. MILK WEED.
Dr. Richard S. Cauthorn, of Richmond, Ya., lias given
the root of this plant with success in six cases of intermit-
tent fever.
Dr. Cauthorn has used the root in the form of pills, con-
taining- two or three grains, aes combined with cap-
sicum, sometimes given alone. A cure has followed the
me dozen of the pills, two having been taken at in-
tervals of every two or three hours. He affirms that the
root of this plant produces none of the distressing symp-
toms which often attend the administration of Quinine.
Monthly Stetho
>MMON SALT. CHLORIDE OF SODItJST.
Dr. Scelle Montdezert appears to have been the first to
call the attention of the profession to the value of Chloride
Sodium in the treatment of intermittent fever; and
however fanciful his notion that every paroxysmal fevev is
cured by the presence of fibrin in the venous blood, which
should in the normal state be e procee
. and that th their power
heir ability to dissolve
fibrin pr<
pable of arresting palu lal fever, Juinia il
fardtohi
lit for having discov<
widely diifu uts that 'eruvian
"veprin iiiia, which arc not onlyvcry
764 Joseph Jones, on the Indigenous [October,
costly, but are liable to adulterations, monopolies, and to
final destruction from the wasteful and reckless manner in
which these are gathered and prepared for the market.
In his memoir upon the treatment of Intermittent fever?
presented to the French Academy of Medicine, July 1850,
Dr. Scclle Montdezcrt declared that from the results ob-
served during several years, with the beneficial effects of
Chloride of Sodium in the treatment of interjnittcnt fever,
this medicine should share with the salts of Quinia the pe-
rogative of arresting the paroxysms of intermittent fever.
He says that half an ounce of salt administered in half
a glass of infusion of Coffee, in the morning before eating,
during the apyrexia, will be sufficient to arrest the paroxysm.
Its use in this manner should be continued three days.
According to the testimony of Dr. W. P. Lattimore, M
Piorry, who was one of the committee appointed by the
Academy to report upon the Memoir of Scelle Montdezcrt,
experimented extensively with the Chloride of Sodium in
intermittent fever and confirmed the previous observations.
This subject is of so much interest that we present the tes-
timony of Dr. Lattimore to the success of M. Piorry with
the Chloride of Sodium in intermittent fever, in full:
" M. Piorry holds that in all paroxysmal fevers the spleen
is enlarged ; that the anatomical lesion is the cause, the fe-
ver only the symptom ; that whenever the spleen has a
greater length (measuring in a line extending from the
middle of the axilla to the anterior superior spenous pro-
cess of the ileum,) than from 31 to 33 lines, intermittent
fever exists. Believing thus, the symptoms for him are
zero, while the state of the spleen stands at the other end
of the scale, and is everything percussion (pleximetric) of
course, being the ezperimentum cri<
"We cannot resist the temptation of here paying a tri-
bute to the skill with which M. Piorry employs percussion
in making a diagnosis. With him auscultation is but an in-
taut when compared with its full grown brother percussion.
By its aid lie interrogates the abdominal viscera as frequently
1861.] Remedies of the Southern Confederacy. 7G5
he thoracic, and with no less success, for he has brought
it to an almost incredible degree oi' perfection. With his
plate of ivory and his flattened fingers1 ends lie diagnosti-
everything tumors of the abdomen, abscess-
rerywhere, aneurisms, &c. All acknowledge the deli-
cacy and accuracy oi' his test, while the looker on is lost in
admiration, and wonders whether all his senses are not
really concentrated in the ends of his fingers, which by
constant drumming have at length become the very reverse
of tapering.
" Wishing, then, to experiment with salt, a few cases of
intermittent fevev, (old stagers,) contracted in Algiers were
selected as subjects. Behold, then. Piorry at the bedside.
The patient asserts that he contracted the fever and ague
several years since in Africa ; that he has frequently been
cured, but that the disease has constantly reappeared at the
end ot fifteen days, or one month at farthest. The type of
the fever is tertian. The spleen is pei cussed and found to
be abnormally dull throughout its wbole extent; the entire
splenic region is sensitive upon percussion, particularly over
the dullest points ; and each blow is accompanied by
marked contortions of the countenance. The sensibility
extends but little beyond the region of dulness, which last
occupies an extent of fifty-three lines, measuring in the di-
rection indicated above. To this patient a drachm of sali-
cin is administered without producing any change in the
dimensions of the spleen. A few minutes subsequently,
half an ounce of salt, mixed with a cup of soup is given,
and upon carefully percussing the splenic region at the end
of four minutes, this organ is found diminished one inch,
from above downwards. The next day the spleen is found
to be of the same size, but upon the administration of a
second dose of salt, it suddenly contracts and measures
nearly three quarters of an inch less than ay. The
mance throughout the entire organ has increased while
the sensibility has diminished. The succeeding day the
attack of fever is very slight, and upon giving a third dose
7'!<i onilu Indigenous [October
the disease does not return, and when seen six weeks sub-
sequently ilir patient is still free from his African enemy.
Tims we see thai a diminution of twenty-four lines in the
,ii of the spleen was the result of the medicament, the
fever being cured more effectually than ever before, i. e. the
patient Lad remained free from all relapse for the space of
six weeks: one month having previously been the longest
period of immunity.
" We have the notes of seven cases of well-marked in-
termittent fever, in all of which the administration of the
Chloride of Sodium was followed by rapid decrease in the
volume of the spleen and cure of the febrile symptoms.
We also have the record of three eases in which salt was
unsuccessfully used. In one of these the sulphate of Qui-
nine effected a cure, in a second it, too, failed, while in the
third it was not tried. These were well marked cases of.
intermittent fever, such as would pass muster in any of our
own malarious districts.
"Let it be remembered that most of the fever and ague
met with in the Parisian Hospitals, is of long standing, and
imported from the malarious districts of Algiers, which ge-
nerate a form of the disease even worse than that found
amid the marshes on the banks of the famed Maumee;
that these eases have been treated again and again, have
been cured now by the Sulphate of Quinine, now by arse-
nic, but only to reappear upon the slightest exposure or im-
prudence, in short to recur as only the shakes can recur.
"We witnessed many of the experiments of M. Piorry,
and in the great majority of them the fever yielded to the
salt quite as readily as to the suits of Quinia. And as to
the theory of M. Piorry, the spleen diminished under the
use of the remedy, pari passu, with the febrile symptoms,
in every ease where the i was cured, proving that this
an really shows the influence of remedies over th}s class
rers; thai it is, as it were, a febro barometer, for the
diminution of the spleen is a constant phenomenon accom-
L] TUT
panying the cure i . er the curative
employed.
"M. Piorry's method of administering the Chloride of
Sodium is to give half an ounce in a cup of thin soup du-
ring the apyrexia and fasting. It usually agrees with the
iach perfectly well, but in some few cas< - we have scon
it exeite vomiting and diarrhoea. Three doses commonly
Feet a euro : the fin ken on suc-
ceeding davs and the third after an interval of one day.
>
Should the spleen be undiminished in volume by the first
. we may be sure that the remedy will not cure the
and the same is true of all the anti-periodics. Ex*
Lng in rare cases, the diminution of t lie spleen occurs
immediately upon the administration of the remedy, (salt,
sulphate quinine*) and may frequently be detected within
one minute, after which the organ remains stationary until
ond dose of the medicament he administered." On
the Employment of Chloride of Sodium in the Treatment
of Intermittent Fever. By W. P. Lattimore, M.D., Amer-
ican Journal of the Medical Sciences, July, 1852, No. xlvii
In . S. pp. 102-104.
The observations of Dr. Moroschkiu upon the value of
I in the cure of ague, agree with the testimony of the
preceding obsen
He states that during the prevalence of scorbutus and
e in the Transcaucasian province of the Black Sea, Qui-
nine sometimes entirely lost its power.-. When no very
prpmim ' utic affections were present he administered
one ounce of salt in water in tv. 3, daily, during the
of the apyrexia. In patients in whom the parox-
incomplete, very abundant sweating followed.
the skin resumi >rnial appearance, and the various
other signs of ainendn;
d in a few <h\y.-. and tl. having to be diminished.
In cases in which the impr ial, Qui-
nine now hi more em andred and
mpletely cured, and the others
sbfhJohi [Octob
ameliorated. Rank' :ract of Med. Sciences.
January to July. Jahrb. Xo. 6, 1856.
Dr. Hutchinson, of Brooklyn, Las placed on record
- of intermittent fever which were treated
wit
_- iven varied from eight
veive drachms during the apyrexia. At first eight
drachms were given, hut the amomv subsequently in-
sed to nine, ten, and even twelve drachms, in one in-
stance, with obvious benefit. Children required somewhat j
larger proportional doses than adult-.
Mi -elected as the vehicle, on account
of its and because it sufficiently disguised the
remedy, which was deemed a matter of importance; for it
would have lost much of its efficacy, or have been repudi-
flier, had the patients known they were taking
simply comma: tie following was the formula
:
Chloridi g 3 ij :
Ulmi pulv. .".ij ;
iij.
Infuse ira and strain.
Th saturated solution. Dos poonful
y two, three or : -o that five or six doses may
da. It whs not deemed ne
to precede its employment by evacuants, because the
pat' : recent. such remedies during their for-
mer attacks, and. moreover. Dr. Hutchinson preferred to
its real value could thus be bet-
letermined. When it ' $ary to precede the
. emetics or cathai
ing better for the purpose in
dinary ly administered id
which will usually produce s
ate catfa rt of the the remedy was well
1861.] Remedies of th Southern Confederacy, 760
tolerated by the stomach, nausea or vomiting having occured
in but four instances, four cases also had moderate alvine
evacuations, unattended with pain. There was considera-
ble thirst in every cum-, hut no other unpleasant effects.
When given in the above manner (dissolving it in as small
a quantity of water as possible,) it is less likely to disturb
the stomach than the same or even a less amount, would in
a larger proportion of the solvent The taste was objected
to by some, while others disliked it much less than Quinia.
The following are Dr. Hutchinson's conclusions:
1. Although interior to cinchona and its preparations, it
yet forms a very good substitute for them in intermittent fe-
ver, having failed, as we have elsewhere seen, to produce a
speedy suspension of the paroxysms in 31.8 percent of the
- only: in a majority of cases, therefore, it may he
substituted for quinia.
"2. It may be used instead of, and, indeed, preferably to
quinia: First, in cases, not unfrequently met with, where
the latter remedy is forbidden by the very unpleasant ner-
vous and cerebral symptoms it produces (delirium, tinnitus
aurium, cephalalgia, faintness, &c.) an example of which 1
have recently seen in the Xew-York Hospital, where sul-
phate of copper was substituted.
3. It is commended on the score of economy, which is a
consideration of importance to the poor, especially, who
are now, in a measure, debarred from the use of quinia, by
its high price. And fourthly, it is always at hand, whilst
quinia sometimes cannot be obtained.
It has been found to be more energetic in curing ague
than any of the vegetable or mineral tonics commonly used
for that purpose, excepting bark, and should, therefore, be
preferred to arsenic, which has been ranked by If. Andral.
Prof. Wood, and, indeed, most other authorities, next in
value to quinia. And, moreover, I think arsenic should
never be used until after quinia and common salt have failed
to do good, Mi account of its unpleasant, and sometimes
disastrous consequences to the general system and Btomach,
49
770 Joseph Jones, on the Indigenous [October,
and the increased facilities it affords for using the remedy
as a toxicological agent. Rankin's Abstract of the Medi-
cal Sciences, Xo. xx, 1854, p. 88. New-York Journal of
Medicine, March 1854.
BYDROCHLORATE OF AMMONIA. SAL
AMMOXIAC.
Dr. Felix Jacquot has carefully experimented with IFy-
droehl orate of Ammonia in the Military Hospitals at Home,
with a view to determine its value in the treatment of ma-
larial fever.
The doses employed were from eight to twelve grammes
in the day. The experiments were made upon twenty-one
subjects with the following results : In six cases the fever
was cut short, giving 28 per cent ; 1 case presented one-
paroxysm after the administration of the medicine, that is,
4 per cent, of the whole number ; 1 case presented two
paroxysms, also 4 per cent ; 11 cases, or 52 per cent, pre-
sented three or more paroxysms in spite of the medicine ;
and there were two cases which could not be placed in these
catagories, but which were not cut short. It will be seen
from these experiments that more than one-half the cases
were uninfluenced by the Ilydrochlorate of Ammonia, and
whilst the six cases (28 per cent.) of the entire number cut
short, would appear to show a powerful febrifuge operation,
it is only apparent and not real, for according to M. Jacq-
not more than one-third of the cases submitted to expecta-
tion recover spontaneously.
The results of these experiments, as far as they extend,
not only show that the greater part of the fevers are unaf-
fected by this salt, but that where the fever is not arrested
the marsh cachexia becomes quickly developed and assumes
an accelerated course during its administration.
According to this observer, sulphate of quinia succeed-
admirably in arresting fevers against which sal ammonia \^
1><>\\. and he concludes that hydrochlorate of ammo-
nia bears no therapeutical pretensions in the intermittents
1801.] // Ik Southern Confederacy. 771
of hot countries, and that there is much doubt of its capac-
ity of rendering any service in those of Europe. " Exper-
iments with several pretended substitutes for cinchona in
the Military Hospitals at Rome. By Dr. Felix Jacquot,
hives Generates, June 1854 p. 678.) Abstract of a
Report on Materia Medica, by Edward Ballard, M. D. Brit.
ft For. Med. Chir. Rev. vol. xvi. p. 191.
NITRIC ACID.
Dr. George Mendenhail, of Cincinnati, called the attention
of the profession to the use of Kitric Acid in the treatment of
intermittent fever in 1854 : the facts upon which his paper
was based was chiefly derived from an Inaugural Dissertation
by Dr. E. T. Bailey, of Indiana.
Dr. Bailey states that in the section of country in which lie
le8, there is a large portion of marshy land, and, therefore,
the circumstances are favorable to the development of autum-
nal fevers. His attention was first attracted to the use of
nitric acid in the treatment of intermittent fevers, by noticing
its effects in a case of chronic intermittent, which was attend-
ed with pmfuse night sweats, and for which complication he
administered the remedy. In this case there had been daily
paroxysms for the preceding five days; night BWeats profuse,
the tongue coated, and the bowels constipated. Nitric acid
was given in doses of six drops, diluted with water in the
evening; and he was agreeably surprised to find that the
paroxysm.- did not return on the following day ; and this cir-
cumstance induced him to try its effects in other cases as an
anti-periodic. Since that time he has treated over ninety
- of intermittent fever with this article, with remarkable
success. Of this number, all recovered promptly except ten :
and in every one of these unsuccessful r-a-es, the remedy was
discontinued contrary to directions.
Fifteen of the whole number were of the tertian type, and
nty-five of the quotidian. In fifty cases there was no re-
turn of the chill after commencing the use of the acid. The
others were rarely attended by more than one paroxysm, and
77-? Joseph Jones, on the Indigenous [October;
in no case by a third. When the patient had a paro.
after taking the medicine, it was in every case diminished in
intensity and duration.
In Dr. Bailey's practice, this remedy Lag entirely superce-
ded every other article for the purpose of interrupting the
paroxysms oi intermit tents. His mode of proceeding is to
give from five to eight drops of the commercial nitric acid,
properly diluted, once in six hours, without regard to inter-
missions or exacerbations. Cathartics and alterants may be
necessary for the purpose of changing certain condition
the system : but so far as the interruption of the paroxysms ig
concerned, the acid may be given without any preparatn
the system whatever, if we choose to do so. American Jour,
of the Medical Sciences, October, 1854, pp 581-5xl'.
Dr. J. C. Thompson, of Arkansas, has recorded in the
Southern Journal of the Medical aud Physical Sciences,
August, 1857, the successful trials of nitric acid in six cases of
intermittent fever, in which the customary remedies had fail-,
ed. In one case in which there was menorrhagia, a powderj
consisting of one grain of opium and two grains of sugar
lead was given every two hours until the discharge subside
in two others, blue mass was prescribed in conjunction w
the acid, and in the remaining three cases, pills of sulphate of
iron, aloes and rhubarb were given in addition to the acid.
lie recommends one ounce of the acid to be diluted with
six ounces of water; of this the patient is to take one drachm
in an ounce of water every two hours during the intermission.
The chairman of the Ohio State Medical Society admin]
tored nitric acid successfully in 35 cases out of 36,
Dr. William A. Hammond has added his strong testimony
to the yalue of nitric acid in intermittent fevers, published ii
the Maryland and Virginia Medical Journal tor February
1861. Dr. Hammond, after presenting the results of the em
ploymenJ of nitric acid, in tabulated form, remarl
"The table forms the basis of a report made about four year
since to the surgeon general of the army, and has never beei
published. The cases were troated at Fort Riley, Kansa-
lth
1861.] Remedies of thi Southern Corfederaey. 773
territory, in the post hospital, then under my charge, In a
weeks in the summer. Upon referring to the
able, it will be seen that in all, forty-one cases were treated,
on of those being of the quotidian typo, and thirty-one of' tfie
[ertian.
Thirty-two cases were treated with the nitric acid, and nine
with tlie sulphate of quinia. Of the cases cured by nitric
acid, three had previously used quinine without effect} and of
those in which quinine had proved successful, nitric acid had
been employed without benefit in two, and in one other had
to he omitted on account of causing nausea, heartburn, etc.
The average period of treatment before the disease was
permanently arrested, was the same witli cacli remedy three
days. The nitric acid was uniformly given in doses <>f ten
Jrops (properly diluted with water) three times per day, the
Jninine in dose- of eight grains three times a day.
Besides the fact that the nitric acid was equally successful
with quinine in arresting the disease, the difference in the cost
W the two articles rreatly in favor of the former Bub-
kance as to render it an object of importance to make its
curative properties more widely known.
going cases were treated, I have very fre-
quently employed nitric acid in the treatment of intermittent
id have rarely been disappointed in my expections of
action. In fact, in simple uncomplicated inter-
nt, I seldom have occasion to use anything else,
[n ncnt of the spleen, consequent upon fre-
quent attacks of the ague, the remedy in question has, in my
lands, proved very advantageous."
Tli ly that nitric acid is a
valuable substitute \'->v quinine; and we can readily
by a v powerful alterative effec
mercury, that it would be beneficial
in remittent, typhoid and typhilfi f<
hi and facility of administration, added to
and decided eft' raid lead at Leas! to
trial of it by the profession of the Confederate
America.
7 74 Joseph Jones, on the Indigenous [October,
AESENIC, (AKSENIOUS ACID.)
The value of Arsenic in the treatment of malarial fever has
been celebrated by numerous reliable observers; and the
medicine ranks with many practitioners, second only to
quiuia : we shall not, therefore, enter into any extended ex
animation of its medicinal properties; but shall content our-
selves with the presentation of the recent and most valuable
investigation of Dr. Felix Jacquot in the Military Hospital at
Home, premising that arsenic exists in the Southern Con-
federacy, and only needs an effort for its extraction from the
earth.
The paper of Dr. Jacquot is a summary of a memoir
addressed to the Conseil de Sante des Armecs, on the employ-
ment of arsenic in the treatment of intermittent fevers in
general, and of those of Home in particular, based upon 282
observations ; and we present it without alteration, as it ap-
peared translated in the British and Foreign Medico-Chirnr-
gical Review, vol. xvi, 1855, pp 189 to 191
"1. Mode of ' xperii7ienting. In order to establish the effi-
cacy of arsenic as a febrifuge, its administration should be
limited to those cases which have resisted treatment without
the use of quinine. The author of the paper before us has
not strictly followed this course, since, giving the arsenic at
the outstep in the majority of the cases, he had no means of
judging whether the fever was about to proceed steadily
with its paroxysms, or whether, on the other hand, it had a
tendency to spontaneous disappearance. But as the sulphate
of quinia was administered in the same way, it was at least in
a position to establish the comparative efficacy of the two
medicines. His researches, too, permit him to consider sepa-
rately the treatment with arsenic alone, and the complete
treatment by this remedy, emetics, &c. Arsenic alone cut
short the fever only in S.33 per cent, of the cases, but the
complex treatment in 16.66.
But while the efficacy of the arsenic is doubled by the con-
joined uses of emetics, the febrifuge powers of the sulphate of
quinine are so great, that those of emetics simultaneously em-
A\ nu dies of the South I ifedi racy.
ployed are lost, or absorbed in them ; thus, the per centagc
of fevers cut short by sulphate of quinine without emetics is
2, and by sulphate of quinine with emetics, 50.47, as cal-
culated in 210 teveis.
2. Formulw, Dose, Duration op Us< of Ars< ,,'(< -The lor
muhe used was the following: Arsenious acid, 1 gramme;
distilled water. 1 kilogramme. The arsenic is boiled with
more than tin- quantity of water till dissolved, and the latter
reduced to the prescribed quantity, some soda being added
should the solution he imperfect.
The dose of Bolution was administered in canella-wine.
The author could derive nothing but confused ideas of the pro-
per dose from writers on the subject, nor vet of the rapidity
of its action.
3. ( I nts. Tolerance. Most subjects bear with-
idents, three centigrammes at the outset; vet
'her hand, the tolerance has persisted sometimes in
continued large doses. Out of 72 cases treated
by arsenic, ho has only noted general accidents six times.
never fatal, and only once a source of anxiety. The local
and tolerances are quite independent of each other.
The author considers the action of arsenic to le sedative,
hyposthenic. In one of his subjects the pulse fell to fifty.
General loss of strength, lassitude particularly affecting the
- and loin-, have appeared to him the earliest phenomena
of poisoning by moderate doses of arsenic ; and while lie thus
differs from those who class it among the tonics, he asserts that
it has no tonic operation, even upon subjects suffering under
marsh cachexia.
i. 1 -Out of the 7- cases treated
by arsenic, i intestinal accidents.
! ammo may omiting and
: hut, on the other hand, he ha- seen six ccntl-
crai by the mouth tolerated ; and in others he ha-
nth without the stomach
it. Although the conditions favorable to
arc not well known, yet he can mention the
776 Joseph Jones, on1 the Indigenous [October,
smallness of the dose, its ingestion in divided portions, and the
quantity, and perhaps nature, of the vehicle. The local acci-
dents are nausea, vomiting, diarrhoea malaise, and sometimes
pinchings at the epigastrium, and an insurmountable disgust
at the medicine. Either general or local accidents followed,
in 31 out of his 72 cases, or in 43 per cent.
5. Autopsies of Individuals treated with A n>enic. In three
subjects examined, nothing was discovered which could be
imputed to the employment of arsenic, either in the heart, or
in any other part of the body.
6. Degree of the Efficacy of 'the Arsenic, Comparison with
Sulphate of Quinine, die. The cases in which M. Jacquot
iounds his comparison are those which had not received any
previous treatment calculated to interfere with the accuracy
of his experiments. Tie thns tabulates his results :
SULPHATE OF
QUININE. AKSENIC.
Fevers cut short, i. e., which have not )
presented a single paroxysm from the > 50.00 13. SS
the commencement of the medication, )
Fevers which had presented one paroxO
ysm in spite of the medication, but in > 25.71 22.i!2
which the second had been averted. . j
Fevers which have presented two par- )
oxysms, but in which the third has V 7.61 12.50
been averted )
Fevers which have presented three or [ r QO o < .-o
more paroxysms j
Fevers which cannot be introduced into )
these categories, but which must be > 11.42 16.66
regarded as not cut short )
The arsenic with or without the emetic has cut short the
fever 13. SS times per cent.; the sulphate of quinine with or
without emetic?, 50. times percent.; that is to say, the arsenic
lias been efficacious as one, the sulphate of quinine three times
and a fraction. The arsenic with emetics cut short the fever
16.66 times per cent.; the sulphate of quinine without an
emetic, 50.47 times per cent.; that is to say, the arsenic has
1861.] Renu the Southern Confederacy. 777
been efficacious as 1, the sulphate of quinine as three and a
fraction.
The arsenic without emetic has cut short the lever v
times per cent.; the sulphate of quinine without emetic, 49.52
times per cent.; the proportion being arsenic as l,to sulphate
of quinine as 5 and a fraction. Lastly, in comparing the
a the most favorable to the arsenic, viz.: those in which it
was administered in large doses, three to ten centigrammes,
accompanied by emetics, and a diet whose only limit was the
appetite of the patient, with the cases least favorable to the
quinine, we arrive at the following results :
Fcvcr< cut short by arsenic, - - - 9.6S per cent.
quinine, - - 49.52 " "
As respects the cases not cut short, it will be perceived, on
referring to the first four iigures of the two vertical columns
of the table, that in the instance of the fevers treated with
quinine, the numbers arc smaller and smaller, according as
we examine the categories of cases more and more refractory,
whilst the contrary is noticed in the instance of the arsenical
treatment. The contrast is perfect.
In about 35 cases it was possible to compare the effects of
the quinine and arsenic, the two medicines having been ad-
ministered in succession to the same patient, either for the
same fever, or in two separate attacks. In a sixth of the
senical and quinine treatment were of little effica-
cy: in another sixth, the two medications were followed by
: in the four other sixths, the sulphate of quinine
showed itself the most active, or the only active remedy of
the two ; and one observation furnished a very marked in-
stance of fever resisting the sulphate of quinine, and cured by
mic. In short, the author concludes that we see more
rs which resist arsenic, yielding to quinine, than we do
fevers, refractory to quinine, disappearing under arsenical
treatment. lie believes, also, that h< ablished the fact
of the greater activity of the sulphate of quinine in the cases
which have received no previous arsenical treatment (T>4 per
778 Joseph Jones, on the Indigenous [October,
cent, cut short,) than in those first submitted to the action of
arsenic, (40 per cent, only cut short.)
The general conclusion lie draws is, that the sulphate of
quinine is not replaceable by arsenic ; and especially is this
true in respect to the fevers of hot climates, where it is nee
sary to apportion the dose to the intensity of the malady ;
under the latter circumstances, we are immediately arrested
in the arsenical treatment by the fear of poisoning. In those
countries where, from one paroxysm to another, the pyrenia
may become more severe, remittent and pernicious, arsenic
should not be employed during the endemo-epidemic season.
Confirmation of Results by other Observers. After mention-
ing MM. Mayer, Cordier, Pasquier and Gouge, as arriving at
similar conclusions to his own, he states that in the Pontine
marshes, Dr. Minzi, physician to the Central hospital of that
country, has experimented with arsenic in more than 400
cases, giving it to the extent of three centigrammes a day, and
at last abandoning it from want of success. M. Salvagnoli
Marchetti also, out of ID cases, found 15 resisting arsenic.
Arsenic in Inveterate Cases and in Marsh Cachexia. The
observations of M. Jacqnot do not encourage recourse to arse-
nic in inveterate fevers ; and M. Cordier also concludes from
his experience in Algeria, that it is the more recent and
slighter cases which yield most readily to arsenic. In the
palustrial cachexia he thinks that arsenic may perhaps be used
as an alterative, but that it is incapable of replacing iron and
other tonics, which it is necessary to conjoin with it.
IZelajiscs. In preventing relapses, arsenic is inferior to sul-
phate of quinine. Out of 72 cases treated with arsenic, the
relapses wrere 22 or 20 percent. certainly a large proportion.
They were less frequent in the cases treated with quinine.
The relapses occurred even during the period of administra-
tion of the arsenic, which was continued after the cessation of
the fever. This was not observed in the instances of the qui-
nine treatment.
l.] /;//. )j Southern Confederacy, WO
Ar& nic in th> Fngranesa nt and /?< mdttent Fevere. In five
3 it was observed that in spite of and during the employ
ment of arsenic, the simple fever became aggravated remit-
tent, sub-continued and pernicious a fortiori, then, this
medicine would have no action npon a fever already of this
character.
>-. Arsenic is not for a moment to be regarded
a^ a substitute for sulphate of quinine. It will probably find
a limited place in the treatment of indigenous intermittent
fevers, but it has absolutely no pretensions against the recent
endemo-epidemic fevers of hot countries. We are scarcely
authorized to employ it except in the fevers which resist all
the preparations of bark. Uncertainty and contradiction reign
over almost all points relative to arsenic. It is a medicine
which we cannot yet handle with the double certainty of ob-
taining the effect desired, and of avoiding the dangers con-
nected with its administration."
These results of the carefnl observations of M. Jaequot, arc
worthy of most carefnl consideration by the physicians of the
South, on account of the similarity of the held of experiment
with a large portion -o/ the South; and they are especially
worthy of most careful examination, from their antagonism to
the most astonishing results which M. Bondin, of Paris, claims
t<> have accomplished with arsenic in the treatment of inter-
mittent fever. M. Boudin affirms that in 4,000 cases of inter-
mittent fever treated with arsenic, in the hospitals of Mar-
seil! ailles and Paris, from 1843 to 1851, he had not
had occasion to resort in a >ingle instance to sulphate of qui-
nine ; and out of 311 cases treated at Versailles in a period of
39 months, If. Boudin had but 10 relaps
It may well be asked whether the intermittent feven
Par [lies do not differ greatly in B<
rity and obstinacy from those at Rome; if it be true that
they are far then the observations of M. Jaequot
would express far more truly the value of th [y to the
inhabitants of the rich low 1. ramps and marshes of the
mfedera
780 Joseph Jokes, on (he Indigenous [October,
LKiATI Ki: OF THE EXTREMITIES IX INTEE-
MiFEENT FEVERS.
J have had no faith in and consequently no experience with this
mode of treating intermittent fever. The following summary
of a valuable article by Drs. J. DeBrauw and II. J. Braers,
taken from the North American Medico-Chirurgical Review,
of March, 1859, presents this method of treatment in a strong,
and, in fact, the most favorable light which I have yet seen :
'According to Drs. DeBrauw and Braers, the ligature of
the extremities is a measure which has been already employ-
ed by ancient physicians to aid the treatment of intermittent
lever, but has unjustly nearly fallen into oblivion. Already
Pinius, (Hist. Nat. xxviii, G) knew this antiperiodic, as Pitts-
clioft (Hufelands Journ. ii, 3, pp 47, 48) states, and in Tan
Sweeten's Commentaries to Boerhaave* Aphorisms, the 'levis
brevisque compresseo venarum in arbutus,' is strongly recom-
mended as a means to relieve the burning heat of fever. Dr.
V. Hildebrand, however, declares the remedy, in his Institu-
tiones Practico-Medicce, to be unreliable, and in many re-
spects unsafe, and recommends caution in the use of it. Jos
Frank, (Prax. Med. TTniv. Precepta,) speaks of it in a very
superficial manner, like many others, particularly more recent
authors. One of the most enthusiastic commenders of this
method is George Ecllie, (Duncan's Medical Commentaries,
vol. xix,) who, during the seige of Willemstadt, by the French
army, in 1793, cured many cases of intermittent fever (which
had resisted the use of quinine) completely, by compression of
the extremities. Upon this recommendation several physi-
cians in England for instance, Veitch and "Wallich, (Mediz.
.National Zeitung, July, 1798, and in the Netherlands, (Age~
mene Yaderl. Lettervefningen, 1808, 5) tried this method
with signal success. Of the more recent communications on
this subject, that of Prof. Chladni, (Ilufeland's Journal, xlii,
p. 138) is worth particular attention. This celebrated savant
being attacked il] L813 by an obstinate intermittent fever,
used the remedy with much advantage. He discusses it. as
quite innocuous, and explains its curative influence by f]\o
l.| Remedies of the Souths leracy. 781
supposition, that by ligature of the extremities, the return of
blood to the heart, and to tlie centres in general, is hindered
or partially suspended, an<l that the full development of one
of the principal symptoms, the chill, being thns interfered
with, an interruption and disturbance of the whole type of
fever takes place.
This method belongs, moreover, to one of the oldest popular
remedies used in Russia, England and France. In Canstatti
Jahresbericht, (Jaborg, 1848, p. 118,) the cure of a quartan
by application of Jimod's boot is mentioned, a fact winch
seems to be intimately connected with the subject in question.
According to dully, (Diet, de Med. ei de Chir., tome xi, part
i. p. 363,) wh<> gives a detailed account of the ligatures circu-
mbre&j the ligature should be applied to the four
extremities at the same time, but in such a manner that only
the circulation in the superficial vessels is suspended. Marti-
net. Robinau, Recamier and llusson,kept up the compression
for not longer than twenty -live to fifty minutes, and com-
menced with it in the cold stage. Jolly recommends taking
off the ligature one by one, at intervals of several minutes, as
by the simultaneous removal of the same, too much blood
would be at once introduced into the circulation.
The most complete information on the subject of his inves-
tigation, the author found in a dissertation of E. V. Baerle :
UJD valdi multipli m intermettentium mecticcUione
latum <l> membrorum majorum oiraumsirictione temtemvin-
innosocomio acadetnico espplorata" Utrecht, 1809. In
this treatise the ligature of the extremities is thoroughly illus-
trated by the report of seven cases, and highly recommended.
A'. Baerle commenced the treatment with the administration
gentle purgative; the patients were kept in bed, and sub-
jected to a rigid diet during the paroxysm : shortly before
the commencement of the cold stage, the thighs and upper
arms were encircled by ligatures exercising a moderate |
Bure, which were removed in from six to fifteen minutes, or
later, according to the effect they produced ; after Wallich's
mple, he forbade warm drinks during the cold stage, but
782 Joseph Jones, on the Indigenous [Octob er
recommended cold drinks in the hot stage. From observa-
tions of this kind, the author draws the following conclusions :
The ligature of the extremities is a safe and powerful means
of assistance in the treatment of intermittent fever ; it is not
only an adjuvant to other antiperiodics, but also a febrifuge by
itself. It cures the febris intermittens simplex and duplex, as
well as the quotidiana. In regard to the quartana no experi-
ence has been made.
The ligatures must be allowed to remain until the last
stage begins ; a longer application does not lessen the effect.
The method seems to owe its curative property to the dis-
turbance of the usual course of the fever, (Chladni.)
Sometimes the paroxysm is transferred under this treat-
ment from the third day to the second, but generally so
that the tertian type is not interrupted, or that a febris du-
plex is developed. The compression of the extremities is
always followed by some increase of the heat and perspi-
ration, the signs of an energetic reaction. After repeated
use of this method the fever gradually subsides. Contra
indications to it never existed, but may be easily inferred
from an examination of the modus operandi of the remedy.
