Southern Medical and Surgical Journal, 1866-1867

SOUTHERN

MEDICAL AND SURGICAL

JOURNAL.

EDITED BY

L. A. DUG AS, M. D.,

PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF GEORGIA.

VV. H. DOUGHTY, M. D.,

PROFESSOR OF MATERIA MEDICA IN THE MEDICAL COLLEGE OF GEORGIA.

DeSAUSSURE FORD, It D.,

PROFESSOR OF ANATOMY IN THE MEDICAL COLLEGE OF GEORGIA.

JE PRENDS LE B1EN OU .IE LE TROI'VE.

Whole Series. Vol. XXI.

Augusta, Ga.:

E. H. PUGHE, PRINTER AND PUBLISHER.

1867.

SOUTHERN

fptkal $ ^nrgital foraral

ik*IG*I STAj GA,

Vol. XXlifc} JULY AND AUGUST, 1866. [No. 1.

ORIGINAL COIVnMXJNIC-A.TIONS.
ARTICLE I.

Heport on Spurious Vaccination in the Confederate Army. By
S. E. Habersham, M. D., formerly Surgeon in the Pro-
visional Army of the Confederate States.

Chimborazo Hospital, Div. rJo. 2, November, 1863.

To Surgeon W. A. Carrington, Medical Director

Sir : I have the honor to inform you that, in accordance
with your order of the 29th June, 1863, 1 have received
all the patients sent into this Division, with a "peculiar
eruptive disease," supposed to be the consequence of
vaccination, and herewith forward you the results of my
investigation into this anomalous affection.

In compliance with an order issued' from the Surgeon
General's Office in the month of November, 1862, general
vaccination was practiced upon all soldiers as soon as they
were admitted into this Division, and in order to insure
the full protective influence of vaccination (not antici-
pating any evil consequences therefrom), the order was
strictly obeyed, and all the patients, even those having
recent scars upon them, were re-vaccinated. A few days
after the insertion of the virus, and, in many cases, within
twenty-four hours, the seat of puncture became very much
inflamed, with a deep inflammatory blush around it,

Habersham on Spurious Vaccination. [Jnfy,

whieli gradually implicated, in the severe eases, nearly the
whole of the affected limb. A pustule rapidly formed,
instead of a vesicle, which very soon discharged an
ichorous fluid. This fluid was, in the course of forty-
eigjdt hours, converted into a dark, mahogany-colored,
irregularly shaped scab, prominent, and firmly attached at
its; base. A dark-red areola of several lines in diameter,
m/easuring from the edge of the scab, was then developed,
which, in turn, seemed to exude an ichorous serum,
^his was soon converted into a scab surrounding in juxta-
position the first, and presenting the appearance of a single
jiscab. This process continued for several days, and there
was often formed a scab, one inch or two and a half in
diameter. "Pari passu" with the increase of this scab,
the erysipelatous blush on the limb diminished, and when
the blush had disappeared, this scab ceased to enlarge.
As this inflammatory process subsided, the discharge lost
its serous character, and seemed to be converted into pus,
which exuded from under the scab, loosening its firm
attachment at its base, and thus rendering it liable to be
removed prematurely by the patient in his sleep, or even
by the friction of his clothing. When this occurred, a
foul bleeding, irregularly shaped phagedenic ulcer was
revealed, with everted edges, and presenting the appear-
ance of a Syphilitic phagedenic ulcer, involving the sub-
cutaneous areola tissue, exposing, in many cases, the
muscular tissue below. The process of destruction of
parts did not end here, for the ulcer continued to increase,
and from the loosened edges an ichorous discharge con-
tinued to pour out from under the skin, which seemed to
destroy the edges of the ulcer, thus increasing its dimen-
sions. Wherever the ichorous pus from this ulcer touched
the sound skin, another pustule of a similar character was
formed, in some cases reaching the size of the -primary
sore. This, however, was seldom the case, but a smaller

1866.] Habersham on Spurious Vaccination. 3

ulcer generally resulted, which often healed and cicatrized
before the first.

The Axillary Glands, when the arm was affected, and
the Inguinal Glands, when the leg was the seat of the
disease, sometimes became inflamed and discharged pus,
presenting the microscopic character of healthy pus. Thi3
enlargement of glands, however, did not occur in a suffi-
cient number of cases to make it a natural sequence of the
disease. Attending the early stages of the formation of
the ulcer, before pus was discharged, there was always
more or less pyrexia, with furred tongue and loss of appe-
tite ; these symptoms disappearing as soon as ulceration
was established. In these highly aggravated isases, suc-
cessive crops of pustules made their appearance on the
affected limb, often developing themselves also upon the
lower limbs of the affected side, but seldom crossing the
mesian line, and never developing themselves upon the
trunk or head.

The less malignant form of the disease resembled the
first in character, but not in degree. For a few days after
the insertion of the virus, merely a small inflamed spot
was discerned, which seemed to be more the result of the
injury done to the skin by the prick of the lancet than any
inflammatory action resulting from a specific cause.
About the fifth or sixth day a minute pustule was discerned
upon a scarcely larger inflamed base. This pustule and
areola gradually increased, but the diameter of the areola
was not as great, and there was no deep inflammatory
blush upon the arm, merely a diffused redness of several
inches in diameter. The same process, however, took
place an exudation of serum from the areola which, in
turn, became a crust, and which gradually increased in
size; but it never reached the diameter of the more
malignant type; and when it was detached by the process
of ulceration, which occurred at an earlier period, the

4 Habersham on Spurious Vaccination. [July,

revealed ulcer was neither as deep nor as malignant in its
appearance. The edges were not everted, and there was
no discharge of pus from under the edges of the ulcer ; it
only presented the appearance of an ordinary ulcer,
showing no tendency to increase, and but little to heal.
Pyrexia very seldom attended this form, nor was the
appetite impaired.

The third and mildest form of the disease made its
appearance as a small pimple, in from two to ten days
after the introduction of the virus, which gradually formed
a pustule ; a dark brown scab succeeded in from three to
four days, which remained attached sometimes as long as
two weeks, and when it become detached, a livid or brown
spot was revealed, the size of which was equal to the scab*
This scar, however, was very sensitive to the touch, and
liable to bleed from the least friction of clothing, and when
this occurred, it would exude serum or blood, and another
scab would surely form. If the system became suddenly
depressed from any cause, it would almost always assume
the ulcerative process, and become a sloughing ulcer,
which only healed with the general improvement of the
system.

As thus described, this disease has prevailed in the
Army of Virginia, both in field and hospital. The Sur-
geons of the Army of the Southwest, report its prevalence
there. It was developed, in the early part of the year, in
a Cavalry Regiment in the mountains of Virginia, the
Colonel commanding suffering severely from the disease.
In every case, its origin has been traced to the introduc-
tion of vaccine virus into the system. How far an epidemic
cause may have exerted its influence in its early develop-
ment, it is impossible even to surmise ; we know, however,
that it originated in Virginia, at a time when our Army
was upon very short rations, and that many of the soldiers
sent from the field at that time presented a decidedly

1866.] Habersham on Spurious Vaccination. 5

scorbutic appearance. Many had been reduced and were
broken down by exposure to the inclemency of a cold
Winter, and the depressing influences of low diet, want of
clothing, and many other prolific causes of disease, calcu-
lated to deprive the blood of its healthy constituents,
particularly of its fatty matter. Hence, this may have
produced a predisposition. In verification of this fact, I
will state, that when it was found how frequently the
disease m consideration supervened upon Vaccination in
this hospital in broken-down and depraved constitutions,
it was deemed prudent to postpone the introduction of the
virus until the patient was restored to a healthy condition
by improved diet and medical treatment. At the first
appearance of the evil consequences of Vaccination, I was
inclined, with other Surgeons, to believe that the virus
was impure, and, because of this suspicion, I threw away
the matter we then had, and obtained a vaccine scab from
Dr. Knox, a practitioner on Church Hill, who assured me
he had used it in several cases with a perfect result.

The introduction of this virus into the arms of some ten
patients resulted in the development of the disease in
question in three of them, while in the remainder it pro-
duced apparently a true pustule. From this fact, and the
immunity which healthy looking men enjoyed, I was led
to believe that the predisposing cause existed in a vitiated
and impoverished condition of the blood, and so reported
in my first report, and that the introduction of pure virus
into the system was the exciting cause of a latent disease.
This view, I see, is also held by Surgeon Frank A. Ramsey,
of the Department of East Tennessee, in a communication
on file in office of Surgeon General. This view I have
never had reason to change, though I am aware that
many men, apparently in health, have suffered from the
effects of Vaccination. *

In one case, which I here quote, the influence of a good

6 Habersham on Spurious Vaccination, [July?

condition of the general system seems to have exerted a
wonderfully modifying influence.

Case No. 29. J. L. Turner, a private, Company G, Fifth
Virginia Cavalry, aged 27, married, parents healthy he
himself enjoying good health never had any venereal
disease. Entered the service, April, 1861 has been in
service ever since was vaccinated about a month ago,
when in Hospital at Farmville.

This patient, Turner, was vaccinated last Winter by
Assistant Surgeon Vaiden, of this Division. It not having
had any effect upon his system, and feeling assured from
this and previous Vaccinations that he was proof against
the effect of it, he insisted upon being vaccinated by
Assistant Surgeon Moses, from the effects of which he has
suffered since, and for which he was on the 8th September
admitted to this Hospital, presenting the following appear-
ance : A number of pustules, resembling Impetigo, on left
arm and leg, which were developed in successive crops,
appearing as soon as the original pustule began to heal.
This was a remarkably mild form of the disease, and was
improving on Cod Liver Oil, when he was furloughed on
the 20th September, being a paroled prisoner. This
patient was young, vigorous, and comparatively healthy,
when he received this Vaccine into his system.

The search, for parasitic or cryptogamic vegetation, with
a good microscope, revealed none. The pustule was
seldom developed where Parasites make their habitation,
namely, in the bulbs, or at the roots of the hair. The pus
presented microscopic characteristics of pus globules float-
ing in a homogenous fluid. These globules were not as
abundant as in laudable pus, and not so distinctly nucleated,
and were irregular in outline in some of the cases exam-
ined. This appearance of pus globules, however, often
exists in healthy or laudable pus, when it has been exposed
to the air any length of time. In the many cases I have

1866.] Habersham on Spurious Vaccination. 7

examined, I have yet to find a patient who will acknowl-
edge that he has had any Syphilitic disease at any period
of his life, though many of them have had Gonorrhoea.
This exemption from Syphilis, however, is not strange,
since it is a very uncommon disease in the rural parts of
our country, the inhabitants of which comprise the very
large majority of our Army. We also know the tendency
of the secondary form of Syphilis is to develope itself in
the forehead, chest, back, and trunk, generally, and yet no
cases, developed upon these parts of the body, have pre-
sented themselves to my observation. Many of the
patients, also, have suffered long enough to have had the
tertiary form of Syphilis developed nodes, etc., and yet no
such symptoms have been seen by me.

From what I can learn, the Army of the United States
has so far escaped these evil results of Vaccination. A
few eases, however, originated among the Federal officers,
in the Hospital of Libby Prison, who were vaccinated in
the Prison by one of their Surgeons from his own arm,
some weeks after their confinement, which presented all
the characteristics of the disease as it has appeared in our
Army. I was assured by these officers that they had
neither seen or heard of such a result of Vaccination in
their Army. Does not this fact alone lead us to infer that
its cause or origin may be traced to some abnormal condi-
tion of the blood, in these cases, induced by confinement
in a vitiated atmosphere, without the means of eliminating
the materies morbi from the system by exercise, and care to
the* function of the skin?

The classification of this disease is difficult and unsatis-
factory, since it commences as a Pustule, and assumes
often the outward form of Eupia, which, by all dermatolo-
gists is classified among the bullae. If we classify it among
the pustulse, we find no disease there describing it accu-
rately, some cases resembling Ecthyma, others Impetigo.

8 Habersham on Spurious Vaccination. [Jufy,

Inasmuch, however, as it oftener assumes the characteris-
tics of Chronic Ecthyma, either in a mild or aggravated
form, according to the healthy or unhealthy condition of
the patient,. I propose to name it Vaccine Ecthyma.
Like all chronic cutaneous diseases, it shows a decided
tendency to return whenever the system becomes reduced
from any cause, or when the patient is exposed to causes
which produce an undue action in the circulation of the
capillary system. An undue amount of exercise in warm
weather seems to excite its appearance. This was illus-
trated in those soldiers supposed to be thoroughly cured,
and who were about to be ordered to their Regiments for
duty, when a raid was threatened, in the month of July,
upon the City of Richmond. These men were among the
volunteers from the hospital to defend the city, and were
marched through a hot sun some four miles to the lines at
the extreme limits of the western end of the town. They
returned with a new crop of pustules, which, however,
healed by resolution in a short time.

Treatment There is every reason to believe that the
disease results from a blood disease, only to be eliminated
from the system by enriching the blood and supplying its
deficiency of fatty matter with rich nutritious food and the
judicious use of alteratives. It is vain to treat the ulcers
locally, for without alterative treatment with nutritious
diet, all the local applications which were tried seemed to
aggravate rather than improve them ; but as soon as the
general condition began to improve, so did the ulcers,
The milder cases began to improve a few weeks after
admission, without any treatment, except dietetic, in con-
junction with the Iodide of Potash, Syrup Iod. Ferri, and
Sarsaparilla ; in others, merely applying simple dressing
to the ulcers, was found sufficient to subdue it. Under
this treatment, all the cases gradually, but slowly improved.
In the early part of August^ we received a large supply of

1866.] Habersham on Spurious Vaccination. 9

Cod Liver Oil, and I was thus enabled to test fully the
treatment which the supposed cause of the disease natu-
rally suggested. Some few of the patients could not
digest the Oil, but those who could began rapidly to
improve, and many were well enough on the 18th of
August to return to their Regiments, whilst others were
thought well enough to be transferred to their respective
State Hospitals, in compliance with an order issued at that
time. Those who were unable to digest the Oil, continued
the Syrup Iod. Ferri, which was thought the best alterative
indicated in their cases. Their improvement was scarcely
perceptible. In the early part of September, however,
another effort was made by them to take the Cod Liver
Oil, which they were enabled to do in a little Whiskey ;
their improvement soon became very evident to them-
selves, and though not yet entirely well, the ulcers are
rapidly granulating. !No new pustules are being developed,
and the patients are in a fair way to recover. I have no
doubt that the best remedy has been found in the Cod
Liver Oil ; and this, locally applied, and internally admin-
istered, with an entire change of air, and nutritious diet,
will remove, and eventually eradicate, this obnoxious and
filthy disease from the system.

From the above mentioned facts, I am led to draw the
following conclusions : That the disease is pustular at its
first appearance ; that it resembles Ecthyma in its general
character ; that it is but a local manifestation of a general
disorder, or vitiated condition of the blood; that this
vitiated condition resulted from improper and spare diet,
together with inattention to cleanliness, thus impairing the
eliminating functions of the skin ; that Syphilitic virus has
had no influence in producing the disease ; that the morbid
effects have in most of the cases resulted from a deficiency
in condition, independent of any imperfection in the
Vaccine Virus ; that the disease can only be removed by

10 Habersham on Spurious Vaccination. [July,

those means calculated to improve the general condition,
and restore the healthy play of all the functions.

Summerville, April 28th, 1866.

Dr. Joseph Jones, Augusta

Dear Sir: The above report of an anomalous dis-
ease, or result of vaccination, was written shortly after
its first appearance in the Army of Northern Virginia,
and after a careful study of the cases especially assigned
to the Hospital under my charge for "treatment and
report." At the time there was much discussion among
the Medical Staff, both in Field and Hospital, as to the
aetiology and pathology of the manifestation which by
some, and, indeed, most of the observers, was attributed
to impure virus, and especially syphilitical inoculation.
This latter opinion was very ingeniously advocated by
Surgeon Breckinridge, and no doubt many cases may
have resulted from such an accident. In none of the cases,
however, assigned to my Division of Chimborazo Hospital
could I discover a sufficient number of symptoms to lead
me to suppose that such might have been the cause, either
in its prodroma or development, hence I could not
attribute the cause of the eruption to any other than that
assigned in the report. This view as to its aetiology was
subsequently very ably maintained by Surgeon Frank A.
Ramsey, in a report referred to me by Surgeon-General
Moore, and which was preserved among my papers, but
lost at the time of the evacuation of Richmond, together
with the history of all the cases, and diagrams intended
to illustrate the above report. In consequence of the
loss of these papers this report is not as perfect as it
should be ; but I hope the general description and history
of the disease is sufficiently clear and comprehensive to
embrace every thing of practical importance concerning

1866.] Eead's Report on Wounds of Large Joints. 11

this horribly disgusting and filthy accident, or result of
vaccination, as seen in our army.

Since the termination of the war, I have had several
opportunities of conversing with a few intelligent Sur-
geons of the Federal Army, and ascertained from them
that such a disease had appeared among their soldiers in
regions of the country where the scorbutic diathesis
manifested itself among the troops, and to which the
disease was generally attributed by them, though there
were also Surgeons of that army who attributed it to
syphilitic inoculation. I find the same view as advanced
in the above report held by most of the Surgeons of
the Federal Army, as stated in Circular No. 6, Surgeon-
General's Oflice U. S. Army, November 1, 1865.

If you think the above report of sufficient importance
to appear upon the pages of your journal, or if it can in
any way advance the cause of medical knowledge, you
are at perfect liberty to make use of it for that purpose.
With much respect, I remain,

Very truly, your obedient servant,

S. E. Habersham.

article II.

JReport on Wounds of Large Joints made to the " Confederate
States Association of 'Navy and Army Surgeons" Rich-
mond, Va., 1864. [By J. B. Read, M. D., Surgeon in
the Provisional Army of the Confederate States.]

Your Committee approach the consideration of the
subject proposed, "A Report on the Wounds of the
Large Joints," fully impressed with its importance to
Military Surgery, and with many misgivings as to their
ability to add anything new, or of consequence to the
knowledge that already exists on the subject. They are,
however, encouraged by the hope that if the records of
the Military Surgery of the war, at this date, do not

12 Read's Report on Wounds of Large Joints. [July,

afford any very useful statistics as to these serious injuries;
that the very knowledge of the want of accurate and
complete reports of cases will direct the attention of
Surgeons in the Confederate States Army to making
investigations of Hospital case books and records of the
past, and to the keeping of minute and accurate notes of
all such cases for the future.

The records in the Surgeon-General's Office, collected
and tabulated by Surgeon Sorrel, from the Surgical
Registers, sent in monthly, and the special reports of cases
of interest, have been thoroughly studied, and such
information as could be derived from them will be found
collated in this report. Beside the records, we have
called on Surgeons in charge of Hospitals, in and around
the city, for the records of their experience, which will
also be found embodied here. In the coming campaign
of the Spring and Summer of 1864, it is to be hoped that
such records of cases will be obtained as to settle defi-
nitely by statistics many points of great importance, and
which the material on hand necessarily leaves imperfect,
and perhaps erroneous. It may thus happen that some of
the ideas now promulgated as to the treatment of these
wounds may be faulty ; should such be the case, none will
be more glad to be so instructed than your Committee,
for our sole desire in this report is the advancement of
Military Surgery, and the benefit and welfare of our
fellow men.

It is a matter of surprise in looking over cases of such
important and grave injuries as those of the large joints,
to find how little attention has been given to details of
moment, and how loosely the reports seem to be strung
together. In many records, the peculiar nature of the-
wounds; what tissue was particularly injured; whether one
or all the bones entering into the formation of the articu-
lation, with their articular cartilages, were implicated ;

1866.] Read's Report on Wounds of Large Joints. 13

whether the foreign body inflicting the injury remained
lodged in the joint or passed through, or whether the
Synovial Sack itself was alone injured, are all absolutely
ignored in the description of the cases. In other cases
we are at a loss to know if the wound was produced by a
round or conical ball, or by some cutting instrument, the
date of the setting in of constitutional disturbance, the
time that suppuration began in the joint, the method of
treatment pursued ; whether incisions were made prima-
rily, secondarily, or at all, into the joint; whether warm
or cold applications were employed; whether blood-letting,
general and local, was resorted to ; and in those cases
which resulted well for the patient, the length of time
demanded for the cure, and the condition of the joint as
to the future utility of the limb, are entirely neglected.
In the larger number of cases recorded, no mention is
made as to whether they resulted in ankylosis or in good
or partial motion. They are generally recorded in this
fashion : Private A, Company B, of such a Regiment,

wounded date, part injured. Recovered, fur-

loughed..

These cases thus reported are worse than useless, for
they lead us to suspect that only the cures being thought
wonderful, are reported; while the fatal cases have no
report made of them, that result being the only one
thought likely to occur. This will explain to the Asso-
ciation the rather extraordinary tables that have been
compiled from the Surgical Register, which certainly
presents some astonishing features. It may be true that
figures don't lie, but in order to make this correct, there
should be true record of every case of Joint Wound that
has occurred during the war, and not of the cures alone.

The joints of whose injuries we shall treat are the
diarthrodial, or those lined with synovial membrane.
They consist of the orbicular or ball and socket joints,

14 Read's Report on Wounds of Large Joints. [July,

and the hinge joints ; under the orbicular, we meet with
the shoulder and hip articulation; and of the hinge, the
elbow, the wrist, the knee, and the ankle. The wounds
inflicted on the joints of the upper extremities tend more
generally to a favorable result than do those of the
inferior. The simplicity of construction, and the smallness
of the articulating surfaces of the orbicular joints give
them decided advantage over the more complex hinge
joints. These articulations consist of various tissues and
membranes, which all act in modifying the inflammatory
process, and the diseases that arise in them from traumatic
or constitutional causes. The constituent parts are the
synovial membrane, cartilage, bone, ligament and invest-
ing fibrous capsules.

The synovial sack is the part most generally involved,
and which, either primarily or secondarily plays the most
important and often most destructive part in its diseases
and injuries.

This is what a careful consideration of its physiological
properties lead us to expect, for the more vascular, living
organs are, and the greater the extent in which they are
employed in secreting, the more liable they are to de-
rangements of this function and inflammatory engorge-
ments. These membranes are of extremely fine and thin
structure, and are composed of epithelium and a fibrous
envelope to which they owe their strength ; between these
is the connective tissue, in which ramify numerous blood
vessels and nerves. The membranes are arranged in the
joints as short, wide tubes, the open ends of which are
reflected in upon themselves, and firmly united with the
articular cartilage near its border, or rather to its envelop-
ing perichondrium, having previously invested the bone
and made connection with its periosteum. "Wliere it
adheres tp the bone and soft parts it has great vascularity ;
but when it is reflected over the articular cartilage it is

1866*] Read's Report on Wounds of Large Joints. 15

thin and easily torn, and few if any vessels can be demon-
strated in it The synovial sack is really a serons mem-
brane like the pleura and peritoneum, and resembles them
in its function and uses. Certain flattened folds are often
found just where the membrane unites the articular
cartilages, and are denominated its vascular processes.
The fluid secreted by this membrane is in health barely
sufficient to lubricate the joints; it is clear and yellowish,
thick and tenaceous, producing a sticky feeling when
rubbed between the fingers. It consists of water 94.8,
mucus and epithleum 0.5, fat 0.7, albumen and extractive
matter 3.5, and salts 0.9. The result of the inflammation
produced on this membrane by wounds is precisely the
same that occurs in the serous membranes from the same
cause. The membrane contiguous to the injury first
becomes conjested and reddened, there is evident increase
of vascularity, and less of its peculiar shiny satin-like
appearance. The fluid within the sack under this hyper-
aemic condition becomes altered in character and increased
in quantity, it becomes thin and serous, and has floating
about in it effused plastic material. In a few cases,
especially of incised wounds, the inflammation may stop
here; but in a majority of cases where the lesion is pro-
duced by a ball, or by a blunt weapon, or when there is a
passage-way for the entrance of air, the inflammatory
process goes on to an unfavorable issue. The congestion
and vascularity of the synovial membranes increases, it
becomes finally echymosed, and this condition results in
the pouring out of a thin purulent fluid. The contents of
the joint becomes enormously enlarged and -turbid, the
cells take on degenerative action, and pus is formed.

Under this inflammation of the membrane, other struc-
tures of the joint take on the process of disintegration ;
the articular cartilage becomes thin, soft, and ulcerated,
and the articular facets of the bone become involveda

16 Bead's Report on Wounds of Large Joints. [July,

The acrid and offensive contents of the sack making their
way through these ulcerated points, pass up through the
cellular interspaces of the muscles. This destructive
synovitis of joints' in many cases ends by the death of the
patient, or in the total loss of the use of the articulation.
The ends of the bones entering into the formation of the
joints are covered by a whitish elastic tissue, the articular
cartilage, one end of which is firmly united to the bone,
and the other free in the cavity of the joint. This is
covered over its edges by a membrane continuous with
the periosteum, and called, from the tissue and its envel-
opes, the perichondrium. It is with this membrane that
the synovial sack has such intimate connections that they
cannot be separated. These cartilages are composed of a
clear hyaline matrix filled with corpuscles, containing
other cells and nuclei. These corpuscles are arranged in
parallel lines. Near the bone the cartilage has a hard,
calcified layer, called the articular lamella. ~No blood
vessels or nerves permeate the substance of artificial
cartilages, they are extra vascular, and are nourished by
the vessels of the vascular folds of the synovial mem-
brane, that project into the cavity of the joint, and by the
tortuous convoluted and sinus forming vessels that exist
in the cancellated structure of the epiphysis entering into
the formation of the articulation ; these lie directly under
the articular lamella of the cartilage. This calcified
lamella has the power of transmitting nutritive fluids from
the blood to the cartilage corpuscles and cells, by endos-
mosis, and this force continues between the individual
cells of the tissue itself. Cell life, is active and persistent
in articular cartilage, their own peculiar changes for
effete material and the reproduction of new are constantly
going on, and the nutritive plasma for this is derived from
the vessels of the bone, and from the "plicae vascular" of
the synovial membrane. As articular cartilage possesses

1866.] Read's Report on Wounds of Large Joints. 17

no blood vessels of its own, but depends entirely for its
nutrition upon those of its two adjoining tissues, any
change in these must seriously interfere with its well-
being. It is probable, however, that cell changes of
increase and diminution continually at work within them,
may produce changes of structure, and thus in many cases
the cartilage may degenerate into bone, or be softened and
disintegrated by ulceration. It is probable that, cartilage-
like, the similarly nourished tissue, the cornea, may easily
take on the ulcerative process.

Weber distinctly asserts that cartilage suppurates.
Having no blood vessels of its own it cannot take on the
true inflammatory action. The ulceration in articular
cartilage, always in wounds of joints, begins from the free
surface; under the influence of this process the cells
break up, and the tissue crumbles away by granular dis-
integration, and leaves the articular ends of the bone
free, and frequently covered by granulations which are
prone to unite with others, and thus produce ankylosis.
This is ordinarily the method of repair in joints destroyed
by synovitis, by the pouring out of exudative plasma from
both surfaces of the bones, and then being united by the
coalescence of these together. The diseased conditions of
the articular end of the bones in the joints are only of
importance as they produce changes in, and affect the
condition of the articular cartilages and the synovial
membrane. In acute affections of the joints, such as
those induced by Gun-shot Wounds, the fibrous capsules
and the ligaments are not apt to be affected. They may
soften and become elongated, or separated from their
insertions, thus permitting the dislocation of some of the
bones of the joint. They are only important pathologi-
cally in these cases, because of their dense unyielding
structure, they retain and refuse exit to the accumulated

fluids in the sack. Two tissues, therefore, the synovial
2

\

18 Read's Report on Wounds of Large Joints. [July,

membrane and the articular cartilage, are principally im-
plicated in wounds of joints, and it is to their peculiar
action under the excitement of violence, and when brought
into contact with air, that many, if not all, the destructive
results of such wounds are directly attributable. Injuries
to the bone, save insomuch as they are connected with the
destruction of form and usefulness of the articulation, and
the extension of inflammation from these two mentioned
tissues, does not modify or exert any specific importance
in the phenomena that arises.

The acute and destructive inflammation of the tissues
forming a joint or membrane is called Traumatic Arthritis.
It differs from ordinary acute arthritis, which may like-
wise be destructive to the parts affected, in this : in trau-
matic arthritis the disease begins from the centre of the
articulation ; and in simple acute arthritis it starts from
the periphery. In the one it commences first by the
inflammation of the synovial membrane ; in the other, in
the bone or surrounding tissue. The danger in these
traumatic cases is much augmented by the presence of air
in contact with the living membrane of the joint. This
acts as an irritant to the sack, causes it to become en-
gorged, and pour out a thin, reddish secretion, which
rapidly becomes acrid and putrescent, and is mixed with
flocculi of fibrin and blood. From the rapidity with which
this secretion, when the over-distended sack has given way
and its contents permitted to permeate through the boun-
daries of the joint into the meshes of the intermedullary
ariola tissue, produces destructive consequences in the
parts it comes in immediate contact with, it seems to have
some peculiar irritant property. It is to this property of
the inflamed membrane of rapid hypersecretion of a
copius and easily putrescent fluid, that in most cases the
great danger in joint wounds are due. This action of air
on the sack and its secretions is established by the fact

1866.] Read's Report on Wounds of Large Joints. 19

that in many cases of injury to the joints by external
force, in which no air is admitted, although the actual
injury to the articulation may be great and extensive, still
no such results ensue as are wont to happen after a slight
wound in which air is admitted into the cavity.

Sir Benjamin Brodie, and other Surgeons, habitually
made valvular incisions into the synovial sack, to extract
loose cartilages from their interior; when this is done
carefully, and air not admitted, no evil consequences
result

In many operations for this purpose, the distinguished
Surgeon just mentioned, saw severe inflammation take
place in but a single case, and in this the synovitis yielded
to suitable antiphlogistic treatment, and no permanent
injury to the joint remained.

Traumatic arthritis presents numerous points of great
interest to the Surgeon. In many wounds of large
joints, at first neither pain or great inconvenience is
noticed. The articulation may be fairly opened, and
the synovial fluid escapes; the articular end of the
bones of the joint may be shattered, the epiphysis
of the Femur may be split off in the largest joint of
the body, the knee, and the patient experience little
shock, and will often walk some distance with ease- and
comfort; so little inconvenience in many cases is expe-
rienced, that the wounded man refuses to believe himself
seriously hurt, and, on this account, is unwilling to permit
the Surgeon to undertake such operative procedure as his
experience teaches him to be best and most suitable for
the safety of his life or the preservation of his limb. We
are aware, from a lamentable experience in these cases,
that as certainly as a Gun-shot wound into the articulation
exists, so surely will this traumatic arthritis supervene, and
at a period from the reception of the wound that is very
variable. It seldom occurs earlier than the first thirty-six

20 Bead's Report on Wounds of Large Joints. [Juryf

hours, and is often postponed until the tenth or thirteenth
day. This condition is ushered in by a chill, or rather
rigor, the pulse quickens, and becomes full and bounding,
the eyes are bright, and the cheeks flushed ; synchronously
with these constitutional symptoms, changes take place in
the injured articulation. The wound or wounds of the
joints, those of entrance and of exit, if the missile has
passed through, though previously looking healthy and
discharging laudable pus, become tumid and swollen,
the joint becomes enlarged, and a thin, reddish-brown
serum, with small clots of blood with fibrin intermingled,
leaks out from the external wound. The swelling in-
creases rapidly, the skin and the periarticular tissues
become tightly distended, red and engorged, the cutaneous
veins seem filled with dark blood, and can be easily felt
with the fingers, acute pain of a grinding character,
comes on rapidly. The slightest motion of the bed, the
slipping of a pillow, a heavy tread on the floor that gives
a jar to the patient, causes him to cry out. The sensa-
tiveness of the part is so great that he can illy bear to
have it touched or examined. The discharges soon
become mixed with globules of pus. This quickly aug-
ments in quantity, becomes acrid, offensive and putrescent,
and has a peculiar decomposed odor. The limb becomes
swollen and cedematous, and when pressed with the hand
has a feeling of crepitation caused by the passing under
pressure of the gasses retained in the part, that are
generated by the putrescent condition of the contents of
the synovial sack, through the meshes of the ariola tissue
connecting the muscles and forming their sheaths. The
constitutional symptoms stride apace with the local mis-
chief. The pulse becomes quicker and feebler, and rigors
followed by profuse sweats take place. There are nightly
exacerbations, marked by restlessness and profuse diar-
rhoea; abscesses form under the deep seated facia, and

1866.] Bead's Report on Wounds of Large Joints. 21

between the muscles of the limb, dissecting, in many
instances, the periosteum from the bone ; at a later period
more superficial deposits of pus collect under the integu-
ment, and between the outer layer of muscles, which thin
the skin and "point" in divers places.

In a greater number of cases where the larger articu-
lations are the seat of injury, hectic fever now supervenes,
and colliquative diarrhoea destroys the little remaining
strength, and hurries the sufferer to his end.

Sometimes, however, these abscesses break, and the
sinuses empty themselves of purulent contents, or when
opened by the knife of the Surgeon, discharge a large
quantity of putrescent pus ; and after months of patient
endurance and great suffering, the case recovers with a
limb, more often than otherwise, ankylosed in a faulty
position.

Sinuses leading from diseased and necrosed bone,
generally exist; and from the length of time consumed
in the treatment of the cases, and the natural desire of
both patient and Surgeon to place the limb in a position
that affords most ease and rest, this faulty ankylosis can
hardly be avoided, and the limb left is worse than none,
for it is a useless encumbrance.

In these cases the rapidity of the fatal issue, or the
tardiness of the protracted cure, depend mainly on the
surroundings of the patient, as regards nursing, attendance
and food; and more than all upon his age, strength of
constitution, and freedom from previous bad habits and
constitutional dyscrasia.

The collection of these purulent secretions in the tissues,
and the direction the abscesses that form under the facia
and in the ariola tissue of the intermediate interspaces
follow, seem to be controlled by the position of the
muscles, and their tendinous expansions as they are
inserted into the heads of the bones constituting the

22 Read's Beport on Wounds of Large Joints. [Julyy

articulations, and by the position that the part injured
must necessarily assume during treatment. In penetrating-
wounds of the shoulder-joint, the purulent depots are
sometimes found beneath the periosteum, but more often
external as far as the insertion of the deltoid in the
humerus. They are also found at the anterior and poste-
rior border of the axilla.

In some instances that have come under our observation
they have been found to extend over the chest, under the
pectoralis major muscle. The position of the arm in
these cases causes the pus to gravitate downwards. In
the elbow this dissection of the muscle by pus is down-
wards to the arm, for no matter how carefully the
wounded arm may be placed on the pillow or splint, unless
this be at a considerable elevation from the raised position,,
ordinarily assumed by the upper extremities whilst being
on a bed, and especially if the patient be walking about.
the fore arm and hand assume a general declination
downwards. In wounds of the hip-joint, this being the
most depressed point of the body in the bed, sinking as
it were in a pit, the purulent depot is around the tube-
rosity of the ischium, and near the trochanter major, and
the abscess will be found to point in the inner side of the
thigh near the insertion of the adductor muscles, or in
the groin, dissecting along the course of the iliacus
interims and psoas magnus muscles. In this case the
purulent matter often dissects up the periosteum from the
Femur for some distance, and is held in this position by
the deep fascia.

In the knee-joint unless the injury comes from the lower
part of the articulation, the head of the tibia being alone
penetrated by the ball, the pus invariably burrows
upwards, first dissecting the periosteum from the Femury
and destroying the ariola tissue connecting the muscles
under the deep fascia, afterward forming abscesses in the

1866.] Read's Report on Wounds of Large Joints, 23

more superficial muscles outside the fascia uuder the
integument.

In the anatomical formation of this joint, we must bear
in mind that two processes of the synovial sack or tube
extend up a little higher than the upper edge of the
patella; under the vasti muscles, especially under the
vastus internus ; we must recollect, also, how dense the
fascia is at the joint, and how closely the tendinous
expansion of the flexor and extensor muscles of the leg are
connected with the capsule of the joint as they pass over
and near it, to be inserted into the upper end of the tibia.

By referring to the pathology of the diseases of the
synovial sack inclosing the articular ends of the bones,
and the rapidity with which the covering cartilages take
on the ulcerative and degenerative process, and the close
and intimate connexion of the synovial membrane with
the perichondrium lining the outer edge of the cartilage,
and that the perichondrium is really nothing but the
extension of the periosteum, we can without much diffi-
culty, comprehend how, by the inflammation of this highly
vascular envelope of the bones, it would become loosened
as is its habit under this state of things, from the bone,
and thus permit the acrid and putrid contents of the
inflamed and disorganized joint to pass along beneath
and come in contact with the parts adjacent to it.

Moreover we have the testimony of so great a patholo-
gist as Weber, that cartilage itself suppurates in this way ;
when disintegration has taken place in it, the pus may
pass out of the cavity, and light up anew, destruction in
the tissues.

Penetrating wounds of the joints we have to treat of, may
be classed as those produced by cutting instruments, and.
those caused by missiles projected from modern imple-
ments of warfare by the explosive force of gunpowder.
The missiles usually employed in this war, and with the

24 Read's Report on Wounds of Large Joints. [Jul}7,

injuries inflicted by which on joints we have to do with,
are conical balls and shells. The wounds produced by the
fragments of these explosive iron cases may in some in-
stances be classed with incised wounds.

It will be well, perhaps, before treating directly of these
wounds into the joints, to spend some moments in dis-
cussing wounds in situations near, but not penetrating or
entering the synovial capsule. These wounds are called
"periarticular" by Liguest. They may be inflicted by
cannon or other balls, and may produce great destruction
of the soft parts near the articulation. If the case progress
favorably, no injury to the joint itself will ensue, except
that the cicatrices that form during the healing process
may have troublesome contractions, that interfere greatly
with the use of the limb. This danger should always be
borne in mind, and guarded against. Balls often pass in
the neighborhood of the articulations, and inflict no actual
injury upon them ; yet, at some time during the suppura-
tive period, traumatic arthritis will be lighted up, and run
through its course as fatally and rapidly as if the joint
had been first opened.

The inflammatory action excited in the parts after
the reception of the wounds, and necessary in most
instances for the healing of such injuries, extends to
the articulation. The synovial membrane becomes in-
flamed in some cases, but generally, we think, the dis-
integrating process is started in the articular cartilage,
by the inflammation that exists in the bone which
underlies it, and upon whose vessels and those of the
plicae vasculosae of the synovial membrane, it depends
for its nutrition. We can readily call to mind some
instances of this extension of the inflammation from the
neighborhood to the joint, and the subsequent traumatic
arthritis caused by this, followed either by the death of
the patient or the loss of the use of the articulation.

1866.] Read's Report on Wounds of Large Joints. 25

A private in the P. A. C. S., wounded at the disastrous
fight at Bristow Station, was received into the General
Hospital, JSTo. 1, in this city, under the charge of Surgeon
Charles Bell Gibson. The ball entered the leg, and
produced a compound comminuted fracture of the fibula
near its head ; after some days it was thought necessary
to excise the head of this bone ; shortly after this, the
patient had rigors, and grave constitutional disorder was
developed. The knee-joint became swollen and tender,
the thigh became cedematous and pitted under the
pressure of the finger ; there was a feeling of crepitus in
the parts. Traumatic arthritis had been developed, and
pus existed in the synovial membrane, and had burrowed
up the thigh.

Surgeon Gibson made free and bold incisions in the line
of articulation on each side of the joint leading from the
patella down to the hamstring muscles, a large quantity
of putrid purulent pus found exit through these incisions.
The articular facets of the bone were felt to be rough and
entirely denuded of their cartilages, the condition like-
wise obtained as to the articular facets of the patella.
The leg was put upon a posterior splint, padded so as to
fit into the hollow of the hams, and inclosed on the side
by bracketed splints, devised extemporaneously by Acting
Assistant Surgeon Howell Thomas, attached to the Medi-
cal Staff of the Hospital. The wound was kept constantly
washed from all offensive discharges, and the whole of the
articulation was freed from accumulations of putrid matter
by being injected with warm water; none of these
dressings required the displacement of the splint; from
this time the patient improved, and when last seen (when
he was transferred from this Hospital) was doing well.
\Ve have since learned that ankylosis had taken place.
The wound had nearly cicatrized, and there was every
prospect of a useful limb.

26 Read's Report on Wounds of Large Joints. [July,

The following report of a case seen by Surgeon Michel
and the Chairman of this Committee, is given as reported
by Surgeon Gravatt, in charge of Seabrook Hospital, in
this city. L. W. Wamsly. This man was wounded at
the battle of Gettysburg, and had his leg amputated
there, just above the ankle. He was held as prisoner
of war some length of time during the Fall. He was
transferred to this Hospital from ~No. 11, on the 15th
of December, 1863, in a very feeble condition ; nu-
merous abscesses had formed along the leg, and at the
time of his admission he had an extensive collection
of pus around the knee-joint ; this was immediately
opened, and discharged a large amount of fetid pus,
showing that it proceeded from a diseased condition of
the bone. He was put upon a tonic, nutrative and stimu-
lating plan of treatment, with a . view to building him up
sufficiently to bear amputation.

The Consulting Board, consisting of Surgeons Read
and Michel, were convened on the 29th, and decided upon
immediate amputation, which was performed by Assistant
Surgeon C. M. P. Brock, by the circular method, Surgeon
Michel compressing the femoral artery by digital pressure
against the pubis ; very little blood was lost, every thing
was as favorable as possible under the circumstances.

Upon an examination of the limb after amputation, it
was found that a portion of the shaft of the tibia, some
four inches long, which had been split off by the ball in
the first place, had been left in the first amputation, and
gave rise to all the subsequent disease, viz. : caries and
inflamed condition of the entire tibia, complete disorgani-
zation of the knee-joint, with carious condition .of the
articular surfaces of both the tibia and femur entering
into the formation of the joint. Chloroform was used
with the usual good effect, the patient rested tolerably
well, and spoke of feeling better than he had done for

1866.] Read's Report on Wounds of Large Joints. 27

weeks, but died in twelve hours after the amputation.
The disease of the joint in tins case, evidently originated in
the inflammation of the tibia. This condition of the bone
seriously interferes with the nutrition of the articular
cartilage, covering its head and thus producing degenera-
tion and ulceration, and by this means opened the articular
cavity. Had it been possible to recognize the condition
of the knee-joint before hectic fever had been established,
and free incisions made into the cavity of the articulation,
so as to give vent to the retained secretions, might not a
different result have been expected ?

Many wounds noted in Monthly Surgical Registers, and
entered as wounds of joints, are probably of this periar-
ticular character, and are not penetrating wounds of the
synovial membrane.

Lax and careless examinations of individual cases, that
seem to be doing well in large Hospitals, or immediately
after a battle, are too much the rule, and no special
attention is called to the case unless some serious dis-
turbance arises during its progress.

In wounds in the vicinity of large joints, especial
diligence should be employed in their thorough examina-
tion, for often, on the early knowledge of their condition,
the life of the wounded depend. In some cases there may
be an orifice of entrance and one of exit, at opposite parts
of the joint, and still the synovial membrane has not been
penetrated.

This may be readily understood, when we think how
often these injuries happen when the limb is strongly
flexed, the patient at the time having been in rapid motion
or movement, and when the limb is straightened, the
position of the wound would naturally lead us to infer
that the projectile has passed through the articulation,
when such is not really the case. Moreover, we know
that the conical ball in general use in modern warfare,

28 Read's Report on Wounds of Large Joints. [July.

though, it ordinarily goes with great directness of track
through the part upon which it has impinged, at times is
found to have deflected from contact with tissues, especi-
ally the fibrous, and have made a circular path for itself
around a limb or joint; this is more apt to be the case, if
in striking some substance before entering the tissue, the
ball will have been turned sideways or butt foremost.

The treatment of these periarticular wounds, where
they have been already decided to be so, and that they
have not involved the tissues of the joint, must be con-
ducted with the view of preventing the extension of the
inflammation to the capsule. In the examination of these
wounds the finger alone can be employed. The probe is
inadmissable, from the danger of its being pushed through
the delicate membrane. If the finger cannot be readily
introduced into the orifice of the wound to make this
exploration satisfactorily, the opening should be enlarged
freely and the practice of "debridement" thus resorted to.
The limb should be firmly and carefully fixed, in some
immovable apparatus, so devised as to permit the dressing
of the wound with suitable applications, and at the same
time to keep the articulation perfectly at rest. This can,
in the lower extremities, best be obtained by the bracketed
splint of Mr. Abernathy; or in field practice by the fitting
and adjusting Smith's anterior wire splint, bent into a
bracket, and fastened securely by a straight splint, the
piece between the bracket being sawed out. The wound
should be treated on general antiphlogistic principles,
constitutionally and locally ; cold dressings are peculiarly
suitable to these wounds, near joints, and may be em-
ployed, as ice in rubber bags or bladders, by constant
irrigation, or by the drip. In general, water of the tem-
perature of the nearest well or spring answers all pur-
poses, as well as any other.

The swelling of the tissue external to the capsules,

1866.] Read's Report on Wounds of Large Joints. 29

which is apt to come on, if painful, must be combated
with leeches or wet cups, the latter being probably of
more utility on account of the incisions that are made in
the skin, relieving tension. If only this condition of
swelling around the joint obtains, the constitution does
not seem to suffer, more than it ordinarily does, from the
febrile reaction that exists in most cases of Gun-shot
wounds of similar tissue, in other parts of the body.

During the treatment of these periarticular injuries, if
rigors, excessive constitutional disturbance, with sudden
swelling of the articulation, accompanied by acute pain,
and distention of the superficial veins of the integument,
should be developed, no time is to be lost, and free inci-
sions must be made directly into the articulation, thus
permitting all the putrescent contents of the sack to be
evacuated.

If doubt exists in the mind of the Surgeon wThether pus
be in the cavity of the joint, an exploring trocar may be
employed, by first drawing aside the skin, so as to make
a valve to exclude the air, if the cavity be not diseased.

The joint being thus opened, and air freely admitted
into contact with the already diseased synovial membrane,
profuse suppuration must ensue, terminating in the total
destruction of the membrane, and the disintegration of
their articular cartilages. Our attention during the period
must be turned to supporting the patient, by nutritious
diet, and to modifying the character and diminishing the
quantity of purulent discharges.

[To be concluded in next.]

30 Doughty on Ligation of the Subclavian. [July,

ARTICLE III.

Report of two cases of Ligation of the Subclavian Artery. [By
Wm. H. Doughty, M. D., Augusta, Gfa.]

Private Jacob H. Kittrell, Co. D, Third Tennessee
Regiment, C. S. A., was admitted July 15, 1863, into
Walker's Division Hospital, at Lauderdale, Miss., having
suffered an amputation of the right arm as near the
shoulder-joint as it was possible to perform it, without
involving it. This operation wTas performed on the 12th
of July, near Jackson, Miss., for a Gun-shot Wound
sustained in an action of that date. His general condition
was good, and the stump healing kindly. At midnight
of the 20th JTffy a slight hemorrhage occurred, which
was controlled by pressure.

At this time adhesion between the flaps was firm, and
the ligatures upon the axillary artery and most important
branches had not come away.

The hemorrhage recurred profusely at 10 A. M., 28th
July, whereupon the patient was placed upon the table
for the purpose of ligating the subclavian artery ; but at
the instance of consulting Surgeons it was determined to
try the expedient of continued digital compression over
the point at which the blood escaped. This was faithfully
practiced, night and day, by a relay of assistants, until 6
A. M., 2d of August, when the bleeding again took place.

An attempt was then made to separate the flaps and
secure bleeding vessels, but firm adhesion had long since
taken place, and it was found impracticable to secure it
without too great violence to the structures.

The only alternative was the ligation of the subclavian
artery ; which was adopted, the ligation being applied at
its external third. The plan of operation was by an inci-
sion parallel to the upper margin of the clavicle, and
subsequently by a slow dissection with the aid of a director

1866.] Dougiity on Ligation of the Subclavian. 31

down to the vessel as it crosses the first rib. During the
operation, the patient lost perhaps a pint of blood from
the stump, notwithstanding the pressure employed to
restrain it, in consequence of which it became necessary
to administer stimulants freely. After the application of
the usual dressings he was put to bed, and his condition
on the succeeding day, August 3d, reported as follows :
Has high irritative fever ; is slightly nauseated ; coughed
up a clot of dark blood this morning, but had several
hours of sleep during the night; stump is swollen, hot
and painful.

Treatment. Irrigation to the stump ; warm water enema
to open the bowels. Diet, beef tea and eggs.

August 4th. Patient has less fever ; is quite comfort-
able, as well as cheerful. General treatment continued,
and perfect rest enjoined.

August 6th. Patient rests well; is inclined to eat;
pulse 96 ; respiration 24 ; stump looks healthy, and the
local inflammation is subsiding. Treatment continued.

August 15th. Patient continues to do well ; pulse and
respiration quiet ; appetite good.

August 25th. Is still improving ; is gaining flesh and
strength ; stump is quite healed ; ligature to subclavian is
still apparently firm, not yielding to gentle traction.

September 4th. Ligature came away to-day ; the gene-
ral condition of the subject is as good as could be desired.
He was furloughed on the 25th September, and started
for his home in Tennessee.

Remarks. The success of this case is attributable to
the robust constitution of the individual. The early and
firm adhesion between the flaps of the stump, even after
they had been forcibly torn asunder to secure possibly the
bleeding vessel, shows that his blood was rich in plastic
material.

Note. "We were afterward informed by Surgeon Daniel

82 Doughty on Ligation of the Subclavian. [July,

F. Wright, who performed the primary operation on the
field, that an unusual number of ligations were applied at
the time, and from the size of these vessels he was led to
apprehend the occurrence of secondary hemorrhage.

Case 2. Private Jonathan W. King, Co. C, Twenty-
ninth N. C. Regiment, was admitted October 5th, 1863,
into Second Georgia Hospital, Augusta, Ga., with a Gun-
shot "Wound of the right shoulder, received September
19th, 1863, at the battle of Chickamauga. Sixle3n days
had elapsed since the receipt of injury, and at the time
that our relations with the case commenced (8th October,
1863), the wound was very much inflamed, and discharg-
ing profusely ; the entire limb was greatly swollen, with
a serous infiltration and a diffuse inflammation of the
parts, neither strictly erysipelatous, nor yet resembling
ordinary phlebitis ; there was no evidence of continuous
infiltration of pus downward from the wound ; no enlarged
lymphatic glands ; no enlargement and induration of the
venous trunks. We ascribed the condition of the limb to
an inflammation of the lymphatics (anguoleucitis).

Character and precise location of the Wound. The ball
entered anteriorly near the coracoid process of the scapula,
passed directly through the joint, fracturing the head and
surgical neck of the humerus, and emerged opposite the
spine of the scapula.

All operative interference being at this time inadmissi-
ble, the arm was moderately bandaged ; irrigation to the
shoulder ordered, and quinine and opium administered to
subdue irritative fever, relieve pain, etc.

At 11 P. M., October 10th, the patient doing tolerably
well in other respects; hemorrhage occurred from the
anterior orifice of the wound, which was soon arrested ;
but at 9 A. M., of the succeeding day, it gushed from both
orifices so abundantly as to forbid reliance upon anything
short of a ligature. With a comminuted fracture of the

1366.] Doughty on Ligation of the Subclavian. 33

humerus, and the state of the soft parts already cited, it
was entirely impracticable to open at all the seat of injury ;
hence it was deemed best to ligate the subclavian artery
and await the progress of events for further interference
at the proper time, at the joint

Accordingly, at 1 P. M., of October 11th, a ligature was
cast around this vessel at its external third ; the difficul-
ties, to say nothing of the danger of the operation, were
much increased by the anomalous position of the subcla-
vian vein ; instead of being in front of (but beneath) the
artery, it was above it, and required to be held aside for
the ultimate exposure of the vessel. At 3 J P. M., two
hours after the patient was put to bed, there was no pul-
sation at the wrist, and the limb was quite cool ; it was
enveloped in cotton ; and opiates, with strong beef tea,
ordered as the general treatment.