Dr. DeBrauer generally applied compression to the ex-
tremities only, but considers the ligature of all four, far
more efficacious in obstinate cases, and recommends the
method as being capable in some cases to substitute the use
of quinine.
In cases of relapse of intermittent fever in which the pa
tients complain of that characteristic pain in the lumbar
region, (fifth lumbar vertebrae) against which cups are used
without effect, Brocrs recommends the application of the
galvanic current to the mentioned spot as a highly service-
able, though occasionally inefficient means. After the se-
cond or third application of this remedy the cachectic ap-
pearance, as well as the depressed feelings of the patients,
underwent a favorable change. Relapses of the fever, con-
lequent upon a return of the patient into the malarious dis-
trict, yielded quickly to this niodo oi* treatment, even when
L861.] R dies )f the Southern Confederacy. , x^
quinine was administered without success*" (Nederland
Tijdsche, 1858, and Medizinsche Neuigkeiten, 1858,No. 44.
COLD WATER IX THE TREATMENT OF MALA-
RIAL FEVER.
It would be foreign to our purpose to enter into any dis-
jion of the mode of action of water in Fevers, for, as
the most universal of all solvents in which the elements of
the blood are dissolved or suspended, and as the largest
constituents ut the solid as well as of the fluid components,
and as the great medium of the introduction of the nutri-
tive elements, and of the chemical changes which develope
the forces which work the machinery of the human body,
as well as of the removal of the products of these chemical
changes, water occupies such a prominent position in all
the processes of health and disease, that it would be impos-
sible to discuss either its value or its mode of action in fever
in the limited space now at my command, and must content
ourselves with a few practical observations and reliable tes-
timony to the value of water as an external application, re-
serving the extended discussion for a future occasion. Xow
that the old notions with reference to the injurious effects
of water and fresh air, have vanished with the progress of
medical practice, based upon sound physiological principles,
we can scarcely realise the powerful effects of water, in the
treatment of fever, without a careful comparison of the
symptoms, progress and mortality of diseases before and
after its free use.
I external application, the value of cold water though
not unknown and not unemployed by the ancients, was not
appreciated by the profession until after the publications of
Dr. William Wright- 1586, and especially of Dr. J. Cur-
of England.
: Formerly of tin- [aland of Jamaica, published an account in tin
<lon \ arnal for 1786, of the successful treatment of some i
Fever, by the ablution of cold wat<
edical Reports on the effects of water, cold and warm, a- a remedy
er.
784 Joseph Jones, on the Indigenous [October
Dr. Wright first adopted the practice in his own case and
succeeding in arresting the progress of the fever after twice
applying the cold effusion.
The success of this trial led other physicians to adopt
this mode of treatment ; and Dr. Carrie eleven years after-
wards published in Liverpool his valuable Medical Reports
founded upon accurate observations of the effects of cold
water, which exerted a most beneficial effect in removing
the strong and injurious prejudices against the free use oi
cold water in fevers.
We might adduce numerous testimonies to the value oi
the external application of water in various fevers, as Ty-
phus, Typhoid, Intermittent, Remittent, and Congestive,
from the time of Dr. Curric to the present, but we must de-
fer these for a more extended discussion, having room
merely to present a few points of practical interest :
Precautions recommended by Dr. Curric when the Cold Affu-
sion is contemplated. 1. This remedy should never be used
when there is any considerable sense of dullness, although
even the thermometer indicate a morbid degree of heat
If the affusion of cold water on the surface of the body 1><
employed during the cold stage of the paroxysm of fever
the respiration is nearly suspended, the pulse becomes feebli
and fluttering and of incalculable frequency, the surfaci
and extremities are doubly cold and shrivelled, and the pa
tient seems to struggle with the pangs of instant deatl
Under such circumstances the repeated affusion of a fei
buckets of cold water would extinguish life.
2. Neither ought the cold affusion to be employed who
the heat, measured by the thermometer, is less than, (
equal to the natural heat, notwithstanding the patient fee
no sense of chilliness. This is sometimes the case towarc
the last stages of fever when the powers of life are weJ
3. It is also necessary to abstain from the use of this 1
medy when the body is under profuse sensible perspiratic
and this caution is more important in proportion to the co
tinuance of this perspiration. En the commencement
18GL] Remedies qfth s p^ Confederacy, 785
specially, If \i haw been brought on by violent
exercise, the affusion of / cold w^ter in the naked body, or
even immersion in the cold bath, may be hazarded with
little risk, and sometimes may he resorted to with great
benefit. After the sweating has continued some time, and
Mowed freely, -ally if the body lias remained at rest,
either the aifusion or immersion is attended with danger,
even though the heat of the body at the moment of using
it be greater than natural. Sweating is always a cooling
process in itself, but in bed it is often prolonged by artifi-
cial means, and the body prevented from cooling under it
to the natural degree by the load of heated clothes. A\ nen
the heat has been thus artificially kept up, a practitioner,
judging by the information of his thermometer only, may
be led into error. In this situation the heat sinks rapidly
on the exposure of the surface of the body even to the ex-
ternal air, and the application of cokl water, either by affu-
sion or immersion, is accompanied by a loss of heat and a
deficiency of reaction which are altogether inconsistent
with safety. Medical Reports, &c. By J. Curry, 1797.
According to the experience of Dr. Carrie, if employed
on the first or second day with the precautions recommend-
ed, the progress of the fever is often checked, but it is scl-
saful when applied so late as the third or fourth
day, though when administered about the eighth or tenth
day, or even later, it moderates the symptoms and shortens
the duration of the fever.- More recent observations have
shown, however, that whilst Typhus fever may be thus cut
short, this remedy fails almost universally in arresting Ty-
phoid fever, which runs a definite course and is character-
by as definite pathological alterations, as Scarlet fever,
and Small Pox.
When the fever has rim on for eight or nine days and the
patient is weak, the heat of tin- water should be only a few
below that of the patient, and at this period it is
preferable to sponge the body with cold or tepid vinegar
and water.
786 Joseph Jones, on the Indigenous [October,
Testimony of M. Fleury to the value of Cold, Douches in the
treatment of Intermittent iever. M. Fleury in his memoir
on this subject presented to the>French Academy states that
lie was led to these researches by the assertion of Dr. Cur-
ric, that the accessions of ague might be prevented by the
affusion of cold water, and that by its repetition four or five
times, the disease might be entirely cured. M. Fleury has
employed this means one or two hours before the expected
paroxysm in the form of a general douche, and in that of
a local one to the region of the spleen.
The ends attained by the above plan he believes to be
1 . A shock exerted on the nervous system, and on the gen-
oral capillary circulation. 2. The opposing of a vigorous
reaction and general stimulation of the surface to the cold
stage of the fever. 3. A modification of the circulation of
the spleen, combating congestion of that organ. lie has
pursued this treatment in eleven cases of intermittent fever.
1 1\ seven of them the disease was recent, and there had
been but from three to seventeen paroxysms ; quinine had
not been administered in any one. In two cases the spleen
preserved its normal size ; in five it was enlarged a cure
was effected in all. In one a single douche sufficed to cut
short the fever. In two others, two affusions were neces-
sary to do so, and to restore to the spleen its natural di-
mensions. In the remaining four, affusion was practiced
three times.
I n those patients where two of three douches were used,
the effects produced were constantly the same. By the first
a] (plication the accession was retarded two or three hours,
the rigors loss violent, and shorter by one-half or five-sixths
the time, the heat and headache were equally lessened, and
the total duration of the lit was diminished at least one-half.
Age and the type of the fever did not exercise any ap-
preciable influence over the effects of the treatment.
Where, however, the volume of the spleen was larger, the
time required for the cure was augmented. Four patients
had Buffered from the disease for from two to eleven months,
L] ria. 787
baring had several relapses, and resisted the action of sul-
phate of quinine, and presented the ana?mia, emaciation,
anorexia, &c. seen in those who have long been affected by
ague. Three douch< required in two of these eases,
and five in one other to remove the fever, hut from eight to
eleven were necessary to cause the splenic engorgement and
the cachectic symptoms to disappear. In one case the liver
was very greatly enlarged, but this condition disappeared
by perseverance with the affusions.
M. Fleury arrives at the following conclusions : 1. In
the treatment of recent intermittent fever, simple and with
little or no engorgement of the spleen, cold douches may
be substituted for quinine.
2. In the treatment of old-standing ague, where several
relapses have occurred, and there is considerable enlarge-
ment of the spleen, or of the liver, with a cachectic condi-
tion, cold affusions are to be preferred to quinine, for they
cut short the fever, restore the viscera to their natural vol-
ume, and remove the cachexy more safely than quinine, the
latter in large doses, not unfrequently acting injuriously
upon the nervous system, or on the digestive organs. (Bul-
letin des Aeadem. and Lancet.) Kanking's Half Yearly
Abstract of the Medical Sciences, Xo. vii. Jan. to June,
1848, p. OS.
DiphtJu
The following practical observations upon the treatment
aken from a very interesting paper lead
>re the New York Academy of Medicine, by Dr. James
Wynne. After giving an elaborate history of the epidemics
of this affection, he proceeds t}n\< :
1) -It la not a difficult matter generally t<> give a
correct diagnosis in diphtheria, especially when the practi-
tioner is cognizant of the fact that a false membrane has
i or is forming. The diseases with which it is possible
788 Dvphtlima. [October,
to confound it, are angina maligna and croup. In the first
of these affections, the medical man has the general symp-
toms of scarlatina to guide him, and especially the eruption
whichis absent in diphtheria. In scarlatina, the tonsils are
of a bright red, resembling the juice of the strawberry, and
the membrane which covers them is simply inflammatory ;
while in diphtheria the hue is deeper. The exudation in
scarlatina is white, opaque, cheesy and easily furrowed ;
while in diptheria it is yellowish, tenacious and not easily
impressed by the action of a hard body. The inflammato-
ry action in scarlatina is observed at the beginning in all
the soft parts of the throat; while in diphtheria it almost in-
variably shows itself at the commencement upon the ton-
sils. As the disease progresses, diphtheria manifests a ten-
dency to invade the air passages, which is not one of the
characteristics of scarlatina.
The main distinction between croup and diphtheria is to
be found in the part affected. In croup the trachea is pri-
marily the seat of diseased action ; in diphtheria it is only
reached after the disease has made considerable progress.
In croup the earliest symptom is stridulous breathing; while
in diphtheria the primary symptoms are chiefly observed in
the organs of deglutition. In croup the false membrane on
the tonsils is not present; in diphtheria, it is an invariable
symptom.
Complications. Diphtheria may manifest a disposition to
the formation of a false membrane in other parts than those
primarily affected, as the skin, the mucous membrane of the
nose, the ears, the lungs, and the anus ; or it may prevail
coincident with other affections, as influenza, bronchitis,
measles, scarlatina, erysipelas, or it may be affected by a
particular epidemic condition, in which it becomes compli-
cated with hemorrhage of the nose, skin, and mucous mem-
branes of the intestines or lungs, or a typhoid type ol
disease.
Prognosis. When diphtheria is confined to the tonsils, \\
usually terminates in a restoration to health ; but when the
false membranes extends to the nasal cavities or the laryni
especially if accompanied with grave constitutional symp
toms, the patient is placed in imminent peril. Even in fa
vorable cases, the prognosis should be given with mucl
consideration.
Treatment. The practitioner has three important indica
lion to fulfil in the treatment of diphtheria :
1861.] Diphtheria. 780
1. To arrest the spread ot' the pseudo membrane.
'2. To alter the character of morbid action, upon which
the formation of this membrane depends ; and
'>. To sustain the patient until these shall have benn ac-
complished.
These necessarily involve both a local and general
treatment.
The local treatment consists chiefly in the application of
caustic and astringent substances, in one form or another,
to the affected part. Of these, the most usual are nitrate
ot" silver, either solid or in solution, powdered alnm, chlo-
ride of lime, chloride of soda, sesqui-chloride of iron, and
hydrochloric acid.
M. Bretonneau almost invariably employed the last of
these remedies as a local application in his own practice,
with the most marked success. The hydrochloric acid may
be employed very nearly of the strength of the dilute acid
of the shops, or considerably reduced in strength depen-
dent upon the severity or mildness of the attack. The best
method of applying it is to moisten a small sponge attached
to a probang, or a camel's hair pencil with the fluid, and
while depressing the tongue with the left hand, to carry the
brush foiward with the right, until the fauces are reached,
when those parts of the tonsils, uvula, or soft palate on
which the membranous deposit appears, may be moistened
with the fluid, and the instrument withdrawn. The hydro-
chloric acid should be applied not only to the membranous
surface, but to the parts immediately surrounding it, by
which means the spread of the membrane is often arrested.
The application should be renewed several times a day.
Care, however, must be taken not to apply it of too great
strength, or too often at the onset of the disease, especially
if the symptoms are not of an aggravated character; other-
wise the local disease may be enhanced, by the unnecessary
injury inflicted upon the surrounding parts. The symptoms
often appear momentarily aggravated by the local applica-
tion, which is not unfrequently followed by an attempt to
dislodge the membrane by vomiting. Should this latter
result follow, the tonsils and palate will appear a
shrunken in substance, and spotted here and there with a
few drops of blood upon the surface formerly occupied by
the membrane.
When this does occur, the application may he renewed
directly upon the surface of the gland, in order to arrest tie-
700 Diphtheria. [October,*
almost invariable disposition of the membrane to renew it-
self upon the abraded part. As the disease progresses, and
the membrane extends towards or into the pharynx, the
difficulty in making local applications becomes greatly en-
hanced : but 1 he practitioner should not hesitate, for fear
of inflicting temporary pain, from thoroughly exploring
and covering the parts affected with the solution of hydro-
chloric acid. For the purpose of effecting this, it is often
necessary to place the head of the patient upon the knee of
an assistant, and with a spatula to depress the tongue and
the lower jaw firmly at the same time, by which means a
view of the whole fauces may be obtained, and an oppor-
tunity afforded of making a thorough application of the
local remedy.
Nitrate of silver has been warmly recommended by
Trousseau, Gucrsant and Yalleix, in France, and was the
application almost universally resorted to in England at the
commencement of the epidemic in that country. The
usual mode of using nitrate of silver in England was in so-
lution. Dr. Kingsland advised a solution of 16 grains to
an ounce of distilled water, and Dr. Hart, 30 grains to an
ounce of distilled water. The mode of its use resembles
that of the hydrochloric acid.
When the local application ot nitrate of silver is made in
a solid form, care should be taken that it does not slip from
the holder, or break, as in such an event it might fall into
the stomach. Such an accident actually happened to M.
Guersant, fortunately, however, the stomach rejected it, but
this might not always occur, and few medical men would
be willing to take so hazardous a risk. Dr. Hauner, of
Austria, considers nitrate of silver as the very best local
application to the diseased surface, and advises its use in a
solution of from a scruple to half a drachm, to an ounce of
water.*
Subsequent experience did not confirm the good opinion
entertained for nitrate of silver among the English practi-
tioners, and many who were at first loud in its praises came
to disuse it altogether. A substitute for this was found in
the scsquichloride of iron, which is recommended by Dr.
Hanking as being very efficacious in its effects upon the
false membrane. He advises its use in the form of a gar-
gle, of the strength of two drachms to eight ounces of
CEsterrtecliisclie JaftrbTw!) far Kinderheilknnde, 1^50, vol.ii.
1861.] Diphtheria. 701
water, to "be applied to the throat by means of a brush.
In the United States, opinion appears to he divided as to
the best local application. Dr. Blake, of Sacramento, has
found the greatest benefit resulting from an application of
strong hydrochloric acid : a view in which he is sustained
by Dr. Bynum and Dr. Thomas, both of whom have had
much experience in the treatment of the disease. f Frof.
Comegys, of Cincinnati, is in the habit of applying nitrate
of silver, either in substance or strong solution in water.
Sometimes when the ulcerations are deep, he touches them
with strong nitric acid, by means of a brush. In some
cases he lias employed, with considerable benefit, inhala-
tions of tannic acid dissolved in sulphuric ether, applied by
means of a cloth wetted with it, to the mouth. J The for-
mula is :
IJ-. Tannic acid, - - f. 5ij-
Sulph. ether, - - f. 5j. M.
l>r. Jacobi, of New York, who, as physician to the Canal
Street Dispensary, which treats a large number of German
children, has had a very large experience, says:
" The local treatment consists of cauterization of the
membranes and surrounding parts with the solid nitrate of
silver, or with strong or mild solutions of the same salt in
water, (5ss-j.: j ;) of gargles consisting of solutions of (or
applying in substance,) astringents, such as tannic acid,
alum, sulphate of zinc, or claret wine ; in gargling with, or
applying such medicinal agents as are known to have some
effect on the constitution and tissue of the pseudo-mem-
branes, as chloride of potassium, chlorates of potassa and
soda, diluted or concentrated nitric or muriatic acids, liquor
of sesquichloride of iron, etc. Astringents will prevent
maceration, render the exudation dry and hard, and alter
the consistency of the surrounding hyperaemic and (edema-
tous tissue. It will thus prevent, sometimes, the extension
of pseudo-membranes to the neighborhood of the parts al-
ready affected, and in some cases may accelerate the expul-
sion of the membrane as a whole. We have thus seen the
best effects from tannic acid, either applied directly to the
parts by means of a curved whalebone probaug, or dissolved
Ranking on Diphtheria.
t Transactions of the Third Session ol" the Medical Society of tin- St;it.-
of California, p. 108.
* Proceedings Cincinnati Academy of Medicine.
792 Diphtheria. [October,
in water as a gargle (5ss-ii : 51.) Of the tinct. sesquichlor.
iron we have seen no particular effect. Cauterization with
nitrate of silver we have found to be generally of very little
use when applied to the pharynx. Its effect is superficial
only, it will form a scurf but will destroy nothing. Des-
truction of 'the parts cannot be effected except by forcing
the caustic into and below the membrane ; this can seldom
be done in the pharynx of children, and for this reason
cauterization is unavailing at this point, but will prove ben-
eficial, we believe, by confining the process of exudation to
its original locality. Tn cutaneous diphtheria cauterization
may be exercised to its full extent, but as these cases are
generally attended with extreme prostration, the general
treatment will prove both more necessary and successful.
If cauterization is to be resorted to, we generally use, and
with good effect, more or less concentrated muriatic, or
acetic, or nitro-muriatic acid. Where, however, cauteriza-
tions are made, great caution is necessary not to mistake
afterwards the result of the caustic for pseudo-membrane.
This remark is particularly applicable where nitrate of sil-
ver has been used."
Alum, chloride of lime, and calomel are sometimes re-
commended. When their use is deemed advisable, they
may be applied by dipping a brush, or the finger, in the dry
powder, and carrying it directly to the affected part, or
blowing them through a quill.
Prof. Metcalf advises the use of the bromide of iodine,
in the form of two drops to an ounce of the mucilage, or
gum arable, as a topical application. lie also gives drachm
(loses of this mixture internally, with the happiest results.
When there is a considerable accumulation in the nares
and behind the velum, the debris and foul secretions may be
removed, and much temporary relief obtained by an injec-
tion of an infusion of chamomile with a few drops of creo-
sote, which may be best effected by a laryngeal syringe.
The syringe of \>v. Warren, of Boston, answers a very good
purpose for injecting fluid either into the nares or below
the epiglottis. It, however, is liable to the objection that
it is likely to produce irritation, by coming in contact with
the irritable portion, exactly at the opening of the glottis,
which is found by the researches of Prof. Horace Green, to
b the seat of sensibility, instead of the epiglottis, as has
heretofore been supposed. The common glass syringe, with
either a curved extremity or a straight one dependant up-
lMil.] Diphtheria. 793
on the part to be reached answers all ordinary purposes,
and s the advantage of being easily obtained at the
apothecaries, and is of slight cost.
For correcting the foetor of the secretions, the chloride
aoda, in the proportion of one drachm to six ounces of
water, may he used with much benefit Dr. Banking sug-
gests on the supposition of the presence of some vegetable
parasite, the use of sulphurous acid and hyposulphate of
soda, in the form of a saturated solution.* uThe power of
the latter," he adds, "in destroying the fungoid growth of
favus, as well as the oidium which infests the vine, I have
myself experienced, and I strongly recommend it provided
the vegetable origin of diptheria be confirmed by further
observations."
Much relief is often afforded by inhalation, especially af-
ter the second or third day of the attack. An excellent
means of fumigation is to pour boiling water upon catnip,
or the leaves of any similar plant, with the addition of a
little vinegar, and to allow the patient to inhale the fumes,
either by inclosing the head under a blanket, or by apply-
ing the mouth to a tube connected with a close vessel con-
taining the materials from which the vapor is generated.
The immediate effect of fumigation is extremely grateful to
the patient. Dr. Ghirdon Buck advises the addition of La-
barraque's solution of the chloride of soda, in successive
portions of a teaspoonful each, to the liquid used for fumiga-
tion. Mr. ('. T. Ilodson recommends the inhalation of
boiling water, to which has been added a tablespoonful of
chlorinated lime.
General Dreatrm ni. The general treatment must be regu-
lated by the type of the disease. Shortly after the appear-
ance oiM. Bretoneau's treatise, a great variety of treatment
was recommended by different practitioners, all, however,
with a view to arrest inflammatory action. Leeches to the
neck, counter-irritation, especially by means of blisters,
active mercuriaiization, and purgative medicines furnished
the basis of most of the plans advised. Calomel, especially,
obtained great celebrity, and was at one time considered as
the most effective remedy in arresting the progress of the
disease. It was first prescribed by Dr. Connolly, who was
ling at Tours, at the appearance of the disease; and
was so efficient in his hands, in minute doses, as speedily to
Ranking on Dipl
704 Diphtheria: [October,
find favor with tlie French practitioners. But, whatever
may have been the success attendant upon its administra-
tion at that time, it is now found to require great caution
in its use.
Blisters are contra-indicated, and so far from furnishing
relief, tend to increase the danger by assuming an un-
healthy, and frequently sloughy appearance. The bites of
leeches often give rise to passive bleeding, extremely diffi-
cult to arrest, which greatly reduces the already exhausted
energies of the patient. Everything, in fact, which tends
to lower the powers of life, or induce prostration, should be
sedulously avoided, in the type of disease which at present
prevails ; and certainly differs from that for which Breton-
neau, Conolly and other medical men in France, at that
period, were called upon to prescribe.
The type of the disease as it now prevails exhibits a ten-
dency to extreme prostration from the very beginning, and
requires a tonic treatment to sustain the patient. The most
effectual method of accomplishing this is by means of qui-
nine, the various preparations of iron and steel, stimulants,
in the form of brandy, milk punch and wine whey, and a
generous diet, consisting of beef tea, Liebig's extract of
meat, and a decoction of coffee. Sulph. quinine may be
administered in grain doses, conjoined to two grains of the
sulph. of iron, repeated as often as the symptoms appear to
require usually every three hours. It is well to alternate
this remedy with doses of chlorate of potassa, which appears
to exercise a beneficial influence upon the disease of the
mouth and throat. Chlorate of potassa may be given in
doses of from five to ten grains, in distilled water, or a bit-
ter infusion. Prof. Barker, of Xew York, advises the chlo-
rate of potassa, in doses from 5ss. to 5j- The chlorate of
soda has been recommended with the same intention, but
does not appear to be equally efficacious with the chlorate
of potassa.
The tincture of the sesquichloridc of iron has met with
favor among the English practitioners, as a tonic. Dr.
Ranking gives it the preference to other tonics, although he
frankly admits that it matters but little which of this class
of medicines is used, provided the strength of the patient be
sustained. "Personally," he remarks, "I give the prefer-
ence to the tincture of the sesquichloridc of iron, not only
from the inference drawn from the analogy of its unques-
tionable usefulness in the more asthenic forms of erysipelas,
1861.] Diphtheria. 796
but al>o from the positive evidence of its benefit derived
from the experience of several gentlemen in the country,
amongst whom I may mention Mr. Dix, of Smallhurg ; Mr.
Prentice, ofXorth Walsham ; and Mr. Cowles, of Stalham:
each of whom lias had unusual opportunities of testing its
advantages.'" The tincture of the sesquichloride of iron
may he administered in doses of from eight to sixteen drops
in a little water.
Whatever may he the success or ultimate failure of this
remedy, its first introduction into the treatment of this dis-
ease is undoubtedly due to Professor Thomas P. Ilelsop, of
Queens College, Birmingham, who after repeated trials in
his own practice, brought it to the attention of his clinical
- at Queens Hospital and the Medico-Chirurgical Socie-
ty of Queens College. His own success appears truly
astonishing. *T have given in this disease," he says, "to an
adult twenty-five minims of the London tincture of the
sesquichloride of iron every two, three, or four hours, and
have conjoined a few drops of dilute hydrochloric acid. I
have also applied daily, sometimes twice a day, by means
of sponges, a solution of hydrochloric acid, but little weaker
than the dilute acid of the London Pharmacopoeia, and
have always enjoined the regular use of weak gargles of the
same acid. This, with the constant administration of stimu-
lants, beef-tea, milk and jellies, has constituted my treat-
ment ; and I repeat here, what I have already stated in
other quarters, that since I have become aware of the value
of this medication, nearly ten months, I have not lost one
An excellent formula for administering a combina-
tion of chloride of potassa and the sesquichloride of iron, is :
Chlorate of potassa, from <S to 20 grains; tincture sesqui-
chloride of iron, 10 to 25 drops; rose-water or orange
syrup, one drachm; water, four ounces. Where there is
difficulty in administering medicine, the bulk may be re-
duced by omitting the water altogether, and increasing at
pleasure the amount of syrup. The success which has at-
tended the use of this remedy in England warrants a care-
ful trial of its merits at the hand- of practitioners in the
United Btal
Where the disturbance of the secretions ap1, indi-
the use of mercurial preparations, and they arc not
irivcly contra-indicated by the depressed state of the
patient, calomel may be administered, in doses of one-tenth
of a grain, mixed with sugar, and placed dry upon the
796 Diphtheria. [October,
tongue. \)\\ Bigelow has found this remedy valuable in
the disease as it prevails at Park ; and Mr. Thompson was
equally successful with it at Launcestown, England. Dr.
Anderson, oi* New Vork, and Dr. Briggs, of Richmond,
have employed calomel with marked benefit. It is a ques-
tion, when calomel and chlorate of potassa are administered
conjointly, whether the effects of the potassa do not entirety
annul those of the calomel. Dr. Bigelow, as the result of
some recent observations, says that although it may retard
or prevent the specific effects on the salivary glands, it does
not in any way modify its action upon the secretions. It
may be well, however, when the effect of the calomel is
important, to intermit the use of chlorate of potassa for
twenty-four hours, or to alternate the use of these medicines
at wide intervals between the administration of the two.
Emetics are serviceable when portions of the detached
membrane are lodged in the throat, without being expelled,
or when the disease is making rapid progress, and threatens
to invade the larynx. The action of the emetic in this in-
stance is frequently to detach the pellicle and dislodge the
pseudo-membrane. At the same time that the membrane
is thus ejected, the throat is relieved of the foul secretions
which might otherwise be received into the stomach, to the
great detriment of the patient.
But, whatever treatment may be adopted, the fact should
never be lost sight of, that the system is laboring under the
influence of a powerful and most depressing poison ; and it
matters but little, so far as the constitutional treatment is
concerned, whether this poison be at first local, and after-
wards disseminated through the system, or is from the be-
ginning of a general character, and -incidentally developed
m the mucous membranes of the air-passages. In the per-
formance of her functions in the eliminations of this poison,
Nature requires to be sustained, not only by the free use of
the tonics already indicated, but by a liberal allowance of
the most concentrated and nutritious articles of diet, in
which beef tea, milk, cj;'j;>, brandy, wine and coffee stand
prominent. W"hen there is difficulty in swallowing, not
only these articles of diet, but quinine may be introduced
by means of injections ; a resort to which should not be
deferred until it is impossible to administer medicines by
the mouth, but whenever the difficulty of swallowing be-
comes at all a prominent feature in the complaint. Injec-
tions should not be administered in greater quantities than
1861.] Ul 797
two ounces at a time, and Bhould not be often repeated;
otherwise they will give rise to a local irritation in the rec-
tum, which will prevent their retention. One or more drops
of tinct. opii, accordingl ; j of the patient, will greatly
aid in the retention of the injection.
A-'- the violence of the disease has been checked, a con-
tinuance of the tonic treatment should he persevered in for
some time, not only to prevent the sequelre liable to follow,
but a recurrence of the attack, which often reappears after
an interval of several w< pecially when the patient is
exposed to those depressing influences which are too fre-
quently attendant upon poverty and uncleanline
On t: by Nitrate of Si
and other Substitute .By E. J. Tilt, M. D.,
M. R. C. P.
In using these agents, we only apply the general princi-
ples of therapeutics to the treatment of inflammatory affec-
tions of the womb and its associated organs. The utility o(
ration of acetate of lead in inflammatory affections of
the skin implies similar utility in inflammatory affections of
the vaginal mucous membrane ; the utility of solutions of
borax and of chlorate of potash in affections of the mouth
pointed to their trial as vaginal injections ; the utility of
sulphate of zinc and nitrate of silver in urethral stricture-,
demonstrated by J. Hunter. Sir E. Home, Laliemand, &c.,
ed their employment in uterine catarrh; the sove-
reign utility in the solid nitrate of silver for the cure of cu-
ous ulcerations caused it to be tried in ulceration
Ae womb. To whatever mucous membrane these agents
arc applied, they act in the same way they substitute a
therapeutical irritation, susceptible of being graduated to a
morbid irritation, which might uncontrollably compromise
the structure- attacked a temporary irritation that tends
permanent
In treating of injection-. I have already enumerated seve-
ral agents which act in this way, such as borax, chlora;
. alum, Bulphate of zinc, &c. They
generally given largely diluted, but if used in a solid or
highly concentn >n of these agents would
798 Uterine Inflammation. October,
be analogous to that of two other important agents, nitrate
of silver and tincture of iodine, which are called caustics by
courtesy, but are no more caustics than tincture of cantha-
rides. I wish it to be clearly understood that I hold these
agents sufficient for the surgical treatment of uterine inflam-
matory diseases in the large majority of cases, and so does
Dr. II. Bennett, although it has been stated that we use
strong caustics in ordinary cases of uterine disease. In a
comparatively small number of instances, the structures of
the womb have been too deeply modified by inflammation
or by hypertrophy, are in so low a state of vitality that the
above-named agents are insufficient to bring about a cure
of the disease. Then I have recourse to another class of
substitutive agents, which arc undoubted escharotics, for
they cause a loss of substance proportionate to the amount
of caustic used. Those caustics induce healthy acute in-
flammation in the tissues tmderlying the eschar, and, by
judicious management of this healthy inflammatory action,
the cure of chronic cases is often induced.
The caustics of which I shall treat are, the acid nitrate
of mercury, potassa fusa cum calce, potassa caustica, and
the actual cautery. At first sight it may seem strange to
class together sulphate of zinc and potassa fusa cum calce,
but one is justified in doing so, because the substitutive
action which I ascribe to a solution of sulphate of zinc is
pre-eminently shown in the results of potassa fusa cum
calce, which often so raises the vital endowments of the
uterine tissues as to promote rapidly healthy nutritive action
in tissues which had been diseased for many years.
Such is my mode of practice, and I am glad to find that
it accords to a certain extent with the practice of all whose
opinion carries weight, and who having in vain tried to cure
uterine diseases by nitrate of silver or milder measures,
have recourse to one or the other of the strongest caustics.
Dr. Fleetwood Churchill depends on nitric and muriatic
acids, and on the acid nitrate of mercury, which is also pre-
ferred by Dr. E. Kennedy and by Dr. West, and although
this distinguished pathologist considers ulceration of the
cervix to be a condition of slight pathological importance,
when he has to trace out a plan of treatment for his pupils,
he has none other to propose than that already long ago
carefully laid down by Dr. H. Bennett. The late Dr. Rig-
1>\\ though adverse to the surgical treatment of uterine
affections, admitted that there were certain cases of uterine
L861.] T99
ulceration requiring i fusa, or potassa fusa
cum calcr. Jh\ U. Beunett prefers potae a fusa cum calce.
This is not energetic enough for Professor Simpson, who
a; while the French strongly advocate
a remedy older than Ilippocrates, the actual cautery.
These comments upon the treatment of uterine inflam-
mation will show that i am an eclectic, and that I use all
the valuable agents which I have enumerated in certain
es which I shall specify. Again reminding the reader
that I am not writing a treatise, I shall proceed to comment
on the use of our principal substitutive agents.
Tincture of I 'I'm'. It is the ordinary tincture of the
Pharmacopoeia which I mean, not the caustic tincture. I
shall he brief on this agent, having already mentioned it as
a revulsive, and having compared it with others then under
discussion. Tincture of iodine seems to act as an astrin-
gent when slightly applied to the hypertrophied or in-
flamed surface of the neck of the womb, but as a vesciant
if several applications are made at one and the same time,
and as a resolutive it re-applied every third or fourth day.
It is much less useful than nitrate of silver as a topical ap-
plication, but it suits better some idiosyncracies, and is well
borne in diphtheritica! inflammation, when nitrate of silver
should not be used. The fact that a solution of iodine can
be injected into closed cavities and fistulous passages with-
out severely inflaming them, marks it out as the best liquid
to be injected into the bod}' of the womb, in the very rare
es requiring such treatment ; for it has less frequently
11 rise to the alarming symptoms of peritonitis, which
have very often followed the intra-urine injection of a solu-
tion of nitrate of silver. I use one drachm of the tincture
to an ounce of distilled water, and inject it by means of an
instrument similar to that devised by Mr. Coxeter for in-
jecting fluids into the larynx.