October 12th. The natural warmth of the limb has
been restored; its capillary circulation is good, but no
pulsation at the wrist can be detected; the inflammation
and swelling of the arm are unabated; copious discharge of
bloody pus from the wound ; pulse is irritable and fre-
quent. Treatment, Brandy, quinine and iron. Nutritious
diet.

October 13th. The inflammation of the arm, particularly
about the elbow, where suppuration seems imminent, has in-
creased ; no pulsation at the wrist ; pulse is irritable and
frequent. Treatment continued.

October 14th. Pulse 90 ; patient is more cheerful, but
has a slight diarrhoea ; no pulsation at the wrist ; inflam-
mation of the limb unchanged. Treatment continued.

October 16th. No material improvement ; no pulsation
at wrist ; arm suppurating at the elbow ; pulse 98 ; diarrhcea
controlled. Treatment. Free incisions for the discharge
of the pus, and Tine. Iodine (diluted), locally; general
treatment continued.
3

34 Doughty on Ligation of the Subclavian. [July,

October 17th. Had a severe chill at 9 A. M. ; pulse 92 ;
diarrhoea returned ; arm subsiding. Add 10 grs. quinine
to usual treatment.

October 19th. Another chill this morning; extreme
restlessness through the night ; pulse frequent and feeble.
Hospital gangrene invades the posterior orifice of the
wound. Treatment. Increase the stimulants.

October 20th. Gangrene appears in the wound, caused
by the operation; at 9 J A. M., an oozing hemorrhage
occurs from this wound ; continued two hours ; patient is
evidently sinking. Treatment. Brandy and ammonia.

October 21st. Died at 2 P. M. ; no further hemorrhage.
An autopsy was made at 4 P. M. ; Hospital gangrene had
invaded both wounds ; at the seat of operation, the sub-
clavian artery was corroded at the superior part of its
cylinder, where the knot of the ligature rested, but the
other part was firm, and apparently undiseased. The
axillary artery was intact, showing that the hemorrhage
took place from some of its branches, but in the confused
gangrenous mass, it was impossible to ascertain the pre-
cise vessel.

Remarks. From the nature of the wound in this case,
it is evident that a resection of the head of the humerus
should have been performed upon the field ; at the time
of his admission into the Hospital, the condition of the
wound and limb precluded the possibility of surgical
interference. There was no alternative but to await a
favorable moment for a secondary resection or amputa-
tion ; to this end, means were adopted to abate the local
inflammation, and sustain the strength of the patient. In
the meantime, the hemorrhage occurred, adding greatly
to the complication of the case.

By ligating the subclavian artery, it was hoped that
three purposes would be subserved directly and incident-

1866.] Doughty on Ligation of the Subclavian. 35

ally, i. e. : 1st, The control of tlie hemorrhage temporarily,
perhaps permanently. 2d, It would not interfere with the
performance of the prospective operation, provided morti-
fication of the limb did not ensue speedily from an
arrest of its circulation, a contingency not very likely to
follow on account of the already existing enlargement of
the collateral vessels about the shoulder. And, 3d, By
diminishing the supply of blood to the inflamed parts,
a reduction of the inflammation would be produced in a
short time, and the propitious moment for the operation
at the joint hastened.

The hemorrhage was arrested, but no effect in the
reduction of the inflammation ensued. It was not, how-
ever, increased. In all probability, if Hospital gangrene
had not attacked the wound; on the 19th, by the time the
ligature came away it would have been practicable to
perform the other operation. There were a number of
cases of Hospital gangrene in the house at the time, but
every precaution was taken to prevent its appearance in
this case ; everything except his removal from the Hos-
pital was done, and this was at the time rendered imprac-
ticable, by circumstances over which we could exert no
control. He died from this incidental disease before the
ligature had time to come away.

At the time that this case was under observation, we
had read with much interest the chapter on hemorrhage
contained in a Manual of Military Surgery for the C. S.
Army, published in 1863, and issued from the Surgeon-
General's Office. It is understood that Surgeon H. F.
Campbell, formerly of this city, but then having official
relations with the Georgia Hospitals at Richmond, was
the author of that essay. We confess to a great interest
in that portion of it which refers to the "incidental benefit"
hoped for from " experimental effort to cure the inflammation
in a limb by cutting off its arterial supply, by ligation of the

36 Dugas' Lecture on Suppuration. E%fy?

main trunk which supported that inflammation." (Page 103f
Manual of Military Surgery C. S. Army.)

The several cases there alluded to in which this expe-
dient was adopted, presented almost parallel complications
secondary hemorrhage and inordinate local inflamma-
tion with the one then on hand; and the success of
the experiment in those cases fully justified its adoption.

The effect upon the inflammation was not, however, as
hoped, in those reported by him. He says : " In all of the
six cases the Hunterian operation was chosen, with the
distinct end in view of combating and checking, if possibler the
destructive progress, and, in some, the septic tendency of the
inflammation. In all of these, the pain, the swelling and
turgescence were almost immediately relieved, and the
most remarkable change was soon presented, as seen in
the character of the discharges. (See Note, page 104.)

In the case reported above, it failed to produce any such
results.

+

ARTICLE IV.

A Lecture on Suppuration. By L. A. Dugas, M. D., Pro-
fessor of Surgery in the Medical College of Georgia, at
Augusta.

The term Suppuration is employed to denote the pro-
cess by which pus is formed, whether upon or beneath the
surfaces of the body. More modern writers have used
the word pyogenia or pyogenesis, to convey the same idea,
and we may find it convenient to do likewise, by way of
variety.

But, before we proceed to an explanation of this
process, let us see what are the characters, physical,
chemical, and microscopic, of the fluid called pus. In
order to do so understanding^, however, we should re-
member that the term is often loosely applied to fluids

1866.] Dugas' Lecture on Suppuration. 37

presenting very different peculiarities, and we should
therefore confine our description to that alone which is
denominated laudable pus, by which we simply mean pure
pus pus unmixed with extraneous elements.

Bad pus, sanies, or ichor is thinner than good pus, its
color greenish, grayish, or brownish, its odor is more or
less fetid, and it sometimes resembles an oily, mucous, or
serous fluid, somewhat modified by the materials it con-
tains. Pure pus may be obtained from acute abscesses,
or well-conditioned ulcers in process of healing, and such
as occur in habits not unduly depraved. It will then be
found to be a homogeneous fluid of the color and consis-
tency of fresh cream, presenting a yellowish-white tin4,
opaque, somewhat sweetish or insipid, usually more or
less inodorous, and slightly unctuous or tenacious. It is
a little heavier than water, and will therefore settle at the
bottom of the vessel in which these two fluids have been
mixed, and then allowed to be at rest. It may be coagu-
lated by heat, alcohol, or hydrochlorate of ammonia, and
will resist putrefaction for some time. When pus is
allowed to stand at rest, it separates into two parts ; the
one, opaque and dense, occupying the bottom of the
vessel, and the other, more liquid and transparent, floating
above.

The chemical composition of true pus is variously stated
by different observers. Gueterbock found in pus taken
from a mammary abscess the following constituents :

Water 86.1

Fat, soluble only in boiling alcohol 1.6

Fat and osmazome, soluble in eold alcohol 4.3

Albumen, pyine, pus globules and granules, soluble neither in hot nor

cold alcohol 7.4

Loss 0.6

100~6

But the discrepancies observable among authorities on
this subject evince still so much uncertainty in organic
chemistry that I will at once proceed to the consideration
of the microscopic appearances.

38 Dugas' Lecture on Suppuration. [July,.

Much attention has been bestowed upon the microscopic
examination of pus, whether pure or modified by pertur-
bating influences, or by the presence of extraneous
materials. Upon placing pure pus under the microscope
it is found to consist of a thin, colorless and transparent
fluid, called liquor puris, in which may be seen floating
small spherical bodies, termed pus globules, or pus corpus-
cles. These are cells, whose diameter is estimated to be
from two to three thousandth part of an inch, and which
contain distinct nuclei. Their outline is irregular, and
more or less rugged, but when the pus is mixed with a
little water some of these cells appear to become distended
by imbibition, and assume a more regular shape. Their
nuclei, which appear to be numerous and not in contact
with each other, are found, upon the addition of acetic
acid, to become more distinct, to coalesce, and to vary in
number from one to three or four, and sometimes more.
The specimen should therefore be successively examined
by itself, then with water, and lastly with acetic acid.

Besides these nucleated globules, pus often presents
still smaller particles, called granules, estimated to be not
more than the ten thousandth part of an inch in diameter,
and which are considered by some as rudimentary cells,
while others regard them as fragments of broken cells,
or as particles of fibrin, having no relation to the cells.

Such are the microscopic appearances of laudable pus,
the pus globule constituting its essential peculiarity. As
the suppurative process deviates, however, from the
normal standard, we find the product correspondingly
affected, and the microscope may then reveal the presence
of fragments of disintegrated tissues, withered or shriv-
elled cells, fatty matter, blood corpuscles, fibrinous shreds,
etc. The character of the liquor puris may also vary, as
well as the relative proportions of this and of the solids it
contains. Pus coming from secerning organs may be

1866.] Dugas' Lecture on Suppuration, 39

mixed with, the secretions; hence, it may contain bile,
urine, semen, etc., the presence of which may be readily
detected by the microscope. That derived from specific
diseases will contain the contagious element peculiar to
each ; but as this does not change its microscopic appear-
ance, it may escape detection.

The purulent discharge from ill-conditioned ulcers,
especially those connected with diseased bone, or those of
a cancerous nature, is, not unfrequently, denominated
sanies or ichor. It is thin, sometimes fetid, and often
more or less excoriating to the surface over which it may
flow. It often contains fibrinous flakes, grumous blood,
and other detritus.

Carbuncles, diseased joints, etc., give rise to a thick
lead colored pus, combined with lymph, which is some-
times called fibrinous pus ; and scrofulous pus will not
unfrequently be found to contain tubercular matter,
besides shreds of cellular tissue and curdy flakes. In-
flammation of the mucous surfaces yields an admixture
of mucus and pus, which is therefore called muco-purulent
pus} and which has served to perplex very much those
who have sought to establish a distinction between mucus
and pus. We now know that it is not necessary that the
pulmonary mucous surface should be in a state of ulcera-
tion to furnish pus globules, and hence their presence does
not possess the important diagnostic value formerly
attached to them in the investigation of pulmonary
affections.

With the graphic diagrams before you, representing the
microscopic appearance of laudable pus, and of pus modi-
fied by the various circumstances to which I have referred,
you are now prepared by an examination of other dia-
grams to see the difference between them and blood,
milk, tubercular matter, cancerous matter, etc. You will
observe that the blood corpuscles are much smaller than

40 Dugas' Lecture on Suppuration. [July,.

the pus corpuscles, and present a very different appear-
ance. "When pus and blood are commingled, however,
the pus globules are apt to be so masked that it requires
very nice discrimination to detect their presence if in
small numbers. The globules of milk and of tubercular
matter are also smaller than those of pus, and radically
different in appearance. The cancer cell, especially,
deserves your careful attention, and will be fully studied
when we come to treat of the class of affections to which
it belongs.

Pyogenesis. Having thus hastily, and perhaps, too
briefly, studied with you the nature and characteristics of
pus, I must beg leave to dwell a little longer upon the
important question of pyogenesis, or the mode and
mechanism of suppuration. How is pus formed ? Is it
formed at the expense of the surface upon which it is
found? Does it exude already formed from the blood
vessels ? Is it the result of an act of secretion, similar to
that which takes place in secerning organs ? or is it not a
substance formed on the surface upon which it occurs,
out of materials poured upon it by the capillaries ?

Pus is not formed at the expense of the surface upon which
it is found, because this would lead necessarily to a loss of
substance, which does not always attend suppuration,
however abundant it may be. Suppuration of the skin
may occur and be abundant for an indefinite length of
time without loss of substance. It is true that the cuticle
will be elevated, dissolved, or otherwise destroyed by the
suppurative process; but this coating, you know, pos-
sesses no vitality, and should, therefore, not be taken into
consideration in studying the morbid vital act of suppu-
ration. Whenever a suppurating surface or locality
evinces a loss of substance, this is in consequence of the
disintegration of the tissues, which nutrition fails to
reproduce. Inasmuch as the particles which constitute

1866.] Dugas'* Lecture on Suppuration. 41

our tissues are continually disintegrating and being
replaced by new nutritive deposits, it follows that any
impairment or suspension of the great function of nutri-
tion in any given locality, must of necessity be attended
with a loss of substance. No loss of substance can take
place so long as the processes of disintegration and of
nutritious deposit keep pace with each other. If disinte-
gration be in excess, there will be loss of substance, and
if nutrition be in excess, there will be hypertrophy. The
act of suppuration has, in itself, therefore nothing to do
with the loss of substance which sometimes accompanies it.

Does pus exude from the blood vessels ready formed ? It
has been long known that pus contains all the elements of
blood, with the exception of its coloring matter, and also
that pus is often found ready formed within blood vessels.
The mere fact that pus contains most of the elements of
blood, only shows that many of its constituents are derived
from the circulation ; but we should bear in mind that
pus contains peculiar characteristic globules which do not
belong to blood, and which are generally admitted to be
too large for transudation through the pores of the blood
vessels. Admitting then, that the elements of pus are
derived from the blood, we must also concede that they
have to undergo some change before they can constitute
pus. This change being brought about after the exuda-
tion of the blood elements, must necessarily take place
outside of the blood vessels, and the pus cannot therefore
be said to exude ready formed from the blood vessels.

It is true that pus is frequently found within blood ves-
sels; but in these cases the pus is introduced into the
vessels of a suppurating locality in consequence of acci-
dental or ulcerative opening of their walls, thus allowing
the pus to enter them without difficulty ; or it may be
formed upon the lining surface of the blood vessels under
the same influences and in the same manner as it is

42 Dttgas' Lecture on Suppuration. , [July,

produced upon tlie serous membranes elsewhere. There is
no reason why suppurating inflammation may not occur
just as well in the internal coat of arteries, veins, and
lymphatics as upon any other surface of the body. In
such cases pus would be found in the blood, but would
not escape from its vessels unless these were opened by
ulcerative or other process, for as I have already observed,
pus corpuscles are too large to exude through the vascular
coats.

With regard to the theory which assimilates suppuration
to the act of secretion as this occurs in the liver, kidneys
and other secerning organs, and to which Hunter lent the
sanction of his great name, I would remark that secretions
are the products of organs specially constructed for the
purpose, that they are the result of physiological action
under the influence of special nervous supplies, and that
it is not safe either in physiology or in pathology to admit
that a secretion can be formed in any other way, or by
accidental causes. Secretion is a complex act, by which
certain elements are taken from the blood and recombined
so as to give rise to a new product. The liver does not
separate bile, as such, from the blood, although it un-
questionably derives from this source the materials which
go to to form the bile and we have no good reason to
believe that bile can be formed by any other organization
than that peculiar to the liver. And yet we are asked to
admit that pus, a peculiar and well defined product, may
be secreted by organs and tissues the most dissimilar, and
never in the physiological condition of the parts, but on
the contrary always under the influence of morbid action.
Pyogenesis is essentially a morbid act, and should there-
fore not be confounded with those which are strictly
physiological.

We now come to the consideration of the last question,
and I repeat it: Is not pus a substance formed on the surface

1866.] Dugas' Lecture on Suppuration. 43

or in the locality in which it occurs, out of materials poured
upon it by the capillaries f This view lias been advocated
by many able pathologists ; but they differ with regard to
the manner in which the change is effected, and predicate
their belief upon theories more or less groundless. To
James Paget, of London, was reserved the honor of solv-
ing the question by direct observation, and by the exer-
cise of that rare inductive discrimination which charac-
terizes all his investigations. In his Lectures on Surgical
Pathology, delivered at the Royal College of Surgeons of
England, we find his views most beautifully unfolded, as
he passes from the consideration of the repair and repro-
duction of injured and lost parts, to the study of the
materials for the repair of injuries, the processes by which
wounds are repaired, and finally to suppuration and the
perfection of scars.

We are reminded of the correctness of Mr. Hunter's
declaration that " injuries done to sound parts are of two
sorts, according to the effects of the accident. The first
kind consists of those in which the injured parts do not
communicate externally, as concussions of the whole
body, or of particular parts, strains, bruises, and simple
fractures, which form a large division. The second con-
sists of those which have an external communication,
comprehending wounds of all kinds, and compound frac-
tures. The injuries of the first division, in which the
parts do not communicate externally, seldom inflame;
while those of the second, commonly both inflame and
suppurate." Paget then states that " the healing of open
wounds may be accomplished by five different modes,
namely : 1. By immediate union ; 2. By primary adhe-
sion; 3. By granulation; 4. By secondary adhesion, or
the union of granulations ; 5. By healing under a scab.
The repair of subcutaneous wounds may be effected by
immediate union, but is generally accomplished by con-

44 Dugas' Lecture on Suppuration. [July*

nexion, or the formation of bonds of union between the
divided and retracted parts. Very rarely it is effected by
means of granulations without suppuration." " Of these
modes, it is the peculiarity of the first, or process of im-
mediate union, that it is accomplished by the mere union
or re-joining of the divided parts, without the production
or interposition of any new material. In all the others,
new material is produced and organized." Now this new
material is called lymph, or coagulable lymph, the essen-
tial vital property of which is " its tendency to develope
itself; a tendency which it has of its own properties. It
thus displays itself as a plasma or blastema ; a fluid to be
classed with those others that manifest the capacity to
assume organic structure ; such as the lymph and chyle
that develope themselves to blood, and the semen, which,
at first fluid, gradually developes itself into more and more
complex structures.

" The natural tendency of coagulable lymph is to de-
velope itself into the fibrous, or the common fibro-cellular
or connective tissue the lowest form of vascular tissue,
and the structure which, in nearly all cases in man, con-
stitutes the bond by which disunited parts are again
joined,"

" The development of the fibro-cellular or connective
substance through nucleated cells may be observed in the
material of granulations, or in that of inflammatory
adhesions (whether in a serous sac or in a wound healing
by primary adhesion), in inflammatory indurations, and in
the naturally developed fibro-cellular tissue of many parts.
The process is, with slight and apparently not essential
modifications, the same in all.

" The cells first formed in granulations are spherical,
palely or darkly nebulous, from about l-1800th to l-2500th
of an inch in diameter. They contain a few shining,
dark-bordered granules, and lie imbedded in a variable

1866.] Dugas' Lecture on Siqopiiraiion. 45

quantity of clear pellucid substance, by which they are
aeld together, and which it is hard to see, unless acetic
xcid be added. When water is added, it penetrates the
sells, and as they swell up their walls appear more distinct,
md their contents are diffused. Some cells thus become
nauch larger and clearer, and show in their interior nume-
rous vibrating molecules ; others display fewer molecules,
rat a distinct, round, dark-bordered nucleus, which appears
ittached to the inside of the cell- wall. Such a nucleus is
'arely seen in granulation-cells, unless they are distended
frith water ; acetic acid, acting more quickly than water,
jrings the nucleus more evidently and constantly into
flew, and often makes it appear divided inte two or three
portions."

Having with much minuteness detailed the process of
aealing by granulations, Paget concludes as follows : "But
.et me add, that although one may so clearly trace in the
development of granulation-cells, and in the end which
; :hey achieve by the formation of fibro-cellular tissue and
i suticle, an imitation of the natural processes and purpose
! 3f the corresponding developments in the embryo, yet is
there a remarkable contrast between them, in regard to
the degrees in which they are severally liable to defect or
error. We can scarcely find examples of the arrests or
errors of development of mere structure in the embryo ;
but such events are quite common in the formation of
granulations, as well as of all other new products. All
the varieties in the aspect of granulating wounds and
sores, which the practiced eye can recognize as signs of
deflection from the right way of healing, are so many
instances of different diseases of the granulating sub-
stance ; diseases not yet enough investigated, though of
much interest in the study of both the healing process
and the organization of new products in inflammation.

? A comparatively few observations enable one to trace

46 Dugas' Lecture on Suppuration. [July?

morbid conditions of these new structures, closely answer-
ing to those long known in the older and more perfect
tissues. Thus, one may find simply arrested development
of granulations ; as in the indolent healing of wounds and
ulcers, whether from locally or generally defective condi-
tions. Herein even years may pass, and the cells will not
develope themselves beyond one or other of their lower
forms. There is probably a continual mutation of parti-
cles among such cells, as in common nutrition; or they
may increase, as in growth ; but no development ensues,
and the wound or the ulcer remains unhealed.

"In other cases, the cells not only do not develope
themselves, but they degenerate, becoming more granu-
lar, losing the well-marked characters of their nucleus,
and acquiring all the structures of the pus-cell ; thus are
they formed in the walls of fistuke and sinuses. Or, worse
than this, the granulation-cells may lose all structure, and
degenerate into a mere layer of debris and molecular
substance. Thus they may be found on the surface of a
wound for a day or so before death or exhaustion, or in
erysipelas, or fever ; and in this state they are commonly
ejected when a granulating wound ulcerates or sloughs.

" With more active disease, granulations become more
turgid with blood, or aedematous : such are the spongy
masses that protrude beyond the openings leading to dis-
eased bone, or, they inflame ; and abundant large inflam-
matory granule - cells are found among their proper
structures, or, they suppurate internally, and purulent
infiltration pervades the whole mass.

" All these are among the many hindrances to healing ;
these are the dangers to which the healing by granulations
is obnoxious; it is the proneness to these things that
makes it even slower and more insecure than, in its
proper course, it might be. And these are all instances
of a class of changes which it is most important to study

1866.] Dugas' Lecture on Suppuration. 47

for exactness in morbid anatomy. I mean the diseases of
the products of disease."

" The formation of granulations is not necessarily
attended with the production of pus. I have already
referred to this fact when speaking of the formation of
sub-cutaneous granulations, such as are sometimes seen
on the end of bones that do not unite, in the ordinary
way, after simple fractures. Mr. Hunter also expressly
describes these cases ; and the same kind of granulations
without suppuration may be sometimes seen springing
from the ulcerated articular surfaces of bones, in cases of
diseased joint without any external opening. However,
when granulations are formed on an open wound, there
is always suppuration. "

"Pus not distinguishable from that of granulating
wounds is formed in many 'other conditions; as in in-
flamed serous and mucous cavities, and in abscesses. But
the histories of all cases of the formation of pus concur,
with that of suppurating wounds, to the conclusion that
pus may be regarded as a rudimental substance ill-devel-
oped or degenerated ; as a substance essentially similar to
the materials of granulations, or of the lymph of inflam-
matory exudation, but which fails of being developed like
them, or, after having been developed like them to a
certain stage, degenerates.

"To illustrate this relation between the pus and the
granulations of healing wounds, I may state that the last
figure (in the illustrations) was copied from sketches that
I made, at the same time, of some granulation-cells from
the walls of a sinus, and some pus-cells from a healthily
granulating wound. I chose those sources purposely, that
I might be able to compare ill-developed granulation-
cells with well-constructed pus-cells ; and a comparison of
them showed that, whether as seen without addition, or
as changed by the action of water and acetic acid, they

48 Dxjgas' Lecture on Suppuration. [July,

were not to be distinguished from one another. Had I
*not seen the vessels in the tissue that the granulation-cells
formed, I might, in the first examination, have almost
thought I was deceived in thinking they were not pus-
cells. The six varieties of the appearances of the cells
which are represented might have been taken from either
source; so might some other varieties; but these may
suffice to show the apparent identity of structure between
well-formed pus-cells and ill-developed or degenerate
granulation-cells, such as are found in the walls of sinuses
and the like half-morbid structures. I do not mean to
say, generally, that granulation-cells and pus-cells cannot
be distingued ; for between well-formed granulation-cells,
such as are found in healing wounds, and any particles
that are usually found in pus, certain distinctions are
almost always manifest. The pus-cells are darker, more
and more darkly, granular, more various in size, and more
various, not in shape, but in apparent structure, more
often containing numerous particles, like fatty molecules,
more rarely showing a nucleus when neither water nor
acetic acid is added, and much more commonly showing
a tripartite or ill-formed nucleus under the action of the
acid. None, however, of these characters is indicative of
essential difference; and between even the widest ex-
tremes there are all possible gradations, till distinction is
impossible ; so that when you place, as I have often done,
ill-developed or degenerate granulation-cells, on one side
of the microscope-field, and pus-cells on the other, there
is not a form of corpuscle on the one side which is not
repeated on the other.

" From this, one cannot but conclude that the cells of
pus from wounds are ill-developed or degenerate granula-
tion-cells. Some of them may be degenerate, i. e., they
may have been, as granulation-cells, attached for a time
to the surface of the granulation-layer, and having lived

1866.] Dugas' Lecture on Suppuration. 49

time, may, in ordinary course, have been detached and
shed, as epithelial cells are from healthy surfaces. They
may be thus detached after more or less degeneration, and
hence may result some of the modifications that they
present. But some pus-cells, I imagine (at least in the
healing of wounds), may be ill-developed; that is, im-
perfectly formed of material which exudes from the sur-
face of the granulations, and which, being exposed to the
air, or being too remote from the supply of blood, cannot
attain its due development, and, in an imperfectly devel-
oped state, is soon cast off. It cannot but be that organi-
zable matter is constantly oozing from such a surface as
that of granulations; but the conditions into which it
enters on that surface are such as are very likely to hinder
any but the lowest or some imperfect organization.

" The many characters of imperfection or of degene-
racy that pus-cells show, accord with this view ; such as
the general imperfection of their nuclei; the frequent
abundance of fatty-looking granules in them ; the large
quantity of fatty matter that analysis detects in pus ; and
the limitation of the cells to certain forms, beyond which
they are never found developed, though none of these
forms is more highly organized than that of the youngest
or most rudimental granulation-cell.

" A further confirmation of the opinion that pus-cells
are ill-developed or degenerate granulation-cells, is fur-
nished in the cases, to which I shall hereafter refer, in
which pus-cells are produced after, or together with,
inflammatory lymph-cells ; as in abscesses, inflamed mem-
branes, and the like. Now such lymph-cells are not
distinguishable in apparent structure from granulation-
cells, and, like these, they may show every gradation of
form to that of the pus-cell.

" But it is not only in the cells that we may trace this
appearance of the degeneracy or incomplete development
4

50 Dugas' Lecture on Suppuration. [^7?

of pus. It is equally shown in the fluid part, or liquor
puris, which, unlike the intercellular substance of granu-
lation and inflammatory lymph, is incapable of organiza-
tion, even when, by evaporation or partial absorption, it
assumes the solid form. The liquor puris answers to the
solid or organizable blastema of granulations; and as
undue liquidity is among the most decided marks of ill-
formed pus, so the abundance of the blastema, in propor-
tion to the cells, is one of the best signs that granulations
are capable of quick development,"

I have thus freely quoted from the work of Paget, in
order that I might give you his views in his own lan-
guage. I could have substituted none more concise and
graphic, and I think that you will agree with me that he
has satisfactorily demonstrated that pus is not formed at
the expense of the surface upon which it is found ; that it
does not exude already formed from the blood vessels ;
that it is not the result of an act of secretion ; but that it is
really formed on the surface upon which it occurs, out of
materials poured upon it by the capillaries.

It would now be interesting to determine whether any
good end is attained by the formation of pus, or, in other
words, what are the uses or purposes of suppuration. We
may understand that the tender granulations may be
somewhat protected by the pus, especially if this be of
good character and be permitted to form a scab by drying.
But beyond this I can conceive of no good it can accom-
plish. In abscesses and phlegmonous inflammations it
would rather seem to constitute the disease, and, as such,
can hardly be regarded as salutary, unless by the visionary
advocates of an obsolete pathology, who considered all
discharges beneficial, by eliminating supposed impurities
of the blood. It is true that when splinters or other
foreign bodies are introduced into the tissues, a process
of elimination is set up, characterized by suppurative

I860.] Dugas' Lecture on Suppuration. 51

Inflammation and ulcerative destruction, by which an exit
is made for the extraneous material. But, even in these
cases, the formation of pus is only incidental to the other
acts of inflammation, and the expulsion of the offending
object might be secured by the liquified detritus of broken
down tissues, without necessarily involving the formation
of any genuine pus,

"With regard to the effects of suppuration upon the
healing of wounds, ulcers, etc., it must be obvious, that,
inasmuch as pus results from an abortive attempt at the
organization of granulations, these must be retarded in
their evolution in a direct ratio with the quantity of pus
formed. Without this interrupted organization there
would be no pus formed. Hence it is that any course by
which we may impede the formation of pus, must favor
the development of granulations, and vice versa, by pro-
voking suppuration we must retard granulation.

The materials constituting pus, being confessedly de-
rived from the blood, and we may add, from the most
important elements of the circulating mass, it follows that
the quantity of pus daily discharged must be the measure
of the tax upon the blood to which the patient is sub-
jected. And, if it be true that the daily loss of even a
small quantity of blood must ultimately impair the
general energies of the system, we have the ready
solution of the problem of the injurious effects of long
continued suppuration. . The hectic fever, night sweats,
emaciation, diarrhoea, loss of appetite, etc., which so often
accompany extensive or protracted suppuration, all clearly
indicate the radical injury done to the great pabulum of
life. The patient has to contend with the combined in-
fluence of the irritation attending inflammation and of the
drain upon the circulation, which is thus being continually
impoverished. Hence the difference between the effects
of this drain, and those of daily or often repeated hem-

52 Dugas' Lecture on Suppuration. [July,

orrhage, by which the patient may be rendered anemic
without hectic fever and its concomitants. Instances in
illustration of this difference very often present them-
selves in individuals affected with bleeding hemorrhoids,
who lose more or less blood almost every day. Their
whole system testifies to the injurious effects of such re-
peated loss of blood ; they become anemic and all their
energies are impaired in proportion to the degree of
anemia ; but they have very few of the symptoms which
characterize the injurious effects of protracted suppu-
ration.

Another element of constitutional injury arising from
suppuration, is to be found in the fact that pus, or some
of its combinations, occasionally find their way into the
circulation, so as to contaminate it to a greater or less
degree. It has often been argued that pus cannot be
absorbed, because its cells are too large to pass into the
veins or lymphatics, unless these be opened by accident
or diseased action. This may be true, and yet these pus-
cells may themselves become dissolved or otherwise de-
stroyed, so as to enter the circulation in this altered
condition; or portions of the liquor puris, which is not
amenable to this objection, may become so vitiated as to
give rise to injurious consequences when absorbed. Now
the degree of poisoning to which the blood is thus exposed
may, and probably does, vary from the slightest to the
most overpowering effect. Hence it is that, while suppu-
ration, even considerably protracted, may exist without
seriously implicating the general condition of the system,
there are instances in which hectic fever is induced, and
others in which the purulent infection, so called, proves
speedily fatal; the victim dying with all the symptoms
of blood poisoning by animal matter.

While the beneficial effects of suppuration are therefore
very problematical, it is quite evident that the formation

1866.] Dugas' Lecture on Suppuration. 53

of pus is fraught with mischief in very many instances,
and that it should be regarded as a disease demanding our
most serious attention. Instead of yielding to the popular
error, that suppuration is necessary to the process of heal-
ing, we should, on the contrary, look upon it as one of its
injurious complications, and endeavor to lessen it as much
as possible, if we cannot altogether prevent it; we should
also use such means as may prevent it from assuming the
condition of a poisonous material which may contaminate
the whole economy. Let us recollect that pus is the result
of an abortive attempt at organization, and that, when
once formed, it may, more or less readily, undergo the
putrefactive process; and we shall at once perceive the
propriety of a resort to antisceptics, for the double purpose
of lessening the tendency to suppuration, and of prevent-
ing the decomposition of the pus after it has been formed.
Among the antisceptics of the Materia Mediea, there
are some which exert a much greater influence in lessen-
ing suppuration than others. It would perhaps be well
to designate these as anti-pyogenks, for the purpose of
drawing attention more forcibly to them than has hereto-
fore been done. As an anti-pyogenic, chloride of soda
(Labaraque's solution), stands pre-eminent. For some un-
accountable reason, that prepared by the French is incom-
parably superior to any made in the United States, and
should therefore always have the preference. The printed
directions which accompany the French bottles may,
however, lead into error with regard to the strength to
be used for lessening suppuration, as they refer principally
to the dilution proper in cases of mortification. I find
that half an ounce of French chloride of soda in a quart
bottle of water, will usually make a solution of the proper
strength for our purpose. A safe rule is never to make it
so strong as to be painful when applied; for if too strong
it will act as a powerful irritant, and increase, instead

54 Dug as' Lecture on Suppuration. [Tu1y,

of lessening, the suppuration; made of the proper strength,
the solution should be used as a wash, once or twice a dav,
and the lint of old linen used in dressing should be kept
wet with it.

A solution of alum (two to four grains to one ounce of
water), or of tannin (one or two grains to one ounce of
water), and the vegetable infusions containing tannin as
tae active principle, especially the red oak bark infusion,
will all be found beneficial but they must not be used
too strong. I have derived much advantage from the use
of tar water, which can be procured upon any of our
plantations. This is prepared by simply pouring a gallon
of hot water upon a gill of pine tar, and stirring it a little.
The water will soon become saturated, and may then be
used without farther dilution, in the same way as directed
for the diluted solution of chloride of soda. I may here
add that it is the best disinfectant I know of in hospital
gangrene, and altogether, I think, the best application.

In conclusion, I must urge upon you to watch the con-
dition of the system whenever you have to treat wounds
or diseases attended with suppuration, so as to detect the
first inroads upon the general stamina. The patient
should be sustained by good and nutritious diet, and any
constitutional deterioration should be promptly met by
tonics; the best of which, under such circumstances, is
the muriated tincture of iron. This should be adminis-
tered three times a day in doses of from twelve to fifteen
drops in a tumblerful of sweetened water. You should
give it thus largely diluted, in order that it may not offend
the stomach, as it would be very apt to do if given in a
more concentrated form. It may be taken either before
or after eating, as the patient may prefer. The tartrate
of iron and potash, so highly recommended by some, is apt
to act upon the bowels, and thus defeat our object. A
moderate allowance of malt or alcoholic liquor is usually

1866.] Jones' Notes on Hospital Gangrene. 55

beneficial, and always necessary in the treatment of those
addicted to intemperance.

P. S. Since the delivery of this lecture, I find that
Professor Polli, of Milan, has called the attention of the
profession to the treatment of zymotic diseases by the
alkaline sulphites; and the experiments made by him
with this new class of remedies, seem to indicate that
they would be of great value in purulent infection or
pyemia. Sulphite of soda is given in doses of thirty
grains, three or four times a day, in water. It is well
worthy of trial, especially as it is said to be perfectly
harmless.

article v.

Notes upon the History of Hospital Gangrene. By Joseph
Jones, M. D., Professor of Medical Chemistry, in the
Medical Callege of Georgia, at Augusta.

It is impossible to determine the time of the first ap-
pearance of Hospital Gangrene. The records of the
ancients furnish only negative testimony : that is, we are
not justified in asserting that this disease had never
appeared amongst the wounded of the immense armies
of the ancients, simply because a description is not pre-
served in the fragments of their writings which have
come down to us. Not only have many of the works of
the ancients been lost, but it would also appear, that
amongst some of the greatest nations of antiquity, it was
impossible that any accurate history of diseases could
have been written, because of the absence of both medical
science, and of physicians devoted to the treatment of
diseases. Thus Herodotus affirms, that the Assyrians,
even at the time of the greatest splendor and power of
the Babylonian Empire, had no physicians ; but were in
the habit of exposing the sick in the market place, that

56 Jones' Notes on Hosjntal Gavgrene. [July,

they might confer about their diseases with the passing
multitude. If the passers by had themselves been afflicted
with the same disease, as the sick person, or had seen
others so afflicted, they advised him to have recourse to
the same treatment, as that by which they escaped a
similar disease, or as they had known to cure others.
Herodotus also relates, that amongst that nation of the
Indians called Padreans, who were cannibals, it was the
custom when any one of the community was taken sick,
whether man or woman, for the nearest connections to
put the sick person to death; and they justified this
barbarous treatment, on the ground, that if the sick
person wasted with disease his flesh would be spoiled,
those attaining old age, were in like manner sacrificed
and devoured. Herodotus adds, that few amongst them
attained to the state of old age, for before the limit of life
wa: readied, every one had been destroyed in consequence
of some distemper.

Whilst it may be true, that in the early ages of the
world, there could not be much occasion for meulcal
science, on account of the simplicity of manners, and
plainness of diel1, aid temperance in meat and drink, and
tlu! active pastoral life of the first inhabitants; and that
as the world became more populous and the people were
gathered together in crowded cities, various epidemic
and contagious diseases appeared, which were before
urilvnpwn: at the same time, it is in like manner true,
thar, the texture and materials of construction and scarcity
of the clothing of the ancients, tended to the generation
and propagation of various contagious diseases, and es-
pecl illy of skin diseases. Reasoning from our present
knowledge of the mode of origin and propagation of
Hospital Gangrene, we are led to infer, that in equal
numbers of wounded in ancient and modern times, the
more vigorous constitutions and more simple habits of

1866.] Jones' Notes on Hospital Gangrene. 57

the former, as well as the custom of sleeping in the open
air, without tents or houses, would greatly tend to prevent
the occurrence of such diseases as Erysipelas and Hospital
Gangrene ; while on the other hand, the scanty supply of
suitable materials for dressing and cleansing the wounds,
would tend to promote the origin of these diseases, even
when the wounded were kept in the open air.

As far as our knowledge of the immense armies of the
ancients extends, we are led to believe that they were
subject to very much the same forms of fever, bowel
affections, and pestilence, generated by the collection
of large masses of human beings, which afflict modern
armies. Thus we find numerous allusions to the pestilence
amongst armies, and in beleaguered cities in the sacred
writings of the Hebrews; and Homer opens the Iliad
with an account of a fatal pestilence in the camp of the
Achseans, which sent many gallant souls of heroes to
hades, and made their carcasses a prey to dogs and birds
of prey. Herodotus relates that during the hasty retreat
of Xerxes from Thessaly to the Hellespont, a large
portion of his army perished from hunger, dysen-
tery, and pestilence. Pliny, in his " Natural History,"
refers to a disease, called by medical men, stomacace and
sceloturbe, characterized by loss of the teeth, and total
relaxation of the joints of the knees, which afflicted the
army of Csesar in his German campaign, and which from
its cause, symptoms, and method of cure, appears to have
been the scurvy. This disease appeared in a Roman
camp, beyond the river Rhenus, near the sea. The water
was brackish, and the only fresh water to be obtained,
was from a spring in the vicinity of the sea. The
habitual use of this water for two years, caused the loss of
the teeth and general debility. A remedy was discovered
in the plant known as the Britannica, which Spregnel and
Desfontaines identify with the Rumex aquaticus, and Fee

58 Jones' Notes on Hospital Gangrene. [July,

with the Inula Britannica, of Linnaeus. It is probable
that the Romans were not unacquainted with scurvy, and
with the best means of preventing this disease ; for they
are said to have constantly carried vinegar and wine with
their fleets and armies, and even the common soldier and
sailor daily partook of both. These facts are of interest,
for in modern fleets and armies, scurvy has often been
associated with the most dangerous forms of Hospital
Gangrene. We might multiply these examples by refer-
ence to the pestilential fevers which afflicted the Grecian
and Roman armies at various times, but our limited space
will not permit of farther illustration of the similarity of
diseases in ancient and modern armies.

The strongest argument against the ancient existence
of Hospital Gangrene, lies in the fact, which is well
established by the writings of the Hebrews, of Homer,
Herodotus, and many others, that notwithstanding the im-
mense armies of the ancients, and the immense slaughter
which took place in their battles, the dead being numbered
by tens and even hundreds of thousands, at the same time,
there were few or no wounded who survived the immedi-
ate conflict. The contending armies of the ancients came
to close quarters and engaged in desperate hand to hand
fights. In such contests, it was difficult, if not impossible,
to remove the wounded from the field of battle ; and as
soon as an adversary had wounded or disabled his an-
tagonist, he followed up his advantage, and did not desist
until his victim was slain and robbed of his armor.

The qualifications of the ancient warrior were very
different from those considered essential in modern times.
The rigid discipline and mechanical movements of modern
armies, appear to have been less practiced, if not unknown
in ancient times; and the success of the ancient warrior
depended chiefly upon his strength and presence of mind,
personal bravery, experience in the use of weapons, bodily

1866.] Jones' Notes on Hospital Gangrene. 59

strength and agility. The eye of the ancient warrior
acquired an animation, his countenance an expression of
fierceness and eagerness, and his voice a power and
variety of cadence, and his whole frame a degree of
athletic force and energy unknown amongst the com-
paratively sluggish and mechanical masses of modern
armies.

Thus Homer describes the Trojans, as advancing to
battle with a clamor and a shout, like the scream of
cranes, when fljing from winter and excessive rains, they
wing their way over the floods of Oceanus, carrying death
and destruction to the Pigmies; while the Grecians moved
on in silence, breathing forth valor; and as the south
wind spreads a mist upon the brow of a mountain, by no
means agreeable to the shepherd, but to the robber better
than night, in which a man sees as far only as he can cast
a stone, so rose the troubled dust under the feet of the
hostile hosts, as they rushed across the plain. "When
Alexander advanced in front of the Trojans, with the skin
of a panther on his shoulders, and shaking two brazen
spears challenged the chief of the Grecians to mortal
combat, Menelaus perceiving his adversary advancing
with long strides, rejoiced like a hungry lion, who lights
upon a huge carcass, and burning with revenge, leaped
from his car to the ground.

Again, in the second meeting of the hostile armies,
Homer compares the advance of the columns of the
Grecians to the rushing of waves upon a resounding
shore, which rising in the deep water, and urged on by
the winds, are dashed against the shore, roaring and
swelling and curling around the rocks. When advancing
on both sides, the armies meet, the spears and bossed
shields and brazen corselets are dashed together; the earth
flows with blood, and the shriek and the shout of the
slaughtering and slaughtered warriors mingle together

60 Jones' Notes on Hospital Gangrene. [July,

as when the torrents of winter rolling down the steep
mountain from their vast sources, pour together their
foaming waters in some lake, within the hollow glen.

The description by Homer, of the personal conflicts of
the individual warriors, still more forcibly illustrates the
deadly and ferocious nature of ancient battles, and explains
the reason of the disparity between the wounded and the
slain. The Grecian Antilochus, was the first who slew a
Trojan warrior his brazen spear struck the cone of the
helmet crested with horse hair, and pierced the helmet
and bone within. Elephenor, the leader of the Abantes,
seized Echepolus by the feet as he fell, and dragged him
from amongst the weapons, that he might plunder him of
his armor ; but his eager efforts were short, for Age nor
seeing him dragging the body, thrust his brazen spear
into his side, which was uncovered by his shield as he
stooped. Over the dead body of Elephenor, the Trojans
and Grecians rushed upon each other like wolves, and
engaged in deadly strife. Here the Telamonian Ajax,
with his spear, struck upon the breast near the right pap,
Simceisius, a noble and vigorous youth, and the brazen
spear went to the opposite side through the shoulder.
Antipus, a son of Priam, then hurled his sharp javelin at
Ajax, and missing him wounded Leucus, the comrade of*
Ulysses, as he was dragging the body of the youthful
warrior to the other side, and the body dropped from his
hands, and he fell upon it. Then Ulysses, enraged on
account of the slain, armed in glittering brass, advanced
amongst the foremost combatants, and threw his shining
spear, which struck Democoon, a bastard son of Priam,
upon the temple, and the brazen point passed through the
other temple, and his armor rang upon him as he fell with
a crash. Hector and the foremost warriors then giving
way, the Argives loudly shouted, dragged away the dead
bodies for plunder and rushed forward. After the Trojans

1866.] * Jones' Notes on Hospital Gangrene. 61

had been rallied by Apollo, who had been looking on
from the Citadel of Troy, the battle was renewed with
increased fury. Perios the leader of the Thracians,
hurled a large rugged stone which struck the right leg of
Diores, near the ankle, and crushed the tendons and
bones. As Diores fell in the dust, with both hands
stretched out to his comrades, Perios rushed upon him,
and plunged his spear into his bowels, so that all his
entrails gushed out upon the ground. Thoas, the ^Etolian,
rushed upon Perios, and drove his spear through his
breast into his lungs, and jerking the spear from his
breast, and drawing his sharp sword, plunged it into his
belly, and in turn deprived him of life. But Thoas did
not strip his fallen foe of his armor, for the Thracians
closing over the dead body, drove him back.

And in a similar manner Homer describes the fierce
and bloody contests of many other of the Grecian and
Trojan heroes, and has thus given a graphic, and as far
as the testimony of other writers extends, a truthful pic-
ture of ancient battles.

It appears, therefore, that in the battles of former times,
few or no wounded survived, and the prisoners which
were captured, were either immediately destroyed or sold
as captives. In the wars carried on between the Israelites
and the surrounding nations, persons of rank* were fre-
quently reduced to the most degrading slavery, some
prisoners were put under saws and harrows of iron, and
made to pass through the brick kiln, others were beheaded
or mutilated in various ways, mothers were murdered
with their children, pregnant women were ripped up, and
infants were dashed against the stones. And amongst the
Romans, prisoners were frequently sold to the infamous
schools for gladiators.

The time at which regular army Surgeons were first
employed, as well as the date of the establishment of

62 Jones5 Notes on Hospital Gangrene.,.. [July,

Hospitals, for the treatment of wounded and siek gene-
rally, are points of interest in the discussion of the origin
of Hospital Gangrene.

With the Hebrews as well as among the Egyptians, the
art of healing was committed chiefly to the Priests.
Moses, who was reared in the Court of the Prince of
Egypt, and instructed in all the knowledge of the wise
men, and of the learned Egyptian Priesthood, has left a
most valuable monument to the history of medicine. The
writings of this great law-giver and statesman, contain
hygienic rules of the highest sagacity designed to regu-
late not only the intercourse of the sexes, but also to
prevent the origin and spread of contagious diseases
amongst the hosts of Israel. As the Hebrew Priests ac-
companied the armies to battle, it is probable that their
ministrations to the wounded were of a physical as well
as of a spiritual nature. The careful precepts of the
Hebrews regarding cleanliness, in all, whether healthy or
diseased, as well as the free use of oil and wine on
wounded surfaces, would appear to have been eminently
calculated to favor the speedy recovery of the wounded,
without the supervention of the diseases which so often
infest modern Military Hospitals. The instructions of
Moses, regarding the signs of the leprosy, and other
contagious diseases, and the measures to be adopted to
prevent their origin and spread amongst the people, are
certainly most accurate and minute. Many of the ex-
pressions of the sacred writers, as those of Job, indicate
that they were acquainted with unhealthy and even gan-
grenous sores and wounds ; and some of these descriptions
would apply with force and accuracy to the severest forms
of Hospital Gangrene.

That physicians frequently accompanied and ministered
to the leaders of armies, at an early period, may be estab-
lished by many facts* Thus Homer, in his account of the

1866.] Jones' Notes on Hospital Gangrene. 63

wounding of Menelaus by the barbed arrow of Pandarus,
represents the King Agamemnon as calling for a Surgeon
to probe the wound, and apply medicaments to allay pain.
Machaon, son of the famous JSseulapius, who in response
to the call of Agamemnon, extracted the arrow, squeezed
out the blood, and sprinkled upon the wound soothing
medicaments, winch Chiron of old had kindly given to
his father, is presented by Homer in the light of a warrior
and hero, as well as of a Surgeon. According to Plutarch,
Alexander the Great was assisted in the study of Physic
by Aristotle, and not only loved the theory, but also the
practice, and prescribed for his friends medicines and a
proper regimen. And it is evident from the account
given by the historian, of the illness of the great Con-
queror, in Cilicia, supposed to have been caused by
bathing in the cold waters of the river Cydnus, that
Alexander was accompanied by regularly appointed phy-
sicians. The physicians are represented as consulting
together, fearing to administer medicine to the King in
his dangerous illness, lest in case of a fatal termination,
they should be accused of poisoning; and the life of
Alexander was said to have been saved by the bold and
timely ministrations of Philip the Acarnanian physician.
The fears of the physicians appear to have been wTell-
founded, for Alexander himself crucified the physician
Glaucus, after the death of Hephsestion, a favorite soldier
and officer, who when sick of a fever, took the opportu-
nity whilst Glaucus was gone to the Theatre, to eat a
roast fowl and drink a flagon of very cold wine, in conse-
quence of which he grew worse, and died a few days
after. It is clear, also, from Herodotus, that Darius kept
around him the most learned physicians of foreign coun-
tries. Shortly after the overthrow of Orcetes the Persian,
Darius in leaping from his horse, while hunting, twisted
his foot with such violence that the ankle-joint was dislo-

64 Jones' Notes on Hospital Gangrene. [July,

cated. Thinking that he had about him those of the
Egyptians who had the first reputation for skill in the
healing art, Darius made use of their assistance ; but by
twisting the foot and using force, the Egyptian physicians
made the evil worse; and the pain was so great that he
lay seven days and nights without sleep. On the eighth
day, as the King still continued in a distressed state, some
one who had before heard of the skill of Democedes the
Crotonian, made it known to Darius, who ordered him to
be brought as quickly as possible. This physician by
using Grecian medicines, and applying lenitives after
violent remedies, caused the King to sleep, and in a little
time restored him to health, though he had before des-
paired of ever recovering the use of his foot. The sur-
gical skill of Democedes was still farther attested by the
cure of Atossa, daughter of Cyrus and wife of Darius,
who had a tumor on her breast, w^hich after some time
burst and spread considerably. As long as it was small,
she concealed it, and from delicacy informed no one of
it ; when it became dangerous she sent for Democedes.

It would appear that at a comparatively remote period,
the Eoman armies were furnished with regularly appoints
ed physicians, with determinate duties. Medicus cohortes
and Medicus legionis are said to appear in ancient inscrip-
tions; and Salmasius, in noticing a passage about an
army physician, exercitus medicus, in the work of Achilles
Tatius, who lived about the third century of the Christian
era, says that each cohort had in general a physician. In
the sixth century the emperor Mauricius had attached to
his army dejmtati, who were distributed amongst the
cavalry, and were obliged to carry off their wounded in
battle. They had on the left side of the saddle two
stirrups, in order that they might more easily take up the*
wounded behind them ; and for every person thus saved
they obtained a certain reward. They were also obliged

1866.] Jones' Notes en Hospital Gangrene. 65

to cany a bottle of water, for the purpose of reviving
those who might have fainted through loss of blood.
The emperor Leo VI, in the ninth century, mentions
besides the officers necessary for each band or company
of a regiment, the deputati, physicians, and attendants on
the sick.

We know but little beyond the bare fact that the
Roman armies were provided with a medical staff, and
little or nothing of the diseases of the sick and wounded
soldiers who fell to their care.