NUtraii of SUvi r. --The application of nitrate of silver is a
means, under certain circumstances, of subduing external
inflammation. Might it not, on this principle, be of ser-
vice in the treatment of the internal phlegmasia '.'" Such
the question asked by Mr. Uigginbottom in the preface
of his admirable little work on uThe Lunar Caustic," pub-
lished in 1826. Jlis question i a answered in the
affirmative by a great many practitioners, who have applied
nitrate of silver for the cure of inflammatory affections of
the mucous membrane of the irs, mouth, throat,
800 Uterine Inflammation. [October,
urethra, the intestines and the rectum. As regards the
mucous membrane of the genital organs, Dr. Sewel, in
1830, strongly advocated its use ; and I have no hesitation
in saying that this great agent is quite as useful in curing
the varied inflammatory conditions of the genital organs as
in curing those of the skin. It is often necessary to preface
the use of nitrate of silver by linseed tea, poppy-head, or
other cooling injections, in the same way that Mr. Iliggin-
bottom repeatedly inculcates the utility of cold poultices
previous to applying nitrate of silver to the inflamed skin.
If, after antiphlogistic treatment, the solid nitrate of silver
increases too much habitual pains, or causes the ulcerated
surface to bleed for two or three days afterwards, it is well
to try a solution of from forty to sixty grains of nitrate of
silver to an ounce of distilled water. In many cases the
solution is sufficient to effect, a cure ; it gives less pain, but
it may be necessary to repeat it every third or fourth day.
Sometimes I nse a solution of nitrate of silver containing
one ounce of the salt to two or three ounces of distilled
water, as an application to ulcerated surfaces. Chronic
uterine catarrh, or inflammation of the mucous membrane
lining the neck of the womb, which has been truly called
an open gland pouring out mucous from ten thousand folli-
cles, seems to me the most frequent of all uterine diseases.
Without having the slightest abrasion, the mucous mem-
brane lining the neck of the womb and its vaginal surface
may be of a dusky, livid hue, tender on being touched, and
secreting pus. This condition may last for years, but it
generally leads to more or less extensive denudation of
the villi of the uterine mucous membrane, and gives an ex-
coriated appearance to the neck of the womb. Such ca-
with or without excoriation, can be cured by the nitrate of
silver in solution, and every fourth or fifth day, with the
occasional use of the solid nitrate. If the mucous mem-
brane lining the cervix be principally affected, it is often so
obstinate as to render the painting of it with the solution of
little use. The solid nitrate must be freely employed, and
when the cervical canal is usually dilated, I sometimes
leave about one-eighth of an inch in the canal ; by which it
will be clear that, so far as my experience goes, should the
stick accidentally break in the cervical canal, it need give
no alarm. What cannot be removed will cause more pain,
some loss of blood, and perhaps even a return of menstrua-
tion : hut the patient may be repaid for greater suffering by
I. j i -/'. 893
a speedier cure. It has been stated by Nonat that this mod<
of treatment has caused Btricture of the uterine canal in hie
practice and that of Richet. I have never met with this
accident, and I think its occurrence is to be prevented by
the occasional } if the uterine sound lor a few weeks
after this Beverc application.
With regard to the treatment <>f the various forms of
ulceration of the neck of the womb, I pan add nothing to
what has been bo well laid down in J)r. II. Ben net's work.
Mr. Higginbottom, whose statements with respect to the
action of nitrate of silver deserve the highest eonsiderai
affirms that its action does not extend beyond three day-
after its application : and it is generally received that it is
necessary to repeat the use of this agent so soon as the epi-
thelian pellicle has fallen off, or every third or fourth day.
In many instances this is the best way of ensuring the most
rapid recovery: but I do not recommend the too strict ad-
herence to this precept, as it is often well to leave five, six
-ven days' interval between the applications, or we
might work as did Penelope, and retard the cure of the
. This, however, is a matter of surgical experience in
each individual a
Whether vaginitis occurs spontaneously or as the result
of uterine catarrh, it is best cured by the injection of a solu-
tion of nitrate of silver. This is an excellent idea of Dr.
Jewel, but if the solution be sufficiently strong to do good
it cannot be safely trusted to the patient. The patient
being placed on her back, a small glass speculum should be
introduced as far as possible, and an ordinary glass syringe
full of a solution of nitrate of silver containing forty grains
to the ounce should be injected. 1 ne speculum should then
be withdrawn to the vicinity <f the vulva, and the fluid
should be left in contact tor three or five minutes, after
which ti withdrawn, ami the fluid re-
red in a -mall cup. Sometimes 1 apply a speculum of
appropriate size, and ;is [ withdraw it pretty freely touch the
vagina with the -olid nitrate of silver diluted by chloride of
silver, as prepared by Mr. Squire. This is a modification ol
a plan recommended by Ricord.
1 recommend these injection- where there i> evidence of
inflammation of the womb, with excoriations of its cervix,
in virgin- in whom the integrity of the hymen prevents the
introduction of a moderate-sized Bpeculum. This plae
should be first tried before forcibly dilating or iucisiug the
r>\
802 Uterine Inflammation. [October,
hymen an operation which is very rarely required. I have
frequently made these injections in many cases, and I do
not (nice remember having traced monorrhagia to their ad-
ministration. I mention this as it seems to have often
occurred in the practice of Dr. Fleetwood Churchill. So
many serious accidents have followed the injection of the
solution of nitrate of silver into the body of the womb,
that I prefer using tincture of iodine in solution whenever
intra-uterine injections may be required. In very rare cases
of chronic internal metritis it may even be necessary to ap-
ply the solid nitrate of silver to the internal surface of the
body of the womb, as well as to adopt other modes of
treatment, for an account of which I refer the reader to my
papers on the Treatment of Internal Metritis.*
In follicular inflammation of the labia in eczema and
prurigo pudendum, or pruritus both external and vaginal,
a piece of cotton wool should be soaked in the solution of
nitrate of silver, and carefully rubbed for two or three min-
utes over the diseased portions of the skin and mucous
membrane. I can speak with confidence of this plan, for I
have lately cured several patients who had been suffering
in this way for four, eight, and thirty years. When cases
have lasted so long the pudendal skin looks and feels like
parchment. It was so in the case of a lady in whom the
disease had lasted tor thirty years, and I first rubbed in the
solution every day, then every other day, then every fourth
and fifth day, until the skin became soft and pliable, and
the sleep was no longer disturbed in darts of pain flashing
along the nerves. This patient was cured in three months.
and has had no relapse during the last year.
I trust I have said enough m praise of nitrate of silver :
but in many forms of uterine inflammation much more se-
vere agents are required to restore the womb to a healthy
state. This fact is admitted by so many authorities at home,
in America, or in foreign countries, that I am surprised to
find the contrary asserted by Dr. Meigs and Dr. Tyler
Smith. After describing the evil effects of caustics in the
treatment 'of uterine disease, the latter pathologist, in his
work on "Leucorrhea," (p. 203) gives as his opinion that
'there is no good which can be effected by the more pow-
erful caustics which cannot be accomplished by the nitrate
The Lancet, 1853, vol.
1861.] Uierbu Inflammation*
ver, or by other moans. It is true that by the prolong-
ed application of the nitrate of silver, loss of substance may
aused ; but this is far less likely to occur with lunar
caustic than the more powerful escharotics, It is also true,
that some practitioners apply the more violent caustics
lightly that they do not exceed the milder medical action o['
the solid nitrate of silver : but in such cases it would be
quite as well to use the safer remedy where a caustic is re-
quired." And at p. 2(^6, "In applying the nitrate of silver,
the aim should he not to produce any slough or loss of sub-
Btan< Thus it is clearly stated that the slight applica-
tion of the Btrong caustics is tantamount to the full action
of the nitrate of silver in like cases of uterine disease.
My experience, on the contrary, teaches me that nitrate
of silver is no more a caustic than tincture of cantharides,
a- Mr. Hiffffinbottom lias lonsr ago asserted. The distinc-
PC ~ o
tion that Dr. Meigs draws between the antiphlogistic
touches and the escharotic action of nitrate of silver, does
not hear examination. Use it as you may the nitrate of
silver does not cauterize. Leave it in the neck of the
womb, it will cause more pain, loss of blood and subsequent
discharge, hut no destruction of tissue, unless coagulated
mucus mixed up with epithelial scales and insoluble chlo-
rides of silver can be called such. Even when applied to a
fungous ulcer, the slight loss of substance is rather due to
the friction of a hard body on a pulpy than to the chemical
combination of the neutral salt and the diseased tissues, .V
densely hypertrophied neck of the womb might be whiten-
ed with the solid nitrate of silver every fourth day until
doomsday, without much reducing its bulk. Indeed I have
seen >\\o}i a plan of treatment injudiciously continued for a
year or longer in a case of hysteralgia, the neck of the
womb 1 - althy and of an average size, and the effects
were rather astringent than caustic, condensing the tissues,
narrow]' ervical canal, and rendering its dilatation
necessary and difficult Thus, while nitrate of silver may
repeatedly applied without inducing a loss of Bubstance,
the slightest application of the potassa fusa to the neck of
the womb produces an evident loss of substance ; ami th<
fore, the two agents, however applied, produce totally dif-
ferent effect- in similar cases. This i- a question of surgical
therapeutics which can be decided by any experienced
urgeon. Writing on the treatment of Btricture caused by
gristly thickening of the urethral mucous membrane, Mi-.
804 me Inflammation. [October,
Wade records his twenty-live years' experience of the com-
parative advantages of nitrate of silver and of potassa fusa,
and he states : "] cannot let this opportunity pass without
again calling attention to the fact, that the effects of the
argentum nitraturn and of the potassa fnsa admit of no com-
parison, as they are totally dissimilar: that the former,
when freely used, from its tendency to cause adhesive in-
flammation, has often been found to increase the urethral
obstruction, whilst the remarkably solvent powers of the
latter have no such tendency. "*
The too fret' use of the nitrate of silver to the modular
tissues of the urethra causes Urethral stricture, as the too
free use of the same agent to the cervical canal causes stric-
ture of the neck of the womb, but without loss of substance.
Indeed, if the whole range of diseases in which nitrate of
silver is now nsed be passed in review, it will be found that
it always acts by its dynamic, astringent and antiphlogistic
properties : whereas escharotics can only raise the standard
of vitality of any given tissues by the previous destruction
of their superposed surface. I maintain, on the contrary,
that there is one good to be done with the more powerfu
caustics which cannot be accomplished by the nitrate 01
silver; that is, to shorten the treatment of many cases ii
which it is <jt first, judicious to try it. Ulceration of tin
neck of the womb, on a hypertrophic basis, may doubtless
be sometimes cured by the use of the nitrate of silver, bu
the treatment might be indefinitely prolonged; whereas i
can be very much shortened by one or two applications o
the acid nitrate of mercury or of potassa fusa. e. calce
When the inner cervix is chronically inflamed, nitrate o
silver may enable us to effect a cure : but with that ageni
however applied, cures are sometimes so tedious that it i
well to resort to one or two applications of the acid nitrat
of mercury or of potassa fusa c. calce. In fungous an
varicose ulceration the nitrate of silver causes the surface
to bleed profusely, and does more harm than good ; when
as I find that in these Cases the acid nitrate of mercury an
the actual cautery stop the bleeding and promote a cure,
think it right to be sparing of caustics to the neck of I
wonib in pregnant patients ; but I have seen cases simili
to those described by Dr. Bennet in which it was ne<
i< tureof the l relhra 1th edit., p. 1 1
i
1861.]
to stop an abundant purulent and bloody discharge from
a large varicose ulcer, and 1 have dpne so with the acid
nitrate of mercury, after doing more harm than good with
the nitrate of silver. So little are caustic agents and nitrate
of silver interchangeable substances or therapeutic equiva-
lents, that T find nitrate of silver in some cases to Be |
tivelv poisonous, while potassa fusa c. calce conduces to re-
rv. In diphtheric intlammation of Jhe uecJs of the
womb and of the vagina, nitrate of silver arts as a poison.
in a case now under treatment there is a small patch, of
false membrane on the posterior lip of the os uteri, and
around it are numerous ulcerations. Were I to touch them
with nitrate of silver they would soon be covered with false
membranes. Tincture of iodine would not produce this
effect, neither would thq potassa fusa c. calce ; these, there-
fore, are the best means of curing this most tedious com-
plaint, and of which I have seen two instances, and Dr.
Bennet three, and he would endorse what I affirin of such
asionally we meet with cases like two I am now
attending, in which an extensive superficial excoriation of
the neck of the worn!) bleeds profusely, and for the follow-
ing two days, even when only touched with the solution
of nitrate of silver, which likewise makes the sore more
angry. In these cases 1 have nearly effected a Cure by
jsing the wound with tincture of iodine or the acid
nitrate of mercury.
The profession is more and more convinced of the great
utility of caustics in many diseases; were it otherwise, sur-
gery would be deprived of a valuable remedy, and the
obstetric art robbed of the only means of curing the most
distressing cases of uterine inflammation. Patients would
thus have to drag on from year to year their weary load of
misery, with the only hope that the cessation of menstrua-
tion, by putting an end to the physiological liability of the
womb, might also check its liability to inflammation.
Lori'1 1, io t.
806 Phlegmasia Dolens. [October,
The Pathological Lesion of Phlegmasia Dolens. By W. Til-
bury Ford, M. ]>., of London.
This paper was an appendix to a former, and its object
was to solve two main questions : 1. The essential condi-
tion or lesion of the limb in this affection. 2. The mode of
production of this lesion.
In regard to the first it was maintained that the presence
of fibrinous serosity in, with more or less hypertrophy of,
the fibro-cellular tissue, is the essential, the sufficient, path-
ological lesion; that the inflammation, the abscess, the
sloughing, etc. are not peculiar or necessary parts of the
affection, but common to many diseases, and the result of
an eliminative act to rid the system of some blood-poison ;
that the latter may produce lymphatic and venous obstruc-
tion, and hence phlegmasia dolens; but it passes beyond
this, giving rise to a distinct disease, such as abscess,
pyeemia, etc.
Phlegmasia dolens in these cases is a local complication
of the general disease, and the general symptoms are but
parts of the phlegmasia. There are then two types of this
disease :
a. The complicated, in which an eliminative process (in-
flammation, abscess, etc.) takes place, these being the an-
swer acts of the tissue to the blood state ; the epidemic
form, in which an effect is produced by a virus, superadded
to what occurs in
pJ7;. The other class the uncomplicated where the blood
state does not require any eliminative actions to be per-
formed on the part of the tissues, but where simple obstruc-
tion exists, such as pressure by tumor, etc. and simple
thrombus; this being the essential, simple, ample disease,
all else being superadded and accidental.
It having been shown that venous obstructions produced
oedema only, and this plus lymphatic obstruction, (phleg-
masia dolens,) the second question as to the mode of pro-
duction of the lesion in the limb might be stated thus :
I low can obliteration of the lymphatics produce the peculiar
change of the limb in phlegmasia dolens ? The lymphat-
ics being obstructed, the three offices of removing waste,
of absorption, and of formative power, could not come into
play.
it was then argued at length that the amount of lymph-
atic distribution and fibro-cellular tissue are in direct ratio
1861.] Termination . \ es. 807
that fibrin is the pabulum of the Utter tissue and that
Yirehow's views on this point clash with sound doctrine.
Lymphatic obstruction being followed by the retention of
fibrinous serosity iu the cellular tissue, the inference allow-
ed by the foregoing tacts was, that one office of the lymph-
atics is to remove all superfluous material from the cellular
tissue; to keep the balance of nutrition there correct ; hy-
pertrophy and retention of fibrin in the cellular tissue ensu-
ing upon lymphatic obstruction ; and this explanation is
confirmed by the behavior of the lymphatics in cases i)['
cancerous ulceration, etc. (When a blood poison is present
spec' actionSj as abscess and the like, are superadded.)
It was attempted to be shown that absorption by the lymph-
atics from ulcerated surfaces might give rise to thrombus
at the entrance of the thoracic duct into the junction of the
jugular and subclavian veins, and thus account for phleg-
masia dolens occurring in the upper extremity in cases of
disease of other parts of the body, e. </. cancer uteri. Brit.
Med. Jour. OcL 2<>, 1860.
On th< Termination of Nerves in the Voluntary Muscles of Mm
>>/<</ YtrtLhi'dic Animals. By Lionel Beale1.
Beale's researches have already been briefly referred to in
our Half- Yearly Physiological Report in the January num-
ber. We propose now to consider them more in detail.
The paper, we believe, will be published with the drawings
n the forthcoming number of the " Philosophical Trans-
itions."
Beale has been led to conclude from recenl observations
hat every elementary fibre of voluntary muscle is abun-
mtly supplied with nerves, which form a network and lie
ipon the surface of the sarcolemma, with which membrane
t least in many . the delicate fibreg seem to be incor-
oratcd. They do not penetrate through the sarcolemma,
t is stated nerves never terminate in points, as i- now ._.
'rally supposed, neither ran a single elementary fibre of
the Royal Society, So. J>. vol. x. ]>. 619,
SOS Termination of Nerves. [October,
voluntary muscle be found which is not abundantly supplied
with nerve-fibres. The elementary fibres of the tongue
and diaphragm of the white mouse arc nearly covered with
nerve-fibres and capillaries ; the sarcolemma indeed appears
to be principally composed of these structures. The mus-
cular fibres of mammalia and birds receive a much larger
supply of nerve fibres than those of fishes and reptiles, but
in insects the most wonderful structure exists on the sur-
face of the muscle. In some muscles the entire surface is
covered by some long, spindle-shaped, and very large nerve
vesicles, which can be shown to be continuous with^he
nerves. This beautiful structure is completely destroyed
very soon after death, and not a trace can be discovered if
a little water comes into contact with the muscle.
In mammalia, the nerves arc seen to run for a long dis-
tance with the arteries, and their ultimate divisions come
into very close relation with the capillary vessels.
As the nerve-trunks approach their distribution, each in-
dividual fibre divides and subdivides, and the fibres result-
ing from this subdivision often pursue a very long #nd com-
plicated course, running for some distance parallel with
other fibres derived from different trunks, but it is not pos-
sible to follow any one individual fibre for any great
distance.
Fine trunks, composed of from three to seven or eight
fibres, can often be seen traversing the muscle. The fibres
pursue different directions ; some dip down between the
elementary muscular fibres, some pass over the surface and
form with others, from a different source, small compound
trunks, while others may be traced onwards for some dis-
tance : the individual fibres which gradually separate from
each other being distributed to different parts in succession,
of several different elementary muscular fibres. When the
finest nerve fibres can be seen passing round the elementary
-cular fibres, they cleailv consist of very delicate flat*
tened bands.
Of the Oral Bodies or Nuclei. Connected with all nerves
in every part of the \)Oi]\\ sensitive, motor, vascular, and pro
bably in all animals, are little oval bodies or nuclei, wnic"
are the organs by which the nerves arc brought into th
closest relations with other textures, and from them ne
branches are developed. The nerves multiply at their di
ti'ibution by the division of these little bodies, and upo
them their action and, in all probability, the manifestatio
il.] Termination of Nerx
of the nervous phenomena depend. A great number of
these little bodies are associated with perfection of nervous
actions, aiul vice versa. They are found very freely con-
nected with the vascular nerves, and are abundant on those
nerves near the ganglia from which they proceed, and in the
ganglia themselves. These bodies with the nuclei of capil-
lary vessels and those of fat vesicles, and probably other
structures with peculiar cells, which alone deserve the name
have been included under the term " areolar-tissue corpus-
cles," ( Bmdcgetoebe-JKprperchen.) As specimens are usually
prepared, it is quite impossible to distinguish these struc-
tures from each other. Beale believes that the gelatinous
fibres, or fibres of Remak are, after all, real nerve fibres,
and not a peculiar modification of fibrous tissue, as is now
generally believed.
The nerves and vessels, and with them, of course, the
oval bodies, may be Stripped oil' from the elementary mus-
cular fibre.
the manner in which Nervei. terminate. The fibres con-
necting the oval bodies or nuclei form with them a network
the branches of which are of course, continuous with the
subdivisions of nerve fibres. The arrangement of the net-
work, and especially the number and proximity of the nu-
clei to each other, differs materially in different localities.
On sentient surfaces the meshes arc wvy small and the nu-
clei close together: but from the complexity and great num-
ber of the fibre- ; from the fact that many fibres which ap-
pear to be Bingle can be resolved into three or four individ-
ual fibres, and from the circumstances of the network being
imbedded in mosl cases in the midst of fibrous tissue, it is
very difficult to describe \\< exact relations and disposition.
However, from the connections of this network with the
nerve fibres, it would seem to follow that an' impression
made upon a given portion of a sentient surface might be
transmitted to the nervous centre by contiguous fibres, as
well as by the one which would form, bo to say, the short-
est route, and it is possible that impulse- to notion may be
conveyed t< muscular fibres by a more or le<s circuitous
path, as well as by a direct one.
tied Tabular Membrane. This is a transparent
structure in which the m-rve-fibres are imbedded. It can-
not strictly be called a membrane, 1 in many cases
eral fibres are imbedded in it, and often it is much thick-
er than the fibres it contains. By examination with high
cl<> Termination of Nerv October,
] towers (700 diameters) many fibres which appear to be
single when seen by lower powers, can be resolved into
three or more, all enclosed in the same transparent tissue.
As the nerve-fibres approach their distribution, this trans-
parent structure becomes much spread out. It is intimately
connected with nerve-fibres and capillaries, and with them
tonus a delicate expansion over the muscular fibres, and in
other parts. Delicate libres also, in connexion with the
nerves and capillaries, may be observed in it. In some
cases this expansion seems to be incorporated with the sar-
eolemma, and it is probable that in certain instances it is
really the structure which has received that name.
Axis Cylinder and White Substance. Beale has been led to
conclude that in consequence of the free division of the
axis cylinder and white substance near the point of distri-
bution of the nerve, a single fibre in the trunk of a nerve
may earrry impressions to or from a much larger extent of
surface than is generally supposed. The white substance
which surrounds the axis cylinder gradually diminishes,
until in the finer ramifications it is impossible to say that a
fibre consists of an axis cylinder and white substance, for
its general appearance and refractive power are the same in
every part, except where the nuclei are situated. Beale
considers that the definite characters of the axis cylinder
and white substance in the trunks of the nerve maybe due
to the gradual growth and altered relations of the fibres
which occur during the development of the entire organism.
In the ultimate ramifications the whole fibre seems to con-
sist of a very transparent and perhaps delicately granular
substance, but no tubular membrane, medullary sheath, or axis
cylinder can be demonstrated as distinct structures.
Qf the Formation of New Fibres. In connexion with the
terminal ramifications, new fibres are being continually de-
veloped by the division of the nuclei, and old ones undergo
removal. " The remains of the latter may, however, be seen
in the form of very delicate fibres, in connexion with active
nerve fibres. Beale regards much of the so-called connec-
tive tissues between the elementary libres of muscle and in
some other situations, as of this nature as the remains of
structures whose period of functional activity was past, and
which have been removed, with the exception of this small
quantity of insoluble material.
The method of preparing the specimens is then briefly
described. Observations were conducted principally on
L861.] Thrminatiqn ttf Ner Ml
white mice, which wore injected with Prussian blue fluid
immediately alter death. : l.eale concludes his paper.
which will he published at length in the 'Philosophical
Transactions,' with the following summary of the most
important facts elucidated in the inquiry :
'1. That nerve-fibres in muscle and in many other tissu
if not in all, may he traced into, and are directly continuous
with, a network formed of oval nuclei and intermediate
tibr
:2. That the organs by which nerves are brought into
relations with other textures, and the agents concerned in
the development of nerves and the formation of new fibres,
are the little oval bodies or nuclei which are present in con-
srable number in the terminal ramifications of all nerves.
A -Teat number of these bodies is associated with exalted
aerrous action; while, when they are sparingly found, Ave
may infer that the nervous phenomena are only imperfectly
manifested.
".. That every elementary fibre of striped muscle is
abundantly supplied with nerves, and that the fibres of
some muscles receive a much larger supply than others.
4. That the nerves lie with the capillaries, external to,
but in close contact with the sarcolemma. They often cross
the muscular fibre at right angles, so that one nerve-fibre
may inline] . reat number of elementary muscular
fibres. There is no evidence of their penetrating into the
interior of the fibre."
The paper is illustrated with drawings, most of thorn
magnified 700 diameters. Brit. S- lr<>r.31e>?. Chirur. Rev
8 at their Periphery and in Differ-
By Jacobowitch.f
- author, from his observations, comes to the follow-
ma :
1. That each nerve, of whatever nature, takes origin from
The V ita application t< Practical Medicine, p. ',:;.
r In a v mmunicafc A.cademi . 7th,
1800, ]. 7'
812 Development of Bloodvessels. [October
a iutvous cell in the central nervous organs, and terminates
at the periphery or in the interior of an organ :
[a) Either in a nerve-cell, and, in the case of nerves o\
sense, in the nucleus itself;
(l>) or in the mass of a cell {Hans la masse (rune cellule)
in the interior organs in the ease of the ^anplio-
nic nerv<
or finally, by forming a nervous capillary network
where the anatomical differences disappear, the
axis cylinders passing the one into the other.
2. That the nervous system, central as well as peripheric,
forms a whole which, like the sanguineous system, exists in
every part of the organism, penetrating across different
parte, and arriving at the ultimate elements without at all
becoming lost in a vague or confused manner.
8. That the nervous elements, the cellules as well as the
axis cylinders, are always in course of development in the
central organs as well as at the periphery.
4. That the part played by the cellules varies, for they
either preside over special functions, as in the organs of
sense, or subserve the preservation of the organs them-
selves, as in the case of glandular and nervous organs; the
physiological function (properly speaking) of the organs
arising from the connexion of these nervous cellules with
the central nervous system.
5. That if the anatomical difference disappears in the
capillary nervous network, owing to the axis cylinders being
cOnfhsed, the physiological difference remains. Hid,
On (he Development <>f Bloodvessels. By E. Rindiieiseh.*
The transparent border of the tadpole is the best used for
observation, and the most recent layer of connective sub-
stances between the free margin and the outermost capillary
loops is found to he that in which the new vascular forma-
tion proceeds. In certain place's, blind projections take
i-t. [naug. Berlin I860: quoted from Yin-how's Archiv., J5;m<l
. '. 2, p.218.
L] Muscular jR&i
place which gradually grow, form an arch, and return to
the original tituting a new capillary loop. Bui
se blind terminati found to pass into fine threi
and around are seen lying numerous stellate connective-
tissue corpuscles. It' i1 reads are in connexion with
the latter, they may be looked upon as pro< from
them, and the capillary network as a metamorphosis of
cellular elements : but it such a connexion does not exist,
then the thread-like appendages must be looked apoi
ial formations preliminary to the future vessels. The
author addressed himself with proper precautions I
tain which ws was the right one, and
came to the conclusion that the vascular^outgrowths neither
; nor avoid the cellular elements. The same animal
several times in the course of two or three
days. On one < rascular growths were seen
to pass without any other connexion, i touch the
-. to widen and acquire nuclei in their walls.
Here and there slight zig-zag curves were seen at their ter-
mination. Some were en partly in evident con-
nexion with a stellate cell, and in some cases there was un-
doubtedly extension of the cell-pro to the wall of a
capillary vessel ; then the cell-bodies were exceedingly dis-
tended, all proc< rly visible, hi I I ob-
ation, the contents appeared to umilated, and a
- than the thread-like one was seen. In the
of two cells so concerned, it' the direction of the pro
be in the region of a neighboring cell, the same will par-
ticipate in the formation of the vascular wall ; hut if it be
ernal to the adjoining cell territories, then the vascular
takes an apparently i [course. Ibid.
i
/ ;
ervations concerning
the minute structure of the pulmoBarj cells have differed
remely and attracted much attention. In 1845, \i
'. .1 from the Wieiu r
brift.
814 ( orpuscles of the Spleen. [October,
Bchott had asserted that their walls contained muscular
fibres. Acknowledgment of tins was refused by llossignol,
Adriani, Kolliker, llarting, Dondere, Reichert, &c; but
< ierlach admitted the fact of their presence, and Molesehott,
fortified by this opinion, addressed himself to reverify what
lie had previously stated. Accordingly, the lungs of the
pig, of the ox, and of man were examined, adult animals
being found the best. The process is as follows : Portions
are to be cut oft' and macerated in tolerably concentrated
acetic acid for some months, then macerated for twenty-four
hours in distilled water, and examined, moistened with
very dilute acetic acid. In this way the walls of the pul-
monary vesicles may be seen to contain smooth nucleated
muscular fibres of a somewhat yellowish hue ; or they may
be seen by inflating and drying the lung, and then making
thin sections, which must be left for three or four hours in
very dilute acetic acid; and for more complete isolation of
the fibres, they should be macerated for half an hour in a
weak solution of potash. The first method of preparation
best suits the lung of man and of the ox; the second suits
best the pig's lung. In the case of the ox lung, fascicles of
two, or four, or more muscular fibres in juxtaposition may
be seen, but in man, two fibres are but seldom seen united.
Molesehott gives minutely tlie form, situation and chemical
reaction of the fibres, as well as of their nuclei, and dis-
criminates between them and other elements, such as fusi-
form epithelium of small arteries and elastic-tissue cellules,
with which thev might be confused. Ibid.
On the M(rtpighian Corjniscles of the SpLcn . By N'
Kowalewsky.*
In his observations, the author made use of the spleens of
the dog and cat, either in a fresh state, or hardened in an
aqueous Bollition of scsipiichloride of iron, as used by Fuhrer
and Billroth. According to him, the Malptghian bodies lie
in the neighborhood of tolerably large arterial and venous
\ itvliou\ Arclriv. Band rx. Hefte. 1. 2, p. 208.
L861.J Develop toftk Follicles of the Ovaries, c. 815
1>. They project with their free surface1, which is cover-
ed* with the venous epithelium (the Bpleriic fibres of earlier
authors) into the cavities of the cavernous network ; the
meshes, consisting of areolar tissue, go between the epithelial
cells with the Malpighian bodies, ami become narrower
within them. On each Malpighian corpuscle, beneath the
venous epithelium, runs a small arterial vessel which becomes
lost on its surface (in a tuft-like manner) in ;i great number of
capillary twigs, many of which allow but a r.ingle blood cor-
puficle to pass. The capillary wsr-ols pass from the surface
into the interior of the Malpighian corpuscles, and become
larger within, owing to the concurrence of many twigs. After
their union in a central vein, this passes out into the surround-
ing cavernous network to embouchure into a larger vein.
etiinee, hut rarely, Bmaller isolated veins also pass from
these bodies in addition to the central vein. The larger cen-
tral vessels are evidently veins, not only from their emptying
into larger veins, hut also from their walls being thinner than
those of arteries, and from their having the characteristic
epithelial cells of splenic veins on their inner surface. The
space between the- meshes of the cavernous network in the
splenic corp: filled with white blood-corpuscles, which
only appear to differ from those in the body generally by their
being smaller, and having a BOmewhat clearer outline. This
may be from the deficiency of fluid. On ligaturing the
inic artery of a t\<>'j:, and killing it some days afterwards, it
will he found that \\ic central vein of each splenic corpuscle
may he seen with the naked eye as a red point on a white
ground, and the corpuscles appear enlarged. Moreover, the
central vein may he seen very clearly in the spleen in c,
wherein >oine time previous to death the sympathetic nerve
addressed to the spleen has been divided. Ibid.
],, J '), /, loprru at of tin Follicli 8 of //>> Ovarii a and of tin
Ovum in tl- mammalia. By Otto Spiegelberg.
The following ations were conducted <>n the human
enduy... a- well a- on the embryonic and newly-born rabbits,
The author was unable t' recognise the
tKon: Ges : der Wiss. zu Gottiu i, Juli, No. 20; aa quoted in
Virchow'fl Arohiv. Band rx. I!. 210.
Mi; Ammomcemh. [October,
tubes in which the ovarian follicles should be found, described
by Valentin. At the time in which the sexual differentiation
begins to proceed, and the male germ-glands possess seminal
canals, the ovary is seen to be composed of large bright cells
which, by reason of very delicate areolar-tissue-partitions and
bloodvessels extending from. the hiius to the periphery, are
arranged into irregularly-shaped heaps. These germ-cells
Spiegelberg terms primary ovarian cells, and their large vesi-
cular nucleated nucleus he designates "germs.'' During the
growth of the germ-cell the nucleus divides, at first into two,
later on to a greater extent, and the wall of the mother-cell so
originating appears to he doubly contoured. These mother-
cells are the primordial follicles, and are very like the sper-
matic cells. As soon as they are quite tilled with germ, one
of them, generally the central one, greatly enlarges; and
besides the nucleus, a delicate investment and a granular con-
tents may be seen within. The germs surrounding also
increase meanwhile and form into cells, and become covered
by an investment. The first of these cells is the ovum, the
last forms the element of the "membrana granulosa." Thus,
according to our author, is the formation of the ovum in the
higher animals assimilated to that observed by Meissner in
the ascarides, &c. Soon after birth the formation of germ-
cells into primordial follicles is complete, the latter being,
later in life, no more formed anew. In newly-born animals
the younger follicles are always found at the periphery of the
ovary, the older at the deeper parts. .By the growth of areolar
tissue and vessels the mother-cells become isolated; very
rarely only do two or more become fused into each other.
Ibid.
Aramonuvhuo. A paper by Professor Jaksch, in the Viertel-
jahrschrift f. Praktische Heilkunde, 1S60, ii. Translated
by C. A. Hartmann, M. I)., Cleveland, O.
The word ammonhmma, first used by Prof. Treitz, should
be applied to a kind of uraemia arising from putrescent urine
containing carbonate of ammonia, being resorbed and intro-
duced into the blood a condition which must not be con-
founded with Blight's disease, for it is essentially different
from it, although both affections may appear in conjunction
with each other, drsemic manifestations are not developed,
L861.J lid. 817
in Blight's disease, before the uriuiferous tubes beconie im-
pervious ; but true ajnmoniaamia is the consequence of urine,
in a - decomposition, being received into the blood ; an
occurrence which may happen either from a torpid or para-
lyzed state of the urinary bladder, from dilatation of Mal-
pighi's pyramids and the renal pelvis while the ureters arc
impervious, or from abscess, tuberculosis and other diseases of
the kidneys. The urine has, in this disease, always a pun-
gent, ammoniacal odor ; hydrops is never connected with am-
monisemia, but there is a persistent dryness of the mucous
membrane of the mouth and fauces; the patient feeling as if
even* particle of humidity had been dried up by some
absorbent. Sometimes this dryness will spread to the Schnei-
derian membrane, the conjunctiva of the eye, and the liga-
ments of the larynx, producing hoarseness or aphonia. There
is always a strong and well-marked ammoniacal odor in the
air expired by the patient ; and the same odor is perceived by
lifting the bedclothes. A great aversion to meat is never
wanting-, and violent intermittent chills arc of frequent occur-
ence ; while neither convulsive fits, nor croups, nor diphtheric
exudations have been observed during the disease we are
treating of, nor have disturbances of the vision been noticed.