The employment of appointed physicians in armies,
appears to have fallen into disuse, with the decline of the
Roman power; and the first Christian armies of the
middle ages appear to have been without any medical
organization; the various celebrated physicians who were
present at the battles and sieges of those times appear to
have served not in an official capacity, as army surgeons,
but as soldiers. It was not until the fifteenth century that
the attempt was made to furnish some of the European
armies with medical organizations. In fact, notwithstand-
ing the efforts of the Germans, and of Henry V, of
England, and of Ferdinand and Isabella, of Spain, no
very efficient organization was established, until the time
of Gustavus Adolphus, who appointed four surgeons to
each regiment, which he reduced from the number of two
or three thousand, first to twelve hundred, and afterwards
to one thousand and eight. We cannot look to the barber
surgeons, to whom these armies were entrusted, for any
very accurate accounts of the various diseases.

As far as our knowledge extends, there were no- organ-
izations for the treatment of sick and wounde<J soldiers
and of the sick generally amongst the ancient Greeks and
Romans, corresponding to the military and civil hospitals
of the present day. "When the sick were carried to
certain temples, as that of ^Esculapius, they received no

66 Jones' Notes on Hospital Gangrene. [July,

special medical attention, and looked to supernatural
means entirely for restoration. The view that the taberna
nieritoria was a house or hospital, in which Roman soldiers
disabled by wounds, or worn out by the fatigues of war,
were received and cared for, does not appear to be well
founded. That the Grecians and Romans paid some
attention to the welfare of their soldiers, rendered unfit
for service, either by wounds or old age, is evident from
the fact that Solon deducted something from the pay of
soldiers, and employed it for the education of children
whose fathers had fallen in battle, in order that others
might be encouraged to bravery; Pisistratus made an
order that those who had lost any of their limbs in war,
should be maintained at the public expense; and many
instances may be found, some of which occur in the
Justinian and Theodosian codes, of the attention paid by
the Romans to their milites causaruy who were not only
exempted from taxes, but frequently obtained lands, and
cattle, and money, and were sometimes assigned over, to
be taken care of by rich families and communities.

Hospitals, as well as many other honorable and benev-
olent institutions, were first introduced by Christianity.
In the fifth century, Fabiola, a Roman lady, the friend of
St. Jerome, is said to have built one of the first houses for
the reception of the indigent sick. As soon as pilgrim-
ages to holy places, and especially to Palestine became
customary as a part of religion, it was found necessary to
build numerous resting places, in which both the well and
the sick might find entertainment. Brotherhoods were
formed in the Holy Land, towards the end of the eleventh
centurv,*which undertook to provide for the wants of sick
and indigent persons, and became richer and more nume-
rous as the Crusades increased. Opulent persons when
dying, bequeathed their property to these brotherhoods ;
and in this manner the hospitals in Palestine were con-

1866.] Jones' Notes on Hospital Gangrene. 67

structed on a large scale, and were provided with better
accommodations than those in Europe. They were even
considered as models, and princes and rich persons re-
turning safe from their pilgrimages caused similar ones to
be established in their own countries.

The oldest hospitals, therefore, with the exception
perhaps of the institution founded in Persia, by some
Xestorian priests as early as the seventh century, were
established chiefly under the direction of the clergy, for
the convenience and accommodation of the well rather
than of the sick; and hospitals exclusively devoted to the
treatment of the sick, with appropriate medical officer?,
were not established until the eleventh century. In fact,
in many of the large hospitals, long after the beginning of
the eleventh century, there was no regular medical organ-
ization, and in the large hospitals of Jerusalem, the
knights and brothers attended the sick themselves, and
bound up each other's wounds, and exerted themselves to
obtain the best balsamic mixtures ; and in the houses for
the sick, belonging to the order of Templars, the duties
of physicians and surgeons were not defined until near the
middle of the fifteenth century. Many of the older
European hospitals now existing, are said not to date
back beyond the seventeenth century, and the Hotel dee
Invalides, of Paris, was not commenced until the year
1670, by Louis XIV, and the English hospital at Chelsea
was founded by Charles II, in 1682.

From the facts which we have now presented, concern-
ing the mode of warfare of the ancients, the imperfection
<>f their medical knowledge, and of their arrangements
tor the treatment of the sick of their armies, and the com-
paratively modern origin of military and civil hospitals,
we are justified in the assertion, that the mere absence of
special descriptions of this disease in the writings of the
ancients, is no proof that Hospital Gangrene is not a

68 Jones' Notes on Hospital Gangrene. [July?

disease of great antiquity. The essential conditions for
the origin and spread of this disease were frequently
present in ancient times.

Pliny, in that portion of his Natural History which
treats of the remedies derived from plants and animals,
has mentioned various ulcers; as phagedena, which he
describes as an ulcer of the corrosive kind; malignant
ulcer eaecethes ; serpiginous ulcers, the cure of which,
Pliny considers more than doubtful ; corrosive sores ;
putrid sores; callossities or putrid sores; corrosive sores
known as nomoz ; defluxions ; aposthemes ; sordid ulcers ;
suppurations; abscesses; fistulous ulcers and gangrenes;
also, contused and incised wounds, and simple and com-
pound fractures. Pliny also recommends various remedies,
as the juice of the Tilhymalos Charaeias, bull'3 gall, leek
juice, woman's milk, bull's blood dried and pounded with
the plant Cotyledon, and ashes of cow's hide mixed with
honey, for the cure of gangrenous, phagedenic sores, and
putrid ulcers.

Mr. Blackadder has shown in his " Observations on
Phagedena Gangrenosa," that several of the ancients in
their descriptions of foul gangrenous bleeding ulcers,
must have alluded to the same kind of disease, which is
now usually denominated Hospital Gangrene. Besides
the use of the actual cautery, several of the old writers,
as ^Etius, Paulus, Rolandus, Avicenna, Guido, and others,
appear to have employed for the cure of such ulcers,
arsenical applications.

Paree, more than two hundred and fifty years ago, says
that, in siege of Rouen, the air was so noxious that no
wound healed; and the besieged, finding that all their
wounds became gangrenous, reported that the besiegers
had poisoned their balls ; the besiegers, also, seeing none
but putrid sores in the camp, believed that their wounds
were poisoned; and both within and without the city,

1866.] Jones' Notes on Hospital Gangrene. 69

such was the state of the air, and so putrid were all the
wounds, that the surgeons could scarcely look upon the
sores, or endure the smell ; and if they neglected them
for a single day, they found them full of worms. Paree
complained that in the Hotel Dieu, sores would not heal,
and no operations could be rightly performed. And,
after him, Diorus, more than one hundred and fifty years
ago, protested against performing operations in the Hotel
Dieu ; and advised that an hospital should be built in the
environs of the city, for those who were wounded or
required operations. And other army surgeons of former
times have remarked, that in some seasons, those wounded
in battle, and those operated upon became afflicted with
gangrene ; and however trifling the wounds at first sight
might be, the patients usually fell victims to the gangre-
nous affections which ensued. Lamotte, in 1722, mentions
Hospital Gangrene as being known in the Hotel Dieu, of
Paris, by the name of La Pourriture, and as a disease
which attacked the wounds inflicted by operations, and
the ulcers and abscesses of those who breathed the cor-
rupted air of this hospital.

The first description of Hospital Gangrene, as a distinct
-disease, appeared in 1783, in the third volume of the
posthumous works of M. Pouteau, chief surgeon to the
Hotel Dieu, of Lyons. The attention of this author
was directed to the disease, by having been himself
affected with it while employed as dresser in the hospital.
M. Dussassois, the successor of Pouteau, in the same
hospital, published in 1788, an account of this disease in
a pamphlet of about ninety pages. This was followed
shortly after, in 1796, by a small pamphlet upon this
disease, by Moreau and Burdin. According to Dr. John
Thomson, who published near fifty years ago, a valuable
.chapter on "Hospital Gangrene or malignant ulcer," in
his "Lectures on Inflammation," the first accurate account

70 Jones' Notes on Hospital Gangrene. [July.

of this disease published in the English language, ap-
peared in the sixth volume of the London -Medical
Journal, in 1785, and was entitled " Observations on the
Putrid ulcer, by Leonard Gillespie, surgeon of the Royal
j^Tavy." Dr. Thomson regards the sore described by Dr.
Rollo, in his work on Diabetes published in 1797, in the
section, " A short Account of a Morbid Poison, acting on
sores, and of the Method of Destroying it," as one and
the same disease with Hospital Gangrene.

Various writers have recorded observations upon Hos-
pital Gangrene, as :

Pouteau, (Euvres Posthumes, vol iii: 1783; 8vo. Gilles-
pie, Observations on the Putrid Ulcer, in London Medical
Journal, vol vi : p 373 ; 1785. Dussaussoy, Sur la Gan-
grene des Hopitaux: Geneve; 1787. Sir Gilbert Blane,
Observations on the Diseases of Seamen : third ed., Lon-
don ; 1799. Thomas Trotter, Medicina ]N"autica An
Essay on the Diseases of Seamen; 1799. John Hunter,
physician to the army, Observations on the diseases of
the army of Jamaica : 1796, chap vi, of sores and ulcers ;
p 221. Thomas Clark, Observation on the nature and
cure of fevers, and of the diseases of the West and East
Indies, and of Ameriea : 1801 ; p 118. John Bell, Dis-
coveries on the nature and cure of wounds, 2d ed..:
1800; vol 1, p 244. Principles of Surgery, vol 1, 1801.
Wolf Ploucquet, De Gangraena sic dicta ^fosocomiorum :
1802. Leslie, De Gangrama Contagiosa JSTosocomiale:
Edinburgh ; 1805. John Burns, Dissertations on Inflam-
mation : discourses iii and iv, on the Phagadeenie and
some other species of Inflammation. Evard Home, Prac-
tical observations on the treatment of ulcers of the legs,
etc. John Thompson, Lectures on Inflammation : 1813 ;
chap on Hosp. Gan. or malig. ulcer. Penard, iiber den
Hospitalbrand : Mairz ; 1815. Delpech, Memoire sur la
Complication des Plaies et des Uleeres connue sous le nom
de Pourriture d; Hopital : 1815. Delpech, Clinique Chi

1866.] Jones' Notes on Hospital Gangrene. 71

rurgicale de Montpellier : vol i, p 78. Gerson, iiber den
Hospitalbrand, nach eigenen Erfahrungen : Hamburg;
1817. Dr. Hennen, London Medical Repository: March;
1815. Professor Burgman, of Ley den, Annales de Lit-
terature Med.: vol 19; 1815. Blackadder, Observations
on Phagedena Gangrenosa : 1818. Hennen, Military
Surgery. Samuel Cooper, Dictionary of Practical Sur-
gery: art. Hospital Gangrene. C. J. M. Langenbeck,
Neue. Bibl. 2 B: p 611, etc.,; 1820. Brugmans und
Delpech, iiber den Hospitalbrand, ubersezt mit Anmer-
kungen und Anhang Von Kieser, Jennal; 1815. Boyer,
Traite des Maladies, Chir. T. i, p 320: Paris; 1814.
Sketches of the Medical Schools of Paris, by J. Cross: p
82 ; 1815. Baron Larrey's Memoirs of Military Surgery.
"W. Werneck, kurzegefasste Beitrage zur Kenntniss der
ISTatur, du Entstehung, der verhurtung und Heilung des
Hospitalbrandes : Salzburg ; 1820. Brauer, Observa-
tiones qusedam de Gangraena Nosocomial! quse anno-hujus
Sseculi, xiv, Lipsise inter milites variarum nationum gras-
sata est: Lipsise; 1820. Alexander, iiber den Hospital-
brand in Hippocrates Magazin, von Sander und Waepter :
vol v, p 1-220. Boggie, in the Transactions of the Medi-
co-Chirurgical Society of Edinburgh: vol iii, p 1; 1828.
Olliver, Traite experimental du Typhus Traumatique
Gangrene ou Pourriture des liopitaux : Paris ; 1822 .
Guthrie, Treatise on gunshot wounds. Benjamin C.
Brodie, Clinical Lectures on Surgery. Macleod, Notes
on the Surgery of the "War in the Crimea. Medical and
Surgical History of the British Army, which served in
Turkey and the Crimea, during the war against Russia,
1854-56, 2 vols.: London; 1858.

Observations on Hospital Gangrene occur, also, in the
various systematic treatises on Surgery, and in the nume-
rous medical journals of Europe and America, under the
head of Phagedena, Putrid or Malignant Ulcer, Hospital
Gangrene, Hospital Sore, Gangraena Contagiosa.

72 Beale's Anatomical Controversy* [July? j

RE VI E W S.

ARTICLE I.

An Anatomical Controversy. The Distrilulwn of Serves to
Voluntary Muscle, including the Discussion of the following
Questions: Do Nerves Terminate in Free ends? Or do they
invariably form circuits and never end ? By Lionel S. Beale,
M. D.r F. R. S., Fellow of the Royal College of Physicians;
Physician to KiDgs College Hospital; Professor of Physiology
and of General and Morbid Anatomy in Kings College, London.
(Reprinted from the Archives of Medicine. London: John
Churchill and Sons, 1865; p. 38. Plates 6.)

The author of this "Anatomical Controversy," is well known
to the profession by his works " On Some Points in the Anatomy
of the Liver of Man and Vertebrate Animals, with Directions for
Injecting the Hepatic Ducts, and making preparations ;" " The
Microscope and its application to Clinical Medicine," and by his
various papers upon the minute anatomy of certain organs, pub-
lished in the "Archives of Medicine."

In a paper upon the distribution of nerves to the voluntary
muscle of vertebrate animals, published in the Philosophical
Transactions of 1860, p. 611, Dr Beale arrived at conclusions
which were opposed to the views entertained by most authorities,
especially Kolliker, Gerlach, and Kiihne. This paper was fol-
lowed by a communication from Kiihue, in which he supported,
by investigations upon the breast muscle of the frog, conclusions
advanced by him previous to the publication of Dr. Beale's paper,
in favor of the view, that the nerves in insect muscle terminate in
ends beneath the sarcolemma, and are in fact, continuous with
rows of nuclei which lie among the contractile tissue.

Kolliker, a month after Kuhne's paper appeared, put forward a
memoir in which he agreed with Ktihne as to the termination of
the nerves by ends, but with Beale as to the fine nerve fibres
being upon or external to the sarcolemma, instead of penetrating
through this membrane and coming in contact with the contractile
tissue.

Here then are three utterly incompatible inferences with refer-
ence to the termination of the nerves : 1. That the nerves termi-
nate in ends external to the sarcolemma; 2. That the nerves

1866.] Beale's Anatomical Controversy. 73

terminate in ends beneath the sarcolemma ; 3. That the nerves do
not terminate at all. It might be said that all are wrong ; but it
is an absolute necessity that two are wrong, since no two of the
preceding arrangements can coexist.

Notwithstanding the appearance of many new memoirs upon
this subject in 1862, 1863, and 1864, the views of which as a
general rule differ from those of Dr. Beale ; this microscopist
does not yield ; "for the simple reason that I have seen what I
have figured, and have indeed found no difficulty in following fine
fibres structurally continuous with dark-bordered fibres for a long
distance beyond the point where Kiihne, Kolliker, and others,
make them end. Moreover, my specimens show the arteries and
capillaries as well as the nerves, and I have now worked at this
anatomical point so long and so hard that I have a right to ask
that my opponents should prepare the specimens by the same
process that I have followed, and give drawings of what they
observe. I would then reply by giving drawings of the very
same structure, showing what I have seen. Independent observers
would then be in a position to judge between my opponents and
myself." We consider this proposition of Dr. Beale as just,
and as calculated to settle definitely some of the ni< st difficult
and important questions in anatomy and physiology.

Our knowledge of the minute anatomy of many organs, is at
prescut, by no means as perfect as we have every reason to believe
that it will be in the future, by the aid of the improved instru-
ments and methods of microscopical research. Up to a compara-
I tively recent period, the methods of preparation, as well as the
character of the optical instruments employed, were unsuited to
the accurate determination of the mode of distribution of the
nervous fibres, in such structures as the papillae and tactile bodies
of the skin, in the Pacinian bodies, in the retina and cochlea, and
in the mucus membrane of the nose and mouth. Thus Geber in his
efforts to determine the ultimate distribution of the cutaneous
nerves, overcame the opacity of the cutaneous tissue of man and
quadrupeds, by boiling portions of skin, and then steeping them
in oil of turpentine, until they were rendered transparent; and
Krause in similar investigations, treated the skin with nitric acid ;

74 Beale's Anatomical Controversy. [July,

and many of these violent modes of boiling and coagulating and
metamorphosing and coloring with strong chemical re-agents, are
still used in microscopical investigations, into pathological as well
as anatomical or normal structures.

In all future anatomical discussions, of difficult questions, the
method of preparation as well as the power and character of the
instruments employed, should be so fully and emphatically stated
that the observations may be repeated and the drawings subjected
to that critical scrutiny which the importance of the subject
demands.

We look with great expectations to the application of the art of
photography to the correct representation of the minute anatomy
of structures. Wiiilst it is true, that no mere photograph can
ever convey the knowledge acquired by patient and intelligent
microscopical investigation of delicate structures viewed in thous-
ands of varying attitudes and lights; at the same time the
photograph when perfect, will tend to correct these regular dia-
grams so beautifully executed by some anatomical artists, and will
also tend to expose the errors of those who are able to make the
anatomical structures which they delineate, correspond exactly to
the pre-existing theories of' their minds.

In the paper now under consideration, Dr. Beale claims that he
has demonstrated :

That the nerve fibres passing to a muscle, divide at length into
a vast number of exceedingly fine, pale granular fibres, which
ramify upon the external surface of the sarsolemma, connected
with which fibres at certain intervals, are oval nuclei, and that
these fine fibres, after an extensive and in many cases very circuit-
ous course are continuous with other fibres to form dark bordered
fibres, which at length pass toward the nervous centre, either in
the same bundle as the dark-bordered fibres passing toward the
muscle, or in other bundles.

It therefore follows, that of the dark-bordered nerve fibres
distributed to a muscle, some pass from the nervous centre toward
the muscle, some from the muscle toward the nervous centre, and
that the nerve fibres do not end in the muscle at all. The results
of these researches considered in connection with those arrived at

1866.] Beale 'g Anatomical Controversy. 75

from the investigation of various kinds of nerve centres, justify
the inference that the fundamental arrangement of a nervous
apparatus, is a complete and continuous circuit. These observa-
tions of Dr. Beale, the importance of which cannot be over-
estimated, as they involve the typical arrangement of every
nervous instrument, show therefore, that so far from their being
distinct ends to nerves, that in all cases complete circuits exist 5
and that in these circuits are included central nerve cells, and
peripheral nerve cells generally termed nuclei, which are connected
by intervening fibres. The course of any given fibre may be
extremely complicated, and there may be many minor circuits
connected with the greater one, but in all cases there is a circuit
a nerve never ends.

The importance of these results are seen in a clear light, when we
attempt to apply them to the explanation of certain nervous
diseases.

Thus if we attempt to apply these anatomical facts to the expla-
nation of Traumatic Tetanus, we observe

1st. The nerves in their ultimate branches and ramifications,
form a network of great complexity and of immense extent.

2d. Within this extended network, and connected by both
efferent and afferent nerves, with the central ganglia, are potential
elements, true nerve-force generating cells.

3d. A local injury or irritation is capable of producing a state
of super-functional activity in the nerve cells of the periphery of
the sensative and motor nerves. As these nerve cells exist in
.mniense numbers even in comparatively small portions of struc-
ture, and as they are within the same closed circuit with the nerve
?ells of the gray matter of the cerebro-spinal axis, a state of
3uper- functional activity or of irritation, might be readily trans-
mitted from the periphery to the central ganglia. Thus a local
aervous exaltation of nervous function in the peripheral ganglionic
nuclei, is capable of propagating itself, first to the nervous cells
ncluded in its own peculiar circuit, and from these latter, through
:he channels of intercommunication, to the various segments of
:he spinal axis.

76 Beale's Anatomical Controversy. Puty

It is but right that we should add, that in the preceding obser-
vations, and in our application of the results of the labors of Dr.
Beale to the explanation of the phenomena of Tetanus, we do not at
all claim for Dr. Beale the discovery of the formation of extensive
networks in the peripheral fibres of the nerves, and the reunion
of the ultimate fibres composing the networks, into nerves which
return to the central ganglionic masses.

Thus Valentin, Burdach, and other observers, represent the
nervous fibres distributed to the skin of the frog, as dividing into
numerous small fibres, and forming a close anastimosing network,
which does not end in the tissue, but after coursing for a longer
or shorter way, returns sooner or later, to the larger branches of
the nerves. Schwann observed that the nerves in the web or fin of
the tadpole's tail, and in the mesentery of amphibia, divide into
numerous fine fibres destitute of the white substance, without any
dark outline, and presenting little enlargements from whence
delicate fibres spread out in various directions, and connect them.
selves in the form of a delicate and extensive network. The sub-
sequent observations of Quain confirmed* those of Schwann, and
also showed that the smallest nerve fibres presented here and there
along their course, elongated corpuscles, like cell nuclei. The
researches of Rudolph Wagner, upon the distribution of the
nerves of the electrical ore ns of fishes, in like manner establish
the doctrine that the peripheral nerve fibres divide and subdivide,
and reunite, and are distributed in a plexiform manner, like the
ramification of the capillaries. Here Bilharz has shown that the
small nerve which supplies the electrical organ of the electrical
Silurus (JMalapterurus), keeps continually dividing, until it finally
resolves itself into an enormously great number of ramifications,
which spread themselves out upon the electrical organ, thus allow-
ing of the sudden diffusion of the nervous influence over the
whole extent of the electrical plates. The investigations of
Meissner and Billroth have shown that the submucous layer of the
intestines, is as Willis had long before declared it to be, a nervous
turn The afferent nerves of the intestine, after having divided,
finally break up into extensive networks, presenting at certain
points, nodules having the appearance of ganglions, from which

1866.] Harris' Hygienic Experience in N, 0. 77

the nerve fibres spread out into interlacements like the network
of capillaries.

This arrangement not only enables us to understand the nature
of peristaltic action; but it also offers a groundwork for the expla-
nation of Tetanic spasms, and convulsive affections arising from
irritating substances in the alimentary canal, similar to that
afforded by the distribution of nerve fibres to involuntary muscles-

We are enabled by such facts to understand how a local irrita-
tion may excite super-functional activity in the adjacent nervous
centres, and these in virtue of their communications with other
nerve centres may extend the influence over larger tracts of the
intestines, and the excitation may also extend to the central sym-
pathetic ganglia, and from thence be reflected upon the spinal
axis.

Such physiological applications as we have made of these inves-
tigations, do not appear to have suggested themselves to the mind
of Dr. Beale, or to the other observers to whose labors we have
referred.

The tendency of the more careful investigations, appear to be,
the establishment of the peripheral division and expansion of the
nerves into extensive networks, or of their direct connection with
special apparatuses, as in the retina of the eye.

The plates illustrating this "Anatomical Controversy," executed,
by Dr. Beale from nature, combine clearness, finish and beauty,
and certainly most forcibly illustrate the views of the author, and
present a striking contrast to the more confused and rude diagrams
of Kuhne and Kolliker, which are presented by Dr. Beale for
purposes of reference.

ARTICLE II.

Hygienic Experience in New Orleans during the War: Illustrating
the Importance of Efficient Sanitary Regulations. By Elisiia
Harris, M. D. (From Bulletin of the New York Academy
of Medicine, No. 30: September; 1865.

All facts relating to the origin, causes, and means of pre-
vention of yellow fever, are of vital importance to the
inhabitants of the Southern cities. A correct knowledge of the
laws which govern yellow fever; and all other diseases, can bo

78 Harris' Hygienic Experience, in N. 0. [July,

obtained only by the accumulation of a large number of well
observed and undoubted facts. Those who are instrumental in
the discovery and establishment of the laws which govern the
origin and spread of so great a scourge as yellow fever, should
surely be considered as honored and useful instruments in the
hands of Providence. The author of the observations now under
consideration, is well known for his devoted and untiring labors
in the cause of sanitary science, and his testimony, therefore,
upon this or any other subject of hygienic experience, is entitled
to the confidence and respectful consideration of the medical
profession.

The personal inquiries of Dr. Harris in the city of New
Orleans, were made during the month of July, 1865, while
pursuing certain investigations relating to the hygienic experience "
of the military forces.

As these notes upon the civic hygiene of that important
military district were submitted to the Academy of Medicine,
without any attempt to present an exhaustive statement, we shall
limit the present review to a bare presentation, in the language
of the author, of those facts which are of the greatest interest
in their bearing upon the sanitary regulations of cities subject to
yellow fever.

Shortly after the occupation of New Orleans by the United
States' forces, the most stringent sanitary regulations were
promulgated (May 1st, 1862), and an efficient sanitary police
established.

"Throughout the entire period, upwards of two years, the Provost
Marshal, the Military Governor, the Mayor (an appointee of the
provisional government), together with the Medical Director of
the post, and certain subordinate health officers, have vigilantly
administered the regulations relating to municipal hygiene and
cleanliness in New Orleans and its vicinity. During all that
period the accustomed scourgings of yellow fever have been
suspended in that city, while the dire forebodings and prophecies
of the inevitable pestilence that would quickly destroy the
Northern soldiery on reaching the Gulf coast, remain unrealized.
The conditions under which the " Crescent City " has obtained

1866.] Harris' Hygienic Experience in N. 0. 79

this remarkable immunity from a doom which her own bitter
experience seemed to fasten upon her, are now as well under-
stood as were the apparently inexorable causes of her former
insalubrity.