A constant symptom is a singular grayish discoloration of the
face, with progressive emaciation ; very acute cases are accom-
panied by a rapid collapse of the features, and a muscular
weakness bordering on paralysis. In such acute cases, vomit-
ing, accompanied or followed by diarrhoea, is always present ;
:ldom, or only for a short, time, occurs in the chronic form
of the disease. Death is always preceded by a soporous state,
lasting fmm a few hours l<> several days.
Acute ammoniaunia runs its course in a few (from two to
six) days, and terminates, if properly attended to, in recovery ;
if not, in death. More or Less vomiting is usually the first
symptom in such cases ; often soon followed by febrile mani
testations, rapid collapse and sopor.
The chronic form may last weeks, months and years, with
temporary improvements and changes for the Averse ; it can
terminate favorably, even after a long time, if recognised and
correctly treated ; but may induce death in spite of all treat-
ment when its causes cannot be removed. There are always
ccompanying chronic ammonhemia, but
they are often mistaken for catarrh of the gastric and intestinal
mucous membra' may also occur which simu-
late typhoid or intermittent fever. On account of these vary-
ing symptoms, it is rather difficult t<> give a good description
818 Ammoniamia. [October,
v^^%/\y
of the* disease, and it appears, therefore, better to describe the
different forms according to their cause and predominant
symptoms, after having mentioned what is common to all the
forms, and necessary to the diagnosis.
Most frequently, ammoniajmia is produced by diseases of
the urinary bladder more particularly torpor and paralysis ;
a morbid condition of the ureters or kidneys but rarely causes
it. Torpor of the bladder may develop itself gradually, turn-
ing into complete paralysis only after a long time, or it may
arise rapidly. Accordingly, the symptoms of ammonisemia
will be either manifest, to a slight degree, but for a long time,
so that they are scarcely heeded and easily overlooked ; or
they appear more suddenly and with great intensity, so as to
greatly embarrass both the patient and his physician. The
torpor can be induced by some impediment in the urethra or
prostate, or by a want of innervation or change in its texture
(hypertrophy, catarrh, inflammation, ulceration, carcinoma.)
In consequence of the paralysis, some ulcerative or diphtheric
process, or gangrene may be produced by the stagnant and
decomposing urine in the bladder. The progress of the dis-
ease does not, however, depend entirely on pathological
changes in that organ, but also on the action of the organs
serving to the excretion of ammonia ; the lungs, skin, kidneys
and intestinal tract ; further, in the age and constitution of
the patient, as well as on external influences. A sojourn in
the country, for instance, proves very beneficial in chronic
ammoniremia.
For a correct diagnosis, the following points must be con-
sidered :
1. The degree of torpor or paralysis of the bladder, and the
cause of the same. In the chronic form, sensible and motory
paralysis are generally developed at the same time. Although
there is a large quantity of urine accumulated, distending the
bladder above the symphysis, and not unfrequently to the
navel, the patient experiences no pain, or some dull, painful
sensation, and no inclination to void his urine, unless the
bladder be extended beyond the already habitual measure ;
even then, only this surplus of the accumulation is evacuated ;
the stagnant quantity remains unchanged, or increases even
with the torpor. Acute paralysis commonly produces, in the
beginning, violent tenesmus and pain, which decrease when
the paralysis has reached a certain height, and disappears
with the more developed distension of the bladder.
. 2. With the torpor and paralysis, and usually before they
have been carried to a very great extent, commences the de-
'1861.] vmxmksmia. 819
composition of the stagnant urine, and its resorption, ft is
evident that the decomposition must be hastened by the pre-
sence, in the bladder, or catarrhons secretions, blood, or pro-
ducts of exsudation. At this stage of the disease, the urine,
he it evacuated spontaneously or artificially, presents a pun-
gent, often distinctly anmioniacal odor, ana a mucous or puru-
lent sediment, sometimes mixed with blood. Wherever an
ammoniacal odor is perceivable in recently-voided urine, we
may pretty certainly diagnosticate ammomsemia.
3. The carbonate of ammonia is eliminated through the?
lungs and skin soon after its reception into the hlood ; this is
proved by the distinct ammoniacal odor of the expired air.
and other exhalations. Where this odor is not very distinct,
the expired air may be tested with humid litmus-paper, or
with a stick of glass, previously immersed in muriatic acid.
The chemical analysis of the hlood would, undoubtedly, fur-
nish the best basis for a correct diagnosis; but the patients
afflicted with ammoimemia are always in a state which does
not admit of the depletion of blood.
i. Gastric symptoms, as already described, are always pre-
sent. The evacuations in acute cases do not, at least not in
the first time, present a distinct ammoniacal odor; but this \-
always well marked, when emesis and catharsis appear with
an aggravation of the disease. In chronic ammoniaunia there
may be neither vomiting nor diarrhoea, but rather a tendency
to constipation : the appetite is, however, with very rare ex-
ceptions, disturbed, and a marked aversion to meat present,
such as is not observed in any other disease, even not except-
ing cancer of the stomach. Other gastric symptoms, for in-
stance, a sensation of dull pressure or burning pain in the
ach, accumulation of gases, bad taste, furred tongue, etc.,
are not characteristic of ammonisemia. But the dry condition
of the month and fauces is important, and may often lead to
the diagnosis when other prominent symptoms are wanting.
The discoloration of the face, the emaciation and collapse
the features, finally the continuous depression of spirits, which
is frequently explained as hypochondriacal, will serve to
confirm the diagnosis. The effect on the mind of the patient
may grow >tr<>nir enough to induce the committing of suicide.
In the treatment, stricture- of the urethra, which are fre-
quently present, mnst be removed, and the urine regularly
evacuated by means of the catheter. Milk diet, residence in
the country, generous exercise in the fresh air. are often suf-
ficient, in addition to these mean-, to restore the patient.
Daring recovery, a vigorous diet is required, which may bo
820 Arnmoniccraia. [October,
combined with the use of some acidulous or ferruginated
mineral water.
Strictures of the urethra have often been overlooked ; I
think they alone have given rise to the haemorrhoids of the
bladder, that we used to hear so much about in times not
long gone. Of equal importance with the strictures are
diseases of the prostate in connection with ammonisemia.
Amongst them are, atrophy in consequence of preceding
inflammation, general or partial hypertrophy and develop-
ment of an accessory tumor, pressing on the urethra or the
neck of the bladder. They impede, more or less, the
evacuation of the urine, cause torpor of the bladder, hy-
pertrophy of its walls, diseases of the ureters and kidneys,
and consequently ammoniamiia, which sometimes appears
soon, but often only after a long time. The difficulties of
a successful surgical treatment, in such cases, render the
prognosis rather unfavorable. Hypertrophy of the prostate
will often yield to a strong ointment of iodide of potassium
applied to the perineum, and combined with the internal
use of acidulated waters. With the cautious use of the
catheter, and a decoction of secale cornutum, exhibited in-
ternally, the alread}r developed torpor of the bladder, and
other symptoms, even of chronic ammonisemia, may be re-
lieved.
A long practiced intentional retention of urine is apt to
end in the highest development of ammonieemia, without
any difficulty in, or around the urethra. The greater the
change in the textures, following this cause, the smaller is
the prospect of recovery.
That stones in the bladder result fatally through ammo-
niaemia, has been long known to surgeons; the disease I
designate by this name is well described, with all its symp-
toms in their books. It certainly plays a very important
part in its connection with urinary concretions. Without
an operation death is certain to follow, while success with a
surgical proceeding depends completely upon the presence
and extent of ammoniaBmia. Under the influence of blood
poisoned by ammonia, diphtheritic processes and exulcera-
tions in the artificial wounds are unavoidable.
Cancer of the bladder is always, in the end, accompanied
by ammonisemia. Medullary carcinoma of the inner sur-
face of the bladder induces 'hemorrhage, and thereby de-
composition of the urine.
Mechanical obstruction of the ureters, or destructive dis-
Ammonimmia. 821
a of the kidneys, lead either to ammon"nemia or nra-
mia. A painful anuria, sometimes relieved by copious dis-
charges of bloody urine, pain and swelling in one or both
sides of the abdomen indicate the primitive cause. If there
is a concretion, the ureter becomes dilated above and around
it, the walls are pushed outward, and the room thus made
allows the urine to pass until the stone, pressed downwards
is again wedged in. Even large concretions may, in this
way, reach the bladder, and as long as the other kidney is
not disturbed in its functions, there is not much danger.
.V continued stagnation of the urine in the pelvis of the
kidney may, however, result in decomposition and resorp-
tion ; that is, ammoniaemia. Of course, death may ensue
without that for instance, as a consequence of anuria and
uremia in 6bl iteration of the ureter.
Tuberculosis of the kidneys is also one of the exciting
causes of ammoniremia. How far abscesses of the same
,ns may have the same effect, cannot be at present as-
certained, besause they were complicated with diseases of
the bladder, wherever observed with the disease in ques-
tion. The kidneys may be destroyed by extensive ulcera-
tion, ending in death, without one symptom of ammoniae-
mia. Cancer of the kidneys is also not likely to produce
it.
Another form of ammonimmia, distinguished by a very
rapid course, arises from the decomposed urine penetrating
into normal tissues. This may happen, for instance, into
the cellular tissue of the peritoneum, by ulcerative rupture
oi* the urethra, or into the tissue of the abdominal walls
after puncture of the bladder, when the urine was in a state
lecomposition in consequence of previous dise;
There are violent pains, frequent chills, vomiting and fre-
quent diarrhea, ending in sopor and death.
The senile vesical torpor developes itself, without any
demonstrable morbid affection of the bladder or urethra, in
persona about, or beyond the age of fifty. The circum-
stances influencing its appearance and development, are not
always easily determined. It is only certain that this tor-
por . iher from insuiheient innervation or from retro-
metamorphoHfl and fatty degeneration of the fibres
lie detrusor muscle. Patients afHicted with this trouble
cannot pas< their uri ept with strong abdominal pres-
sure, and then only in a short and interrupted stream. A
complete evacuation of the bladder, if it can be effected at
822 Ammonicemia, [October,
all, requires a considerable time. With the torpor ad-
vanced to a moderate degree, there remains always a certain
quantity of urine in the bladder, although the patient thinks
it completely empty. Upon strong and continued pressure
he is astonished to see the flow commence again. This
stagnant quantity of urine augments in proportion to the
increasing torpor, and frequently forms the basis of acute
chronic vesical catarrh. Cinder such circumstances, a slight
cold, or an intentional repression of urine, are often suffi-
cient to create complete paralysis of the bladder.
This paralysis occasionally occurs as a symptom in other
diseases, for instance, typhoid fever. Here it happens es-
pecially, when the conscience is disturbed, the sensibility
suppressed and the muscles weakened to nearly paralysis ;
if overlooked, an extensive stagnation of urine follows,
commonly inducing vomiting in spite of the unconscious-
ness. This emesis is only removed by evacuation of the
bladder, by means of the catheter. Amnioniremia may also
arise during typhoid fever, in consequence of other morbid
processes dependant upon the fever, for instance, catarrh of
the mucous membrane of the bladder, or croupy exuda-
tion on its internal surface. In some cases, however, these
conditions are present, without exciting any symptom of
ammoniaemia.
Next to typhoid fever, acute diseases of the brain
such as extensive meningitis and cerebri tis, induce not un-
frequently paralysis of the bladder. A careful examination
here always prevents the development of ammonioemia.
But this cannot se easily be accomplished, where the paral-
ysis follows diseases of the spinal marrow, and appears in
association with paralysis of the lower extremities.
In vessical paralysis of a peripheric origin, combined
with cntaneous adynia, from suspended innervation of the
detrusor muscle, I have never observed any symptom of
ammoniaemia, but this disease occasionally appears under a
very obstinate form in conjunction with dysentery. Then
secale oornutum is the remedy.
In all these remarks there is nothing particularly new : I
have only collected and arranged under a system what was
well known to Boerhaave, Morgagni, Van Swieten, Stoll,
Lentin, P. Frank, Soemmering, and others. That they ex-
plained the symptoms they observed as urinary metastases,
don't matter.
Although it was not my purpose to give a complete and
1861.] Ringworm. 823
exhausting delineation of the disease, I will add a few eon-
elusions :
1. Uraemia and ammomemia are different conditions, pro-
ducing, in many respects, different symptoms.
'2. Both appellations point merely to those constituents
of urine which mix with the blood, being* in the one case
urea, in the other carbonate of ammonia. There may be
in the hlood, besides them, some other elements of urine.
3. Ammonhemia has been mentioned and described, by
former physicians, under the names : uroplania, urodilyasis
ischuria, paralysis of the bladder, &c.
4. This disease may result either in direct resorption of
decomposed urine from the urinary organs, or in absorption
of urea changed to carbonate of ammonia, in the intestinal
canal.
The excretion of the morbid matter thus accumulating
in the blood, is effected by exhalation through the lungs,
the skin, and the mucous membrane of the stomach and
intestines. Cincinnati Lancet $ Observer.
On Ringworm. By Jonathan Hutchinson, of London.
1. True Ringworm, or Tinea tonsurans may be defined as a
disease affecting either the scalp or the general surface, in
which circular patches are formed, on which the hairs break
short, and a slight, branny desquammation is seen, both
hairs and epidermic scales exhibiting under the microscope
the sporules and thalli of a fungus.
2. Ringworm in the scalp is rarely seen, excepting in chil-
dren : but on the general surface is not very nnfrequeut in
young adults.
- contagious, and spreads by contagion only.
4. It is not attended by any peculiar form of dyscrasia,
but on the contrary, often attacks children in perfect health.
much more easily cm able on the general surface
than on the scalp, owing to the circumstances, that in the
latter situation the fungus has obtained access to the folic lea
of the hair-.
G. Being a purely local d ringworm does not require,
ay constitutional treatment.
824 Galcano Cautery in Cataract. [October,
7. A purely local treatment, if efficiently pursued, is al-
ways rapidly successful.
8. Epilation, and the use of one or other of the known
parasiticides, arc the measures of treatment required.
!>. There is no real difference between ringworm on the
scalp and ringworm on the general surface.
10. Ringworm, although not unfrequently causing minute
vesicles, has no true analogy with herpes. Medical and Sur.
Ga zettc.
Qahoano Cautery in Cataract (Academy of Sciences.)
M. Tavignot read a short paper on the application of cau-
terization by galvanism to the treatment of cataract. The
apparatus used by this occulist is Grenet's pedal battery
with two appropriate conductors. These consist in two
exactly similar ivory rods, terminated at one extremity by
a prolongation of the central wire to which is attached the
conductor of the battery, and at the other end by a screw to
which is adapted a cataract needle about 8 lines in length.
1. The operator holding a conductor in each hand perfo-
rates the cornea in two different, but not opposite spots; one
puncture corresponds to the transversal, the other to the
vortical diameter of the eye. The external puncture is per-
formed ffrst, the inferior perforation immediately after.
2. Pressure of the pedal of the battery with the foot, at
once causes each ot the needles, when in contact with the
other, to glow; by alternately parting and bringing together
the points, the anterior capsule may be destroyed with the
utmost ease, and the lens itself reduced to a pulp which ab-
sorption will soon cause to disappear.
3. The foot being removed from the pedal, electric com-
munication is instantaneously broken off, and the needles,
} saving cooled, arc. rapidly extracted from the anterior
chamber.
The operation is very rapid, moderately painful, and pos-
it account of t^p perfect immobility of the eye-ball,
a remarkable degree of precision. The transparency of the
cornea moreovci - the operator to follow distinctly
b movement of he instrument', and to measure and
regulate theii fland^ Virqnna Med. Jovr.
l.] Editorial.
EDITORIAL AND MISCELLANEOUS.
ARMY MEDICAL BOARD.
Surgeon General's Office, )
Richmond, Va.,gept. 27, 1861. ]
"Army Medical Boards, lor the examination of Surgeons and Assistant
Surgeous, have been ordered to convene at Norfolk, Richmond, York-
town andMana
Candidates for the appointments of Surgeons and Assistant Surgeons
will be examined by these Boards, on presenting an invitation to appear
before them from the Secretary of War, which may be obtained by for-
warding their application, with testimonials of moral character, to the
AYar Department.
Examining Board- will be held at other points further South at a
convenient time."
The Board of Medical Examiners, appointed by the Governor of Ohio
to examine candidates for the Medical Staff of the army, have adopted
the rule that no person shall be appointed Surgeon who has not a respec-
table diploma, and who has not practiced medicine ten years. A diplo-
ma and five years' practice are required for Assistant Surgeons. The
examination to be made by written questions and answers.
The prevalent opinion that Army Surgeons have more to do with
surgical than other affections is a grievous error, as the history of all
campaigns abundantly t< I ndeed, the danger of being wounded is
the least that a soldier should dread. A writer of distinction declares
that in an army of one hundred thousand men, there will be ten thousand
taken sick in the course of the three first months' service, exclusive of
wounds! And the proportion will be still greater in the event of an
epidemic! How important it is, therefore, that those who have to treat
them should be men <f experience as well as of theoretical acquirements.
The term surgeon docs not imply simply an operator ; bnt one who is
fully competent to treat d and to operate when this may be n
If reports be true, our soldiers have dreadfully from the
inexperience, as well as ignoi their medical advisers, and the
evils call loudly for the adoption of some plan by which better appoint-
ments may be secured. That adopted in Ohio app' cry good.
1
826 Editorial. [October,
MEDICAL COLLEGE OF TEXAS.
An institution with the above title has been organized in Houston
with the following Faculty .
Ashbel Smith, M. D., Prof, of Surgery ; N. N. Allen, M. D., Prof, of
Anatomy; G. A. Fcris, M. D., Prof, of Theory and Practice of Medi-
cine ; W. H. Gantt, M. ])., Prof, of Obstetrics ; W. S. Rodgers, M. D,
Prof, of Diseases of Women and Children ; J. F. Matchet, M. D., Prof,
of Mat. Med. and Therapeutics ; W. P. Itiddell, M. D, Prof, of Chem-
istry and Med, Jurisprudence ; Thos, E. Brooks, M. D., Prof, of Physi-
ology and Pathology ; B. P, January, M. D., Demonstrator of Anatomy.
Opium and Quinine in Puerperal Fever. Dr. B. S. Woodworth,
of Indiana, says : (Cincinnati Lancet and Obs.)
"I have now treated about twenty-five sporadic cases with quinine and
opium without any deaths. I am well aware that the number is not
sufficient to show the superiority of this treatment over any other, and
in an epidemic the result might be different ; still I ieel so well satisfied
with these results that I shall still continue this treatment, aud I think
it well worthy a further trial on a more extensive scale.
Dr. W. administers, on the appearance of the disease, a powder con-
sisting of two grains of pulverised opium and four grains sulph. quinine
every three hours until the subsidence of symptoms.
Prescription fop. Whooping Cougil By Dr. Benson :
R. Acid. Hydrocyan, - - vi. drops.
Ext. Belladonna, - - ii. grains.
Tinct. Opii Camph. - - iii, drachms.
Syr. Bals. Tolu. - - ij. ounces.
Aquae Font. - - - iij. ounces.
Miscc. S. One teaspoonful four times a day. Louisville Journal '.
Chlorate of Potassa in Gonorrhoea, Dr. Irwin, (Med. & Surg,
lleportcr) thus speaks of this remedy :
"I have found it to be such an admirable remedy that I seldom rc-
BOrt to any other in the treatment of urethral inflammation. My method
of wring it is as follows : one drachm of the salt dissolved in eight ounces
of water, of which an injection is given every hour for twelve hours, at
the end of which time, the discharge will have become changed and di-
minished, allowing tin1 remedy to be gradually discontinued until the
md or third day. when the disease will be generally found to have
d."
1861.] Mu
Gororrhcsa. In a paper "on the successful treatment of Gonorrhoea
and Gleet without copaiba," by T, W. Cooke ; surgeon to the Eoyal
Free Hospital, &a, London," the author, in the first or inflammatory
stage, uses antiphlogistic and antacid remedies, avoiding saline purga-
tives, and applying cold lotions. Tn the second stage the treatment (and
here comes in what the author lavs claim to as the great modern im-
provement,) he trusts to injections of chloride of zinc, \ gr. to grs. iii. ad
ounce, with generous diet. Under those means he informs us that few
are not cured within a week, and he has only encountered two cases out
attacks of some thousands in which the remedies had failed.
As arum Europium a Remedy tor Drunkards. Dr. Smirnoff
states that he has become convinced, from repeated trials, that the
asarum europceum well deserves the reputation it has obtained in
Russia of being an excellent remedy for the effects of drinking. The
influence of a continuous abuse of alcoholic drinks is first exerted locally,
but afterward- dyspepsia is produced ; and the nutrition and functions of
the entire economy, especially of the central portions of the nervous
ling interfered with, the blood itself being loaded with an
injurious foreign material, the dyscrasia potat rem is at last com-
pletely established. The asarum fulfils various indications, acting bene-
ficially on the alimentary canal in those cases in which the digestive
powers are so much at fault. Its aromatic principle confers upon it a
stomachic power, and regulates the condition of the intestinal discharges,
producing vomiting and purging when given in large doses. Its most
beneficial action, however, is manifested on the defective appetite, and
tfl counteracting the invincible longing for alcohol. The horrible
sensations with which the drinker awakes in the morning, and which
compel him to seek temporary and delusive relief from renewed liba-
tions, are much blunted and mitigated by means of a -trong in-
fusion of a>arum and some other nervine e. g. valerian. Its immediate
effect is often to produce vomiting, and sometimes purging ; but the
painful sensations at the epigastrium undergo relief, and the appetite
becomes invigorated, Persons who have been long habituated to alco-
holic drinks cannot, however, have these suddenly suppressed with im-
punity; and in leg the author gives the asarum in brandy, apply-
ing at the same time a blister or an issue to the pit of the stomach. By
this means the normal activity of the stomach b< I and the
longing for alcohol diminished. The author, however, cannot agree
with those who would still allow a small quantity of spirits to habitual
drink when the morbid desire for ir bac ppeased. The
i nun, even when it does not succeed
in extinguishing the de-ire for alcohol, ah:
the patient ; and it is reinarkab! in which the individuals
have been long accustomed to periodical intervals of drunkenness, ending
in delirium tremens, how much longer those interval-- will become, and
828 Miscellaneous. [October,
how much less likely delirium tremens is to recur. The patients them-
selves are sometimes surprised at the comparative impunity with which
they can continue their drinking. The author prescribes three or four
glasses a day of an infusion made with three ounces of asarum root, one
ounce of valerian root, and half an ounce of orange-peel, but he does not
state the quantity of water employed. In cases of drunkenness, another
formula is composed of decoction of asarum (made by boiling from half
an ounce to one ounce of the root), six ounces; tincture of valerian, two
to three drachms ; Sydenham's laudanum, gtt.xij ; syrup of orange-peel,
half an ounce. A tablcspoonful of this is taken every two hours. He
finds from two to ttve grains of bismuth, taken four times a day, a valua-
ble adjunct. He has also found the following popular Russian remedy
of service in cases of drunkenness : R. Amnion, carb. half an ounce ;
aceti vini, lbj ; oxymel scill. half an ounce. Two tablespoonsfuls every
two hours. Med, Zcit. Rztsslands and PJtarmaccutical Journal.
"Mortality from Excision of the Knee Joint. In a memoir
read before the New York Academy of Medicine, Dr. Krackowitzer dis-
cusses more particularly the mortality attending excision of the knee-
joint, and the objections which have been urged against the operation.
He has collected, from various sources, two hundred and thirty-three
cases, which give4a result of sixty-three deaths and twenty subsequent
amputations ; the rate of mortality being twenty-seven in a hundred ; or,
including the subsequent amputations, the ratio of failures being thirty-
six in a hundred. Of the two hundred and thirty-three cases, thirteen
occurred in the practice of American surgeons. Four of the thirteen
patients died, and two were under treatment at the time of the report,
with every prospect of recovering a good limb." American Medical
Times.
Excision of the Hip-Joint. In the statistics of resection of the hip
joint collected by Mr. P. 0. Price, mention is made of the operation
having been done 59 times. Of that number 33 recovered with good
and useful limbs and greatly benefitted constitutions ; 11 were partially
successful i. e., the patients lived for periods varying from three months
to two years, and then died, more from other causes than from a recur-
rence of the disease which demanded interference; 14 deaths resulted
directly from the operation, and in 1 the result was unknown. A fair
consideration of the question would show the mortality from the opera-
tion to be only 14 out of the 59 cases, or about 23 per cent. Professor
Pirrie states in his "Principles and Practice of Surgery," that he was
extremely anxious to obtain accurate statistics of this operation, but
failed to "procure them from some parts of the world where it had been
several times performed. So far as he has been able to learn, the opcra-
tion had been adopted in 70 cases, and death has resulted from it in 25.
Sayre, of New York, gives an analysis of 30 cases, of which 20 recover-
ed and 10 died, 4 of the latter within one week after the operation.
Lancet.
1861. "s. 820
Labob Obstructed by Hydrocephalus. Professor Simpson ad-
that when labor is obstructed by a hydrocephalic head, we should
not perforate the cranium and to a certainty destroy the child, but
should tap it with the trocar ; thus performing in utero the operation
most calculated to be of service to it in mundo. Again, when it is a
footliug casej and the hydrocephalic head cannot be born, he advises, in-
stead of using great traction or endeavoring in this awkward situation to
puncture with trocar, to cut across the spine, when the fluid will imme-
diately find exit. Dropsy may occur in the other cavities of the foetus ;
especially pleuritic and peritoneal effusions. Amer Med.. Times.
Illumination. It appears that the difference in the illuminating
power of the same gas may vary twenty per cent, when tested at the
highest and at the lowest points of the barometrical range in this coun-
try, from the effect of the rarefaction of the air alone, without taking into
consideration the different densities of the gas at the opposite decree of
pressure. British Medical Journal.
On Saccharate or Colchicum. That Colchicum is so frequently
found inefficient in cases of articular rheumatism and gout, Dr. Joycux
regards as due mostly to the use of an improper preparation. He con-
siders colchicum "as certain a specific in gout and acute articular rheu-
matism, as iodine in goitre, and iron in chlorosis." The best and most
uniform preparations arc the fresh juice rubbed up in the proportion of
one to five with sugar, and dried in vacuo ; or 2, an extract obtained
from the fresh juice by evaporation in vacuo. The former preparation
he prefers for internal nsej giving, as an average dose, four grammes
(one drachm) daily, in ten divided doses, while he employs the extract
to rub on the painful parts. Giving such divided doses prevents all
irritation of the bowels and diarrlnva, which so many consider as insepa-
rable from the effects of the remedy. Attacks of gout so treated, yield,
at the latest, in two or three days ; acute articular rheumatism "after
fourteen to twenty days. In cases of subacute rheumatism, the remedy
is not so efficient, though it usually gives considerable relief. Gaz. des
Hospitauz. Maryland t\- Virginia Med. Jour.
Arsenic in Apoplectic Congestion. 31. Lamare J'icquot, physi-
cian to the Honfleur Hospital, as the result of ten years' observation and
trial upon between forty and fifty cases, including his own among them,
strongly recommends the prolonged use of arsenic as an effectual" means
of subduing congestion likely to give rise to apoplexy. In very urgent
cases in which hemorrhage seems imminent, he precedes its employment
by a moderate venesection, but this is quite exceptional. In proportion
to the severity and menacing danger of the case, the dose requires to be
larger ; and although, even after a month, benefit may already result, to
be of permanent benefit it will In ontinued for several month.-.
830 Miscellaneous. [October,
The more urgent the case, the more tolerant docs the system become of
the arsenic. The author, regarding apoplexy as consisting essentially in
an extensive increase of globules of the blood, employs arsenic as a pow-
erful agent for decreasing these, as well as the plasticity of the blood,
It becomes, of course, necessary to assure oneself in a given case of the
richness of the blood, for to employ arsenic when the blood is impover-
ished, would be to do mischief. The author has generally found the
dose of one-fifteenth to one-sixth of a grain per diem sufficient. Bull,
dc Tlteroj)., tome lvii. pp. 193-252. Ibid.
On the Efficacy of Digitalis and Quinia in the Treatment of
Hemicrania. Dr. Debout, who has very severely suffered for many
years from attacks of hemicrania, testifies to the efficacy of the combined
use of sulphate of quinia and powder of digitalis in the treatment of this
complaint. The proportions employed are three grammes (about three-
fourths of a drachm) of sulphate of quinia, and one and a half gramme
of powdered digitalis, made into thirty pills, of which one is to be taken
every night at bedtime for at least three months. From the beneficial
effects produced on himself, Dr. Debout prescribed the same treatment
for several patients, and the results in many cases were equally satisfac-
tory. Chemical Gazette. Ibid.
Treatment of Old Fissures of the Anus. M. Gosselin observes
that most of these fissures may be easily cured, whatever be the means
adopted. Still he regards forced dilatation as the most expeditious and
the most convenient for the patient, while incision best guards against
relapse. In many cases he has combined with advantage these two
modes. First dilating, and then incising the fissure, which is then
easily visible throughout its whole extent. He has observed the fissure
and its pains persisting after forced dilatation oftcner in women than in
men. But besides these fissures thus easily cured, there are others
which resist various modes of treatment successively employed, or, when
cured, are succeeded by new ones, just as painful as the others. After,
in such cases, trying the various means one after another, M. Gosselin
resorts to daily dilatation, which he has found attended with good results.
The index-finger is passed into the anus daily until the pains after de-
fecation have disappeared or notably diminished Gaz. dcs. Ho]).,
No. 91. Ibid
Honey and Glycerine in Surgery. Dr. C. F. Moore, Medical
Superintendent of Middleton Hospital and Infirmary, says (Dub. Med.
Press, Dec. 2G, 1860) that several mouths ago he commenced the use of
glycerine to bedsores in bad fever cases, and finding it to excel his ex-
pectations, he used it in all cases where a healing dressing was required.
It occurred to him, some three or four months since, that honey might
1861.] Mi 381
answer as well ; and as a very great difference in price exists, that an
important saving might thereby be effected by using an equally efficient
agent, "as some of the properties of honey previously known to me led
me to think it to be. I have now used it in several cases in hospital and
private practice, as in ulcers left by scalds, in a wound after the removal
of a large tumor presenting some malignant characters from the fascia of
the leg in a woman of 70 years of age, in a case in which dead bone was
being discharged after injuries to a man's leg, bedsore from fractured
thigh, etc. To the readers of your valuable journal I will only now
state that it seems especially useful in cases where a tendency is manifest
in a wound or ulcer to throw up unhealthy granulations instead of heal-
ing kindly. It seems also to protect the skin adjacent by its own con-
itive agency, so to speak, as well as by correcting the styptic proper
ties of the discharges. In evidence of this latter property, I may state
that, in cases which I have treated with it, after having used the more
ordinary dressings previously, the honey most unquestionably removed
all unp easant smell from the discharges, itself no small gain. I must
observe, however, that honey, when first applied especially, causes some
considerable degree of pain, indicating its stimulating effects. In one
case I used a wash of tiuct. opii and water on first applying the honey
dressing, poured oyer the fine linen which had been applied, saturated
with fine clear pure honey. In all the cases, however, the patients them-
selves soon got reconciled to the pain, considering it indicative of benefit
being received from the dressing. It is well, however, to bear this point
in mind, especially in cases where a very large surface has to be dealt
with, or a patient is very susceptible of or sensitive to pain. In such
cases, glycerine, which | uore soothing qualities, might be pre-
ferable. In conclusion, I would insist on the necessity of using pure
clear honey, quite free from any of the numerous articles said to be used
in its adulteration.1' Am. Jour, of Med, Sciences.
Digital CoMniEssio.x in -l. r. M, Miranlt, of rela-
ted to the Paris Surgical Society the following two cases of aneurism,
in which digital compression had been successfully employed :
1. A man, aged 23, exhibited an ancurismal tumor at the bend of the
arm, some time after being bled. When admitted into the hospital this
tumor was about the size of half an egg. Digital compression was made
on the brachial artery, at about the middle of its course, from 11 o'clock,
A. M. to 9 P. ML, and next day it was resumed from 0 A. M to 9 P. 31.
The tumor became more firm, and the compression was employed again
at j A. M. of the third day ; at 8 the pulsations had become indistinct,
and at 12 they had completely disappeared. Thirty-one hours had been
occupied in makiDg compression.
_ A child, aged 9, having had the trunk of the temporal artery
opened, just anterior to the ear, an aneurism about the size of a nut ap-
peared eight or ten days after the accident. Direct digital compression
832 Miscellaneous.
was employed for five hours on the first day ; for ten and a half hours
on the second ; for eleven hours on the third ; for nine and a half hours
on the fourth ; for eleven hours on the fifth ; for ten hours on the sixth ;
for ten and a half hours on the seventh ; and for nine and a half hours
on the eighth making a total of eighty-five hours, at the end of which
time the aneurism had become cured. Med. Times 4* Gaz. Jan. 19,
1861, from IS Union Med. No. 1, 18G1.
A Substitute for the Catheter. Sir Some two years ago, 1
had under my care a man who had received a fracture of the spine.
Inability to micturate was one of the symptoms, and I expected that I
should in this case, as I had witnessed in some others, have to use the
catheter very frequently. It occurred to me, however, that by pressing
over the region of the bladder, the urine might be discharged, and so it
proved ; for when any fluid collected in the bladder the patient was
always relieved by gentle, equable pressure. He never required the
use of the catheter, and, though he survived his accident about three
months, no urine ever escaped except under pressure.