Such immunity from her accustomed scourging of yellow fever
had not been enjoyed by New Orleans the last half century.
Even her wisest hygienists had been generally discredited and
often derided when they publicly taught, as Fenner, Bartcn,
Simonds, and Bennett Dowler had most faithfully, that the active
and localizing causes of yellow fever and the high death-rate in
that city were preventable. There was a truthfulness worthy of
the medical profession in the words of Dr. Barton, who, as Presi-
dent of the New Orleans Sanitary Commission, sitting in grave
and scientific consultation upon the terrible visitations of yellow
fever, unhesitatingly declared the causes of that pestilence and
the city's excessive insalubrity l entirely susceptible of cure.' But
how few persons appreciated the truth of Dr. Barton's words of
prophecy, when he said that ' upon the broad foundation of sani-
tary measures we can erect a monument of public health, and
.that if a beacon light be erected on its top, and kept alive by
proper attention, this city will be second to none in this first ot
earthly blessings/

It is the design of the following notes to show what have con-
stituted the chief causes of insalubrity in New Orleans, and by
what means the redemption from its fearful doom has been
achieved. In doing this it will be shown that for two successive
years the threatening pestilence was localized in a fleet of gun-
boats moored so close to the city levees that they menaced the
streets with death. It will likewise appear that, by the exercise
of absolute and relentless military authority, an impregnable sys-
tem of quarantine was maintained, restraining all the exotic
causes of yellow fever, and controlling such causes at a distance
of nearly seventy miles from the city; and yet that this dreaded
scourge originated spontaneously in more than twenty of the gun-
boats that were moored in the river opposite the city; also that
those naval vessels were uniformly filthy, ill-ventilated, and over-
crowded ) that of the more active, cleanly, and less crowded

I

80 Harris' Hygienic Experience in N. 0. [July,

steamboats (120 in number) employed in quartermaster's service,
no yellow fever occurred ; that in all the city not more than three
or four cases of yellow fever occurred each year, and that the cause
of such immunity from the pestilence of former years was as
certainly the direct result of civic cleanliness and the hygienic care
of the poor, as its accustomed visitations were the result of neglect
of these public duties.

Three classes of facts, concerning which neither doubt nor
uncertainty can be alleged, have conspired to give precise relations
and definite value to the series of events we are about to consider :
First. The relentless rigor and precision of a military government
precluded the ordinary violations of quarantine regulations, while
it gave peculiar certainty to the execution of sanitary regulations
in the city. Second. The official usages and the armed discipline
of the naval fleet in the harbor of New Orleans and upon the
river, enabled the medical officers to trace to its source every case
of yellow fever that occurred in the gunboats. Third. That the
climate of the city and of the river districts, during the past three
years, was not perceptibly different from the climate of previous
years and the periods of yellow fever epidemics; the same evils
from imperfect culture and drainage, imperfact levees, and exten-
sive crevasses, flooding and subsequent evaporation from vast areas
of overflowed land, continued to recur in the latter as in former
years. In short, all the physical conditions that are supposed to
promote the prevalence of yellow fever excepting only such as
are immediately controllable by a sanitary police prevailed con-
tinually and abundantly in the delta of the Mississippi during this
period of immunity from that disease.

The Sanitary History of New Orleans before the War. Con-
stantly recurring epidemics of pestilential diseases had for two
generations seemed to pronounce the doom of the Crescent City?
and, notwithstanding the vast interests of commerce, there have
been dismal forebodings of inevitable decadence of wealth and
commerce. Between the years 1829 and 1852 inclusive, there
were not less than twelve great epidemics of yellow fever, or on*
every second year. Those twelve epidemics killed 22,884 inha-
bitants, or an average of 1907 in each epidemic, which gives an

1866.] Harris' Hygienic Experience in N. 0. 81

average of 888 persons killed by that fever, year by year. As
the fever prevailed to some extent almost every year, the actual
average each year reached about 1,000 persons.

During the epidemic years the average death-rate, from all
causes, was nearly 75 deaths to the 1,000 inhabitants. The
average annual death-rate during all that period, and up to the
year 18^1, was about six and a half per cent. There were years
when the death-rate exceeded ten per cent.

Fresh immigration of Northern or foreign born persons was
always accredited as the chief source of any excessive mortality ;
and to become creolizcd (naturalized to the climate) was esteemed
almost equivalent to a limited life assurance policy. But we
have now seen that during the period of military occupation by
the national troops, a hundred thousand Northern men, uncreolized
and unacclimated, have annually arrived in or passed through that
city without a single individual being smitten with yellow fever,
except in a few instances in which soldiers detailed to assist at the
boats on the levee in receiving and conveying yellow-fever patients
to the Naval Hospital on New Levee and Erato streets.

The Summers of 1862, 1863, 1861, and 1865 have now passed
without any sign of epidemic disease, except from paludal malaria
being manifested at New Orleans, save only the outbreak of small
pox last Winter. That epidemic was at once controlled by a house-
to-house visitation by a corps of medical inspectors, armed with
vaccine virus.

Malarial fever and the ordinary diseases of the climate, not
dependent upon a medical police, continued to prevail, but the
diarrhoeal and infantile maladies were less fatal than in former
years. The following statistics of mortality for the six weeks
that are usually the most unhealthful of the year, show how the
'' hygienic barometer" stood during the Summers of 1863 and
1865 the periods when the largest numbers of Northern men and
anacclimatized persons were in that city. For the Summer of
1863 the records stand thus :

No. of Deaths.

During the woek ending August 2 1(59

During the week ending August 9 176

During the week ending August 16 106

During the week ending Ausnist 22 139

During the week ending August 30 161

During the week ending September 0 145

During the week ending September 13 203

82 Harris5 Hygienic Experience in N. 0. [July,

During the seven weeks of the past Summer (1865), of which
we have received official returns, the records read as follows :

No. of Deaths.*

During the week ending July 2 155

During the week ending July 9 154

During the week ending July 16 155

During the week ending July 23 165

During the week ending July 30 174

During the Week ending August 6 144

During the week ending August 13 168

During the week ending August 22 ,110

During the week ending August 27 141

During the week ending September 5 149

During the week ending September 10 116

New York cannot boast a lower death-rate for the same period,
The total number of deaths in July was 793, and in August just
past, the number was but 623. Compare this with the mortality
in that city in August, 1853, when 6,201 of the inhabitants died I
Or compare with the average mortality of the three years, 1853,
1854, and 1855, which gave more than 1,000 deaths per month,
though the population was far less than during the past summer.

It cannot be claimed that there have been any favoring circum-
stances in the seasons, the dryness, or the humidity, that can
account for such hygienic changes. During the past three years
the levees have been cut and crevassed, and the coustry over-
flowed, as at no former period; and then, in August last, for
example, the swampy surfaces surrounding the city were desicca-
ted, less than a single inch of rain having fallen that month ; while
in the early part of the present month (September), as in the
months of Spring and Summer, floods have descended. Now,
from the sanitary officers of the city we learn that diseases and
mortality have been chiefly diminished in connection with the
abatement of those local conditions that are recognised as the
localizing causes. These causes, in the language of Dr. E. H.
Barton, consisted mainly in

' 1. Bad air.

i 2. Offensive privies, cemeteries, various manufactories, stables,
slaughter-houses, filthy streets, etc.

' 3. Bad water, stagnant water, bad drainage/

These were the causes of disease first noticed and officially con-
trolled by the military government under the national forces.

*The (total population, including the permanent or the transient mtlitcfry forces, was littk
lei than slOO.OUtf.

1-866.] Harms' Hygienic Experience in N> 0. 89

The Appliances and Means of Sanitary Beform. 1. The
streets, the courts, the market-places, and all the private and
public premises of the city have been cleansed and kept in a state
of unusual cleanliness by an absolute authority.

2. The drainage of the city was a matter of constant official
concern, and the steam-drainage works kept in great activity night
and day. [As all the drainage is superficial, by gutters, ditcher?
a'jd canals, the mechanical appliances for drainage, located at the
junctions of canals and bayous leading toward Pontchartrain,
maintain an important relation to civic purity and the public
health. Some of the water-lifting machines -exhaust from the
canals and basins at the rate of more than 100,000 cubic feet per
minute, raising the sewage from the lowest levels of the town,
and sending it forward toward Lake Pontchartrain by way of the
bayous ] During the frequent rain-falls, when the water floods
the gutters and covers whole streets, cleaners are seen at work
with hoes and stiff brooms adding the effectiveness of their arms
to the process of cleansing by water-flushing.

3. The water-suppiy, which is wholly from the river, was, from
the beginning of the military government, a matter of first-rate
importance. Though the river surface is higher than the plane of
the city, the supply depends mainly upon steam pumps and reser-
voirs. The pumps were ordered to be kept in the highest activity,
a-ud the water company was held accountable for any failure in its
works.

4. Street-cleaning was literally a dea as ing ; the faithful broom
was immediately and all night long, as constantly as night returned,
succeeded by a flushing stream of water from the hydrants, filling
aad flushing gutters and the pavement-joints, and, aided by the
sleepless sweepers, thus rendering the Augean work complete. So
ciean a city had never before been seen upon the continent.

5. Scavenging and domiciliary hygiene were enforced by order
of the Provost-Marshal. Privies and garbage, stables and butche-
ries, damp and unventilated quarters, and the haunts of vice and
debauchery, were all brought under police control. The privies
in populous streets, and those connected with places of public
resort, were sometimes cleansed as frequently as twice each week.

34 Harris' Hygienic Experience in N. 0. [iv&Jj

All animals for the markets were impounded at the outskirts of
the city, and the cattle-boats were there scrubbed and cleansed
before proceeding down to the commercial levees. And as an
illustration of the salutary exercise of authority over improper
habitations, the writer would mention that he saw all the tene-
ments upon the first floor of an entire block vacated by peremptory
orders in a single day.

6. The destitute were supplied with wholesome food at the
expense of the city.

Such were the leading features of the sanitary government of
the Crescent City under military rule. The errors of that gov-
ernment, and the criticisms it may have provoked, were neither
the cause nor consequence of the protection it gave to life and
health. All the acts that related directly to the public health
can be repeated in any city, and by any enlightened civil govern-
ment.

Quarantine. Perhaps there has never been a more enlightened
and faithful exercise of regulations in the nature of quarantine
than has been witnessed at New Orleans the past four years.
Yellow fever and small pox were the only infections feared or
guarded against. All the exotic and transportable causes or
fomites of these maladies were detained at the quarantine anchor-
age, sixty five miles down the river, near Fort Philip.

Shall we be told that it was by this very application of a judi-
cious and inviolable quarantine that the city escaped the epidemic
visitations of disease ? We have seen that small pox appeared as
a wide-spread epidemic, and that it was cheeked by a house-to-
house visitation of a medical police armed with vaccine virus !

Yellow Fever. This disease did not become epidemic in the
city. Nearly three and a half years have passed without so many
as a score of sporadic cases occurring in the streets where that
enemy and pest of the city had been wont to destroy its thousand
victims every year, and sometimes to kill no less than five thousand
in a single month !

As the writer's views concerning the transportability and the
infectious nature of yellow fever are already well known to the
Academy, the following statement regarding yellow fever and

1866.] Harris' Hygienic Experience in N. 0. 85

quarantine at New Orleans will not require explanation as respects
the stand-point from which he has examined the facts. With the
peculiar and abundant experience of yellow fever in the ports of
the North fresh in mind, the history of this malady at New
Orleans and in our naval fleet on the Mississippi was investigated
with all the predilections which such experience could justly
impart in favor of the theory of the exotic and imported origin of
the disease.

Well-marked and fatal cases of yellow fever occurred in New
Orleans in the Autumn of 1863, and in the Autumn of 1864. In
the former year the Charity Hospital received two eases, both of
which proved fatal Both were boat hands from the steamer J.
H. Hancock, a river tug. In 1864 there were five undoubted and
fatal cases of yellow fever, terminating in black vomit. The writer
conversed with the physicians who attended these patients, viz.:
Professor Crawceur, Dr. Bennett Dowler, and Dr. Smythe ) and
Dr. Huard has furnished notes of a case that occurred in the
parish prison. These five cases occurred in persons who resided
or daily visited in the vicinity of Erato, Tchapitoulas, and New
Levee streets. They were exposed to known causes of the fever.
Other cases may have occurred; if so, they have eluded all search.

We have referred to the two cases from a tug in the river, in
the Autumn of 1863. Nearly 100 other cases of the fever oc-
curred in the river fleet and in the Naval Hospital that season.
The history of all these cases, in detail, shows that they were not
of imported origin. They nearly all occurred in crowded, filthy,
and unventilated gunboats that were at anchor in the river at New
Orleans. Owing to the inaccessibility of medical officers who had
charge of some of the patients, the tabulated history of these
cases gives way, in this place, to the more complete records of
yellow fever in the Autumn of 1864.

We have mentioned the five cases of black vomit that occurred
near New Levee street, in 1864. The Naval Hospital occupies a.
large pile of old buildings on that street, with yards and accessory
buildings toward Erato and Tchapitoulas streets. One block of
buildings storehouses intervenes between the Hospital and the
n er levee and landings. The accompanying record of yellow

86 Harris' Hygienic Experience in N. 0. P^ly,

fever in that Hospital and in the idle gunboats in the stream,
sufficiently accounts for the concentration of infection in the
particular locality in which the five cases occurred outside of the
Hospital premises. Other cases occurred, but they were direetly
dependent on intercourse with the infected vessels, and the beddic/g
brought from those vessels.

The fact, then, is indisputable, that yellow fever visited twenty-
five vessels in the fleet that was anchored in the river in front of
New Orleans during the Summer of 1864, and that the disease
appeared first, viz. : as early as September 12th, in vessels that
had been for a long time at anehor there. The brief notes here
appended supply the best commentary we could wish. Filthiness,
crowding, excessive heat and moisture, lack of ventilation, and the
stagnation incident to anchorage in a tideless stream, constitute
the leading facts relating to the infected vessels.

To test the merit of this view of the spontaneous origin of the
fever, the writer has obtained the written history of every case of
which any note was made at the Naval Hospital and elsewhere.
He also obtained from the quartermaster in charge of water
transportation, a record of the 120 steamers and sailing-vessels
that were under his control. Of these active vessels, only oe
had yellow fever on board. That these ordinary mercantile and
transport vessels under control of the quartermaster were open,
ventilated, and moving briskly about from place to place, yet
infinitely more exposed to all sources of exotic infection, is the
only comment this point in our record requires.

Our records show that not less than 191 cases of yellow fever
occurred on board the twenty-five vessels we have mentioned in
the fleet at New Orleans, in the year 1864 ; and that of these,
fifty-seven proved fatal. Also, that in addition to these, there
were twelve cases and three deaths among employees and guard
at the Naval Hospital and landing on Erato street. Five other
cases of black vomit occurred in citizens exposed to the same
cause in the vicinity of the landing. The total number of cases
was 208, and the total deaths 65. At the Quarantine statiQn no
other cases or vessels than those mentioned in our record were
seen in 1864; and from July 4th, 1863, to September 10th, 1865,

1366.] Harris' Hygienic Experience in N. 0. 87

only twenty-three deaths from yellow fever occurred, and only one
vessel, besides those we have here designated, brought cases of the
fever to the Quarantine station that, a Spanish war ship, in 1863.
The hygienic lessons taught by the events to which these notes
refer, abundantly vindicate the principles and the methods of
sanitary improvement which are advocated by the medical profes-
sion. These lessons may be entitled as follows :

1. The insalubrious circumstances that produce a constantly
high death-rate, and the localizing causes of disease generally, are
the most important and the most preventable causes of the epi-
demics that afflict cities.

2. That the climate and the topographical disadvantages which
have hitherto been popularly supposed to be the essential causes of
the insalubrity of New Orleans, are but unimportant factors of in.
salubrity, which sink into insignificance when the preventable
causes of disease in the city are controlled, and that "vanquished
Nature yields its empire to man, who creates a climate for him-
self."

3. That yellow fever, the most dreaded scourge of New Orleans,
was unequivocally generated in a large number of filthy and un-
ventilated gunboats and other naval vessels lying idly at anchor
within a mile from the densest portions of the city.

4. That by fomites, or some other material agency, the infec-
tion of yellow fever was communicated to the guard, and to certain
other persons who were exposed in a narrow district, at the Naval
Hospital landing in Erato street, and near New Levee and Tchapi-
toulas streets.

5. That the infected vessels were remarkably close in their
exterior construction; that they discharged no cargoes; were
under an armed surveillance and discipline; and were seemingly
incapable, from these circumstances, of diffusing their own infec
tion, except by the clothing and " dunnage" of the sick when
taken ashore.

6. That vessels and river boats of ordinary construction and in
active service, escaped yellow fever almost without exception.

7. That no vessel infected with yellow fever, arriving by way
of the Grulf of Mexico, was allowed to pass above the Quarantine
station 65 miles from the city.

88 Hamilton's Treatise on Military Surgery. [July,

8. That the utility of a rational quarantine system against the
fomites of yellow fever was not disproved, but the contrary rather,
by the records studied by the writer at New Orleans.

9. That an epidemic of small-pox was promptly arrested by
house-to-house vaccination.

10. That with the prevention of epidemics, and unquestionably
by the same agencies of prevention generally, the death rate from
zymotic diseases as a class has been very greatly diminished."

ARTICLE III.

A Treatise on Military Surgery and Hygiene. By Frank H.
Hamilton, M D., etc. Illustrated with 127 Engravings :
8vo. ; 650 p. New York : Bailliere Brothers, 1865.

Professor Hamilton, already favorably known to the pro-
fession as the author of a most valuable treatise on Fractures
and Dislocations, published at the beginning of our late war
a " Practical Treatise on Military Surgery " to supply the
immediate wants of young Surgeons entering the army
service. He tells us that " the edition was soon exhausted;
but unremitting engagements in the public service prevented
a revision of its pages, and the republication was conse-
quently delayed. Having at length undertaken the revisal,
it was found that four years of war had opened so many
questions of interest, that the limits and scope of the origi-
nal volume were inadequate to their consideration ; and
instead of a new edition, an entirely new work was de-
manded." The work before us, therefore, embodies his
perfected labor, and fully sustains the high reputation he
had before acquired as a writer and teacher in Bellevue
Medical College and Hospital.

In order to present a general view of the scope of this
work, it is only necessary to state that it treats of the
Examination of recruits; General Hygiene of troops; Bi-
vouac, accommodation of troops in tents, barracks, billets,
huts, etc.; Hospitals; Preparations for the field; Hygienic
management of troops upon the march ; Conveyance of sick

1866.] Hamilton's Treatise on Military Surgery. 89

and wounded soldiers; Gun-shot Wounds; Punctured and
Incised Wounds; Gun-shot Fractures; Amputations; Ex-
sections, Arrow Wounds; Traumatic Gangrene; Dry Gan-
grene; Tetanus; Scorbutus; and the employment of Anaes-
thetics. Our limits will not permit us to examine each of
these topics, but we shall cite a few paragraphs in illustration
of some of the author's views.

In describing some of the probes used in the examination
of Gun-shot wounds, the following brief account of Xelaton's
neat little invention is given : " The probe of Xelaton is
often invaluable in determining whether the foreign body,
the presence of which the ordinary silver probe may have
discovered, is lead or bone. This instrument is a small ball
of unpolished porcelain fastened securely upon the end of a
probe. Its size may be conveniently varied from two to
four lines in diameter, but the size which we have found
most generally useful is about two lines. To keep it from
being defaced it should be laid in a small, neatly fitting
gutta-percha case. In using it care must be taken that all
previous stains are removed from its surface by careful
wiping, it then should be pressed down to the foreign sub-
stance, and made to rotate upon it a few times. On with-
drawing the probe, the porcelain will of course be soiled
with blood, but this can be removed by rinsing it in water,
without any danger of effacing the marks made by the
lead." P. 184.

In the primary treatment of Gun-shot wounds by water
dressings, now in such general use, the author makes the
following very judicious remarks, in which we fully concur:
"Xo complaints have ever been made against tepid water.
No one has ever charged that it produced gangrene, or
excessive suppuration even, unless it was continued a long
time, and after suppuration had actually commenced; but
the same cannot be said of cold water and of ice water.
Many Surgeons have declared to us that they have seen
much mischief done in this way, and we have ourselves seen
several conclusive examples.

90 Hamilton's Treatise on Military Surgery. [July,

" It is our confident belief that, where the bleeding has
wholly ceased, tepid water ought to have the preference as
a first application , but that from this point of time, or soon
after, the temrjerature may be gradually and steadily low-
ered for several days ; keeping constantly in mind that our
object ought to be, not to extinguish the inflammation, but
only to control it, and for this purpose we may, commencing
at some time during the first or second day, lower the tem-
perature to 80, 70, or even 60 or 50 Fahrenheit, just in
proportion as the inflammation increases, and then gradually
elevate its temperature as the inflammation declines, or as
suppuration intervenes. Usually, however, it will be best
not to make a change of more than 10 or 15.

" Returning to the matter of temperature, we wish to say
that the final decision as to whether we shall in any case
employ tepid, cool, cold, or ice-cold applications, must de-
pend upon the sensations of the patient. We shall seldom
or never err if we make use of that temperature only which
the patient declares most agreeable. Irritation is the first
link in the chain of circumstances which results in inflam-
mation, and pain is its subjective sign ; we may therefore
conclude that those applications which most effectually allay
pain, or obviate sensations of burning, smarting, throbbing,
etc., will most certainly prevent or subdue irritation and
inflammation and that the opposite of this proposition,
namely, that whatever increases pain, etc., will increase
inflammation, is equally true.

" Upon this one point nearly all the Surgeons who have
used water in the treatment of wounds have arrived at the
same conclusion. The majority have preferred tepid water;
some have preferred cold, and a few have declared their
general preference for ice water. Eut however much they
have differed in relation to absolute temperature, they have
never, so fur as we are aware, deviated from the opinion
that if the application increases the pain it is actually hurt-
ful. Their views will be found further illustrated and sus-
tained in that excellent treatise entitled 'On the Employment

1866.] Hamilton's Treatise on Military Surgery. 91

of Water in Surgery," written by M. Alphonse Amussat of
Paris and published in 1851, and which we translated into
English the same year." p. 211.

In the after treatment of Gun-shot wounds, the author
again refers to the use of water in the following language :

"In regard to the water dressings, the rule which has
been laid down as applicable in the first instance still holds
good, namely, that the temperature be made agreeable to
the patient. It will often be found, however, as the inflam-
mation progresses, that the temperature may be gradually
lowered ; and in a few examples of active inflammation,
invading a large amount of soft structure, even the refrige-
rating mixtures may be employed. It is certain that
actively inflamed surfaces tolerate a greater degree of cold
than surfaces only slightly inflamed, probably for the reason
that caloric is elaborated under these circumstances much
more rapidly. Yet it is possible to freeze inflamed tissues,
and some care is required to avoid this accident. The ice,
snow, or ice water should not be applied directly to the
skin, but always with some non-conductor interposed, such
as cloth, lint, or a beef's bladder ; the latter, half filled with
the cold mixture, constitutes the most convenient mode of
I application. If after the cold has been applied some time
( the patient experiences a sense of numbness in the part, a
total loss of sensation, or a cold clammy sensation, even
though it may not be actually painful, the water ought at
once to be discontinued or its temperature raised. It is our
I opinion also, that in all cases the temperature should be
gradually elevated as suppuration takes place. Indeed very
cold applications must be limited ordinarily to a brief period
of time, or to that period during which the inflammation is
actually culminating.

" In confirmation of what we have said as to the hazards
of cold applications, we shall take the liberty of quoting
the following passages from Amussat, on the use of water in
surgery :

92 Hamilton's Treatise on Military Surgery. [July,

'Goursaud reports a case of Guyenot's, in which ice
having been applied an hour or two upon a strangulated
crural hernia, the hernia was not reduced, and the Surgeon,
obliged to resort to an operation, found the epiploon frozen;
the intestinal knuckle was, however, not injured, and the
patient recovered

' I have notes of the case of a patient affected with a
phlegmonous erysipelas of the arm and forearm, with whom
the continued application of ice produced a solidification of
the pus, so that for its removal it became necessary to resort
to shampooing, and very firm graduated compression.

'My father has been often consulted on account of a
gangrene which he has thought ought to be attributed to
the employment of very cold water; among the cases of
gangrene which I have myself seen, there are several which
must be ascribed to the same cause.

<I have collected also several cases of patients who
having been submitted to irrigations with cold water, have
suddenly died with some nervous malady. What part does
the cold play in the development of these phenomena?
"Without being assured that it is the principal cause, I be-
lieve I can at least say that it has some agency.

i Who will affirm/ says M. Eichet, ' that the application
of a powerful refrigerant upon a large surface will not, by
repelling inward upon the viscera the blood which originally
abounded in the diseased part, occasion congestions, and
give birth to those complications to which I have alluded !
The facts are everywhere to be seen, and the practitioner
ought to profit by them/

' It is well known, says Sanson, i that cold applications
may cease to be, useful, and may even become hurtful, by
rendering the flesh (edematous and pale, and causing it to
become irritable when suppuration is established in the
wounds. Sometimes also they entirely prevent the devel-
opment of inflammation to such a degree as that at the end
of twelve or fifteen days the wound is still in nearly the
same condition as at the moment of the accident/

L866.] Hamilton's Treatise on Military Surgenj. 93

' M. Apvrille reports a fact upon this point, which oc-
3urred in the service of M. Jobert. A woman had received
% blow from the horn of a cow, which had torn extensively
the skin and superficial muscles of the abdomen; cold water
compresses were applied and renewed every ten minutes ;
when this mode of treatment had been pursued for some
Lime, the wound was found to have made no progress toward
a cure, and the cold was suspended. The next day a violent
inflammation ensued; again the cold water compresses were
applied, and the wound returned to its original condition.
A. renewed suppression of the compresses was followed by a
yet more intense inflammation. Gradually a flabbiness
supervened, and the patient died.

1 M. Cloquet has remarked to me that he has observed the
phenomena noticed by Sanson, in debilitated subjects, when
cold has been used perseveringly.

1 Cold/ says Tanchou, < is only suitable for the young and
robust ; with feeble persons, the very old, and with infants,
it is always injurious/ This proposition is the more true as
the time of the application is the more prolonged.

' One will ask, perhaps, why the accidents of which we
speak are not observed more frequently ? I answer, that
in general Surgeons have not taken care to note them, and
farther, the temperature and the quantity of water employed
in a given time being seldom indicated in the report, it is
difficult to understand exactly the degree of refrigeration
produced, and whether, therefore, the accident ought or
ought not to be ascribed to the cold.

* We see from what precedes, that if cold water possesses
some great advantages, it has also many inconveniences, and
under certain circumstances it becomes even dangerous.
We ought then to prefer tepid water, which calms the pain,
and produces the desired effect of subtracting the caloric
without exceeding the proper limits, and without exposure
to any of the inconveniences of cold water, such as chills,
too sudden suppression of the inflammation; and especially
gangrene.' " pp. 214-217.

$4 Hamilton's Treatise on Military Surgery. [July,

In speaking of Gun-shot wounds of the thorax, Prof. H.
thus disposes of the question regarding the propriety of
closing the orifice ;

"Military Surgeons have of late been generally agreed
that in most cases Gun-shot wounds of the chest oujrht not
to be immediately closed. This is in accordance with the
general statement of our own views which we have already
made. Recently, however, Assistant-Surgeon Howard, of
the U.S.A., has recommended an opposite practice. He pro-
poses, having first removed as far as possible all foreign
substances, to hermetically seal the external wounds at once.
In order to accomplish this more certainly, he pares away
with a sharp knife the contused margins down to the bone
or to the pleura, giving to the wounds an elliptical form j
and then approximates the edges with silver sutures, which
are introduced at very short intervals, and made to pene-
trate deeply ; over the whole surface he now spreads collo-
dion, in which the fibres of loosened charpie are imbedded
to prevent more effectually the separation of the edges. A
compress and bandage may be added if necessary.

Dr. Howard claims for this method that it will assist in
controlling the hemorrhage j that it will relieve the dys-
pnoea, and prevent or diminish suppuration.

It is perhaps scarcely proper to attempt a criticism of
these views at this moment, since the results have not yet
been given fully to the profession. It will be proper, how-
ever, to state that this practice, in a form more or less
modified according to circumstances, has been recommended
and adopted in penetrating or perforating wounds of the
chest made by sharp instruments; in all penetrating or per-
forating wounds of the abdomen, whether Gun-shot or in-
cised; and in all Gun-shot wounds of the chest accompanied
with severe and alarming hemorrhage from the pulmonic
vessels. The novelty consists in the application of this
method to all wounds of the chest; and it is precisely this
exclusive view of the practice to wbicli Surgeons will hesi-
tate to give their approval.

1866.] Hamilton's Treatise on Military Surgery. 95

We will attempt to indicate what thoracic wounds seem
to us to demand or permit immediate closure of their ex-
ternal orifices.

First. All simple incised and punctured wounds; in
which class of accidents ample experience has shown that
we have not much to fear from suppuration, and that we
may reasonably expect union by adhesion throughout the
whole course of the channel caused by the weapon.

Second. All wounds made by smooth round balls or shot,
which have not come in contact with and broken any por-
tion of the bony parietes, and into which no foreign sub-
stance has been conveyed.

Third. When both pleural cavities have been opened by
the weapon or the projectile; since the free admission of air
into both sidespf the chest would, in most cases, cause death
immediately, and it is proper to anticipate and provide
against such an occurrence by every possible means.

Fourth. When the pulmonic hemorrhage the blood
escaping freely from the external orifices is very profuse
and alarming. In closing the wound, under these circum-
stances, the purpose would be to allow the blood to accu-
mulate within, with the hope that eventually, and before
fatal syncope was induced, the pressure of the coagulated
mass upon the wounded lungs would close the vessels. In
this case, however, the wound should not be closed by
sutures, but with compresses and adhesive straps, in order
that, if the pressure of the blood became so great as in itself
to threaten death by suffocation, by removing the dressings
it might be allowed again to escape.

Fifth. When it' is ascertained that the sense of suffoca-
tion is due to the presence of air in the pleural cavity and
not to blood; if at this moment the external wound is open
it will be proper to close it, temporarily at least, and to keep
it closed so long as the breathing is thereby relieved.

"The cases which remain after this enumeration, and in
which we cannot from our present experience advise a
closure of the wound, are :

96 Hamilton's Treatise on Military Surgery. [July,

First Gun-shot wounds made by conical rifle-balls, and
by all projectiles of a larger size (with the exceptions as to
pneumo-thorax, pulmonary hemorrhage, and perforation of
both cavities already stated).

Second. Gun-shot wounds made by any form or size of
projectile, in which fragments of bone or other foreign sub-
stances have been sent into the cavity of the chest and
cannot be removed.

Third. 'Penetrating' Gun-shot wounds, or those in which
the missile itself remains within the chest.

In not one of these latter cases would it seem proper to
hermetically seal, or even close temporarily, the external
orifices. The very rare examples of recovery from such
injuries, without excessive suppuration, do not warrant a
reasonable expectation of a result so desirable." pp. 278-280

Gun-shot fractures of the femur have, during the late war,
been very often left to nature, in consequence of the great
mortality which attended amputations, and the statistics
the author has been able to collect are not of such a char-
acter as to settle the practice in these cases. The following
are his conclusions :

We are prepared to say, however, that the Surgeon ought
not to attempt to save the thigh after a Gun-shot fracture,
when any of the following conditions obtain.

When the patient has to be carried far over rough roads
and without adequate support to the limb.

When the bones are greatly comminuted.

When the patient suffers great pain, or violent spasms
continue in spite of opiates and rest.

When the soft parts have suffered great contusion, as in
case of a fracture from a solid shot or shell.

When there is very extensive laceration of the soft parts.

When the principal arteries or nerves are involved in the
injury.

When the fracture implicates the knee-joint, or even when
it is near the knee-joint ; experience having shown that am-
putations near the knee-joint give a better percentage of

1866.] Hamilton's Treatise on Military Surgery, 97

recoveries than any other thigh amputations ; while, on
the other hand, attempts to save the limb in these cases
give a worse percentage of success than in any other frac-
ture of the thigh.

Under the following circumstances we would not, as a
rule, resort to amputation :

When the ball has entered the head, neck, or trochanteric
portion of the femur. Owing to the more spongy nature of
the femur in these parts, and the presence of a less amount
of solid lamellated structure, there is usually here less com-
minution than in Gun-shot injuries of the shaft. The great
vascularity of the trochanteric portion, and the firmness
with which the bone is attached to the adjacent tissues,
diminish the danger of necrosis and exfoliation. The cases
to which we have already referred seem to justify this con-
clusion. If any surgical operation is demanded in these
cases, it is usually exsection.

When the fracture is just below the trochanters; experi-
ence having shown that very few recover after these ampu-
tations. We think we have seen during the last three years
more femurs united after Gun-shot fractures in the upper
third of the shaft, than we have seen successful amputations
after the same injuries.

When the fracture of the femur is caused by a pistol ball,
by a round musket ball ; or by any missile, whose force is
nearly spent.

It will be understood that the last observation has refer-
ence solely to the less degree of comminution which these
missiles usually occasion." pp. 399-401.

We subjoin the author's views with regard to amputa-
tions :

" What conditions of the Limb th Army practice demand
Amputation ?

Simple fracture of a limb; it is unnecessary to say, doee
not demand amputation.

7

98 Hamilton's Treatise on Military Surgery. [July,.

A fracture complicated with considerable laceration of the
skin; or of the skin and muscular tissue, does not of necessity
demand amputation.

A fracture, with laceration of the main arterial trunk
supplying the limb, does not necessarily demand amputa-
tion. If the artery can be tied the limb may be saved, and
the fracture treated successfully.

A fracture, accompanied with the laceration of one or
more of the principal nervous trunks, does not always
demand amputation, yet it is a graver accident than the
one last supposed.

A fracture, complicated with a destruction of both the
principal arterial and nervous trunks, occurring in the
course of a large limb, like the thigh, the leg, the arm, or
the forearm, renders amputation necessary.

Similar lesions, without a fracture, render amputation
almost equally imperative.

Comminuted fractures, accompanied with extensive le-
sions of the soft parts, or with a rupture of either the
principal artery or the principal nerves, in the case of large
limbs, generally demand amputation in army practice.

Compound fractures, with either of the above complica-
tions, in large limbs, generally demand amputation.

Fractures accompanied with extensive and violent contu-
sion, demand amputation oftener than the same fractures
accompanied with cpen laceration.

In army practice, Gun-shot wounds which penetrate fairly
the shoulder-joint, the elbow-joint, or the wrist-joint, demand
in most cases either amputation or exsection.

Gun-shot wounds penetrating the hip-joint are generally
fatal, yet amputation may be practiced under some very
favorable circumstances. Exsection also presents a feeble
ground for hope.

Amputations after Gun-shot fractures of the upper third
of the shaft of the femur are seldom successful.

1866.] Hamilton's Treatise on Military Surgery. 99

Primary amputations for Gun-shot fractures in the middle
or lower thirds of the femur, present a much better average
of successful results.

Gun-shot wounds involving the knee-joint demand ampu-
tation in almost all cases. Guthrie has seen no recovery
from a Gun-shot wound of the knee-joint, unless the limb
was amputated. We have seen a few recoveries, especially
when the joint was penetrated by round balls, or when the
joint was slightly opened.

Gun-shot wounds, in which the ball does not actually enter
the joint, but in which the bone is struck above or below,
and the line of fracture extends into the joint, are subject to
nearly the same rules as that class of eases in which the
ball enters the joint; but the rule is less imperative.

Gun-shot wounds fairly penetrating the ankle-joint or the
tarsal bones, demand either amputation or exseetion.

Gun-shot wounds of the metacarpal or of the metatarsal
bones are often cured without amputation. Similar wounds
of the fingers or toes do not in general result so favorably ;
but the rule in this latter case cannot be stated very posi-
tively.

Second. The point at which the amputation is to be made.

This must depend mostly upon the part of the limb whteh
has suffered injury ; but in general we may say, at as low a
point as will be safe ; or in other words, we would state the
rule to be, to save as much of the limb as possible. Yet in no
case should the life be put at hazard for the sake of a limb,
much less for a small portion of a limb.

There are two reasons why we adopt the rule above
stated. First, because the longer the stump, the more useful
it will be to the possessor; and second, because experience
has shown that the nearer an amputation is made to the
trunk and the larger the circumference of the limb, the
greater is the danger to life. Thus, according to Malgaigne,
only 1 death occurred from 26 amputations of one of the

.100 Circular No. 6, War Department U.S.A. [July,

smaller toes ; 7 deaths from 46 amputations of the great
toe; 9 from 38 p rtial amputations of the foot; 106 from
192 amputations of the leg; and 126 from 201 amputations
of the thigh. Again, in the Crimea the mortality after
amputations of the thigh, in a certain number of cases, was
as follows : Lower third, 56 per cent. ; middle third, 60 per
cent.; upper third, 86 per cent.; hip, 100 per cent. (23 cases).

Stephen Smith, in a paper on hip-joint amputations, has
brought together 98 cases, obtained partly from military
and partly from civil practice, of which 56 proved fatal ; a
ratio of mortality of only 571 per cent. In the Mexican
campaign all amputations at the hip-joint terminated fatally-
In a total of 44 cases of amputations for Gun-shot injuries,
collected by Legouest, 40 died. The four which recovered
were secondary amputations.

During the present war two successful amputations have
been made at the hip-joint. One by Edward Shippen, Sur-
geon, U.S. V., and one by Dr. E. S. Fenner, of the Confederate
Army." Pp. 420-423.

In conclusion we commend Prof. Hamilton's work as a
valuable contribution to Military Surgery, which will do
credit to the United States.

article rv.

Circular No. 6, War Department, Surgeon GeneraVs Offi.ce, Wash-
ington, November 1, 1865. Hcports on the Extent and Nature
of the Materials Available for the Preparation of a Medical and
Surgical History of the Rebellion. Printed for the Surgeon
General's Office, by J. P. Lippincott <fe Co. ; Philadelphia :
J 865. Illustrated with one hundred and nine figures and five
plates.

This circular which has been published by Brevet-Major General
Joseph K. Barnes, Surgeon General, U. S. A., for the information
cfthe Medical officers of the United States Army, is composed of
two distinct reports, drawn up from materials ia the Surgeon
General's Office,

1866.] Circular No. 6, War Department U.S.A. 101

The first report, by George A. Otis, Brevet-Lieutenant Colonel
and Surgeon U. S. Vols., in charge of the Division of Surgical
Records, S. G. 0. and Curator of the Army Medical Museum,
relates more exclusively to the Surgical records of the recent civil
war ; and the second report, by J. J. Woodward, Assistant Surgeon
and Brevet-Major, U. S. A., in charge of the Record and Pension
Division, Surgeon General's Office, and of the Medical Section,
Army Medical Museum, relates chiefly to the Medical Statistics of
the several armies and general hospitals, and to the memoirs and
reports by medical officers, on the causes, symptoms, and treat-
ment, and pathological anatomy of the more important camp
diseases.

We shall confine the present review to the Surgical report by
Surgeon George A. Otis, and shall endeavor to give such an
analysis as will embody every fact of value in the very language
of the author; believing that this information will prove of great
interest and value to the medical officers of the late Confederate
States' Army. The report of Dr. Woodward will be reviewed in
the next number of this Journal.

The materials in the Surgeon General's office relating to the
surgery of the late war, consist of the reports of medical officers
engaged in it, and of illustrations of these reports in the shape of
pathological specimens, drawings, and models. The documentary
data are of three kinds : first, the numerical returns, in whicli the
number alone of the different forms of wounds, accidents, injuries,
and surgical diseases is given ; secondly, what may be called the
nominal returns, in which are furnished the name and military
description of each patient, and the particulars of the case, with
more or less of detail; and, thirdly, the miscellaneous reports. To
the first elass belong the "classified return of wounds and injuries,"
which every medical officer has been required to furnish immedi-
ately after every engagement; the "tabular statement of gun shos
wounds," and the portion of the "monthly report of sick and
wounded," referring to surgical diseases and accidents. The
second class comprises the "quarterly reports of wounded,"
required of all general and post hospitals; the " quarterly sanitary
reports of regimental surgeons;" " the nominal lists of wounded,"

102 Circular No. 6, War Department U.S.A. [July.

procured by medical directors after every general engagement;
and extracts from " case books." In the second class are included
the reports of medical directors of armies in regard to the opera-
tions of the medical department, and the succor given to the
wounded ; reports and dissertations on new methods and modes of
treatment, and modifications of surgical apparatus and appliances ;
pathological researches on morbid processes, pertaining to surgery,
as hospital gangrene, osteomyelitis, pyaemia, and the like; plans
for ambulance organization, and the transportation of the wounded
by land and water.

Surgeon Otis affirms that the extent of these materials is simply
enormous, and that the returns are of as huge proportions as the
armies that have been engaged in active operations for the last
four years. The author of this portion of the work, still farther
expresses his belief that the result of the labors of the medical
officers of the United States' Army has been the accumulation of a
mass of facts and observations in military surgery of unprecedented
magnitude.

Whilst it has been found as yet impracticable to determine with
accuracy the number of wounds received in action during the late
war, some conception may be formed of the vast numbers dealt
with, by a comparison of a portion of the returns with the com-
plete statistics of other armies.

Thus, in the British army in the Crimea, during the entire war,
there were 12,094 wounded, and 2,755 killed, or a total of 14,849;
in the French army, in the Crimea, of a total effective force of
809,268, according to M. Chenu, there were 39,868 wounded, and
8,250 killed, or a total of 48,118 ; whilst in the late war, the
monthly reports from a little more than half the United States'
regiments in the field, give for the year ending June 30, 1862, an
aggregate of 17,496 gunshot wounds; the reports from rather more
than three-fourths of the regiments, for the year ending June 30,
1863, give a total of 55,974 gunshot wounds; and the battle-field
lists of the wounded of the United States' armies for the years
1864-65, include over 114,000 names. Great as these figures
appear to be, they are still below the mark, for many wounded

1866.] Circular No. 6, War Department U.S.A. 103

srere received directly into the general hospitals whose names were
aever entered upon the field reports.

Whilst, therefore, the total killed and wounded in the English
md French armies during the Crimean War, numbered 62,967 ;
the incomplete returns of the United States' armies show three
times this number of gunshot wounds, or more exactly 187,470.

And in pondering over these figures, the reviewer cannot refrain
Tom expressing his wonder, that the imperfectly armed, half- clad,
lalf-fed, and unpaid battalions of a sparsely settled country, with
mperfect supplies of arms and ammunition, without manufacto-
-ies, cut off from the rest of the world, with less than eight
nillions of white inhabitants, with innumerable internal enemies
md spies, and with a dangerous class of laborers which formed an
nvaluable recruiting ground to their enemies in addition to all
Europe : should have bravely withstood, during four long years of
inexampled privation and suffering, three millions of men in
trnis; and have inflicted four-fold as much damage, as the well
ippointed and immense armies of one of the greatest powers of
Europe inflicted upon the combined armies of England and
France.

The gigantic nature of the late civil war between the different
lections of the United States, has been still farther shown by
Burgeon Otis, in comparing the relative numbers of eases of some
mportant injury; as, for example, gunshot fractures of the femur,
t is found that in the French Crimean army, there were 459 such
njuries, and in the English army 194, while over 5,000 such cases
^ere reported to the Surgeon General's office of the United States'
trmy : or if one of the major operations is selected for comparison,
ts excision of the head of the humerus, the Crimean returns give
iixteen of these excisions in the British, and thirty-eight in the
French army, whilst the registers of the United States' army con-
:ain the detailed histories of 575 such operations.

The surgical specimens of the Army Medical Museum are said
to number 5,480, and Surgeon Otis affirms that not only in speci-
mens of recent injuries, but in illustrations of reparative processes
ifter injury, of morbid processes, of the results of operations, and

104 Circular No. 6, War Department U.S.A. [July,

of surgical apparatus and appliances, this institution is richer,
numerically at least, than the Medico-Military Museums of France
or Great Britain.

After several efforts to arrange the original records in a form
more convenient for reference and study, the following classifica-
tion of wounds and their results, and of operations was finally
adopted. It is less elaborate than that employed in the British
statistics of the surgery in the Crimea, and more detailed than
that followed by M. Chenu, in the French Surgical Eeport of the
Crimean War. The appended figures give the number of cases of
each class that were revised and corrected upon the new registers
in September 80, 1865.

Classification of Wounds and Injuries, and Their Results, followed
in the Division of Surgical Records. Surgeon General's Office,
United States Army.

Gunshot fractures and injuries of the cranium 1,108

Gunshot fractures of the bones of the face 1,579

Gunshot fractures of the spine, not involving the chest or abdomen 187

Gunshot fractures of the ribs without injury of the thoracic or abdominal viscera 180

Gunshot fractures of the pelvis, not involving the peritoneal cav.ty 397

Gunshot fractures of the scapula and clavicle, not implicating the thoracic cavity 389

Gunshot fractures of the humerus 2,408

Gunshot fractures of the radias and ulna 7S5

Gunshot fractures of the carpus and metacarpus 790

Gunshot fractures of the femur 1.957

Gunshot fractures of the patella and knee joint 1,220

Gunshot fractures of the tibia and fibula . 1,056

Gunshot fractures of the tarsus and metatarsus 629

Gunshot penetrating wounds of the chest and injuries implicating thoracic viscera. . . . 2,303
Gunshot penetrating wounds of the abdomen and injuries involving the abdominal

viscera 565

Gunshot scalp wounds 3,942

Gunshot flesh wounds of the face 2,588

Gunshot wounds of the neck 1 ,329

Gunshot wounds of the thoracic parictes 4,759

Gunshot wounds of the back 5,195

Gunshot wounds of the abdominal parietcs 2,181

Gunshot Mounds of the genito-urinary organs 4fi8

Gunshot wounds of the upper extremities 21,248

Gunshot wounds of the lower extremities 25,152

Gunshot wounds of arteries 44

Gunshot wounds of veins 3

Gunshot wounds of nerves 76

Sabre wounds 106

Bayonet wounds 143

Simpli' fractures and miscellaneous wounds and injuries 2,883

Cases of tetanus 363

Gase.s of secondary hemorrhage' 1,035

Cases of pyaemia 754

Total

' >.->

1866.] Circular No. 6, War Department U.S.A. 105

Classification of Surgical Operations followed in the Division of
Surgiacl Records. Surgeon General's Office, United States
Army.

Amputations of the fingers 1,849

Amputations at the wrist joint 46

Amputations at the fore arm. 992

Amputations at the elbow joint 19

Amputations of the arm 2,706

Amputations ;it the shoulder joint 437

Amputations of the toes 802

Amputations of the foot (partial) 160

Amputations at the ankle joint 73

Amputations of the leg. 3,014

Amputations of the knee joint 132

Amputations of the thigh 2,984

Amputations at the hp joint 21

Excisions of the head of the humerus 575

Excisions of the elbow 315

Excisions of the wrist 34

Excisions of the ankle 22

f Shaft of humerus")

Excisions in the continuity of the upper extremities \ rthta ' ^

t Radius and ulna. J

(Tibia )

Excisions of the shafts of the tibia and fibula ^Fibula [ 220

(Tibia and Fibula)

Excisions of the knee 11

Excisions of the shaft of the femur 68

Excisions of the head of the femur 32

Excisions of the bones of the face and neck 101

Trephining 221

Ligations of arteries 404

Extraction of foreign bodies 726

Operations for surgical diseases. 443

Operations not included in other categories 23

Total 17,125

ON SPECIAL WOUNDS AND INJURIES.

Gunshot Injuries of the Head. They number 5,056, and have
been recorded in two classes : First, The gunshot fractures and
injuries of the cranium, including the perforating and penetrating
and depressed fractures, the fractures without known depressions,
and the contusions of the skull resulting in lesions of the encepha-
lon ; and, Secondly, the simple contusions and flesh wounds of the
scalp.

In the first class, 1,104 cases are recorded; of 704 of them, of
which the results have been ascertained, 505 died, and 199 re-
covered. In 107 of these terminated cases, the operation of
trephining was performed, of which sixty died and forty-seven
recovered. In 114 cases, fragments of bone or foreign substances
were removed by the elevator or forceps, without the use of the
trephine; and of these sixty one died, and fifty three recovered.
When operative proceedures were instituted, the recoveries were

106 Circular No. 6, War Department U.S.A. [July,

45, 3 per cent. But it must be apprehended that this favorable
exhibit will be materially modified when a larger number of results
are ascertained, and that a greater proportion of the field opera-
tions of trephining, in which the results are stated to be undeter-
mined, were lost sight of and terminated fatally. In the 483
cases treated by expectancy, the ratio "of recovery is only 20, 5
per cent. But the latter group of cases includes nearly all of the
penetrating and perforating fractures, and it would be unwise to
base on these figures an argument of operative interference.

The gunshot contusions and wounds of the scalp that have been
entered on the records, number 3,942, of which 103 terminated
fatally. It is altogether probable that in all of these fatal cases,
some undiscovered injury was done to the cranium or its contents;
or that the peri cranium was removed, and death of bone ensued,
with consecutive lesions of the encephalon. The histories of
many of these cases are now under investigation, and so far as
ascertained, the fatal results have depended upon concussion or
compression of the brain, or upon the formation of abscesses in the
liver or lungs, in consequence of inflammation in the veins of the
diploe. Compression has resulted either from extravasation of
blood, or inflammation of the" brain or its membranes, or from
suppuration. This portion of the report is illustrated with a
number of cases and drawings of fractures of the cranium. The
following remarks upon these cases appear to be worthy of con.
sideration :

"The foregoing case illustrates the fallacy of Potts' views in
relation to trephaning for pus under the skull-cap ; and yet, under
such circumstances, the best modern authorities advise the use of
the trephine as affording the patient the only chance of recovery.
The records attest how slight this chance is, and corroborate the
observation of Mr. Ilewett,* that 'the successful issue of a case of
trephining for matter between the bone and the dura mater is
almost unknown to surgeons of our own time.'"

"According to Mr. Teevan'sf experimental inquiries, the aper-
ture of exit in gunshot perforations of the cranium is always

*A System of Surgery, Theoretical and Practical, in treatises by various authors. Edited
by T. Holmes, M. A., Cantab. London : 18(51 ; vol. i, p 101.
yBritish and Foreign Medico-Chirurgical Review, vol. xxxiv, p 205.

1866.] Circular No. 6, War Department U.S.A. 107

larger than the aperture of entry, because it is made by the
ball plus the fragments of bone driven out from the proximal table
and the diploe."

We would also add, in virtue of the change in the symmetrical
form of the ball and the diminished velocity :

" While the number of fatal results after trephining are very
great, the examples of success are yet numerous. The data are
not sufficiently complete to admit of fair comparative analysis ;
still it is difficult to avoid the impression that a larger measure of
success has attended this operation in the late war, than the
previous experience of military surgeons would have led us to
anticipate. Surgeon D. "W. Bliss, U. S. Vols., alone has reported
eleven successes after the use of the elevator or trephine. Even
in those almost hopeless cases in which compression of the brain
follows a gunshot injury of 'the skull at a late date, instances of
recovery are reported/'

" The occurrence of hernia or fungus cerebri is mentioned in
connection with eighteen cases of gunshot fracture of the skull,
complicated by lacerations of the dura mater and brain. In four
of these cases recovery took place without operative interference
with the protruding fungous mass, which, in these instances,
gradually contracted, was then covered by granulations, and
finally cicatrized. In those cases in which bandaging and com-
pression was resorted to, cerebral oppression was soon manifested,
and stupor and coma eventually supervened. In those in which
the tumor was sliced off, as usually recommended, at the proper
level of the brain, it was commonly speedily reproduced, and
death from irritation ensued." p. 17.

"In looking over the registers of gunshot injuries of the head,
two general facts are noticed : First, that in the after treatment
of scalp wounds, a multitude of surgeons did not consider spare
diet, perfect rest, and antiphlogistic measures as of essential
importance; and, Secondly, that in the treatment of cranial
fractures, the general tendency was to the practice recommended
by Gruthrie, in regard to operative procedures, rather than the
more expectant plan insisted upon by the majority of modern
European writers on military surgery." p. 17.