Your obedient servant,
J. Wearne, M. R. C. S,
Helston, Cornwell, Nov, 18G0. Lancet,
On Iodism. In a recent discussion on iodism at the Academic Impe-
riale de Medecine, M. Velpeau made the following observations : He
had treated about fifteen thousand persons with iodine either externally
or internally, but he had never seen anything exactly resembling^ consti-
tutional iodism. He had observed irritation of the digestive organs,
pains in the stomach, dyspepsia, roughness of the throat, irritation of the
mucous membrane of the mouth and nose, ptyalism, &c , but he had
never seen cases of rapid emaciation, with atrophy of the breasts and
testicles, and bulimia, or in short, with symptoms of poisoning. M.
Velpeau suggests that the difference of the results observed in Paris and
Geneva may be due to the difference in the doses employed, or the va-
rying qualities of the iodized preparations ; but whatever may be the
reasons of the discrepancy, he has never seen in Paris any cases of what
31. llilliet has called constitutional iodism. L1 Union Medicale,
March 22d, 1860.
SOUTHERN
MEDICAL AND SURGICAL JOURNAL
Vol XVI!. A! fiUSTA, BA, PVJIBB AND DECEIJES, 1$6l.
ORIGINAL AND ECLECTIC,
ARTICLE XIX.
ABMY DISEASES.
We are happy to be enabled to give publicity to the fol-
lowing correspondence. It explains itself. The plain and
practical suggestions of Prof. Diigas, the result of matured
experience, are well deserving the attention of practitioners
whether in or ont of the army :
Augusta, Sept. 15, 1861.
I am about to join the army, and as 1 apprehend
re than rhe bails of the enemy, yon will do me a
great favor by giving me sneb simple directions us I may
cam onl in camp, if necessary especially for the treatment
of Typhoid fever, Diarrhoea, Dysentery and Pneumonia, which
I am informed aro the most common diseases of our soldiers.
I an "ii will pardon this call upon your kindness
from
:r friend and Late pupil,
I cheerfully comply with your reque.-t to furnish you
directions for the management of the disease! you
will be mpst like counter in your campaign. You are
S34 Dug as. Army Diseases. [November,
correct in believing that the risk of being shot is the least of
the dangers to which new soldiers are exposed. The radical
change to which they are subjected in all their habits of* life
is well calculated to induce disease, independently of the
exposure to contagious and epidemic affections.
Typhoid f'Y.YKTj is the bane of military camps and hospitals,
and nothing should be neglected that may tend to keep these
places clean and well ventilated. As far as practicable, those
suffering with this malady should be kept apart from those
affected with other diseases, for typhoid fever is unquestiona-
bly sometimes contagious as well as epidemic. But you
wish some simple rules for its treatment. I will then say at
once that, in the present state of our knowledge, typhoid fever
is a self-limited disease ; that it cannot be arrested in its pro-
gress, and that it usually requires from three to six weeks to
run its course. You need not, therefore, trouble yourself, nor
your patients, with attempts to shorten the period of its
duration. Mild cases will naturally occupy less time than
severe ones. What most behooves us is to enable the patient
to live through it as comfortably as circumstances will permit.
Tin's is to l)e done by avoiding all deteriorating medication,
by subduing all debilitating symptoms, by allowing such food
as may be readily digested, and by the administration of ner-
vine* and stimulating tonics.
1st, Avoid deteriorating medication that is to say, do not
bleed, give no purgatives, do not mercurialize, and eschew all
nauseants. They all lessen the energies of the system, already
unduly depressed by the disease. If the bowels are disagree-
ably distended, an enema of tepid water will relieve them.
The more quiet you keep the bowels, the better, for they arc
apt to be too much relaxed. Do not yield to the vulgar error
of supposing it necessary that the patient should have a daily
discharge from the bowels. Asa general rule, the less often
they are moved, the better, for tin's is an evidence that they
are not seriously implicated.
2d. Subdue debilitating symptoms. The most common of
t)n-s<> i- diarrhtiea. (Nmrrol it if possible at its inception-
1S61.] Pi / Diseat 835
and as often as it may evince a tendency to return. The
mixture recommended below, nnder the head of diarrhoea) is
one I have long been in the habit of using for that disei
her idiopathic or dependent upon typhoid fever.
The occurrence of hemorrhage from the bowels or from
some other portion of the mucous surface is always an alarm-
ing manifestation. If from the bowels, I use the dilated sul-
phuric acid or the elixir of vitriol in doses ot 20 drops to the
tumbler of water three or four times in '2-4: hours, (sweetened
if desired by the patient.) This is usually found to bean
agreeable beverage and is often very beneficial. If it fails,
may give 20 grains of alum, dissolved in a quart of water,
through the day, in such draughts as the patient will take
without much reluctance. This may also be sweetened if de-
sired. Large enemas of cold water, retained as long as pt
ble, will, in bad cases, very materially aid in checking the
hemorrhage. These may be repeated as often as the urgency
may require.
If the hemorrhage is from the nostrils or the s;iims, and will
not yield ro cold ablutions, you should use styptic lotions, such
alum, of sulphate of zinc, (5j. to a pint of
water,) the muriated or nitrated tincture of iron, '5j- to a pint
of warer) or the per-sulphate of iron.
1. Feed thepoti rd. 1 think it a matter of great import-
ance to see that sufficient nourishment be taken. The desire
of the patient for certain articles of food should be gratified,
especially when very decided, for it is rare that what he
ill injure him, if allowed in reasonable quant;
Ver; 111 eat too much. The appetite should beencour-
l by such delicacies as you may be able to procure.
4th. j <<l stimulating Ionic*. The
nerv em is more or less affected in all cases of typhoid
fever, and all practitioners concur in advocating the use of
ially directed to it. Subsultus tendinum, sleep-
. muttering delirium, stupor all indicate the morbid
m of the Opium and camphor are
ch circumstances. A piil containing
836 Dugas. Army Diseases. [November,
one grain of opium ana three grains of camphor may be given
at .such intervals as the case may require, and will usually
induce sleep and lessen the action of the muscles. One pill
night and morning will suffice in most cases. The infusion
of valerian is often a valuable adjuvant. It is under these
unstances that a moderate use of alcoholic beverages will
I ! great advantage. I need scarcely say that they
arc indispensable throughout the whole course of the disease,
with those who Jiave habitually used them before. During
convalescence, it will be found advantageous to combine them
with gentian, peruyTan baric or other vegetable bitters.
With this brief outline of treatment for typhoid fever, I will
abject, for I am sure you do not expect me
to be more minnte.
DiAEKHCEA.
For this very troublesome affection, you will, I think, find
nothing better than the following prescription :
i-\ Tincture of Catechu 3 part&
Tincture cf Opium,
Tincture of Camphor,
Tincture of Capsicum,
Tincture of Myrrh of each, 1 part.
Mix- Dose : I teaspobhful in a wineglassfnl of cold water,
two or three times a day, according to circumstances.
This prescription may .seem unnecessarily complex, but
each of its constituents plays an important part in the effect.
Its efficacy wjas stri kingly exemplified in the Crimean army,
where it was introdueed by oao of my ])iipils, who served as
surgeon in the. Uussian service during the whole campaign.
I am informed that it took precedence there of all other pre-
scriptions ip camp diarrhceii and incipient cholera. You
should always keep a bottle of it on hand, and commence its
use as goon as the bowel* are well emptied by the disease.
DUGA6. Army Disease*. 837
DYM XTlRY.
Ibis affection is sometimes attended with a
; : in other instances with comparatively little, li .
>u will iind it advantageous to admini >risk
bartic dose of Epsom or Glauber Palts, pr of Crjeam o1
Turtai at the onset of the attack. lrou fchus disgorge
al capillaries and drive out the fecal inatters, and there-
by relieve the tenesmus. Afier thi> you ^houJd keep up the
- by smaller dos< (a ; dine two
or three times a day, as long as there is an^ tendency to a
return of tenesmus; twenty to thirty oVqps. of Laudanum will
then close the treatment in most cases, .lint- when the!
much fever, the use of Quinine for a few days will v< rj ma
terially aid in the treatment Give eacli morning fifteen
grains, in doses of 5 grains at intervals of A two hours. Tin.-
must not interfere witli the use of the salines. 1 should have
stated when speaking of the salines, thai after the first cath-
artic, a teaspoonful or table salt will often do as well, if not
er, than either of the other salts. In very bad or neglect-
ed eases I have derived great advarifa fas of
cold, or even iced water, repeated .!- return !
tenesmus or hemorrhage be relieved. I en >udiate
the routine practice of Calom^Tan i Dover's Pqw<3 uicli
lauded by old writer-.
l!he Pneumonia, such as it has exhibit* ah-
em i th-westorn ^r:iu< for the h
oin the d
of northei u The di
found in (he type of tl
te and able argument <<.' Lai '
with a form hich will
pletion -f any kind. : ;!n:l.
hie in the pneumonia of
try. 1 cannot now discuss the quest oda\
S3S Dcgas. Army Diseases. [November,
V^^v^.
once to give you an outline of the treatment most successful,
I may say usually successful, with us.
We must recognise here, as well as in our epidemic dysen-
teries, two elements of disease a remittent fever and a local
(pulmonary) complication, either congestive or inflammatory.
By subduing the former, the latter will usually yield readily.
Give fifteen grains of Quinine then every morning beginning
at day break, without regard to the fever, (5 grs. every two
hours, three times) and do this until the febrile paroxysms are
controlled. At night one-quarter of a grain of morphia, or ten
gtii Dovers Powders, will, if necessary, procure good rest.
Warm teas should be taken freely, if they can be had ; if not,
cold water should be allowed as often as desired. The patient
will crave but little nourishment and should not be denied
it.
If there be any pain in'"the side, showing a pleuritic com-
plication, meet it at once by blistering the painful region. A
blister from four to six inches square will be large enough.
This may appear to be a very simple plan of treatment, but
you may depend upon it as infinitely more successful than any
other. If you bleed, purge, or antimonialise your patient, he
will often die when you least expect it. Active antiphlogistics
were formerly very successful here, as they may still be in the
northern States, but the type of the disease has undergone
such a radical change with us, that we can no longer resort to
them with impunity,
MEASLES.
Although you do not name measles among the diseases up-
on which you desire my views, I will add a few Avords on the
i object because our army has suffered very much from tin's
distemper.
In the first"place you should bear in mind that this is a dis-
of self-limited duration, and that we cannot arrest its
course. Since we cannot cure it, therefore, onr business is to
see that its progress be not aggravated by complications. In
natural course of the disease the effect of the poison by
!.. Duoas, Army Disease*.
which it is induced manifests itself upon the skin and the ad-
jacent mucous surfaces of the throat and air passages, an
long as it goes DO farther, there is but little danger. Let us,
then, by careful avoidance of exposure to cold, prevent a re-
cession of the cutaneous affection and its invasion <>f the in-
ternal organs. By so doing the disease will usually run Its
course in ten days. The cough which is often quite trouble-
sonic should be allayed by an occasional dose of Paregoric or
Laudanum. The patient should commit no excess in diet, but
may eat moderately of plain food if he desires it. Purging
ild be avoided, for the susceptibility of the intestim
very great and diarrhoea is one of the principal dangers we
have to apprehend. Its manifestation should be immodi;
checked by the astringent mixture already alluded
to must especially remember that ti: - ibsidence of the
cutaneous affection does not constitute the cessation of danger,
for there seems to be in Measles an affection of the blood, or
of the general stamina which re<pr eral weeks to
overcome after the commencement of convalescence; Hence
it is that many persons under the impression that the db
has | if, commit imprudem iei or exposure, and
relapse. Some will thus take diarrhosa, .-ome dysentery, and
aeumouia, which occurring in an already impaired
constitution, will rapidly carry them to the grave. The great
majority of deaths from Measles will he found to take place
in this way. Xo soldier should, therefore, be allowed to re-
ie duties in less than a month after the disappearance
of the eruption, and during this time it would he well for him
ike tonics, of which the best will probably be found to be
muriated tincture of boon, largely diluted, (in half
tumbler of water,) two or three limes a day. Ti; have
1 to alcoholic liquors should be allowed thein
ble quantities. Warm clothing and mode*
in the open air : . :tribute to the re
B -ur.
I have now, my dear friend, complied with your request
in as brief a manner that in end-
840 Spasmodic Croup. [November,
to avoid prolixity, I may have erred in the other extreme and
left unsaid much that might Le important. I trust, however,
that I have said enough to present at a glance the leading
principles of my practice, and this is, I presume, all you desired.
Wishing you success as a physician and as a soldier in the
imtmitons war waged against us, T remain
Yours very truly,
I, A. DUGAS.
Spasmodic Croup in a Child Three Days GUI Recovery.
By Peterfield Trent, M. D., Kiehmcnd, Ya.
On the 16th day of June, at midnight, I was called to see a
child of Lieut. II. I found my little patient laboring under
great difficulty of respiration, the paroxysms of coughing were
frequent and spasmodic the heart's action was, as usual, con-
siderably accelerated, during the fits of coughing the inspi-
i ation was almost suspended the count enance was flushed,
occasionally it was livid. During the intervals between the
paroxysms of coughing, the child lay as if dead. I immedi-
ately ordered a hot bath, with mustard, to be prepared ; after
it had remained in the bath some 10 or 15 minutes, it began
to revive. As soon as it was taken from the bath, I com-
menced giving a teaspoonful of a mixture composed of one-
half hive syrup and one-quarter each of syrup of squills and
syrup of ipecac, every fifteen minutes until vomiting could be
produced. It was over one honr before I could procure
vomiting, and not then as freely as I desired, until some five
or six doses of the combination had been given. What was
first vomited looked like frothy mucus; towards the last, upon
examining the sputa, I could distinctly discover shreds of
lymph. Fearing to push the emetu?" any further, I ordered
one grain of cal omel to be given every hour until it had freely
operated some five or six times. I left the child relieved of
'" distress in which I found it ; but with little hopes of find-
ing it alive when I should again visit it. Upon paying my
second i ' mother infohKed me that the opprea
breathing had continued during ray a and was al times
il was when I first 3aw the child, with a lpyd
[ found the calomel had operated freely, and
all the seven- croupy symptoms had abated. Ordered calomel
continued; ifneci ... o mustard bath,
itvl every two hours to give a teaspoonful of a cough mixture
composed of equal parts of syrup ills and syrup of
ipecac, until every croupy symptom disappeared From this
my little patient continued to impr - now a
larkahly fine-looking and healthy child.
There have boon but few fea p attacking
Iren within the iir>f six mouths. Andral, out of over 300
as occurring during the first mouth.
3 mentioned by M.. Trousseau, no case is re-
d under 11 months. Cheyne, in his work upon " the
PatholofiTV of the Larynx and Bronchia," mentions meeting
croup in a child three months old. Marley, in his work on
diseases of children, mentions seeing croup in one child at
<he breast, hut does not give the age. Bonchet, on diseases
of iufa ties a case of croup in a child eight days old.
''or in Cerebral Congest Rela-
psy. By M. Trousseau.
Gentlemen : You are aware that there exists in our science
an opinion that apoplectiform cerebra 3tion is a common
well i o well received,
ell appear I it.
I;, which I sident in the Insane
that 1 saw,
iform congestions. Since
I
in my private
iiii any.
for-
that 1 am
842 Cerebral Congestion, <Lc. [November,
mistaken or that they are. It is very evident that I can en-
tertain no other idea than that the error is on their side
otherwise I would change my opinion.
Let vis see, then. A man, either with or without premoni-
tory symptoms, is suddenly seized with apoplexy ; he is
picked up in a state of stupefaction, and for a quarter of an
hour, an hour, and possibly longer, he continues heavy-headed,
confused in intellect, and with uncertain steps. On the mor-
row all is past.
They say that this patient has had an apoplectiform cere-
bral congestion. I have said so like the others, but for fifteen
years I say so no more.
Another, while walking, suddenly becomes dizzy ; he ceases
to see, to speak ; he mutters some unintelligible words ; he
staggers, sometimes he falls, but rises immediately after-
wards. This has lasted a few seconds ; nothing remains but
a little heaviness of the head, sometimes a momentary cloudi-
ness of intellect, and three or four minutes suffice to restore
everything to a natural condition.
They suy that this patient has had a slight cerebral con-
gestion. I, too, have said so, but for fifteen years I say so no
more.
Why, then, gentlemen, have I changed my mind? It is
certainly not through love of the paradoxical. It is that facts
have forced a new light to dawn upon my mind.
In the year 1845, one of my friends was found in his bed
in a state of unconsciousness. His face was swollen and of a
violet hue ; intellect, motion and feeling were gone ; there
was stertorous breathing. This was a vigorous man, forty-
two years old. How long had he been in this state % His
wife could not say ; she had been awakened by a strange
snoring, and she had sent in search of me. At this pe-
riod I had already given up bleeding in apoplexy. I Had the
patient placed in bed in a half-sitting posture; I slapped his
lace with a handkerchief wet with cold water; I applied two
ligatures above the thighs in order to retain momentarily a
large quantity of venous blood in the vessels of the lower
extremities ; then I waited. An hour had hardly passed
when motion was restored, feeling was being re-established
and the patient replied pretty clearly to the questions that
were put to him. On the morrow, excepting a painful still-
ness of the loins, no trace of the storm remained.
Some time after this, I was called in great haste to see one
of my neighbors, aged seventy years, who, while on the
boulevard, had been seized with an apoplectic fit. He had
1861, ( '(/'.
remained unconscious tor fully quarter of an hour. 1 arrived
just at the moment that his 9611860 Were returning. He did
not as yet recognize me, gazed about him in a stupefied man-
ner, and tossed his arms and legs about without knowing what
lie was doing. His lips and DOSe were pulled out, and his
eyes were injected. Gradually everything was restored to its
natural condition without my having had recourse to any ac-
tive medical treatment.
The whole affair lasted some bonus.
The servant man then told me that his master had had
ral attacks of this kind within the space of two or three
years, and that they had passed oft* in the same manner once
after he had been bled, the other timer, after using a mustard
foot-bath.
The same year i was consulted in my om'ee by a lawyer
from one of the provinces, aged thirty-live years, who within
sis in mths had three attacks of apoplexy. He had been bled
each time, and he thought he had derived much benefit from
this: they had purged him, and each month he was leeched
in the region of the anus. The last attack had taken place as
he was going up the steps of his house after pleading an im-
portant case. His head had struck upon the steps, and the
But still bore traces of a pretty' deep wound in the fore-
1. His intellect, sensibility and power of motion were in
a perfectly good condition when I saw the patient, and the
apoplectiform attacks had lasted, at most, one hour.
I am but a small believer in apoplexy among people
'hirty-tive years of age, especially when those apoplectic at-
a recur every two months, and immediately the idea of
epilepsy presented itself to my mind, and I therefore disclosed
fears to that one of my colleagues who had sent the pa-
tient to me. The reply was that nothing justified my suspi-
cions, and that no convulsions had ever been seen. I still
maintained my diagnosis, and a short time afterwards, in the
midst of an audience, the poor lawyer was seized with an at-
of falling-sickness which unhappily left ho doubt in the
:' any one, and he was obliged to give up his profes-
In the meanwhile, my attention had been awakened,
cd myself whether so many people that I had seen with
lectiform cerebral congestions were not epileptics, and 1
varchful.
first patient soon had o ad now he has
3 many as four and live attacks of epilepsy in a
I very often verti sight is
lost and his intellect is sadly altered.
bral Congestion^ (he. [November,
As ftfr tJie old man, of whom J have also given a summary
account, he still lives, and almost every year he has one or
two of these attacks. Since his fall upon the boulevard, he
sr goes out without a servant, and this man has told me
that at the moment when his master is lying on the ground,
his lace undergoes contortions, and he has twitch ings in one
of his arms, which hardly last a minute, but which amply
suffice to characterize epilepsy.
Since this period, every time that I have been consulted
concerning a person suffering from apoplectiform cerebral
congestion, I have sought out, with the greatest care, whether,
from time to time, during the day, there had been observed
sudden and rapid vertigos with the characteristics that I have
Indicated above : whether these attacks of congestion were
not rather nocturnal than diurnal ; whether at the com-
meucement of the attack there had not been nervous move-
ments, and almost always, when the attack came on in the
presence of witnesses, the convulsions could be recognized.
When the congestion had taken place at night, during
sleep, I learned that the urine sometimes passed involuntarily.
and that for several days the tongue was sore. The face, tore-
head and neck were covered with small echymotic spots, like
flea-bites. I learned, moreover, that the attacks recurred at
rather shortened intervals, leaving no lasting ti nee behind.
In one word, epilepsy was evident enough when it was sought
for. when one wished to lind it.
There is not a month that passes that I do not see in my
olfice some patients said to be suffering from apoplexy, who
are epileptics. There is perhaps, not a week that I am not
consulted by adults, old men, and children, suffering with epi-
leptic vertigos, and who have been referred to me as having
slight cerebral congestions. And although epilepsy, in all
its forms, is better known at the present day man it. was
twenty-Jive or thirty years ago, nevertheless many physicians
refuse* to believe in sO terrible a disease, and if they recognise
it they do not wish to tell the family what they think about
it, and prefer to lca\c this sad mission to us.
Very often epileptic vertigo reveals itself in attacks which
are always attributed to cerebral congestion, and to which
those physicians who are occupied with the treatment of the
insane have, long since, called the attention of their col-
leagues.
After the vertiginous attack, it is quite common to see the
patients delirious for some minutes-;' the delirium may even
continue for a considerably long period.
1861.] Cerobral Congestion, &c. 346
The judiciary annals, the archives of the prefecture of po-
:illed with suicides and murders which are too
attributed by ph; to whal bral conj
Lions, while they ought to be attributed to epiiepe
:e may say, almost without tear of being mistaken, I
if a man who has had no premonitory trouble of intellect, who
ire given no sign -. who hi I ecu
poisoned by alcohol, or b; other bud which exer-
- an energetic action upon the nervous system, commits
suicide or kills any one, erne may say that such a man is an
. and that he has had a severe attack, or rather whai
is more common, a simple epileptic vertigo.
These strange acts are, I repeat, attributed by most ph;
cians to | cerebral congestions, for this rea
fully developed attack is often unnoticed, and the simple \<"-
aya so.
ere is a reason which most, often causes epilepsy to be un-
known ; this is the repugnance which families have to reveal-
ing this sad disease to physicians. Even when a mother has
been a witness to a fully developed attack, she refuses to be-
epilepsy, and it* the physician questions her, she
speaks of the coma, of the Loss of consciousness, but will i
often refrain from mentioning the convulsions. She will call
for aid against the accidents which follow the attack, but she
L to avoid suspicion of the sad truth. I have often
been consulted by persons who knew full well that they were
suffering from epilepsy, but who spoke to me only of com
lion ; wives kept back the true state of the husbands, husbano!>
the state of their wives, and most often, parents the symptom.-
experienced by their children. The physician then is always
deceived concerning cpilep-;. : fa eived by the pa:.
himself who knows nothing of his attack, excepting that he
has lost consciousness, and that he remained several hours
a state of half stupefaction. lie ived by the par
who are loth to acknowledge, even ; tat they
have an epileptic in their family. He is deceived by the
recollections of his early medical education during which he
has been repeatedly told that apoplectiform cerebral coi
tion is a common disease. Let n ;>h*'d it'
congestion is -to.
si convulf a which assimila
cerebral congestion. It happens, -. although \
rarely, that i unmehcenient of an epileptic attack, the
c period, that i-: to sa; seles
an absolute rigidity ; it happens some-
$G Cerebral Congestion, &c. [November,
times, I say, that this tonic period lasts two or three minutes,
instead oi' lasting only fifteen or thirty seconds, and
the individuals die asphyxiated, as persons die in a tetanic
paroxysm, as animals die who have been poisoned by sub-
stances containing strychnia, as our colleague, M. Segalas,has
60 well demonstrated nearly forty years ago.
As, in this case, there have been no chronic convulsions,
such as are best known to persons outside of the profession,
and as during the whole continuance of the tonic convulsion,
the face has been swollen, the vessels of the neck have been
distended and knotty, as in fact there has been an enormous
congestion, but an entirely passive one, similar to that which is
produced by exertion, it is mistaken for an active congestion,
while in fact it is only an attack of eclampsia or epilepsy.
Let those of our colleagues who devote most of their atten-
tion to the diseases of women in child-bed and children, recall
their experiences, and probably they will partake of my
opinion. Dr. Meniere has observed for a long time a large
number of patients who are suddenly seized with vertigo,
nausea and even vomiting, who fall upon the ground after
having walked like drunkards, rise with difficulty, remain
pale, covered with a cold sweat, almost in a comatose state ;
and see these accidents very frequently recurring. The first
attacks are considered cerebral congestions and are vigorously
treated by bleeding, leeches and purgatives. The frequent
relapses modify gradually the diagnosis, but the patients be-
come exceedingly uneasy about them, and especially the
doctors, and all enlightened persons who are aware of the
seriousness of cerebral lesions.
In the vast majority of cases, patients affected with these
cerebral troubles, soon perceive noises in their ears, often even
the hearing becomes embarrassed, and these unnatural sounds
cause these persons who wish to free themselves from such an
annoyance, to seek the aid of the physicians of the asylum
for the deaf and dumb at Paris. It is easy, then, to prove
that one ear and often even both are pingularly enfeebled, and
M. Meniere has collected hundreds of observations establish-
ing the fact that these supposed lesions of the brain are really
lesions of the auditory apparatus. lie has pursued these re-
searches with extreme care, and he lias been able to prove
{hat the starting point of these phenomena is in the internal
ear. We will let our colleague bring here the result of so
highly interesting a study. It will' suffice for us to say that
the greater part of the troubles so improperly designated Un-
der tlie title of apoplectiform cerebral congestion have their
1S61.] hral Congestion, <&c. 847
in the semi-circular canals, that the lesions of these or-
gans produce vertigos and sympathetic vomiting, take away
the power of the limbs, and bring about sudden loss of con-
sciousness ; in a word that many o\ the so-called legions of rim
brain belong exclusively to the auditory apparat:;
There is still another disorder which is constantly designa-
ted by the title of cerebral congestion. I speak of vertigo
connected with gastric disorders. This varied form of ner-
vous disease is characterized by the following phenomena.
If the patient makes a sudden motion in bed, the bed seems
to turn round and carry him with it in its motion; if he rises.
and especially if, having risen, he looks upwards, the vertigo
becomes more excessive. As objects turn around him, he
reels, and sometimes is unable to stand. At the same time,
he experiences an insupportable sickness at his stomach, and
very often vomits. These singular attacks are called by the
patients rushes of blood to the head, and we must say, the
greater part of physicians partake of this idea. They bleed.
they apply cups and leeches, give mustard foot-baths, and in a
word, do everything to dispel this imagined congestion, which
they increase by their strange treatment.
The vertiginous diseases of which I have spoken are rather
akin to syncope, and consequently are just the opposite to
congestion ; and, strange as it may appear, it is nevertheless
true that too many physicians still do not recognise the ten
deney to syncope, and confound it with cerebral congestion.
Xevertheless, gentlemen, as I do not wish to exaggerate, I
will suppose that the two states that I have been describing
are unknown to physicians, and I will suppose that they are
never taken for cerebral congestions. But there is an attack
which often accompanies hemorrhages of the brain and which,
by the generality of physicians, is considered a congestion.
I explain myself. "When a patient is seized with apoplexy,
whether this apoplexy be caused by a cerebral hemorrhage,
whether it depend upon a softening, which is more frequently
the case than it is acknowledged or thought to be, or whether
it be the result of an embolus, or at least of a sudden obliter-
ation of one of the principal arteries at the base of the brain ;
when, I say, a patient is seized with apoplexy, there is some-
times a sudden loss of consciousness, and the dullness of the
intellect, and the loss of the power 01 motion last several hours
or even days, then everything is restored to a natural condi-
tion, with the exception of a slight hemiplegia, which dimin-
ishes slowly and finishes by disappearing after some mom
attacks have been almost fulminant, and a^ there
ji 1 8 Cerebral Congestion, <&c. [November.
4,068 not seem to be a sufficient relation between the severity
of these first phenomena and the ulterior troubles of intellect,
sensibility and motion, they say that the cerebral hemorrhage
has been accompanied by a congestion ; that the congestion,
an essentially transitory phenomenon, has produced the apo-
plectic attacks properly so-called, and that when it has passed
away, it has left this slight hemorrhage together with another
slight hemorrhage which has followed these severe apoplectic
attacks,
I do not wish absolutely to deny the existence of such a
congestion, and I even acknowledge that I am tempted to
admit it in a certain degree ; but tlicve is another phenome-
non which has not been sufficiently taken into account, at
least so far as I know. I wish to speak of, what I have called
the cerebral astonishment. When the brain suddenly experi-
ences a tearing and a compression, it bears this grave lesion
with an impatience which varies according to the individual.
but which can be borne to a very great extent by certain per-
sons. I will offer as an example one of the traumatic lesions
qf the brain. When a soldier receives a ball in his head, or
when in a fight, an individual receives a stab from a knife
which penetrates into the brain, they are thrown to the ground
as if they had been struck by a bludgeon ; but little by little,
notwithstanding the intra-cranial effusions of blood which are
the consequence of the wound, and even notwithstanding the
inflammatory congestion which is inseparable from the lacer-
ation of the tissues, intellect, sensibility and power of motion
return sometimes with wonderful rapidity, and thus afford, to
the inexperienced surgeon, hopes which are never realized.
This immediate stupor is what I have called the cerebral
astonishment, and however incorrect this appellation which I
will willingly renounce, may be, still the fact always exist-
and can be contested by no one.
Experiments upon animals give still more positive results.
If one trephine the skull of a dog or a rabbit, and iitroduce
a small ball of lead through an incision in the dura mater, be-
tween the skull and the surface of the brain, one will observe
at the very outset, phenomena of stupor, which rapidly pass
off, to be replaced by hemiplegia which is proportionate to
the amount of cornpres^ioi.
In this experiment one cannot plead cerebral concussion a;-
a caiBo one must allow that the brain is in a manner sur-
prised by an accident which shows itself in transitory disturb-
ances. Am I not, then, right in supposing thai when a sud-
den extravasation of oloocl takes place in the striated body or
1861.] 'ruction of the Palmar Fascia.
in the optic thalamus, the immediate stupor which is ordina-
rily attributed to the simultaneous congestion may, in part at
least, be attributed to cerebral astonishment.
I ran it be said, gentlemen, that I deny absolutely the exist-
ence Ural congestion * Certainly not. 1 admit the
ingestion, hyperemia of the hrain one would
be mad to contest the existence of it; but I do say that what
has been called an apoplectiform cerebral congestion is, in the
majority of cases, an epileptic or eclamptic attack, sometimes
a m ncope. I Bay that, very often, simple epileptic vert:.
or vertigos connected with a disordered state of the stomach,
or from diseases of the ear, are wrongly considered coug
tions of the brain.
Moreover, if the propositions that I have endeavored to de-
fend be true, it will be granted that therapeutics ought less
frequently to have recourse to revulsive and antiphlogistic
treatment which is continually resorted to to combat these
supposed cerebral congestions, and that other indications
should be sought out, more conformed to the idea which one
ought to form of the different states that have too often been
confounded under the same denomination. W. McX. W.
"Maryland <.( Virginia Med. Journal.
r Ike Palmar Fascia, and Us Mode of Treat-
By Win. A. Elliott, F. R. C. S. L, Surgeon to the
Whitworth Hospital, Drumcondra.
.e following cases, illustrative of an affection which has
received, from time to time, so much professional investiga-
tion, may, I trust, prove, in some degree, of practical
interest.
1. Mr. P. B. aBtat. 27, consulted me in June,
for contraction of the left hand, which, upon examination,
presented the following appearances:
The little finger was flexed permanently to a right angle
upon the palm ; the deformity seemed to engage the meta-
carpophalangeal articulation chiefly, and was evidently the
result of a contracted condition of the correspond]
tion of the palmar fascia, which was distinctly to I
and felt as a hard prominent cord leading from the anterior
annular ligament of the carpus downwards to the root of
54
8S0 ( kmi ruction of the Palmar l<ascia. [Koveniber,
the finger. The adjoining portion of the palmar aponeur-
osis seemed also to have suffered, for the ring finger waslike-
wise slightly flexed upon the palm, but not by any means to
such an amount as the little finger.
On attempting to extend the affected fingers upon the
metacarpus, the diseased portion of the palmar fascia be-
came tense, rigid and prominent. On the contrary, it be-
came flaccid, and nearly disappeared when the joints in
question were flexed upon the palm.
The integuments in the palm of the hand were thickened
and tightly stretched over the fascial cord ; there was also
the usual appearance of wrinkled or arched folds, with their
concavities looking downwards and their convexities up-
wards, which apparently adhered closely to the subjacent
structures. The patient stated that when about the age of
14 years he first experienced some degree of tension (but
unaccompanied with pain) in the palm of the hand. This
insensibly increased, but his attention was ultimately arrest-
ed by the state of the little finger, which by a slow contrac-
tile process, had gradually become flexed, until at length
it formed a right angle with the palm ; the power of exten-
sion being lost to a degree commensurate with the aponeu-
rotic shortening.
I endeavored, but in vain, to overcome this rigid con-
traction by means of an instrument adapted to the pur-
pose. But this procedure, I confess, was adopted rather to
test the amount of resistance offered by the fascia, than for
any expected benefit likely to result from the trial.
The late Sir Philip Crampton and Dr. Adams met me in
consultation, and it was unanimously agreed that the
nature of the case was such as to demand operation. The
subcutaneous sections of the contracted fasciae were sug-
gested, but Sir P. Crampton objected, preferring a different
operation, which he subsequently performed in the follow-
in <' manner :
One long incision was made on a line parallel with the
tight cord, and to its inner side. The scalpel was then
passed beneath the fascia in different parts, dividing it at
the same time from behind forwards. This had the effect
of liberating the contraction to a certain extent, but the
flexion of the finger was not entirely overcome until the
bifurcated portion of the fascia which is inserted into the
first phalanx was severed. This being done, the finger was
iramediatelv released from its former state of contraction.
1861.] of the Palmar Faxc in.
The wounds were then dressed with lint, and a weak spirit
lotion directed to be applied for some hours.
The day after operation the hand became aulematous,
painful, and very sensitive to the touch, and in this state it
coutinued almost throughout the entire period of time oc-
cupied in the subsequent treatment, which was thus ren-
dered extremely difficult. Notwithstanding this painful
swelling, it was imperative to apply for a few hours daily,
the instrument for forcible extension of the hand and fin-
gers, and at night a light wooden splint to prevent contrac-
tion, and also to afford ease to the patient.
The treatment of the incisions consisted merely in the
application of water dressing covered with oil silk and sup-
ported by loose bandages, which course was pursued until
cicatrisation was perfected. It is unnecessary to detail the
daily changes which occurred during the healing of the
wounds and the removal of the contraction. I may, bow-
er, observe, that it was with mucb difficulty these twofold
indications were simultaneously fulfilled for the reasons
already stated.
This case terminated most successfully, having occupied
live weeks of very diligent management from the day of
operation. Patient has now, for upwards of seven years,
been in the enjoyment of perfect use of his hand.
2. Mr. J. McG., ictat. 46, consulted me in Sept.
1857, for contraction of the palmar fascia engaging the
middle and ring lingers of the right hand. In February,
1858, the patient returned to Dublin for the purpose of un-
dergoing the necessary treatment for the removal of this
affection, when the following notes were taken of his case :
The palmar fascia feels slightly tense when traced down-
wards from the annular carpal ligament. In the palm of
the hand it is prominent, hard and unyielding. Near the
metacarpo-phalangeal articulation it appears to be abru]
identified with a mass of hypertrophied integument, thick,
firm and elastic in its nature. In this thickened mass the
outlines of the contracted fascia are lost, but they arc again
iy felt where the fascia passes downwards to form the
bifurcation for supplying the two middle fingers. The
middle and ring fingers are ilexed, forming nearly Hghl
angles with the palm ; they are also rigidly approxim*
to each [two sharp prominent ridges exist along the
opposed edges of the affected fingers ; these rid end
from tl: r.rpo-phalangeal articulations to the ungual
852 Coniract'iotioftlic Palmar Fascia, f November,
phalanges, affording such increased measurement in the
anterioposterior direction as almost to convey the erroneous
idea that the sheaths of the tendons had been ruptured.
The integuments in the palm of the hand present nearly
the same wrinkled arrangement which was described in the
former case, feeling also tense, and as if adherent at differ-
ent points to the subjacent structure's, along the course of
the contracted fascia.
Patient cannot assign any cause for the invasion of this
affection, which eommenceel about sixteen years previous
to my seeing him. The contraction first made its appear-
ance in the palm of the hand, near the middle finger, and
gradually extended to the ring linger, causing flexion of
both, but without at any time giving rise to the least pain.
On the 10th February, 1858, I liberated the contracted
hand and lingers by subcutaneous section in the following
manner :
Having placed the hand upon the instrument, and by
this means having rendered the fascia tense throughout its
entire extent, the limb being firmly held by an assistant, I
first divided the palmar portion of the fascia which lay be-
hind the hypertrophied integument by passing a small knife
horizontally under the skin and cutting freely backwards ;
it separated with a sharp crepitating sound. The palm of
the hand immediately became open and flaccid, but the
fingers (particularly the middle) still remained somewhat
Hexed. I then divided by another puncture the bifurcated
portion of fascia supplying the inner side of the middle
finger ; this being effected, all tension was removed.
In forty-eight hours after operation, the dressings were
removed,' and finding both wounds healed, I commenced
the subsequent treatment, which was conducted in the
same manner as described in the former case, making use
of the apparatus for forcible extension during part of the
day, and applying a light splint at night.
In twelve days from the date of the operation, patient
returned home, all contraction in the hand and fingers
being quite removed. He had also commenced to make
use of the limb.
We must confess that our knowledge of the etiology of
this disease is still imperfect, although modern surgery has
revealed the fact that it is of a curable nature. In the in-
cipient stages I have succeeded in removing the contractions
by simple mechanical means; but as the disease progresses,
[861.] of the Pabwr F<u 858
the fascia undergoes a process of rigid shortening, ana ulti-
mately resists the most forcible extension thai we ran with
safety apply to it. From this state it will be. impossible, to
release the hand until the contracted fascia has been divid-
ed : but as the fascia is the active agent in producing the
deformity, it is the only structure requiring section. The
tendons and skin are blameless, as is j morbid
specimens of this disease.
Patient has now perfect use limb without the
slightest appearance of contraction, three ycai*8 having
elapsed since the period of bis treatment.
Doctor Adams in the "Cyclopaedia oi' Anatomy and Phy-
siology,"' vide Abnormal Conditions of the Hand, gives a
clear and comprehensive description of this disease. He
ascribes the ilexion of the hand and lingers to contraction
of the palmar fascia, its palmar and its digital portions be-
ing usually both in fault. This was also the opinion of
Dupuytren, to whom the profession is indebted for having
been the first to elucidate the nature and scat of
affection.
In December, 1841, Dr. Mayne exhibited before the Pa-
thological Society in Dublin a good s] of this dis-
ease, lie states : "The deformity consisted lu a firm per*
manent flexion of the little finger upon Im. Prom
the palm a firm cord could be distinctly felt proceeding op
the anterior part of the carpal annular ligament. The in-
teguments were found to be firmly united to the .
rosis at the wrinkle. The palmar fascia was natural, ex-
its fourth fasciculus, which was very strong and contracted.
The flexor tendons were natural. The deformity appeared
to depend upon the contracted state of the fourth fasciculus
of the palmar aponeurosis, ami a simila: ition of the
Bheaths of the tendons in front of tjie finger-. Et should be
observed that there was in the specimen a branch of the
palmar artery running very near and parallel to the band.
and that this vessel might have been divid
had been resorted t->.'"
It appears to me that I ,.ey
the laws ascribed to it by those ai
in either to a peculiar constitutional dial
orious occupation of the individual, : tamined
carefully many persons Buffering from this affection, whose
statements were opposed to such opinion-', and it is at \\
certain that the great majority of the which have
s-~> I Contraction of the Palmar Fascia. \ November*
fallen under my observation, occurred in persons whose oc-
cupations were by no means of a laborious nature.
! v some surgeons attention has been directed to the par-
ticular finger Which first becomes affected. In a practical
sense, this is unimportant, but we find the disease usually
commencing either in the middle, ring, or little finger, in
each of which I have seen it originate. We sometimes ob-
serve tins affection existing in both hands of the same indi-
vidual. Lately I examined a singular case, in which not
only both hands were engaged, but the contraction had
extended to both thumbs, and to all the fingers.
.- It is of the utmost importance that we should select the
most eligible operation for the removal of the deformity
under consideration. Dupuytren's mode consisted in mak-
ing transverse and occasionally semilunar, incisions, about
six lines in length, opposite the metacarpophalangeal articu-
lation, and also in the palm of the hand, or, as occasion re-
quired, in front of the phalanges, so as to enable the fascia
to be fully divided.
Sir Philip Crampton considered this disease to be of a
peculiarly intractable character, and for its removal recom-
mended that a free incision should first be made parallel
with the tight cord and in its entire length. This he con-
sidered most important, as by so doing the operator would
be enabled to divide with greater ease and certainty the
contracted portions of fascia.
'ho subcutaneous operation seemed to me preferable,
and the advantages which it possesses are obvious viz., it
is comparatively free from risk or pain. The punctures
heal iu a few hours, thereby permitting the subsequent
treatment to be conducted without embarrassment, and
wounds are avoided which would necessarily be kept open
by the process of extension, and when healed might eventu-
ate in the formation of hard and contractile cicatrices, pos-
sessing a tendency to reproduction of the original de-
formity.
The comparatively short duration of time in which (by
tli is operation) we are enabled to cure the disease, should,
I consider, entitle it to additional recommendation. In
adopting the subcutaneous operation it will be necessary to
select a proper situation at which to make the puncture.
The most prominent portion of the fascial cord will be
found invariably lying in front of the superficial palmar
arch of arteries ; and as we cannot determine the depth to
186JU] Directions to Arm;/ Surgeon*.
which pur incision may require bo be carried, this situation
should be avoided. It will be found more satisfactory, and
attended with less risk, to make the puncture about mid-
way between the lowest transverse line in the palm and
the root of the affected finger.
AVhatcver may be the nature ol' the operation deemed
advisable in these cases, the subsequent treatment will re-
quire our utmost attention, ami much difficulty may be
obviated by the use of the instrument which J constructed
some years since, and have found most efficacious in the
removal of many forms of digital contractions, in its con-
struction it simulates somewhat the mote he pha-
langes, and may be applied to one or all the fingers, as the
case may demand. It should be worn for some hours at n
time, but the period must be regulated by the feelings <^{'
the patient. Dublin Medical Press,
Directions to Army Surgeons on the Field of Battle. Uy G,J.
Guthrie, Surgeon General to the British Forces during
the Crimean War. (From his Pamphlet on the Hospital
Brigade.)
1. "Water being of the utmost importance to wounded
men, care should be taken when before the enemy, not only
that the barrels attached to the conveyance-carts are proper-
ly tilled with good water, but that skins for holding water,
such other means as are commonly used in the country
for carrying it, should be procured and duly iili
2. Bandages or rollers, applied on the field of battle are.
in general, so many things wasted, as they become dirty
and stiff, and are usually cut away and destroyed, without
having been really useful ; they are not therefore forthcom-
i required, and would be of no use.
B. Simple gun-shot wounds requite nothing more, for the
first two or three days, than the application of a piece of
wet or oiled linen, fastened on with a strip oi stioking-
plaster, or. if possible, kept constantly wet ami cold with
water. When eold disagrees, warm water should be sub-
stituted.
4. Wounds made by -words, $ Other .-harp-cutting
instruments, arc to be treated principally by position. Thus,
856 Directions to Army Surgeons. [November,
a cut down to the bone, across the thick part of the arm,
immediately below the shoulder is to be treated by raising
the arm to or above right angle with the body, in which
position it is to be retained, however inconvenient it may
bo. Ligatures may be inserted, but through the skin only.
If the throat be cut across in front, any great vessels should
be tied, and the oozing stopped by a sponge. After a few
hours, when the oozing is arrested, the sponge should be
removed, and the head brought down towards the chest,
and retained In that position without ligatures ; if this is
done too soon, the sufferer may positively be suffocated by
the infiltration of blood into the areolar tissue of the parts
adjacent,
5. If the cavity of the chest is opened into by a sword or
lance, it is of the utmost importance that the wound in the
skin should be effectively closed, and this can be done by
sewing it up as a tailor or a lady would sew up a seam, skin
only being included ; a compress of list should be applied
over the stitches, fastened on by sticking plaster. The pa-
tient is then to be placed on the wounded side, that the
lung may fall down, if it can, upon, or appty itself to the
wounded part, and adhere to it, by which happy and hoped-
for accident life will in all probability be preserved. If the
lung should be seen protruding in the wound, it should not
be returned beyond the level of the ribs, but be covered
over by the external parts.
6. It is advisable to encourage previously the discharge
of blood from the cavity of the chest, if any have fallen into
it ; but if the bleeding from within should continue, so as
to place the life of the sufferer in danger, the external
wound should be closed, and events awaited.
7. When it is doubtful whether the bleeding proceeds
from the cavity of the chest, or from the intercostal artery,
(a surgical bugbear,) an incision through the skin and the
external intercostal muscle will expose the artery close to
the edge of the rib having the internal intercostal muscle
behind it. The vessel thus exposed may be tied, or the
end pinched by the forceps, until it ceases to bleed. Tying
a string round the ribs is a destructive piece of cruelty,
and the pings, &c.*, formerly recommended, may be consid-
ered us surgical incongruities.
8. A gun-shot wound in the chest cannot close by adhe-
sion, and must remain open. The position of the sufferer
should therefor e be that which is most comfortable to him.
A small hole penetrating the cavity is more dangerous than
a large one, and the wound is loss dangerous if the ball
Lcoes through the body. The wounds should be examined,
and enlarged if necessary, in order to remove all extrane-
ous substances, even if they should be seen to stick on the
surface of the lungs ; the opening should be covered with
soft oiled or wet lint a bandage when agreeable. The
ear of the surgeon and the stethoscope are invaluable aids,
and ought always to be in use : indeed, no injury of the
chest can be scientifically treated without them.
9. Incised and gun-shot wounds of the abdomen are to
be treated in nearly a similar manner ; the position in both
being that which is most agreeable in the patient, the parts
being relaxed.
10. In wounds of the bladder, an elastic catheter is gen-
erally necessary. If it cannot be passed an opening should
be made in the perimeum for the evacuation of the urine,
with as little delay as possible.
11. In gun-shot fractures of the skull, the lower broken
pieces of bone, aud all extraneous substances are to be re-
moved as soon as possible, and depressed fractures of bone
are to be raised. A deep cut made by a heavy sword
through the bone into the brain generally causes a consid-
erable depression of the inner table of the bone, whilst the
outer may appear to be merely divided.
12. An arm is rarely to be amputated, except from the
effects of the cannon-shot. The head of the bone is to be
aawn off, if necessary. The elbow-joint is to be cut out, if
destroyed, and the sufferer, in either case, may have a very ,
useful arm.
1:5. ]n a case of gun-shot fractuie of the upper arm, in
h the bone is much splintered, incisions are to be made
for the removal of all the broken pieces which it is feasible
to take away. The elbow is to be supported. The forearm
is t> be Treated in a similar manner ; the splints used should
lid.
14. The hand is never to be amputated, unless nil, or
y all its part- are destroyed. Different bones of it and
of the wrist are to be removed when irrecoverably injured,
with or without the metacarpal bones and lingers or the
thumb ; but a thumb and one linger should always be pre-
served when possible.
16. The head of the thigh bone should lie sawn off when
broken by a musket ball. Amputation at the hip joint
<S')S Dlr,eeii<ms to Axmy. Sua'geo^. [November,
sliould only be done when the fracture extends some dis-
tance into the shaft, or the limb is destroyed by cannon-
shot.
16. The knee-joint should be cut out when irrecoverably
injured ; but the limb' is not to be amputated until it can-
not be avoided.
17. A gun-shot fracture of the middle of the thigh, at-
tended by great splintering, is a case for amputation. In
less difficult cases, the splinters should be removed by inci-
sions, particularly when they can be made on the upper
and outer side of the thigh. The limb should be placed on
a straight, firm splint. A broken thigh does not admit of
much, and sometimes of no extension, without an unadvi-
sable increase of suffering. An inch or two of shortening
in the thigh does not so materially interfere with progres-
sion as to make the sufferer regret having escaped amputa-
tion.
18. A leg injured below the knee should rarely be ampu-
tated in the first instance, unless from the effects of a cannon-
shot. The splinters of bone are all to be immediately re-
moved, by saw or forceps, after due incisions. The limb
should be placed in iron splints, and hung on a permanent
frame, as affording the greatest comfort, and probable
chance of ultimate success.
19. An ankle-joint is to be cut out, unless the tendons
around are too much injured, and so are the tarsal and
metatarsal bones and toes. Incisions have hitherto been
too little employed in the early treatment of these injuries
of the foot for the removal of extraneous substances.
20. A wound of the principal artery of the thigh, in ad-
dition to a gun-shot fracture, renders immediate amputation
necessary. In no oilier yart of the body is amputation to be
done in the first instance for such injury. Ligatures are to
be placed on the wounded artery, one above, the other be-
low the wound, and events awaited.
21. The occurrence of mortification in any of these cases
will be known by the change of color in the skin. It will
rarely occur in the upper extremity, but will frequently do
so in the lower. When about to take place, the color of the
skin of the foot changes, from the natural fiesh color to a
tallowy or mottled white. Amputation should be perform-
ed immediately above the fractured part. The mortifica-
tion is yet local.
I.] i Army Surgeons.
2. When this discoloration has not been observed, and
the part shrinks, or gangrene has sot in with more marked
appearances, bnt yet seems to have stepped at the ankle,
delay is, perhaps, admissible, but if it should again spread,
or its cessation be doubtful, amputation should take place
forthwith, although under less favorable circumstances.
The mortification is becoming, or has become constitu-
tional.
23. Bleeding, to the loss of life, is not a common occur-
ence in gun-shot wounds, although many do bleed consid-
erably, seldom, however, requiring the application of a
tourniquet as a matter of necessity, although frequently as
one of precaution.
24. When the great artery of the thigh is wounded (not
torn across) the bone being tmmjured\ the sufferer will pro-
bably bleed to death, unless aid be afforded, by making
compression above, and on the bleeding part. A long, but
not broad stone, tied sharply on with a handkerchief, will
often suffice until assistance can be obtained, when both
ends of the divided or wounded artery are to be secured by
ligatures.
5. The upper end of the great artery of the thigh bleeds
scarlet blood, the lower end dark venous-colored blood ;
and this is not departed from in a case of accidental injury,
unless there have been previous disease in the limb. A
knowleege of this fact or circumstance, which continues for
several days will prevent a mistake at the moment of in-
jury, and at a subsequent period, if secondary hemorrhage
should occur. In the upper extremity both ends of the
principal artery bleed scarlet blood, from the free collateral
Nation, and from the anastomoses in the hand.
. From this cause, mortification rarely takes place after
und of the principal artery of the arm, or even of the
arm-pit. It frequently follows a wound of the principal ar-
tery in the upper, middle, or even lower parts of the thigh,
rendering amputation necessary.
27. It is a great question, when the bone i- red.
where, and at What part, the amputation should be perform-
ed. Mortification of the foot and leg, from such a wound,
is disposed to stop a little below the if it should not
rer ; and the operation, if done in the first
instance, as soon as the tallowy or mottled appearance of
the root rv( d. shoal be done at that part; the
wound of the artery, ai oration f>r securing the ve>-
860 .Directions to Army Surgeons. [November,
sel above and below the wound, being left unheeded. By
this proceeding, when successful, the" knee-joint is saved,
whilst an amputation above the middle of the thigh, is al-
ways very doubtful in its result.
28. When mortification has taken place from any cause,
and has been arrested below the knee, and the dead parts
show some signs of separation, it is usual to amputate above
the knee. By not doing it, but by gradually removing the
dead parts, under the use of disinfecting medicaments and
fresh air, a good stump may be ultimately made, the knee-
joint and life being preserved, which latter i3 frequently
lost after amputation under such circumstances.
29. Hospital gangrene, when it unfortunately occurs,
should be considered to be contagious and infectious, and is
to be treated locally by destructive remedies, such as nitric
acid, and the bivouacking or encamping of the remainder
of the wounded, if it can be effected, or their removal to the
open air.
30. Poultices have been very often applied in gunshot
wounds, from laziness, or to cover neglect, and should be
used as seldom as possible.
31. Chloroform may be administered in all cases of am-
putation of the upper extremity and below thekuoe, and in
all minor operations ; which cases may also be deferred,
without disadvantage, until the more serious operations are
performed.
32. Amputation of the upper and middle parts of the
thigh are to be done as soon as possible after the receipt of
the injury. The administration of chloroform in them,
when there is much prostration, is doubtful, and must be
attended to, and observed with great care. The question
whether it should or should not be administered in such
cases being undecided.
33. If the young surgeon should not feel quite equal to
the ready performance of the various operations recom-
mended, many of them requiring great anatomical know-
ledge and manual dexterity (and it is not to be expected
l hat he should) he should avail himself of every opportunity
which may offer of perfecting his knowledge.
The surgery of the British army should be at the height
of the surgery of the metropolis ; and the medical officers
of that service should recollect, that the elevation at which
it has arrived has been on many points principally due to
the labors of their predecessors, during the war in the Pe-
1861.] Modem Ltihof)*>/. 861
ninsula. It is expected, then, that they will not only cor-
rect any errors into which their predecessors may have
fallen, but excel them l>y the additions their opportunities
will permit them to make in the improvement of the great
art and science of Burgerv. Lancet
Modern Ltfholrity. Dr. dviale's Clinical Experience. To
the Editor of the Lancet.
Sir I have j as t received a letter from my friend and
former instructor. Dr. Civiale, of Paris, in which he re-
quests me to translate and send to you for publication the
result of his practice in operating for stone in the bladder
during the past year (1860.) Dr. Civiale's reputation as the
inventor and perfector of modern lithotrity is so well known
that I lose no time in sending you this interesting docu-
ment.
It may he in the memory of some of your readers that at
the Medical Society of London, and in the Lancet, of Jan.
21st, 1760, I called attention to the following proposition,
as one which appeared to me to he of the very highest im-
portance : That stone in the bladder may, by the exercise
of lair intelligence and skill, be deprived of nearly all its
severity and danger to life ; since it may, in the great ma-
jority of cases, be detected in its early stage when of small
size, and because its destruction in that stage may be ac-
complished with safety and certainty by lithotrity.
I cannot forbear appealing to the following letter as a
remarkable illustration of that great and pregnant truth.
The facts of this letter suggest several objects for critical
remark to the English surgeon, which I shall not touch
upon here. Taken altogether, I think that English experi
ence amongst those who practice lithotrity, will not much
suffer by comparison with the excellent results of the great,
master's work.
The following is a literal translation of the article which
Dr. Civiale has just published in the Gazette des Sciences,
tc, and which he has sent me for the purpose named,
i am. air, your obedient servant,
Hum Thompson, k. R, C, B.
862 Modern Lithotrity. [November,
RECORD OF CIVIALE'S CLINICAL EXPERIENCE IN THE TREATMENT
OF STONE DURING THE YEAR 1860.
I treated, In I860, 54 patients affected with stone in the
bladder; 39 in my private practice, and 18 in the hospital.
A. Private Patients. Twenty-six of these patients had
stone for the first time; 10 had been already operated on
by other surgeons or by myself ; the stone having reappear-
ed, fresh operations were necessary.
I operated on 26 of these patients by lithotrity ; 24 arc
cured ; in 2 others I was obliged to relinquish the opera-
tion, which appeared to aggravate the morbid condition of
the bladder. One of these patients has died ; the other still
lives, and the stone remains in the bladder.
All those calculous patients who were most favorably
circumstanced, whose organs were still sound and in good
health, and who had no other disease than a small stone,
obtained a rapid and easy cure. For this class of patients
the application of lithotrity appears to me to have reached
great perfection ; in fact, the stone is destroyed in a few
minutes, and its debris are expelled with the urine ; all suf-
fering ceases, and the health is re-established and main-
tained. Surely this is all one can desire in the treatment
of calculus.
But lithotrity gives such good results only when its appli-
cation is restricted to favorable cases, in which the stone
has not had time to grow large, and to produce in the
bladder^lesions capable of altering the form and natural
conditions of that organ. I hasten to add, however, that
the proportion of favorable cases augments every day, and
that they will become more and more numerous in propor-
tion as calculous patients, informed as to their condition by
their medical attendants submit themselves to operation at
the outset of the malady.
Ten of those treated had not displayed this prudence;
they only sought the aid of art when their existence had
become insupportable on account of incessant pain.
In two of them the diseased condition of the urinary or-
gans offered an obstacle to the application of lithotrity, and
as lithotomy w?is equally contra-indicated, death occurred
from the progress of the complaint.
Four having large stones were operated on by lithotomy ;
one adult obtained a rapid and complete cure, the wound
having cicatrized by the tenth day: in another adult the
1861.] Modern Lithotntj/. 863
convalescence was tedious, and the cure incomplete. Two
old men died in the second week after the operation.
Two patients are still under treatment; one will be ope-
rated on by lithotrity, the other by lithotomy.
In two others, who became ill at Paris when the winter
set in and returned home, the treatment has been postponed
until the spring.
I). Hospital Patients. Amongst the 18 calculous patients
admitted under my care, there were 3 women and 15 men,
all adults, some old people.
The first of these women, who had suffered during a long-
period of time, was so bad that any operation was contra-
indicated ; and the patient returned to her family.
The second was in favorable condition as regards her
general health, but the calculus was engaged in the urethra,
where it was maintained by violent contraction of the blad-
der. A division of the canal sufficed to accomplish the
extraction. This proceeding appeared to me, in these cir-
cumstances, to be preferable to that of crushing, which
would have been very tedious and painful. The patient
was rapidly cured.
The third woman, an account of whom I have published,
presented one of those extraordinary cases which one meets
with at distant intervals. The stone, a phosphatic one, was
formed upon a mass of teeth, of little bones, and of hair,
arising from a hair-cyst, which had opened into the bladder.
All these bodies and the stone itself were successfully ex-
tracted by lithotrity.
Four of the male patients were not in the condition
which the application of lithotrity demands. Two were
cut; one was cured, but the other has still a fistula. The
third refused to submit to the knife, which indeed offered
small chance of success: he died of renal disease. The
fonrthjis under treatment.
Another male patient was the subject, at the same time,
of a stone of middle size and of strangulated hernia, requir-
ing immediate operation, from which he died.
The 10 remaining patients submitted to lithotrity were
freed from the stone, but the cure in all wai hot complete.
Amongst them, "2 retained some pain and disturbance in
the functions of the bladder, arising from organic lesions
of that vi ml against whicfe lithotrity avails no more
than lith.otomv.
864 On Sub- Involution of the [November,
The recent cases observed at the Hospital decker present
a fact worthy of notice.
Calculous patients form two great classes. In one,
which embraces two-thirds of the cases, the organs retain
their natural condition. Indeed it is only occasionally, and
especially after bodily exercise, that the stone provokes
some functional disorders, which cease by repose. Here
the stone forming of itself the whole malady, it suffices to
destroy or extract it by surgical operation for the patient to
obtain a complete and speedy cure.
In the other class, the phosphate of lime, or the am-
moniaco-magnesian phosphatic calculi form and are devel-
oped, under the influence of a morbid condition of the uri-
nary apparatus. It is not uncommon for this state t'o
persist after operation, to deprive the patient of the complete
benefit of treatment, and even to favor the development of
a, new stone. These cases predominate in the foregoing
account.
To resume. Of 54 calculous patients, of which I have
just presented a table, 3T have been treated by lithotrity.
In 2 cases I was obliged to relinquish the treatment ; 1
died; another retains his stone; 2 of them have not ob-
tained a complete cure, because the stone has not formed
the sole malady, but they are greatly relieved. The rest
are cured.
7 were submitted to lithotomy, which saved 4 of of them ;
but in 2 of these the cure is incomplete.
10 have not been submitted to any operation ; 3 have
died from the progress of the malady, and 1 aftei; the ope-
ration for hernia ; 1 continues to live with his stone. 3 are
under treatment, and will be submitted, 1 to lithotrity and
2 to lithotomy. In 2 cases the operations are postponed.
These facts prove anew the danger of long retaining the
stone, and the utility of lithotrity when we apply it at an
earlier period of the complaint. Lancet.
Lecture on Sub- Involution of the Uterus after Delivery. By J.
Y. Simpson, M.D. F.R.S.E., Professor of Medicine and
Midwifery in the University of Edinburg.
Gentlemen: I have seen this morning a case of a pecu-
liar form of uterine hypertrophy, to which I beg you will
18G1.J Uterus ttftar Delivery.
allow me to take this opportunity of directing your atten-
tion. The pationt in this instance ia a lady from America,
who has Suffered from disordered menstruation, and a fcel-
irig of weight and great discomfort in the pelvis, aitfrce'tne
birth of her last child. She has, in short, most of the na-
tional symptoms oi' a fibroid tumour of the uterus, hut on
making a physical examination, I found there was no brnil
over the uterus, while that organ was equally enlarged t<>
about the size oi' a uterus in the third month of pregnancy
and readily admitted a sound t the extent of three and a
half or four inches into its interior. Now, although T am
not aware that any of the older authors have pointed out
particular1;,- this peculiar form of uterino enlargement, yet
i am sure it is not at all uncommon. There arc at present
in our ward in the Hospital two patients who are the suh
jeets of this disease, and in both of whom the hypertrophy
of the uterus is complicated, as it not unfrc<pient!y i< with
retroversion of the organ. Let me read to you the history
of these two cases as they have been briefly drawn no by
the Clinical Clerk, Mr. Gooding:
Case 1. Margaret R., aged 22, married, was admit ted on
October 19, "I860. Five months after the patient's marri-
age, which took place in March, 185(3, she had a miscar-
e ; the child lived three hours. Six months and a half
he was again prematurely delivered of a child.
which -survived its birth only a quarter of an hour; both of
nificarriag attributes to over exertion. SJic
in became pregnant and experienced, at about the same
time the previous miscarriages had occurred, symptom-
threatening the loss" of the foettm. She was attended by a
Medical man, who enforced resr. After remaining in bed
three weeks, these symptom- patted olf : and in M;
she was delivered at the full time, after an easy labor, of a
male child, which, however, only lived sixteen days. Tic-
lochia c days, but was followed by a yellow
discharge, from the continuance of which, and the existence
; disagreeable sensations' in the epigastrium, and gei i
debility, she applied to \)\\ A. R. EhlhpBOB, under whose
trcatim ,do*\ her health, and continued in good
:th till March, and in April last she was again seen by
Dr. Simpson, who found her pregnant, with ulceration of
the os and retroversion of the atoms. Two months afn r
another feel boul the sixth and a half month
tation. In rwoweek menstruated. 1-
95
866 Oil Sub- Involution of the [Xovember,
quenee of her feeble state of health, -she went into the
country; during her stay she menstruated profusely for nine
days. Only once since this, about ten weeks ago, she men-
struated one day.
State on Adntission. The patient was very weak and ner-
vous. She complains of occasional pains about the chest,
and lias a slight eough. She also complains of weight and
uneasiness in the pelvis, with a feeling of bearing down at
k' the bacl-: x)assage." There is frequent desire to go to
stool, and a feeling of something being left after rising.
At times there is a yellow discharge from the rectum. Mic-
turition is more often performed than usual. The uterus
is much enlarged and retroverted, pressing on the rectum,
and lying low in the pelvis. The os is directed anteriorly,
and the uterine sound enters easily for more than three
inches.
I need not trouble you with any further detailed account
of her treatment, and of her progress during her residence
in the Hospital, but I shall content myself with merely sta-
ling that the condition of the womb has undergone a mark-
ed change for the better, for it has become reduced to the
normal size, and although still retroverted to some extent,
\vt it has become so far righted in its position, that the pa-
th nt experiences no discomfort so long as she wears a vag-
inal pessary of the peculiar form that I shall afterwards
have occasion to describe to you.
( 'a 2. Agnes R., aged 17, married, was admitted on
,\ ovember -0, into the Royal Infirmary. The patient states
ihar. since her marriage, which tookplacc six years ago, she
has had two children and one abortion, which occurred
eighteen months ago, at the second month of gestation.
She has not been pregnant since that time. She had en-
joyed good health previous to the occurrence of the abor-
tiun, on the iifih day alter which she had rigors, and in a
day or two pain in the hypogastric region, and in the back
and loins. On the eighth day when she arose from bed,
Mie found she could not walk without great difficulty, and
when scaled could rise only with great suffering. In a short
time the severity of these symptoms abated, but ever since
: (ho lias experienced similar pains in a less degree. The
menstrual function is regularly performed. In the inter-
between menstruation there is a slight leueorrhu-a.
She has for a long time been obliged topaas her water much
more frequently wan before There is a slight amount of
1801.] tUerUM cjirr Bdfoery. s'f.r
pain when at stool, otherwise the bowels ore unaffected.
The uterus is retrdverted and Considerably enlarged, the
uterine sound passing only with the point directed back-
wards towards the promontory qf th l sacrum, and entering
at once to an extent of nearly three inches.
Both of these patients, then, are suffering from enlarge
hieut of the womb, consequent on an arrest of the r-
grade metamorphosis that normally occurs ihthatoVgftn
after parturition. I have, I repeat, seen many cases where
this form of uterine hypertrophy existed to a greater or less
extent, and 1 assure you you will find the subject of sum"-
cient scientific interest and sufficient practical importance
to demand for it your most careful study and attention.
Let me tell you briefly what is
The Pathological Nature of the Disease;
After parturition, as you are aware, the greatly enlarged
uterus begins regularly to involve or absorb, and rapidly
diminishes in size, till it has been reduced almost to its
pristine dimensions. I have had occasion in another de-
partment of our course to call your attention to the won-
derful changes that go on in the uterus in consequence of
impregnation, and to tell you how, from being a small body
two or three inches long, it comes in the short space of nine
months, to attain the length of a foot or more, while it is
correspondingly enlarged in all its other dimensions am!
diameters. And I may here repeat the conviction that \
then expressed, that if ever the laws of nutrition are to be
clearly made out, the inquiry will probably be most sue '
fully pursued by investigating these laws as they are seen
in operation on a large and gigantic scale in this very* Or-
gan ; for in no other organ, 30 far as 1. remember, do \w
see nutrition and growth going on so rapidly as hi
where out of a mere mass of nucleated fibres and cells an
, moils body of numerous and well marked mn.-cular
fibres become developed within the course of the nine
month- of pregnancy. Hardly less wonderful than ihi
it development of the uterine walls during the procj-t -
tion, is the still more sudden diminution that occurs
in these walb after parturition has been completed. The
muscular fibres perhaps weakened and exhausted ,
suit of their violent action during the parturient proa
and ) rendered prone ^degenerate and deprived also to
BOmi . of tic -lip] !\ of bl00(1 b|.;i|!--(it to them o
So'S (hi Sub-Involution of the [November,
profusely (hiring the time that the uterine circulation was
so lunch exaggerated, now undergo, after parturition, a
fatty metamorphosis, in consequence of which they almost
all melt down and disappear ; so that in the brief space of
five or six weeks the whole organ dwindles down and dim-
inishes to nearly its original dimensions. The muscular
walls of the uterus arc not absorbed as muscle, but like'
many other effete structures, they^ first undergo fatty dege-
neration and arc absorbed as fat. This fatty degeneration
commences on the inner layers of the walls, and passes
from them to the outer layers. The fatty metamorphosis
of the uterine muscular fibres appears under the microscope
a lew days after delivery, as a series of glistening particles
deposited in the course of each individual fibre. Now the
patients with whose cases I introduced my present observa-
tions, are suffering from this curious condition of the ute
rus, that after the birth of their last children, this retro-
grade metamorphosis of the uterus ha3 not taken place
during the puerperal month, or rather, let me say, has taken
place only to such an imperfect degree that the uterus is of
the size we usually see it have at the end of the first week
or so after delivery. They arc suffering, then, from a hy
pertrophy of the uterus which is pathological in its perma-
nency, but which results from a hypertrophy purely physi-
ological in its origin.
Its ./Etiology.
What, you will be ready to ask, is the cause of this en
largcment of the uterus remaiuing permanently ? How is
it that the retrograde changes in the uterus become arrested
and the absorption or involution of its walls is prevented?
To these, questions it would be difficult, or indeed impossi
ble, with our present limited knowledge of the processes oi
development and degeneration that go on in the uterus, tc
furnish a satisfactory reply, but let me point out to you
some causes which occasionally appear to lead to the pro-
duction of this hypertrophy from arrested involution of the
uterus.
1. Rising too soon after Confinement We know that bott
in the healthy and in the morbid state the uterus is apt tc
Keeonv more eongested when the patient assumes the ercci
po./ition, aiid that a morbid degree of congestion interfere*
with the various physiological functions. And we can easily
imagine that it a delicate woman gets up toosoon after hei
1861.] Uterus after t>e!w$r, 8l?9
delivery, and remains lor a lengthens! period < reet, while
the womb is still more than usually targe, the circulation in
its walls might yet get so impeded, and such an amount of
congestion bo produced as would prevent the normal
changes in its walls, and impede the free absorption of its
disintegrated particles.
2. Repeated Miscarriages. However it may he, we. know,
further, that in a number of eases an enlarged condition of
the uterus of the same nature as that of which I am speak-
ing, results from the frequent and rapid recurrence of a sc-
ries oi% miscarriages, or abortions in the same patient. You
are aware that a woman who has once aborted is extremely
liable again to abort at the same period whenever she again
becomes pregnant. In such cases it is, moreover, remarka-
ble that the patient often conceives again in a very short
time after the occurrence of the abortion ; and when this
process has been several times repeated the uterus under-
going the enlargement of a new pregnancy, before it has
had lime, as it were, to recover perfectly from the hyper-
trophy of a proccding one, the case sometimes ends in a
complete disturbance of the normal physiological process of
degeneration and diminution in the uterine walls, ami the
womb is left in a permanently hypertrophied conditio! i.
3. Metritis* Again, if you inquire minutely into the his-
tory of patients affected with this form of disease, and ask
them particularly as to whether anything has gone wrong
with them in their puerperal state*, you will very frequently
iind, as in the case of the second of our Hospital patients,
that within a short time after their confinement they have
been the subject of an attack of inflammation in the uterus
or ovaries, or neighborhood pelvic organs. They will, per-
haps, tell you that a week or two after their child was horn
had a shivering, followed by pain in the region of the
womb and more or less fever, which compelled them to
iain in bed for some time. It would appear as if the
irrencc of metritis, or perimetritis, in the puerperal
male, exerted such an influence on the substance oftlic
uterus as to prevent the occurrence of those changes Hi.!'
normally to its diminution in size.
lis Sk:ieiolo.y.
The patient whom I liave imagined you to b< tioti-
ing as to the history other malady, will probably tell ynu.
. II
#J|Q On Sub-fa coin Hon of the [November
further, that after --lie had recovered so far from her inllam-
Tiiatorv attack, and from the consequences of the bleeding
and glistering to which she laid been subjected for its cure,
as to be able to walk about again, she began to be conscious
of a reeling of discomfort in the lower part of the abdomen,
to which she had never before been accustomed. There in
frequently a sense of weight or bearing down of the ute-
rus, of distress in the lower bowel, and of uneasiness in
connexion with the action of the bladder, and a weakness,
.sometimes amounting to actual pain, in the. lower part of
the back, and, in some cases, a numbness of the lower
limbs, winch are all new to the patient. She attributes,
most likely, these feelings to weakness, and expects that as
she gains more strength, the uneasy scusation will disap-
pear. But some months may elapse, and she begins to be
disappointed at her never getting entirely relieved of this
local trouble ; and after lactation is accomplished, if, indeed,
she have been able to nurse her child at all, she finds that
her menses do not return regularly, or become too profuse
and painful. Leucorrhea, too, is sometimes present to a
greater or less extent; and altogether the patient is in a
late of confirmed and anomalous bad health, that is diffi-
cult of endurance.' By means, perchance, of tonics and
sedatives she strives to regain her health and alleviate her
uneasiness and continues for a time to hope that her former
strength will still return, and that her ailments will disap-
pear. Gradually, however, the conviction becomes forced
upon her that something besides time will be needful for
her cure, and that some kind of medical treatment is re-
quired for her relief. Accordingly she comes to you, and
when you have heard a history such as that I have endea-
vored to narrate, you come to the conclusion that she is
laboring under some disease of the uterus. But what the
precise nature of the disease is you will not be able to fix
and determine by studying the mere history of the symp-
toxfis- To make out a correct differential diagnosis, you
must institute an examination of the uterus.
Its J'hysical Diagnosis.
On placing the hand over the abdomen, you can usually
: the enlarged uterus rising in the form of a tumour out
of the pelvic cavity, and. lying above the pub era, more espe-
cially in those casts w\;;ere the hypertrophy is very consid-
il.] Uterus after Qdivery. 871
erable. In all casca you ci0 discover, on making an exam>
nation per vaginam, that the vaginal portion of the cervix
uteri is enlarged foi\thisis a form of hypertrophy in which
every part of the organ is implicated; and you tiud the
whole uterus to be unusually large and heavy. This kind
of loeal examination is, in the majority of cases, most satis-
factorily carried out when the patient is laid on her back ;
sometimes it is more convenient to have her placed some-
what laterally. But in every instance ol ihis kind you
must hear in mind the importance ot* making an examina-
tion with both hands simultaneously the forefinger of one
hand being employed to explore the uterus through the
vagina, while the lingers of the other are applied to the
fundus through the medium of the anterior abdominal wall.
There is, perhaps, no variety of uterine disease in the diag-
nosis of which this sort ot examination can be employed to
more purpose than in the case of simple enlargement of the
organ. In a few patients the abdominal walls are too thick
to admit of your feeling anything very distinctly on palpa-
: and there are others, still fewer in number, in whom
a certain degree of uneasiness renders the necessary pres-
sure painful to the patient. When you have thus got the
uterus between the two hands, you can easily recognise the
existence of the hypertrophy, and even determine the de-
cree to which it has taken place. You can i'eel thai, the
-welling is not due to the presence ot fibroid masses in the
walls of the uterus, for there is no irregularity and no pecu-
liarity in its shape. It has unmistakably the shape and
contour of the healthy organ ; it is only that organ in ;>
8 of equable hypertrophy. Such a condition oi matters
might still, however, possibly be due to the presence of a
Jibroid tumour growing from the submticuous layers of the
uterine wall, and projecting into its interior; and to make
sure that there is no such tumour present, you must have
recourse to another simple means oi' exploration, viz..
the introduction of a uterine sound.
The cavity of the healthy uterus measures usually,
you know, about two and a half inches in length : and
when 'the sound is introduced, you find its point i- afreste I
at the fundus, when the knob placed on the convex >idc oi
the instrument, at two and a half inches from the etftfrGmity,
haa reached the level of the external orifice oi' the uru'u. .
Where the organ is enlarged, however, the knob 1 speak of
slips past the guiding finger, and tile instrument runs up
822 On Xiih-h)\:oli%iM oj 'the [November
intn the interior to a depth of throe or more indies ; and
when the enlargement of the uterus is of the kind I have
j* <ii describing as dependent on defective involution of the
organ after delivery or miscarriage, the instrument usually
slips iii at once without the slightest difficulty, for the ute-
rine orilicc and canal is pretcmaturally patent. When, on
the other hand, the enlargement is due to the presence of .
a tumor in the cavity of the uterus, the point of the explor-
ing instrument usually meets an obstruction immediately
oil traversing the canal of the cervix, and it may require, in
sfceh a case, the exercise of some skill and a little gentle
manipulation in order to pass it into the interior of the
uterus at all. Besides, after the sound has been fully intro-
duced, you can often feel with it the projecting body ; while
in the case oi* the hypertrophied organ the sound passes
freely and nnobstructedly round in all directions. If, with
the sound thus introduced into its interior, you raise the
uterus towards the hand placed over the abdomen, you will
be able to make out more distinctly and definitely than
ever the real nature of the case. There is one difficulty is
connexion with the rise of the sound in such cases, of which
I ought, perhaps, to warn you, and it is this : The great
weight of the fundus of the" uterus, sometimes aided by in-
ijanimatory adhesions, gives a strong tendency to various
displacements of the organ, and more particularly to retro-
flexion of it. Such a complication you must, accordingly,
be prepared to expect ; and in passing the sound, you must
then remember to turn it with the point and concavity
looking backwards towards the sacral promontory. It was
not long after I had begun to make use of the sound in the
diagnosis of uterine diseases and disorders, that I iirst fell
in with and recognised a case of sub-involution of the
uterus. The patient, whom I saw in consultation along
with the late Dr. Abercrombic, was the wife of a Medical
gentleman, and there was much perplexity as to the nature
of hey disease. There was a large, rounded tumour laying i
over ii^to the right illiac region, which was thought to be j
^>.-ibly either an inflamed ovarian tumour, or an abscess, r
as there was Considerable pain on pressure. On passing a j.
;,;nnd, however, it was found to run right ftp at once about |
four inehes into the very ventre and" top of the tumour. (
'Ihe supposed tumour '#aa thus shown to be neither more
uor less than the uteres considerably enlarged and turned
what to one side,., ga sometimes happens in such cases.
1.) / y ,, Delivery. ?73
That \v;is the first occasiou, so far as T know, in which this
kind of uterine hypertrophy was clearly made out; bul
since then, T have seen it very frequently, usually as a
result of inflammation after delivery, but sometimes associ-
ated with repeated miscarriages in the relation both of
cause and effect
Its Duration and I)e<;eee.
In some cases you will detect the form of uterine hyper-
trophy which I am describing, within two or three weeks,
Of two of three months after delivery. These may be call-
ed the acute, or sub-acute, types of the disease. But oftencr
perhaps iu practice, you will not be applied to till the dis-
ease is chronic till many months, or even years, have
elapsed since the date of the last delivery, or of the last
abortion, which left the uterus in the sub-involved or unre-
duced condition which we arc considering. The degree or
amount of remaining enlargement varies iniinitcly in differ-
ent cases ; and is, perhaps, mainly regulated by the date of
the confinement at which the arrest of the involution takes
place, and the completeness or not of that arrestment. I
have seen instances where the uterus was large enough to
be felt some inches above the pubis, and where the uterine
sound passed into the uterine cavity to the extent of four or
rive inches. In other examples you will find the uterus in
form and length remaining hypertrophied only to a slight
extent, and the sound passing perhaps not more than two
and three-fourths of an inch or three inches. Between
these two extremes, you will meet in practice with all in-
termediate degrees of this permanence of the puerperal hy-
pertrophy of the uterus.
Treatment of the Disease.
In the more acute forms of the disease, I have almost in
variably found that by the immediate employment of local
antiphlogistic:-- the symptoms were speedily and successfully
alleviated, and the process of absorption was set up. Where
any traces of inflammation .till remain, the importance of
this indication is at once apparent, and its fulfilment is in
attended with rapid relief. J hit even in c
where all inflammatory act; i have died out, and
dts remain, we i ften find I cannot well tell
you how that a local antiphlogistic course of treatment
874 On Sub-Involution <rf 'th [November,
has the effect of setting up absorption in ilie enlarged
orgap, and leading ultimately to its restoration to its normal
state. In following out this line of treatment, then, you
will do well if the patient is not very weak and debilita-
ted to begin with the application of eight or a dozen
leeches to the vaginal portion of the uterus, or simply to the
perinrcum, or circle of the anus. I need hardly repeat, that
the abstraction of a small quantity of blood in this way will
be more particularly called for, and more especially benefi-
cial in those cases where there lingers any degree of conges-
tion or of inflammatory action in the uterus. But even in
such acute or subacute cases, and in all the more chronic
forms, your chief reliance must be placed on the use of
counter-irritants applied externally to the surface of the ab-
domen or sacrum. You may use antimonial or croton
ointments, or paint the hypogastric surface twice a day with
strong tincture of iodine till the skin becomes tender ; but
the vesicant which I have found to be most efficacious in
exciting the function of absorption in the womb that is now
in abeyance, is the ordinary cantharides-blister .especially
in the chronic forms of the disease, and when the bladder
is not liable to be irritated. You may order a series of
small blistering-plasters to be applied for a time over the
lower part of the abdomen, or you may paint a succession
of small spots one every second or third day, with blister-
ing liquid until the uterus begins distinctly to diminish in
size. I think you will find the latter mode of applying the
vesicant to be the simplest and the most certain. The plan
I usually follow is to apply the fluid to a patch of about the
size of a crown, and then gradually to surround this patch
with a number of others of like diameter, one being
added every third or fourth day, until the original central
point has been surrounded by a ring of live or six distinct
blistered spots. At the same time that you are thus trying
to excite absorption by the application of counter-irritants
to the cutaneous surface, you must endeavour to promote
this object by keeping the vaginal portion of the cervix
uteri immersed constantly in ointments of mercury or
iodide of lead, or bromide of potassium, or other remedies
likely to have the effect of stimulating the absorptive pro-
cess. This you can do by introducing, or making, the pa-
tient herself introduce, into the vagina one or two pessaries
medicated with these substances every night and morning.
But you will find that these local measures arc not
L] r ' .}/.
always, or ii . sufficient to effect a cure, Von
will be obliged t have recourse also to, the internal admin
istration of some of the class of dcobstrucnt remedies ; and,
of these, the most efficacious are the iodide and bromide of
potassium. I used, at onetime, to rely chiefly on the ad-
ministration of the iodide of potassium. But of late 1 ]..
employed thct>rom"ule much more extensively, for it has
this advantage over t\ie former salt, that its use may he
kept up for almost any length of time by a patient without
her becoming subject to the kind of marasmus which we
sometimes rind attendant on the prolonged use of the
iodide. The bromide. of potassium may not only he given
with safety for a lengthened period, but it may be adminis-
tered with confidence as a good tonic, as well as perhaps
the best deobstruent in the Pharmacopoeia. It may be
depended upon as an active stimulant to absorption, besides
possessing the property, beyond all other remedies that I
know of, of acting as a special sedative on the reproductive
organs. In cases of this kind you must administer it in
larger doses than usual, making the patient take six, eight
or ten grains of it three times a day. Sometimes patients
suffering from this form of uterine hypertrophy present
themselves to you in a debilitated and ancernic condition.
Under such circumstances, you need not hesitate to add
iron, manganese or some form of metallic tonic, alone or in
combination, to the more specific remedies, and endeavour,
always in the more chronic cases of the disease, by means
of good diet and other hygienic means, to raise the pa-
tient's general standard of health.
You will occasionally meet with cases of this disease
inate, that the process of absorption does not begin, or
docs not go on to any satisfactory degree, even after you
have had recourse to repeated leechings, and have kept the
uterus imbedded for a length of time in discutient oint-
ments, and have duly administered all kinds of dcobstruents
and tonics. In such cases you may follow up the course of
treatment which I have sketched for a very lengthened
period without producing any appreciable change in the
size of the womb, or any marked alleviation of the patient's
symptoms. If, however, by any means you can induce the
uterus for a time so to take on an action of increased
growth, you may confidently hope that this temporary
hypertrophy will be followed by a process, of absorption
which will go on perhaps uninterruptedly, until the organ
876 Oa Diseases within the Ear. [December
is reduced to its normal dimensions. Such a transient in-
crease in the size of the uterus you may at any time pro-
duce by taking advantage of the physiological tendency of
this organ to enlarge and become developed around any
foreign body that happens to be lodged within it. You
know that the uterus begins to enlarge when*stimulated by
the presence of an ovum, or of a morbid tumour, or of a
clot of blood in its interior; and in like manner it becomes
developed in size when a foreign body, such as a sponge-
tent or an intra-uterinc bougie, is introduced artificially.
By introducing, then, a succession of very small sponge-
tents into the interior of the womb, or by making the pa-
tient wear for a time an intra-uterine pessary, you can cause
the uterus to take on this hypertrophic action ; and by
afterwards actively and fully taking advantage of the ten-
dency of the organ to undergo a process of degeneration
and diminution on the removal of the stimulus, you may
succeed, by the due employment of the various discutients
and deobstruents I have already mentioned as rest, coun-
ter-irritation, and bromine in promoting the process oi'
absorption to such a degree that the uterus at last be-
comes reduced to the natural standard. In some obstinate
instances I have been obliged to repeat from time to time
this process of artificial irritation and dilatation before a
perfect cure was perfected. Med. Times $ Geizctte.
Oa the Means for Preventing Caries of the Petrous Boiie and
the Formation of Abscess in the Brain in Cases of Disease
within the Ear, By Joseph Toynbce, F. R, S. Annual
Surgeon to St. Mary's Hospital, to the Asylum for the
Deaf and Dumb, etc.
1 may, perhaps, be permitted to add a lew remarks to the
highly interesting observations published in your Journal
of February 23, on Abscess in the Brain, associated with
discharge from the ear.
In order that we may ascertain the causes which lead
various affections of the car to produce disease in the
brain, it is desirable that the ear be always carefully dis-
sected, so that the nature of the affection, its exact locality,
.
1SG1.] On Diseases within (he Ear. 877
and its relations to the petrous bone and surrounding
structures, be clearly pointed out. Your reporter states
that it "it is a very tedious process to take out the temporal
bone for careful examination ;" inasmuch as a section with
a saw in front of the petrous bone as far as the body of the
sphenoid, and one behind, as far as the basilar process, fol-
lowed by the division of the soft parts by a large scalpel, is
all that is required to remove the parts necessary for an ex-
amination of the ear, the process of removal can scarcely
be considered "tedious." The subsequent dissection of the
car doubtless requires some care ; it can be best effected by
means of a small pair of cutting forceps, whereby piece by
piece of the petrous bone is cut awa}r, and no saw-dust pro-
duced, with which the state of the parts is apt to be
marked when the saw is used. I have no hesitation in say-
ing that the breaking up of a petrous bone by the aid of a
chisel and hammer, can lead to no useful results^ indeed,
the bone must be taken away in order that a careful and
searching dissection may be made. Some recent obser-
vations on the mode in which molluscuous tumours devel-
oped in the external meatus, progress inwards through the
petrous bone to the brain and its membranes, tend to con-
firm the opinion I have advanced on several previous occa-
sions, that in all cases of diseased petrous bone and brain,
the nature of the disease, the particular part of the ear
allected, and its relations to the brain and its membranes,
must be ascertained. Of course it is desirable that the
blood-vessels and other parts adjacent to the petrous bone
be also examined. Before taking leave of this part of the
subject, I may add, that if any Medical man, who is too
much occupied to conduct a careful dissection of a diseased
petrous bone that may fall under his notice, will send it to
me, I shall be happy to make a dissection, and will return
the specimen, with notes.
The recent occurrence of a case in private, and one in
Hospital practice, in which the brain suffered from disease
of the ear, induces me to make some observations on the
treatment of similar cases. There can be no doubt that
the usual cause of the disease in the ear advancing to the
brain is, that matter is pent up in one of the cavities of the
ear. I have ventured to suggest that when pent up in the
tympanum it affects the cerebrum; when pent up in the
oid cells it affects the cerebullum ; and when in tjie
vestibule it affects th rarolii, an<] base of the brain
876 On Diseases within the Ear. [December,
Since I promulgated this opinion, some years since, in a
paper in the Medico Chirurrjleal 'JVansactions^ I have had no
reason to alter my opinion. If it be a correct view that
matter, pent up in a cavity of the car, is the usual cause of
disease of the petrous bone and brain, it follows that the
duty of the Surgeon is to prevent the matter from collect-
ing, or to remove it when collected, and if neither measure
can be effected, to diminish by every possible means the
effect of the matter, and to prevent the progress of the dis-
towards the brain. The most simple and most man-
ageable cases are those in which the tympanum is the seat
of the disease, and where the whole, or a considerable por-
tion of the membrana tympani has been destroyed ; the use
of a syringe and warm water twice daily, is then usually
sufficient to ensure the removal of the discharge ; but it
must b<* laid down as a rule that so long as there is any
discharge from an car, so long must the syringe be used,
inasmuch as discharge is apt to become more or less solid,
aria thus act as a barrier to its own escape, and to that
secreted around it. While the discharge is being removed,
of course the thickened state of the tympanic mucous mem-
brane, which gives rise to the discharge, is to be treated
locally and generally, so that, its condition being ameliora-
ted", it may no longer pour out the unnatural discharge, and
thus all fear of disease in the petrous bone maybe removed.
I have met with several cases in which death occurred from
diseased brain where there was no other impediment to the
free escape of discharge than the inspissated secretion itself,
and where the free use of the syringe would have averted
the mischief to the bone ami the brain. In cases where
the orifice in the membrana tympani is small, and where, in
consequence, the discharge is apt to be detained by the re-
maining portion of the membrane, acting as a barrier, addi-
tional care is required by directing the stream of water
ihrough the orifice of the membrane into the tympanum,
in order to evacuate the latter cavity of its contents.
The Inst and most serious consideration is how to avert
mischief to the bone where there is evidence that matter i.-
confined in the tympanum or mastoid cells without any
outlet. The two classes of cases nnflr be placed together,
inashlttch as when there is long-sianding irritation of the
tympanic raucous membrane, an operation on the drum in
<rdcr to establish a permanent orifice in it, must not be at-
tempted, as inflammation of the dura mater may be in
1SGL] On Uliseases within the J. &T9
d. If the menibraiKi tympani be absent and matter is
confined in the mastoid cells, it is desirable by means of a
curved probe to endeavour to make an exit for the matter
through the natural channel into the tympanum, and to use
the' syringe with warm water cautiously : by this mean
is possible in some cases where the mucous membrane of
the tympanum is not very thick, to secure the withdrawal
of the matter from the mastoid cells ; but, unfortunately,
the general rule is, that the matter cannot be reached and
released by the above means, for it is held in bony cells,
where communication with the tympanum has been cut oil'
by the thickening of the mucous membrane lining those
apposing, then, that there is matter in the tympa-
num or mastoid cells which is causing irritation of the
hone, an(J implicating the brain or its membranes, and that
the performance of an operation for giving an outlet for the
matter is not to be attempted, wdiat treatment can be
adopted with a hope of benefit ? My own experience points
to an issue or a seton as a remedy calculated to be1 of the
highest service. One patient whose case is cited at length
in my work "On the Diseases of the Ear," whom I saw
30fne years since in consultation with Professor Miller, of
Edinburgh, who had unmistakeablc symptoms of matter in
the mastoid cells, attended by attacks of giddiness, insen-
sibility, and intense pain in the head, was perfectly cured
by the use of a seton, when all other remedies had been
tried. In what way the seton acts I cannot indicate, but I
have seen several cases, and one very recently, of excessive
r'lty, in consultation with Mr. Holman, of America
square, where the formation of an abscess outside the oar,
there being no orifice in the bone and no dead bone detec-
table, gave relief to the most urgent symptoms produced
by the presence Of matter within the mastoid cells. Tw*
other cases of the same character are now under treatment.
The insidious progress of cases, in which matter in
ies of the ear injures the petrous bone and the brain,
cannot be too often or too forcibly impressed npon the
minds of the Profession. Medical offi [nsurancc
Companies >eem to be aware of the danger liable to. follow
long-continued discharge from the ear, but judging from
instantly brought before my notice, as a rule, tla
e I".. [\},i to he di regarded, until
1' a young officer,
. -d himself in th au war aud Indian muti
880 On Diseases within the Ear. [December,
may be cited in illustration of my observations on this sub-
. L will give a brief outline in tlie case:
Captain R. .!>., aged 25, was brought to me by Mr.
Teevan on January 2, of the present year. He stated thai
when a child he suffered from some infantile disease, which
was followed by discharge from the left car. This discharge
continued, with slight intermissions until I saw him, and
it was accompanied by pain in and around the car. Irrita-
tion within the ear, as is not uncommon, produced a
polypus in the external meatus ; on account of this po-
lypus Surgeons were consulted, and the growth was re-
moved on one or two occasions. The irritation, however,
increased, and while at Aldcrshott, at the end of the year
18G0, it became so severe as to induce him to come to Lon-
don to seek further advice. At the first visit, although the
patient walked into my room, and did not feel himself
seriously ill, I felt convinced that the petrous bone was
diseased, and that there was disease in the cerebrum.
There was a polypus in the meatus; the bone was tender
all around the ear ; there was great pain in the car, which
extended deeply towards the brain. I expressed my fears
to Mr. Teevan of the very dangerous character of the dis-
ease, and stated my belief that there was an abscess in the
cerebrum. In spite of all treatment, the head symptoms
increased ; the portio dura became paralysed, and the pa-
tient also lost the power of articulation, although he was
perfectly sensible. Dr. AVatson, at a consultation a few
days before the patient's death, confirmed my opinion of the
probable existence of an abscess in the brain, but as the
friends objected to a post-mortem examination, the verifica-
tion of the opinion could not be made. At least there can
he no doubt, and there was no doubt in the minds of his
Medical attendants, that the patient died from injury to the
brain produced by long-standing disease in the ear ; and to
mc it is highly probable that if, in early life, the disease in
the ear had been perseveringly combated, its fatal result
mU'-ht have been averted. Medical Time? & Gazette.
1861.] fion.
under the care of Mr. Bryant.)
The live following cases illustrate some interesting points
in the management of urethral obstructions from different
causes. In the first two the cause of obstruction was lacer-
ation from recent injury.
Case 1. C of the Perineum. Hemorrhage from the
Urethra Subsequent Extravasation of Urine Gathei
Impossible Perm " / ft is v >. i Recovery.
A man, aged 53, was admitted on September 5, 18G1, for
extra a of urine. The history obtained was, that five
days before he fell astride on a log of wood, some hemor-
rhage from the urethra was the immediate result, and diffi-
culty in micturition. The day following a catheter was
passed and left in for twenty-four hours ; it was then with-
drawn ; retention of urine followed, and as this persisted
for two days he applied to Guy's. On admission the peri-
neum was infiltrated with urine. Catheterism was impos-
sible. Many fruitless attempts had been made to pass an
instrument, before he was brought to the Hospital, and
profuse hemorrhage had resulted. Mr. Bryant therefore
determined to open the urethra through the perineum.
lie introduced his linger into the rectum as far as the pros-
tate, and then pushed a bistoury into the perineum in the
middle line and cut upwards and succeeded in slitting the
urethra. He then passed a grooved director into the blad-
der, and was able, after passing the catheter down the penis
into the wound, to guide the instrument into the bladder.
( >n the sixteenth day urine passed through the urethra, the
wound healed kindly, and the man was discharged well on
tember 30.
Case 2. Fracture Irls and Laceration of
' hnpractii " Veri Death
.
In the preceding case, as we have seen, the operation wa-^
performed the day after the accident, and when
tion of urine had already taken place. In the follow
Mr. Bryant preferred to anticipate thee: fttion, au
'1 be introduced, I once pi
-
882 Perineai Section* [December^
A man, aged 50, was admitted for fracture of the pelvis
and laceration of the urethra. A cask had fallen on his
hip whilst he was laid on one side. lie had, luckily, made
water about half an hour before. When admitted, there
were evident symptoms of fracture of the pelvis, and rap-
tured urethra, blood flowing from the passage. There was
no extravasation. It was impossible to pass a catheter, and
therefore Mr, Bryant opened the urethra from the perineum,
cutting down on a grooved staff. The man never rallied,
however, from the injuries sustained, and died shortly after.
The perineum in this case was opened in order to prevent
extravasation of urine taking place, which would necessa-
rily have resulted on every attempt to pass water. After
death the ramus of the os pubis was found fractured and
the urethra lacerated.
Case 3. Indurated Stricture of the Urethra anterior to the
Scrotum Internal Urethrotomy Recovery.
A man, aged 23, was admitted under Mr. Bryant's care
for retention of urine. On examination it was found that
he had a stricture in the urethra just at the root of the
penis, and here an induration could be felt. Six months
previously, he had had gonorrhoea. Mr. Bryant suc-
ceeded by force in passing a catheter, and thus relieving
the retention ; but as the stricture was a very tight one,
and from its position was very favorable for internal section,
lie determined to operate on it. lie, therefore, divided it
internally by the urethrotome, and was then able to pass
a No. 11 catheter into the bladder. It was kept in over a
period of five days, after which the patient Was able to pass
Water freely. He was kept in the Hospital a month and
was then discharged cured ; tho local induration having dis-
appeared.
Case 4. Stricture and Extravasation of Urine Free Incisions
Recovery Subsequent Coniraction of the Stricture Peri-
neal Section Recovery.
Robert A., aged 43, was admitted for extravasation of
urine consequent on stricture, lie had had gonorrhoea
twenty years before, but had, lie said, never used injec-
tions. The urine was effused into the cellular tissues of
the perineum, sqrotiim and penis, and extended into the
abdominal wall. Mr. feryaul freely incised tltr- distended
1861.]
parts; and also made an incision into the urethra from the
perineum. Tie then succeeded in passing a catheter
through the opening in the perineum into the bladder.
The man rapidly recovered from the extravasation, and
micturition was tolerably free, but the urethra subsequently
contracted considerably, the passage of a catheter being
almost impossible, the whole passage being like cartilage.
On May 2, I860, chloroform being given, Mr. Bryant
performed perineal section. The case did well, and a rail-
sized catheter could be introduced with ease. A small fis-
tulous opening remained, which proved obstinate. The
es were, however, kept raw by strong liquor ammonia,
and a perfect cure resulted, the man making water better
than he had for years.
Case -5. Retention of Urine in a Bon Difficult Catheleris/n
in the Perineum Perineal Section Hecoveyy.
A boy, aged i>, of good general health, was admitted un-
der Mr. Bryant's care for retention of urine. Before he
was brought to the Hospital, many attempts had been
made to pass a catheter, but in vain. With great difficulty
and with some degree of force, Mr. Bryant succeeded in
-:ng Xo. 1, and drew off a large quantity of urine. The
difficulty experienced was in the scrotal part of the urethra.
An abscess formed in the perineum, and as it was on the
next trial, found impossible to pass an instrument, Mr. Bry-
ant opened the abscess. Urine flowed from the opening,
and but a small quantity passed by the penis. The urine
all along had been puriform. The opening in the urethra
partially closed, but no improvement took place in the
ling of the urine by the ordinary channel. Mr. Bryant,
efore, on March 2, performed perineal section. The
grooved staff was forcibly introduced. Xo Indurations
could be felt at the site of obstruction. On March U urine
ilowed freely through the urethra, and the wound healed, a
perfect cure resulting. The cause of stricture m this case
very obscure, indeed it was doubtful whether such
lad, ami whether chc obstruction had not been some
igenital malformation of the passage. Med, limes &Q
. 884 Ff/cemia. [December.
On Ptfgemia. By Professor Roser. (Archiv fur Ileilkundc
Jahrg, i. BS. 37, 193 und 329.)
The following observations form a brief extract of some
interesting papers on Pyaemia, from the pen of Professor
Roser, oi*Marburg:
1. The Specific Nature of Pyccmia. We are indebted to
the obstetrician, rather than to the surgeon, for any progress
which has been made in our knowledge of the nature of
pyaemia, he having established the miasmatic character of
the pyaemia of puerperal women, and its identity with the
pyamiia of the wounded. The doctrine of " Surgical Fe-
ver," so ably expounded by Simpson, has however made
but little way in Germany, Virchow's views on thrombosis
there predominating, as the doctrine of phlebitis formerly
did in France. Professor Roser shows in some detail, that
neither Hunter's theory of phlebitis, Rokitansky's disease
of the bloodvessels, nor Virchow's thrombosis, afford any
sufficient explanation of pyaemia, conditions being assigned
as causes which are mere concomitants or effects. The at-
tempt to explain its occurrence by the fact of the absorp-
tion of ill-conditioned pus also fails ; for, although various
analogous circumstances are producible by such absorption
these differ much from those of pyaemia, and may be ex-
pressed by the term septaemia. The two conditions, may
indeed, be combined, and we may have a septic pyaemia,
just as we have a septic variola or scarlatina. If pyaemia be
followed out through its various modes of manifestation, it
will be found to exhibit a marked similarity to typhus and
other zymoses; and just as in the case of these zymoses,
while sometimes it appears epidemically and as the result
of contagion, at others it arises spontaneously, without the
prior presence of piis. This fact has long been known in
lying in hospitals, and careful observation will easily detect
similar cases in surgical wards. Stromeyer has observed a
whole series of such cases, and similar ones have come un-
der the author's notice. The explanation of the occurrence
of sporadic cases of pyaemia may be difficult, but it is no
more bo than is the explanation of sporadic typhus or cholera
or other zymoses.
Forms of Pyaemia. Professor Roser confines his atten-
tion io sonic-of these which have excited but little atten-
tion. 1. Pycmtia Febricula. lust as duiingthe prevalence
of typhus we find patients here and here exhibiting bu1
1.] /;.,
Blight symptoms, so in hospitals infested with pyemia, a
mud form of the disease is observable which may be termed
febricula. it has been but little noted, as was indeed to be
ected, by those who were on the lookout for phlebitis,
sepsis, or thrombosis, as the initial phenomena of pyaemia ;
hut the author instances cases in his own and in St minever's
practice. In lying-in hospitals the febricula is termed "milk
fever " a term of doubtful propriety, seeing that the affec-
tion is observed sometimes in almost all the inmates, and
at others in none of them. 2. Pj/cumlc Hfrysipetds. When
in a patient suffering from pyaemia, erysipelas appears, the
natural conclusion is that the pyaemic blood-disease lias
localised itself in the skin, just as it might have done in the
pleura or in a joint. When, however, in a subject of cry-
ymptoms of pyemia appear, the question may arise
whether during the erysipelas the blood poison has become
developed, whether the pyaemia has become added as a se-
cond special process of disease, or whether the erysipelas
itself was only the first manifestation of the pyremic condi-
tion. Lastly, erysipelas and pyaemia may co-exist, and al-
though they may not often be met with in the same patient
they | uently found prevailing among different patients
in the same ward. The author's conclusion is, that hospital
erysipelas is a consequence of pyaemic infection and its lo-
cation in the skin, although he admits that it is doubt-
ful whether another variety of blood-poison may not also
give rise to it. 0. Pyc&nic JJiarrhoca. This affection, well
vn to clinical observers, has obtained but little notice in
hand-books. There are cases in which no other symptom,
the diarrhoea nt, but the author still regards
the- emic, occurring as they do simultaneously with
othe in which the diarrhoea has only been the first of
the whole series of symptoms. When this diarrhoea is com-
bined with the pyaemic erysipela , the disease exhibits
king and rapid contagious properties, and in hospitals in
which precautions against contagion are not taken, this
has] hoea, though little spoken of, i
lent occurrence.
. Although the incurability
in, practitioners in general are not aw;;
number of recoveries which really do take place, and
that even when excluding the .-lighter i >ove alluded
ad admitting only examp ell-marked pyaemia.
The number of re< \iv< increased in proportion as
886 J)/(cmia. [December,
the essential conditions of fresh air and a good diet have
been appreciated. Supporting the patient's strength by
means of wine, has replaced the former mischievous anti-
phlogistic treatment; and, indeed, judging from the use
made of alcohol in England, there is danger of the opposite
extreme being fallen into. Quinine, though usually of no
great utility may, in some cases, be a valuable adjuvant ;
and morphia is an invaluable remedy, serving not only to
check diarrhoea, abate pain, and diminish danger in perito-
nitis, &c., but also to tranquilise the excited and delirious
patient. The most important agent in the treatment, how-
ever, is a frequent renewal of fresh air, and the removal of
all objects likely to pollute it.
Prophylactics. Under this head the author lays great
stress upon simplicity in dressing wTounds, observation of
the strictest cleanliness, and checking the decomposition of
pus by cold and chlorine applications. When the spread
of pyamria is to be guarded against, instruments and nurs-
ing appliances should not be used in common, no autopsy
should be performed by those attending on the sick, and the
surgeon,,, visiting his cases of pysemia last, should change
and ventilate his clothes before seeing other patients. In
all cases of ill-conditioned suppuration at Marburg, weak
chlorined water is employed, and after waiting on such pa-
tients, the nurses carefully wash their hands in the same
fluid. Finally, Dr. Roser protests against the erecting hos-
pitals with large surgical wards, unaccompanied by means
for isolating the subject of pyemia. Small hospitals of
even a very faulty construction, give rise to a less mortality
than some magnificent structures in which the patients arc
assembled together in large numbers.
Juridical Relations. Under this head the author discusses
the question that may come before the surgeon in court of law
viz : whether a fatal pyaemia following an injury not in itself
necessarily fatal, should be regarded as an essential condi-
tion of such injury, or as an accidental and superadded cir-
cumstance; the exact determination of this point modify-
ing in the German courts the amount of punishment to be
awarded. He cites cases in which the pyrcmic complication
has been altogether overlooked, or has been wrongly inter-
preted to the detriment of the accused. He lefers also to
two other conditions to which the same considerations ap-
ply, viz : diffuse inflammation and tetanus. Diffused in-
flammation after wounds of tendons, &c., so often observed.
1861.] Cystwcrciis in the Eye.
in hospital, and so seldom in private practice, should not be
attributed \o the nature of the local injury, but to the pre-
sence of miasmata. In fact it is of a pysemic nature. Wills
respect to tetanus, we know nothing concerning^ its casual
connexion with wounds, and when questioned juridically,
should avow such ignorance. The author himself is
posed to regard it as a zymotic affection, not only be-
c no casual connexion with the wound can be made out
but from its analogy to hydrophobia, which is a zymotic
affection, and from 'its disposition to prevail as an endemic
or epidemic Br. Fur. Med. Chit, Bcv.
of Cystieercus CeUidosm in the Anterior Chamber of the
By Dr. Memle.
The wife of a shoemaker, 25 years of age, of healthy appear-
ance, and far gone with her first child, applied to the author
on account of an obscurity of vision. On inspection a cysti-
cercus was perceived with the utmost distinctness in the
anterior chamber of the right eye. The worm was of a deli-
cate white, the bladder being so transparent that the brownish
iris could be seen through it. It was of the size and shape of
aall pea, and below was a process which was somewhat
whiter and less transparent than the rest of the worm ; and
from this projected a white transparent neck, about a quarter
of a line in length, having at its extremity a small round head,
which examined by a lens, exhibited lateral swellings, and re-
bled the head of a tenia. The bladder of the worm cov-
ered the lower part of the pupil, leaving this free for two-
third circuiitferencc, while in appearance it dipnoi
differ from that of the other eye. The worm was motion]
movements were not induced when the patient in
p when a strong light was directed upon the iy>\
pent examinations during the next three days tile
TO was found to have assumed different positions and
various shapes. It was very interesting to observe thrguhg
a lens how it thrust its head here and there, just as a le
>re it fixed on a spot to commence sucking from; When
888 Morbus Goxarius. [.December,
it attached itself to the anterior of the iris, its neck was bent
backwards, and the bladder almost completely obstructed the
pupil a slight quivering movement, like that seen in the
sucking leech, being imparted to the tube-like process of the
animal while the bladder continued motionless. Sometimes
the process was distended into a bladder much smaller than
the other, below which it was placed, and from which it was
separated as if by a ligature. The woman was confined on
the third day after being seen, and continued under observa-
tion for about three weeks before an operation was performed,
the animal frequently changing its position, attaching itself
to the various surrounding parts, without seeming to inflict
any injury on them by its sucking process. The pupil at last
became narrower than the opposite one, whilst its form was
converted into an oval, and vision got more and more im-
paired. Fearing the production of iritis, a linear-incision was
made, and the worm, discharged with the aqueous humor, was
carefully captured. It was placed in tepid water, but exhib-
ited no movement. The wound in the cornea soon healed
under the employment of ice, and the eye has regained its
perfect powers. The worm three months after its extraction
has contracted from eight to five millimetres in length.
So far as the author is aware, there have been seven in-
stances of cysticeri in the anterior chamber recorded. The
first was discovered by Schott, of Frankfort, and Grafe,
Ilirschler, and Appia have each described a case, and Mac-
kenzie relates three cases. This last writer and Grafe have
also collected cases in which the cysticercus has been found
in various other parts of the eye. Grafts Archw. fur
Ophthalmologic, vol. vii. p. 122.
Morbus Coxarius.
The Academy of Medicine, of New- York, has devoted the
general portion of several of its later sittings to the consider-
) of the subject of morbus coxarius. The Section on Sur-
gery had previously discussed the subject at great length, and
had recommended it to the Academy. Dr. A. C. Post opened
the discussion, by giving a concise history of the pathology
and treatment of hip disease. He was followed by Drs. Bat-
chehler, Puck, Sayre, Wood, Parker, Raphael, Krakowitzer,
I . I M
Branson, and others, and by invitation, l>rs. Banes and Pavis
who were present, participated in the discussion. Little was
said thai el as regards the pathology of the disease,
bnt the mechanical treatment, brought to such a degre
perfection by the Burgeons of this city, was minutely explained
thoroughly criticised and universally commended* The prin-
ciple upon which the mechanical treatment is based is the
separation of the impinging surfaces of diseased bones by
means oi carefully applied splints, producing extension and
counter- :i, and admitting of motion of the joint.
This treatment has been the gradual growth of years. As
early as 1S35, Dr. Harris, of Philadelphia, is said to have ap-
plied extension and counter-extension by means of Gibson's
modification of Physic's long splint, with success in four cases.
A report of these cases was made early in 1S39, but, as Dr.
March states in his paper on morbus coxarius, "without giving
rion of the theory or principles upon which the
practice is founded.'' Later, the treatment was proposed by
Dr. March, of Albany, as an entirely new treatment. He
found he had been anticipated by Dr. Harris. Dr. March
however, explained in his paper just referred to, which was
I before the American Medical Association, and printed in
Transactions of that body for 1S53, the theory of the
:ment. " The most important part of the treatment,"
says Dr. March, "consists in the keeping of the joint in a
use." This is accomplished by a splint,
-ion and counter-extension are used with a view to
rent undue pressure on the delicate and tender surfaces of
bones." " In the advanced stage of the disease,"
continues Dr. March, "the cartilages of the acetabulum and
of the head of the bone arc destroyed ; the carious and spongy
.-red with coagulated lymph, and this adherii
the surface of the bones becomes highly vascular. Now if
a two surfaces, thus covered with organized or organiza-
blc matter, could 1 e. kept in easy apposition and at rest
without too mm re on the one hand, and on the other
without exerting too much separating or sundering force in
many instances a bony anchylosis would be the r
This irst record we nave of the mechanical treal
n pathological conditions. Put Dr.
.have proposed it for other than the
in the early stage, he says Mit
be important to resort se of th -plint, to
maintain the joint in a state immation
may subside," while ext and counter-extension, it ap-
890 Morbus Coxarius. [December'
pears, were used by him in the advanced -stages to prevent the
deformity of the limb.
Next in order to Dr. March is the treatment proposed by
Dr. Bauer, of Brooklyn, by means of an apparatus similar to
the double r/outtiere of Bonnet, of Lyons, having, however,
attached to it a footpiece allowing of extension. This appa-
ratus is made of wire, and has been dubbed with the sobriquet
of the "wire breeches." This apparatus keeps the limbs im-
movable, and permits the patient to be carried about.
In April, 1860, Dr. IT. G. Davis described in this journal a
method of treating hip disease he had employed for many
years. The principle upon which his treatment was founded
was the application, by means of a corrugated steel splint, of
extension and counter-extension, permitting at the same time
the patient to take active exercise in the open air.
For the steps of the treatment and an explanation of the
splint uesd, we refer to Dr. Davis' paper in the Monthly for
1S60. In this instrument is combined all the suggestions
made by Drs. Harris and March, with the addition of elastic
extension applied in all stages of the disease, not for the sole
purpose of preventing or overcoming a deformity, but as a
curative means, and with that freedom of action to the patient
wearing the splint which permitted him to take exercise and
air, so important to the general health. This was attempted
to be accomplished in a measure by Bauer's wire breeches,
but is positively accomplished by the Davis plan of treatment
The report of the Section on Surgery, and the remarks made
by most of the surgeons who participated in the discussion at
the Academy, gave Dr. Davis the credit of having introduced
the methodical plan of treatment to the profession.
To the steel splint of Dr. Davis several modifications have
been made by Dr. Sayre, Dr. Davis himself, and othe^.
Dr. Sayre differs from most of the profession in his views
of the etiology of the disease. He holds that, with few ex
ceptions, the disordered action of the joint can be traced to
direct traumatic influences, and not to a strumous origin, as is
the almost universal opinion. He believes that the effects
have been mistaken for the causes, the scrofulous cachexia
being consecutively developed, and therefore being the results
and not the causes of the disease. In these views he is sus-
tained by Dr. Bauer, of Brooklyn. Amer.Med. Monthly &
.V. Y. 'Review.
- early as 1854, the anti-periodic properties of nitric acid
had been pr< to the profession, by Dr. George Menden-
hall in tl Lancet : and even prior to that time 'had
n availed of by Dr. E. S. Bailey, of Indiana. A recent
article in the Maryland and Virginia Medical Journal, by
r Wm, A. Hammond, late U.S. Surgeon at Ft. Riley,
Kansas, is again attracting the attention of the profession to
its use tor this purpose ; and from it we condense the follow-
ing : cases, ten of the quotidian and thirty-one of
the terti; form a table, the basis of a report made to
the Surgeon-General. Of these, thirty-two were treated with
nitric acid and nine with quinine. Three cases cared by
nitric acid, had previously used quinine unsuccessfully ; and
two, cured by quinine, had been treated with nitric acid in-
effectually, and in one other the acid was discontinued, on ac-
count < i' creating nausea, heart-burn, etc. The average period
of treatment was the same with each remedy three days.
acid was given in doses of ten drops, three times per day,
erly diluted with water; the quinine in eight grain doses,
as often. Dr. Ilammo; les the fact -that the
as equally successful with quinine in arresting
the i 'he difference in the cost of the two articles is so
rly in favor of the former substance as to render it an
object of importance to make its curative properties more
widely . known. Since the foregoing cases wore treated, I
have frequently employed nitric acid in the treatment of in-
termittent fijvui\ and have rarely been disappointed in my
- of its curative action. In fact, in simple, uncom-
plicated intermittent, I seldom have occasion to use anything
In cases of enlargement in the spleen, consequent upon
lent attack.- -T^e, the remedy in question has, in
pr< ved 1 vantage- us. ( h icago j
i
communication on an important
e by Dr. Grima: inx. This learned fellow-practi-
tion ct is to make known the mode oi of
ems m use at Venice, an< France
892 CUt'in [December,
this advantageous manner of collecting and preserving potable
water, for the private and public requirements of a, great
number of places. At Venice, the greater part of the rain-
water is collected in 2077 cisterns, 177 of which are public.
Their united capacity averages 7,100,000 c. feet, and when all
deductions are made, they supply 4rJ gallons of water per day
for each individual of the 120,000 inhabitants of the city. Dr.
Grimaud describes in the following terms, from information
afforded to him by the engineer of the city of Venice, the
mode of construction of these cisterns : The ground is excava-
ted to about nine feet three-quarters ; a depth which the infil-
trations of the lagoons do not allow to exceed. The well re-
ceives the form of the inverted frustum of a pyramid. The
surrounding earth is supported by a solid wood-work of oak
or larch, bearing on the truncated summit and likewise on the
four sides of the pyramid. On the wood-work is placed a
layer of compact and consistent pure clay, the surface of
which is most carefully smoothed down. The thickness of
this layer is proportionate to the dimensions of the cistern,
and in the largest is not more than twelve inches, a depth
sufficient t:> resist the pressure of the water, and also to oppose
an invincible obstacle to the roots of vegetables which may
grow in the surrounding soil. It is considered most import-
ant not to leave any cavities in which air may remain. At
the bottom of the excavation, in the interior of the trun-
cated summit of the pyramid, is placed a circular stone, hol-
lowed in the middle like the bottom of a kettle, and on this
stone is raised a hollow cylinder of the diameter of an ordi-
nary well, constructed with dry bricks laid well together,
those at the bottom only being perforated with conic holes.
This cylinder is raised above the level of the ground, where it
is finished off like the kirb of a well. Tims a considerable
vacant space is left between the cylinder, rising from the
middle of the pyramidal excavation and the walls of the
pyramid, lined with clay and resting on the wood-work. This
space is filled with well-washed sea-sand. Before the whole
is covered in with paving stones, a sort of stone box closed by
a stone lid and perforated with holes, is constructed at each of
the four corners of the base of the pyramid. These boxes,
called casscttoni, are connected with each other by a small
pipe, made of dry bricks, resting on sand. The whole is cov-
ered over with common paving-stone, inclined in the direction
of the four orifices of the casscttoni at the corners. The water
from the roofs runs into the casscttoni, penetrates into the
:m<l through the joints of the bricks of the small pipes, and
1S61.J Prolapsus qf the Rectum. 893
collects, taking its level at the centre of the hollow cylinder,
in which it enters by the small conical apertures at the bot-
tom. A cistern thns constructed, and kept in good repair,
supplies very clear water, and preserves it perfectly to the
last drop. JNow, wherever there is a roof, there is a means of
collecting rain-water; sand, stone, clay, bricks, are every-
where met with. But the clay must be of good consistency,
the sand pure and well-washed; if it contained earth it would
vitiate the water by the addition of fermentable principles ;
the sand must, in addition, be insulated by clay from the sur-
rounding ground. These conditions are easily satisfied, and
when we turn our thoughts to a number of places in which
water is expensive and the supply insufficient, it will be
readily understood that Venetian cisterns would be so many
benefactions. Dublin Medical Press.
Prolapsus of the Rectum.
M.Coulon, house surgeon to the Hopital Saintc-Eugenic, de-
scribes as follows the treatment employed by M. Marjolin for
prolapsus of the rectum in children: The first thing to be
done is to reduce the tumour. The subsequent treatment em-
ployed at the Hopital Saintc-Eugenic by M. Marjolin consists :
1, in the removal of the cause of the procidence ; 2, in the
eral improvement of the system; 3, in the restoration
the sphincter and levator ani muscles to their normal
. 1. For the purpose of contending with the causes, M.
Marjolin checks diarrhoea with preparations of rhatany, tris-
nitrate i :th, laudanumised enemas, and proscribes
every kind of fruit and vegetable. lie relieves constipation
by mild aperients. 2. To invigorate the system he resorts to
tonics in general nse : claret, bark-wine, syrup of iodide
of iron, extract of cinchona, generous diet, cold shower-baths
twice a d mastics, open-air exercise, &c. 3. To re.-'
the I the tissues of the region, herecommends cold tonic
and astringent I frequently applied to the perineum,
either with pure water or with a solution of rha-tany ; and in
addition to modify the mucous membrane, injections of alum
lb. water) or of rhatany twice a day \ mall
When the bowels are moved, care musl be
;i ilia' th be not : Uie oighl I
S94 Ummia. [December,
are so arranged that the feet of the patient do not rest on the
ground. Of course, should the tumour easily protrude, is
must be supported with an appropriate bandage. M. Marjo-
lin has already treated 150 patients suffering from prolapsus
of the rectum, and all have been cured without operation by
the means above enumerated. If these measures are insuffi-
cient, cauterization may be resorted to as practiced by Guer-
sant; but the cases in which it is requisite, are very rare, as
Si. Marjolin has not met with a single one in children. Ibid.
Urcemia from Retention of Urine.
Some time since M. Aran was suddenly summoned at three
o'clock in the morning to attend a child who the previous
evening had suddenly been seized with trismus and slight
spasmodic action of the muscles of the back. The patient
was a vigorous infant eight days old, hitherto free from ana-
sarca or convulsions, had taken the breast with perfect ease,
and its functions appeared in every respect regular. When
first he saw the child, M. Aran discovered no other symptoms
but the muscular rigidity alluded to ; violent tonic contrac-
tions, however, soon set in, at intervals of thirty or sixty mi-
nutes and this condition persisted, without any abatement, for
thirty-six hours, when the struggle ended in death. The cen-
tral organs of the nervous system presented no peculiarities
beyond enormous vascular congestion of the rachidian venous
network, and of the skull, more especially the parietal bones.
No marked morbid change was detected in the thoracic visce-
ra or the liver and spleen. Important alterations existed,
however, and further dissection supplied the explanation of a
problem which the most careful examination had at first left
unsolved. The bladder considering the age of the infant was
enormously distended with urine, and filled the hypogastric
region up to the umbilicus. The ureters were also the seat of
extraordinary enlargement, and they formed under the peri-
toneum, two cylinders of the diameter of thick pencils, open-
ing at their junction with the renal calyces into large funnel
shaped expansions. The urine was perfectly transparent, but
when heated and acidulated with nitric acid, deposited a co-
pious amount of albumen ; the kidneys were extensively dis-
d. The right kidney was in the state of hypertrophy and
1861.] I 898
>w degeneracy which belongs to the third or fourth si
Bright's disease ; the tubnli nriniferi were obstructed a1
their junction with the sinus renalis by crystals of iithal
... The parenchyma of the viscus was destroyed on the
left side ana the gland was converted into a collection of small
ts formed by the dilated infnndibula. The secreting- part
of the texture was entirely diorganised.
The cause of death was, therefore, hydronephrosis a dis-
ease improperly described as albuminuria, and life had been
troyed by nervous disturbances, which of late have been
'dered as resulting from the presence of urea in the blood;
anemia in this instance had originated in retention of urine
caused by the excessive narrowness of the prepuce. M. Aran
was confirmed in this view by the fact that even energetic
pressure of the bladder was inadequate to force Its contents
through the urethra. The presence of urea in the blood which
occasioned death in the present instance, is not uncommon,
and induces very different morbid phenomena. When the
disease assumes a rapid and acute form, convulsions more
usually chronic may appear ; sometimes, en the contrary, the
-ins are permanent, as in the child whose history we" have
related ; in other cases, coma or delirium, with or without
convulsive action is observed. In the chronic variety, the
re much less marked. The patients complain of
a sense of discomfort, of agitation, of more or less headache,
I disturbances of the intellect, of memory, or of the senses,
e\:c. are likewise observed.
How are the convulsions, coma, delirium, and the various
pathological conditions above enumerated to be connected
with uraemia 2 The pathologist will be enabled to reply to
question by the estimation of the precedents of the case,
by the chemical examination of the urine, and more especially
by the specific gravity of this secretion. It should be ob-
ed that the nerve manifestations, referrible to the presence
of urea in the blood, are not merely coincident with albumin-
ous urine, but are also observable in cases of complete de-
letion of the renal texture, when the excreted fluid contains
neither albumen, urea, nor saline ingredients, but e
almost pure water. The specific weight of the liquid is then
very low, and this indication should on no account be neglected
more especially when percuss ws the dulneE i in Uu\ re-
the kidney to have much inc
I
89G Editorial.
MEDICAL COLLEGE OF GEORGIA.
The absence of a large portion of the Faculty of this Institution, en-
gaged in the service of the country, has rendered it impossible to open
the College this season, and its closed doors indicate the determination
which pervades all classes of the Southern community, to sacrifice
every interest rather than submit to the iniquitous domination of our
fiendish foes. No age nor condition has escaped the enthusiasm created
by the war-cry. The robes of the divine, the magisterial ermine, and
the professorial cap arc alike laid aside, to make way for the armor of
deadly strife ; and beardless boys, panting for blood, hasten to the rescue,
while their mothers and sisters prepare materials to dress their wounds.
Such is the condition of our people from the mountain-tops to the very
S2a-beach. No apology is therefore necessary for those who have left
their chairs vacant in our halls of learning ; but we may indulge the
hope that they will soon accomplish their patriotic mission, and return
with laurels upon their brows, to resume their accustomed labors.
Professors Ford and Campbell are at the Georgia Hospitals in Rich
mond ; Prof. Miller with the army at Manassas ; Prof. Jones in the
service on the coast of Georgia ; and Dr. D. Ford at the Culpepper
Hospital, Va. The remaining Professors may bo called into the field at
any moment.
SUSPENSION OF THIS JOURNAL.
It is with much regret that we find ourselves obliged to announce the
suspension of this Journal for the present, and probably during the war.
The high price of paper, the increasing difficulty of getting it at any
price, and the probability that the supply will soon foil entirely, have
combined to compel our worthy publisher to decline a renewal of his
contract with us. We must, therefore, yield to the stern necessities of
the times and take an affectionate leave of our numerous readers. "When
we shall have achieved our independence, the Southern Medical <fc Sur-
real Journal win again, with recuperated energy, resume its scientific
mission. We doubt not that it will then command, as it has done for a
quarter of a century, a liberal patronage throughout the Confederate
1
I4-&1'
INDEX TO VOL. XVII.
J'AGE. T'A(.E.
Void, hydrochloric 57-Atropia glycerines 7'.>
Aconite in tetanus 432| Atropine 192
Ague 272J do in sciatica 4:;i
Ague weed 710; do solution of \''>\
Alcohol, action of '
Ammoniacraia SKi Bailey, A. W. en vesico vaginal
Ammonia, liydrochlorate of. . . . 77 J fistula U':;
Amputation of leg 44o;Belladonna in sore throat 90
Amputations and resections-. . .. 558 Bellinger, M. on rectal touch. . .858
Amputations of foot and ankle. 746 Bignouia Catalpa 700
Anatomy, by Leidy 190|Bismuth, action of (L68
Angina, gangrenous 510 Bloodvessels, developement of.. 812
sthetics, action of 343 Bronchitis, chronic W
Aneurism, digital compression in 340 Bronchocele 512
Aneurism digital compression in. 831 Burns by phosphorus 191
AneurismaT varix 499
Antigalactics 411 Calculus of bladder
Anns, eruptions around 188 Camphor, antidote for strychnine.] 0 1
-eatment of fissure.*- 830 do an antigalactic
Apoplexy of Ketina 54 f''aneer of lip
Apoplexy, diagnosis of 232 Cannabis indica.
lectio congestion, arsenic in. 820 Csrboni
Apoplectic congestion, by Trous- Ca.-tor oil, to improve
seau E
- olachia serpentaria 701
Army, diseases of 074
health of
do medical board 825 (Catheter, sul
d<> diseases 83S{Oerebrs
do surgeons, directions for iron 56
QIC 774 Chlorosis
nic in apoplectic congest ion. 82i Chlorodync
Asthma 2r>8 Chlorotbnn, dangers of I7ti
- Syriacs : do and ether
AsarnmEnropea, for drunkard-.. 827 db in hernia
a#:
INDEX
...768 Diuretic < ffects of
PAGE.
. ide ol Sodium ....
Chlor. Pot. in gonorrhea 826 Dogwood
Chorea 612"
Cisterns for rain water 891
Cod liver oil, how to improve. ..852
Colchicum, sacoharate oi
do as a diuratic ,
do
(In
do
do
do
do
PAGE,
Colchicuin . . .405
677
Dogwood, swamp 689
Doughty, W. K. Diagnosis of
Phthisis ' 113
48, 829|Doughty, W. K. Hospital oases. .
. . .405|Douglas, T. on dysentery 50:'.
827
arm, .183
do locon rheumatism.282
I8d1 do lee. on tetanus. . . .433
,203] do on army diseases. . 833
30] do on typhoid fever. ..834
do on Diarrhoea 836
on dysentery 837
on pneumonia 837
on measles 838
513
Complexion, pigmentary changes.450Drunkards, remedy for
Contraction of palmar fascial. . . /B49|Dhjjas, L. A. paralysis of
( Jon v nlsive diseases
Dymenorrh<ea 85, 18Q, 272
Dyspepsia, hydrochloric acid in. 57
Qysprioia in cardiac diseases.. . . . "!
do
Convulsions, infantile 112 ao
Cornea, opacity of \AA do
( lornus Florida 677 do
do Circinata 689 Qysentery
do Sericea 089
Coaalgia 88$
Cretinism 1 74 !
Croup, spasmodic 84,0
Crvstaline lens, voluntary dislo- Ear, Toy nbee 'on diseases of. . ..
cation or' '. 6p3 Editorial, 109, 189, 200. 400, 51 1, 825
Cucumber ivae G98JEleetrieJty in neuralgia 43]
Cutaneous diseases 177, 192 '"Emory, A. Gr. antidote to strain-
do diseolorations 450! onium 43
S87JEpileps.> 92, 105, 203, 301, 864
do woorara in 3.46
75! do hvdrocvamUe of iron . . 352
112j do statistics of 5.08
&33LEpileptifonn convulsions 057
Cysticercus in the eve
Delirium
do
do
do
do
Oiabet -.
51
tremens
do
do
do
do
new test
Diarrhoea , 88
Diarrhoea treatment of 830
Digitalis in mania-a-potu 75
do do ' 410
Digitalis in hemierania 830
Diospiros Virginiana 099
Diphtheria,
do
317 Ether and chloroform
: 1 0 foipatorium rotunditblium .
perfoliatum . .
do
do
do
do
do
.350
.754
do perionaium VI 1
E)ve J. A. lect on uterine polypi. 33
do do do 273
Excision of knee joint 828
do hip joint 828
(Exophthalmic goitre $55
Eye-halls, prominent 655
82[Eye, cvsticercus in the 887
91 False joints ['$
[Si Favus, treatment of
I lo Fetus discharge^ through abdqna-
U5 inal walls
198
Dislocation of hip, treatment. .
Dislocation of lens, voluntary,
do sh6ul5er,Jdia|
llEever, rnarab ! ' J
continued -:vi
typhoid S:">
recurrent 169
'mine in typhoid'. .,.'.27!
whiskey in typhoid. .
nitric acja in intermittent. 891
.7S7
. 362
,.<553
. 65o I
do
do
do
etc
do
ever.
Ill
id 719
i .
Fevers, cold wat
and qui n. in puerperal 826
pish-] 23d
Ford, J.
walls.. 198 frop. stearal
I I Iron, uiuriated tr.
Icterus with fattj In r
Illumination by gas
. criminal
Indian quinine
Iodine in spina bifida
fodisra
Iritis
anacli, pn -
. anion of
- icrdm
[bow '>14
do of craning) 515
rail in 528
gina 5J0
;is. chronic
mpervireus 7H1
Gentiana qninqnefolinm 71''
.'a Bark 675
rine in skin diseases 192
do an antigalactic 411
do ;;
Ill
".; 432
Gonorrhoea! rheumal
do almia 259
Ill
48|Ligature, metalic
*s' militai ; . ;529, ,;
m '',71
ichloride of 237
Iroii. rerro-cyanurel 272
Iroii. bydro-cyanate :;."<-
rron, per-chloride of, in gangren
. opening of '>-"-
Tones, Joseph report to <
planter's convention I
Iph. <min.
prophylactic
Jones, Joseph, indiginous sub-
stitutes for quinine in the
confederate -
Caber impeded !
do accidents in
i:ial obstructions
Larch bark in pulm'v hemorrh.
do in purpura- hemorrh. 432
Lead, slow poisoning by 31
in 826|Leg, new disease of 194
witho ? ' eneocytho?mia
501
Liriodendrum tulipifera
Lithotomy and Lithotrity in ch..52 !
ialc
512
crania, quiii. and dig a, glaucfl
do acuminata
do grandiflora
do iripetala
A'-'/l Malarial fevers preven'd by quirt. 593
do :!iian cur:
' c ire ....
266 Mai ' . ; pol i 75
chforofor.
. human
>pathic (
}. wild
.... n - m. its grati
:....: Bt Of ....
. . . 272|Med*n a
prof
. . . 7
I,
Mensl , in
IV
[NDEX.
iwon.
Mercury in syphilis 151
Mereurio-syphilis 185
Military surgery, bVGross. .520, Gil)
ftjfflkweed.... 763
Morbus eoxarius 888
Morphia in neuralgia 512
Mullein in bronchitis 89
Muscular fibres in pulmonary ves
Icles 818
Necrology 271
sson, H, diagnosis of Lip dis
location 3G2
Nerves, termination of 807, 811
Neuralgia 112, 431, 512
Nitric Acid 771
do do intermittent lever... 891
Nitrate of Silver in uterine inlPn.70
Node on the patella 498
Opium 37, 1
Opium and quinine in puerperal
fever 826
( Ophthalmia, fomentations in 750
Ovaries, develop, of follicles. . . .815
Ox-gall in frost bites 528
Oxygen inhalations 91
Pains, chronic 4 To
Palmar fascia, contraction of 840
Paralysis 108
d') of upper extremity. . . . L33
do wasting 156
do of spinal muscles 523
Perinearsection of urethra, .881,727
Persimmon 699
Pertussis, prescription for 82ti
Phosphorus, detection of 53
Phoph. acid do 53
Phosphorus, hums i-y 191
Phlegmasia dolcns soo
Phthisis Pulin 113, 447, 718
Pigmentary changes of eompln. .450
i'iu-kneya pubens 670
Placenta, detachment of 342
do previa 662
Pneumonia, treatment ol" 837
Poisoning by Lead 31
by stramonium 45
Poisons, fiflh
Poplar or tulip tree 690
Pregnancy, rectal touch 858
Prolapsus, rectum 893,58
atorrhoen 814
PA<i7..
Puerperal fever 46, 82f>
Pupils, dilatation' of 79
Pulse, chronal law of 334
Pulmonary hemorrhage 433
Purpura hemorrhagica 432, 237
Pyemia 884
Quinine in Rheum. Dysincn 2(>2
do menstruation 432
do prophylactic 593
Rabies an epizotic 49
Rattlesnake bite, treatment of. ..377
Rectum, prolapsus 893, 58
Retina, apoplexy of 54
Resections of 558
Rheumatism and gout 48
do acute 236
do 282
do sacch. of colch 829
Rheumatic dysmennorrh 272
Rhus toxicod. in paralysis 108
Ringworm, true 823, 225
Ricord, banquet to 270
Root of man 768
Sacrum, fracture of 526
Salix nigra 756
do alba 756
Sal ammoniac 770
Salt, common 763
Santonin 72
Scarlatina, pathognomic sign... 072
do ' ." 81
Sciatica, atropine in 431
Shelby medical college 671
Short sight, treatment o( 2G5
Silver sutures 431
Small magnolia 696
Small-pox pitting 192
Snake-root, Va 701
Snake-bites, treatment of 877
Spina bifida 272
Spleen, malpighian corpuscles. . .814
Stereoscope 272
Sterility 280
Stramonium, antidote 45
Strionnine, antidote 191
do in typhoid fever. . . .271
do in bronehocele 512
Stomach, irritable (>72
Surgeons, directions for army. . .855
Surgical miscellanies 494
Sutures, wire and pins 412
Sweet Bay
Syphilis, mercury in 151
da 289,
<lo in infants 641
Syphilization
Tannin in vaginitis
Tape-worm
Tartar emetic in gonorrhoea
Tartro-citrie lemonade
Tetanus, aconite in
do lecture on
do treatment of
Thorough wort
Throat "distemper
do sore
Tinea tonsurous 225,
Tongue, operations on
Tracheotomy
Trent, P. on spasmodic croup. . .
leases of
481
111
J 7"
432
749
711
90
823
402
4S7
840
.
Uremic intoxication
Urine, incontinence
Urethra, strictures 7-7
tion
Uterine polypi
hemorrhage 86
Inflammation nit. arg. in. 797
Uterus Bub-in volution of1
Vaccii ("
Vaginitis, tannin in
ins, . . .. .
Whooping cough, prescript for
Whiskey in typhoid fever 400
Willow, black 756
do white 756
Woorara Ill
do in epilepsy
Wound-, &c
Ulcers, phagedmic 180 Yellow Jessamine .
Umbilical hemorrhage 47
v llo. S94Ziuc. chloride <>:'. .
.177
/5
VUp^L
m.