108 Circular No. 6, War Department U.S.A. [July

" Gunshot Wounds of the Face. Of 4,167 gunshot wounds of
the face transcribed from the reports from the beginning of the
war to October, 1864, there were 1,579 fractures of the facial
bones, and 2,588 flesh wounds. Of the former, 891 recovered,
107 died, and the terminations are still to be ascertained in 581
cases

Secondary haemorrhage has been the principal source of fatality
in these injuries. It is a frequent complication in gunshot
fractures of the facial bones ; and the difficulties in securing
bleeding vessels in this region are very great. Recourse has
often been had to ligations of the carotid artery, with the result
of postponing for a time the fatal event.

Owing to the great vascularity and vitality of the tissues in this
region, gunshot wounds of the face have commonly healed rapidly,
and many creditable plastic operations for the relief of deformities
following such injuries have been accomplished." p. 20.

Gunshot Wounds of the Neck. Of the 1,329 cases of this cate-
gory that have been entered on the records, the ultimate results
have been ascertained in 546 cases only, and in these the mortality
is fourteen per cent. Several instances are recorded in which
large grape shot, on striking the hyoid bone, were deflected, and
buried themselves in the supra-spinous fossa of the scapula, or
among the muscles of the back. These patients died from
laryngnitis or oedema of the glottis, and might have been saved
perhaps by tracheotomy ; but they died suddenly, when surgical
assistance could not be immediately procured, p. 20.

Gunshot Wounds of the Back and Spine. In this class have
been included the fractures of the vertebral column which were
not complicated by penetrating wounds of the chest or abdominal
cavity, and flesh wounds of the region covered by the trapezius,
latissimus dorsi, and gluteal muscles. Of 187 recorded cases of
gunshot fractures of vertebrae, all but seven proved fatal. Six
of these were fractures of the transverse or spinous apophyses.
The seventh case is that of a soldier wounded at Chicamauga,
September 20, 1863, by a musket ball, which fractured the spinous
process of the fourth lumbar vertebra, and penetrated to the
vertebral canal. The ball and fragments of bone were extracted

1866.] Circular No. 6, War Department U.S.A. 109

at a Nashville hospital. The last report states that the patient is
likely to recover.

Five thousand one hundred and ninety-four gunshot wounds of
the back have been recorded, of which a large proportion are
injuries from shell. Troops being often ordered to lie down
under a shell fire, this region becomes particularly exposed, p 21.

Gunshot Wounds of the Chest. Of 7,052 gunshot wounds of
the chest that have been examined and transcribed from the
reports, belonging to the period prior to July, 1864, there were
2,303 that either penetrated the thoracic cavity or were accom-
panied by lesions of the thoracic viscera- The results have been
ascertained in 1,272 of these, and were fatal in 930, or seventy-
three per cent. The 4,759 flesh wounds presented a very small
ratio of mortality. It was observed, however, that they were
commonly long in healing, in consequence, no doubt, of the
mobility of the thoracic parictes.

In the treatment of penetrating wounds of the chest, venesec-
tion appears to have been abandoned altogether. Haemorrhage
was treated by the application of cold, perfect rest, and the
administration of opium. These measures seem to have proved
adequate generally, and no instances are reported of the perform-
ance of paracentesis or of the enlargement of wounds for the
evacuation of effused blood. Haemorrhage from the vessels of the
costal parietes has been exceedingly rare, and in the few instances
recorded, was a secondary accident. Hence, the management of
bleeding from wounded inter-costal arteries has presented theo-
retical rather than practical difficulties. It has been the common
practice to remove splintered portions of fractured ribs, and to
round off sharp edges that were likely to wound the pleura or
lung. After this, with the exception of extracting foreign bodies,
whenever practicable, and performing paracentesis when empyema
was developed, it has been usual to leave these cases to the natural
process of cure.

The records of the results of the so-called method of ' hermeti-
cally sealing' gunshot penetrating wounds of the chest are suffi-
ciently ample to warrant an unqualified condemnation of the
practice. The histories of the cases in which this plan was

110 Circular No. 6, War Department U.S.A. [July,

adopted have been traced, in most instances, to their rapid fatal
conclusion.

Few examples of recovery are recorded where the track of the
ball passed near the root of the lung. The cases in which there
was a fracture of the ribs at the wound of entry were very
dangerous. The established opinion, that penetrating wounds
with lodgment of the ball are more fatal than penetrating wounds,
was amply illustrated. But very few recoveries with balls lodged
in the lung are recorded, and the histories of such cases are less
explicit and complete than could be desired.

Only four cases are recorded of gunshot wounds of the heart
that came under treatment. The patient that lived longest after
a gunshot wound of the heart, survived twelve hours. In this
case a small pistol-shot entered the left ventricle and passed out
through the right auricle, pp. 21-23.

Gunshot Wounds of the Abdomen. Of 2,707 gunshot wounds
of the abdomen reported from the beginning of the war to July
1st, 1864, there were 2,161 flesh wounds, and 543 cases in which
the peritoneal cavity was penetrated or the abdominal viscera
injured. Among the flesh wounds, 114 fatal cases are recorded,
which were, in most instances, cases of sloughing from injuries of
the abdominal parietes by shells. Of the 543 penetrating wounds,
the results have been ascertained in 414, and were fatal in 308,
or 74 per cent.

In many cases faecal fistulae were produced; they commonly
closed after a time, without operative interference, reopening at
intervals, and then healing permanently.

Recoveries after wounds of the large intestines have been much
more numerous than after wounds of the ileum or jejunum.

No case has been reported in which it was thought expedient to
apply a suture to the intestines after gunshot wounds.

Gunshot wounds of the liver were usually followed by extrava-
sation into the abdominal cavity and rapidly fatal peritonitis. Of
32 cases in which the diagnosis was unquestionable, all but four
terminated fatally. All case3 of gunshot wounds of the spleen?
that have been reported, were fatal.

Gunshot wounds of the bladder, when the projectile entered

1866.] Circular No. 6, War Department U.S.A. Ill

above the pubes, or through the pelvic bones, have proved fatal,
so far as the records have been examined. There are many
examples of recovery, however, from injuries of the parts of the
bladder uncovered by the peritonaeum.

Several examples of recovery, after protrusions of the abdomi-
nal viscera through gunshot wounds have been reported. In two
cases in which loops of small intestine issued, they were imme-
diately returned and retained by means of adhesive strips and
bandages, and the patients recovered with ventral hernia. The
escape of omentum, through wounds, would not appear to be a
very serious complication, for in many cases portions of protruding
omentum have been excised, and the patients have, nevertheless,
recovered promptly, pp. 24-27.

Gunshot Fractures of the Pelvis. The records under this head
include only the cases in which the abdominal cavity was not
penetrated. From the beginning of the war to October 1st, 1864,
359 such cases have been reported. Recovery took place in 97,
death in 77, and the result is still to be ascertained in 185. In
256 cases the ileum alone was injured, the ischium alone in 19,
the pubes in 12, the sacrum in 32, and in 40 cases the lesions
extended to two or more portions of the innominata. The gravity
of these cases depended upon the location and extent of the
fracture. The majority of recoveries were from fracture of the
ileum by musket balls, in which the crest was grooved, or com-
paratively slight injury was inflicted. Yet there were many
examples of perforation of the body of the ileum with ultimate
recovery.

In most cases of injury of the pelvic bones, very tedious sup.
puration ensued, and Surgery could do but little, except to facili.
tate the escape of pus, and to remove dead bone as it became
separated. The returns corroborate the observation of Stromeyer,
that there is a great liability to pyaemia in gunshot fractures of
the pelvis.

Gunshot Wounds of the Genito- Urinary Organs. In this
category are included gunshot wounds of the genitals or urinary
organs, that are not complicated with fractures of the pelvis, or

112 Circular No. 6, War Department U.S.A. [July,

with penetrature of the abdominal cavity. To October 1st, 1864,
the reports furnish 457 such wounds, of which 37 had a fatal
result, p. 29.

Gunshot Wounds of the Upper Extremities. Yfhen unaccom-
panied by lesions of the vessels and nerves, the gunshot flesh
wounds of the upper extremity are not very serious injuries. All
foreign bodies having been extracted, they commonly heal, under
the use of water dressings, and the lightest bandaging, in a few
weeks. The 21,248 cases entered on the registers are all copied
from the reports for the last quarter of 1863, and the first two
quarters of 1864.

The gunshot fractures of the upper extremity are recorded in
four classes : those of the scapula and clavicle, which are not, at
the same time, penetrating wounds of the chest; those of the
shaft of the humerus and either of its articular extremities;
those of the ulna and radius ; and those of the carpus and meta-
carpus. It is only with the second class that much progress has
been made. This comprises 2,408 cases of gunshot fractures of
the humerus that have been examined and recorded Recovery
followed in 1,253 cases, death in 436, and the result is as yet
undetermined in 719 cases. In the 1,689 completed cases, ampu-
tation or excision were practiced in 996, and conservative treat-
ment was adopted in 693, with a ratio of mortality of 21 per cent,
in the former and 30 per cent, in the latter. But it is premature
to make deductions from statistics which are daily augmenting and
tending toward completion, p. 29.

Gunshot Wounds of the Lower Extremities. Of these 30,014
cases have been recorded, of which 4,862 were fractures, and
25,152 were flesh wounds. The latter were transcribed from the
reports from October 1st, 1863, to October 1st, 1864. Of the
1,823 cases of gunshot fracture of the femur that have been
entered on the permanent records, the results have been ascer-
tained in 1,233. Of the 1,183 cases of gunshot wounds of the
knee-joint, the results are known in 740.

The following table exhibits at a glance the results of 2,003
cases of gunshot fracture of the femur, or of gunshot wounds of
the knee-joint, out of a total of 3,106 cases hitherto recorded :

1866.] Circular No. 6, War Department U.S.A. 113

TABLE, Exhibiting the Remits of 2,00-3 Terminated Cases of
Gunshot Fracture of the Femur, or of Gunshot Wounds of the
Knee-Joint, out of 3,106 cases that have been entered on the
records.

NATURE OF WOUND.

a
s

<

O
Eh

Amputatiox

EXCISION

CONSERVATIVE

MEASURES

>

z.

a
1

I

B

5*8

s 1

-r

01

>

s

I

a)
d

a
-

T.

01

_ =

4

~
u

-
>
z
~
o

-3

-3
11

c

o

--

a

8

^ -
>-.]

5
S 1

Gunshot Fractures of Femur
implicating Hip Joint

Gunshot Fractures of Upper
Third of Femur

Gunshot Fractures of Middle
Third of Femur

Gunshot Fractures of Lower
Third of Femur

Gunshot "Wounds of Knee
Joint svith or without Frac-
ture

TOTAL .

346

m

2003

2 0

24; 11

m

100

47 54.83
117 46

121 j 331 266

302 m 441

73.23

63.26'

2 10

I
7 IS 6:72.

IN

1 88.33 0 68

2 13
1 1

1 9

13 ha

14 100.

93 237 199 71.81
J |

6 1061 132148 5546

72 101 137 '57. 79

1 90. | 50 258
18,79.68 321 ! 796,

97

00-;

551

NOTE. In this table the rate of mortality is calculated for the finished cases alone.

In examining the above table in detail, it is seen that the results
are ascertained in 822 of the 1,263 cases treated by amputation,
or 65 per cent. ; in 64 of the 82 cases treated by excision, or 78
per cent.; and in 1,117 of the 1,761 cases treated by conservative
measures, or 63 per cent.

The only recorded recoveries after gunshot fracture of the
femur involving the hip-joint are those in which excision was
practiced. In fractures of the upper third, the mortality rate is
greatest for the cases treated by amputation. There were 43 of
these cases, and in 19 of them the amputation was done at the
hip-joint. Excision gives 7 recoveries after fractures of the
upper third ; 2 of these were excisions of the head and a portion
of the shaft of the femur, 4 were formal excisions of the contin-
uity, and 1 was a removal of fragments and rounding off of sharp
edges of bone, which was admitted amongst the excisions with
some hesitation. Under conservative measures 93 cases of frac-
ture of the upper third had survived the injury a year or more,
and are reported as recovered,

8

Ii4 Circular No. 6, War Department U.S.A. [July,

Comparing in gross the 822 finished cases treated by amputa-
tion, with the 1,117 treated by conservation, the mortality rate of
the former has the advantage by 3 per cent. ; an advantage that is
maintained in the different regions, except in the upper third. It
must be remembered that the amputations include most of the bad
cases, and those in which preservation of the limb was attempted
and abandoned, p. 30-32.

Gunshot Wounds of the Arteries. The number of cases reported
under this head is extremely small. In the campaign of the Army
of the Potomac from the Rapidan to the James, in May, June,
and July, 1864, of a total of 36,508 gunshot wounds, only 27
belong to this category. The cases of compound fracture compli-
cated with injuries of the large vessels, the cases in which limbs
are carried away by solid shot or shell, and the cases in which all
the tissues of a limb are disorganized by contusion from a large
projectile, and the vitality of the arteries is destroyed, are all
returned under other heads. Those only are included in which
the canal of a large vessel is primarily opened, and in whieh this
is the principal accident. Such cases are to be sought for among
the dead on the battle-field rather than in the Field Hospitals.
Surgeon J. A. Lidell, U. S. Yols , reports that on the morning of
March 25th, 1865, he examined 43 bodies of soldiers killed in the
combat near Fort Steadman, in the lines before Petersburg; 23
were shot in the head, 15 in the chest, and 5 in the abdomen. The
bodies of all those wounded in the abdomen were very much
blanched, as if they had died of hemorrhage, and the same remark
held true in regard to all but two or three of those wounded in
the chest. In the few cases of primary gunshot lesions of the
arteries that came under treatment, it was usually found that only
a portion of the calibre of the vessel had been carried away, and
that retraction had been thus prevented. But 44 cases are entered
on the records. In most of them, ligatures were placed above
and below the seat of injury; but in a few instances, the main
trunk was tied at a distance, and amputation was practiced when
the bleeding recurred; 20 of the 44 cases terminated fatally, p.
38-39.

Sabre and Bayonet Wounds. The number of sabre and bayonet

1866.] Circular No. 6, War Department U.S.A. 115

wounds that have come under treatment has been comparatively
small ; 105 cases of the former, and 143 of the latter comprise
nearly all that have been reported for the first three years of the
war. Of these wounds, two-thirds were received in action, gnd
the remainder were inflicted by sentinels or patrols. There are 11
deaths from sword wounds recorded, and 6 from bayonet wounds.
From General Sheridan's campaign in the Shenandoah Valley, 25
sabre wounds are reported ; and from the battle of Jonesborough,
in Georgia, 30 bayonet wounds, p. 39.

Tetanus. The 363 cases of traumatic tetanus recorded in
1 the register for that subject, are all that have been reported
during the war. The proportion to the total number of
wounds is not large. Of the total number of cases of trau-
matic tetanus, 336 terminated fatally; of the twenty-seven
recoveries reported, the disease was of a chronic form in
twenty-three ; in the remaining four cases the symptoms
were very grave. In two, recovery took place under the
use of opiates and stimulants; in two, after amputation of
I the wounded part.

The great majority of the cases were treated by the free
, use of opium, conjoined with stimulants and concentrated
nourishment. Chloroform inhalations were very generally-
employed during the paroxysms of spasmodic contraction.
Subcutaneous injections of the salts of morphia and atropia
were frequently used. Cathartics, quinine, camphor, canna-
bis indica, bromide of potassium, strychnine, belladonna, and
aconite are mentioned among the remedies employed. Cups,
^ blisters, turpentine stupes, and ice were among the applica-
] tions made to the spine; and fomentations with opium or
tobacco were, in some cases, applied to the wound. Ampu-
tation, the division of nerves, and the extirpation of neuro-
mata in stumps, were the surgical measures sometimes
employed. The results have not modified the conclusion
of Romberg, that ' whenever tetanus puts on the acute form,
no curative proceding will avail, while in the milder and
more tardy form, the most various remedies have been
followed by cure.' The value of nicotine, of the calabar

116 Circular No. 6, War Department U.S.A. [Mf,

bean, and of curare/* as curative agents in tetanus was not
tested.

Autopsies were made in many cases; but with almost
negative results. There were no microscopic examinations
to corroborate or disprove the assertions of Kokitansky and
Demme,f that tetanus has a constant anatomical lesion,
consisting in a proliferation of the connective tissue of the
whole medullary substance of the medulla oblongata, of the
inferior peduncles of the cerebellum, of the crura cerebri,
and of the spinal cord, producing a viscous mass, abounding
in nuclei, and never progressing to the formation of fibres.
It is frequently mentioned, however, that great congestion
of the brain and spinal cord was observ ed, a condition on
which the lesions of the connective tissue above described
are believed to depend.

The records abound with illustrations of the influence of
sudden vicissitudes of temperature in producing this fatal
affection, and of the effect which unextracted balls and
other foreign bodies and matter confined under fasciae
a>pear to exercise upon its development, pp. 41-42.

Secondary Hemorrhage. On this important subject the
records are still very incomplete.

Of 387 cases of secondary bleeding from stumps, 233,
or sixty per cent, ended fatally; of 650 cases of secondary
hemorrhage from gunshot wounds, 330 cases, or fifty-one
per cent, terminated fatally. In the 1,037 recorded cases,
the, femoral artery was ligated ninety-three times for bleed-
ing from stumps, and forty-five times for bleeding from
wounds; the subclavian was tied five times for bleeding
after amputation at the shoulder joint, and six times for
hemorrhage from gunshot wounds of the axilla. The
common carotid was ligated fifteen times for hemorrhage
from the deep branches of the internal maxillary. Ampu-
tation was practised seventy-eight times for secondary

* According to H. Demme, of twenty-two cases of traumatic tetanus, treated by the latter
agent, eight recovered. See Schweiz : Zeitschuft fur Hcilkunde ; ii, 356.
-i-Schniidt's Jalirbucher, vol'cxii.

1866.] Circular No. 6, War Department U.S.A. 117

bleeding from gunshot wounds, and re-amputation was
performed fourteen times when other means of arresting
hemorrhage from stumps had failed.

The 387 cases of secondary hemorrhage from stumps,
were chiefly examples of arterial bleeding. In ninety-five
cases, the hemorrhage was, perhaps, mainly venous, and
was checked by elevating the stump, or applying cold
water, ice, pressure, or the solution of the persulphate of
iron. When the hemorrhage was arterial, the most common
practice was to tie the main vessel, at the second bleeding,
as near as was prudent to the end of the stump. The
results of tying the vessel above, according to Anel's method,
were very unfortunate.

In reviewing the 650 recorded cases of secondary hemorr-
hage from gunshot wounds, it appears that, during the
earlier part of the war, there were many surgeons who
were not sufficiently impressed by the precepts of Bell and
Guthrie, and who frequently treated secondary hemorrhage
from gunshot wounds by tying the main trunk at a distance
from the wound, even when the bleeding occurred at a
comparatively early period. Later in the war, however,
it was the universal practice to endeavor to secure both
ends of the bleeding vessel at the seat of injury, and some
brilliant examples are recorded in which this was accom-
plished in wounds of the posterior tibial or popliteal, when
limbs had become infiltrated and swollen, and the difficul-
ties of the operations were immense, pp. 42-43,

Pyoemia. On this subject 281 reports have been examined,
and the individual cases detailed in them have been tran-
scribed upon the registers; 251 special reports on the subject
remain to be examined. The histories of 754 cases are
recorded in the register, the post-mortem observations ac-
companying a large proportion of the fatal cases. These
number 719, or 95.35 per cent. Pyaemia supervened in 377
cases of gunshot injury in which no operation had been
performed, and after 295 cases of amputation, of which 155
were cases of amputation in the continuity of the femur.

118 Circular No. 6, War Department U.S.A. [July,.

The purulent infection was subsequent to excision of the
shafts of long bones in twenty-seven cases and to excisions
of joints in twenty-eight cases.

These figures by no means represent the frequency with
which pyaemia poisoning has occurred. It has been one of
the great sources of mortality after amputation, and its
victims are to be counted by thousands. The small number
of cases on the register are taken from special reports.
The reports on the treatment of pyemia are adverse to the
therapeutical utility of the sulphites and hyposulphites in
this disease, pp. 43-44.

Erysipelas. In the ill-ventilated barracks and private
edifices which were sometimes of necessity occupied as
hospitals during the earlier period of the war, erysipelas
was a frequent visitor, p. 87.

Gangrene. The various forms of sloughing phagedena,
and traumatic gangrene, described by systematic authors,
were among the complications of wounds that throughout
the war often rendered the skill of surgeons abortive, but
the ravages of true contagious gangrene were comparatively
limited, p. 87.

SURGICAL OPERATIONS.

Amputations. The histories of 13,397 amputations for
gunshot injury have been examined and recorded, and the
final results have been ascertained in 9,705 cases. The
following table exhibits the number belonging to each
region, and includes both primary and secondary cases. It
shows the regular increase in the rate of mortality as the
trunk is approached.

AMPUTATIONS OP THE SUPERIOR EXTREMITIES

Fingers and parts of the hand

Wrist

Elbow

Forearm

Arm

Shoulder joint

Total

Re-

Died.

Total.

covered.

177S

29

1807

34

2

36

19

19

500

99

599

1535

414

1949

144

93

237

4010

637

4o47

Percent, of
Mortality.

i~oo

5.55

16.52

21.24
39.24

13.70

1866.] Circular No. 6, War Department U.S.A. 119

Imputations op the inferior extremities. C0Vgred.

Died. Total.

I Per cent, of
Mortality.

toes

Partial amputation of the foot .

toikle joint

Leg

Knee joint

rhigh

flip joint

Total of Lower Extremity.
Aggregate

784
108

58
1737

52
568

3310

7320

11
9

611

64

1029

18

1748

2385

790

119

67

2348

116

1597

21

5058

9705

.75
9.24
13 43
26.02
55.17
64.43
85.71

55

24.57

We pass over the observations of Surgeon Otis upon the
minor amputations, and will content ourselves with present-
ing his remarks upon the graver operations.
; Amputations at the Elbow. The returns corroborate the
conclusions of Dupuytren, Malgaine, and Legouest, who
combat the disfavor into which this operation has fallen.
It was done infrequently in the late war, but nineteen cases
having been reported. But in all of these the ultimate
results have been ascertained, and were favorable in every
instance. The success of Salleron, and other Erench sur-
geons, with this operation in the Crimea is well known.
Whenever, then, it is practicable to amputate the forearm,
disarticulation at the elbow should be preferred to ampu-
tation of the arm. The oval method answers the purpose
best in this locality, p. 46.

Amputations at the Shoulder Joint. It is creditable to the
Surgery of the war that the number of cases of amputation
(at the shoulder joint reported is less than the number of
jcases of excisions of the head of the humerus, and that the
latter operation appears to have been adopted in nearly all
the cases in which it was admissible. The reported cases
'of amputation at the shoulder joint, for the entire period
number 458 ; of excisions of the head of the humerus, there
were 575. Of the 237 terminated cases of amputation,
ninety-three died, a ratio of mortality of 30.2, which is 6.7
per cent, greater than the mortality in excisions, p. 46.

Amputations at the Ankle Joint. The record is incomplete.
In the terminated cases, Symes' method was employed in
twenty-five cases, Roux's method in two cases. The operation

120 Grcular No. 6, War Department U.S.A. [July

of PirogofT appears to be regarded with little favor, and it
appears that theauthor himself has abandoned it, finding the
segment of the os calcis likely to become necrosed, p. 46.

Amputations at the Knee Joint. This operation has found
numerous advocates during the war, and has been frequent-
ly performed. The returns to October, 1864, give 132 cases,
of which fifty-two recovered and sixty-four died. In six
cases, amputation of the thigh was subsequently performed,
with three recoveries and three deaths. In ten cases the
result is undetermined. These figures are encouraging, and
if we look at the primary operations alone, the result is still
more gratifying. Of forty-nine cases of primary amputa-
tion at the knee joint, thirty-one recovered, and sixteen
died ; while two underwent re-amputation, of whom one
recovered, and one, a tuberculous subject, died. This gives,,
a percentage of mortality in primary amputations at the
knee joint of 34.9. The mortality in primary amputation at
the lower third of the thigh is much larger than this;
indeed, it has been already indisputably proved by the
Crimean statistics, and by M. Malgaine, that the mortality
in amputation augments in exact proportion as the incisions
approach the trunk, p. 47.

Amputations of the Thigh. In 1,597 terminated cases, 568
recovered, and 1,029 died, or 64.43 per cent., which is within
& fraction of the mortality, after amputation of the thigh: in
the English army in the Crimea, the whole number of am-
putations of the thigh for gunshot injuries was 1,666, of
which 1,531, or 91.89 per cent, terminated fatally. Of these
1,597 amputations, the date of operation is ascertained with
precision in 1,061. Of these, 423 were primary and 636
were intermediate or secondary. The ratio of mortality
was 54.13 in the former, and 74.76 in the latter, p. 48.

Amputations at the Hip Joint. At the commencement of
the war, the uniform fatality of amputations at the hip joint
in the Crimean war was impressed upon the minds of
surgeons, and many believed that the operation should be
discarded altogether. Still it has been occasionally perform-
ed, and several lives have unquestionably been saved by it.

1866.] Circular No. 6, War Department U.S.A.

121

Surgeon Otis sustains the truth of this assertion by the
record of three successful amputations at the hip joint,
illustrated by a handsome plate and wood cut. pp. 48-51.

TABLE, showing the Mortality of Amputations at the Hip
' Joint, for Gunshot Injury, Including Primary, Intermediate,
and Secondary Cases.

Recov'd.

Died.

Total.

I.arrey's primary cases

Larrey's intermediate cases

Guthrie's Ciudad Rodrigo cases (intermediate)

Guthrie's Waterloo cases (primary)

S. Cooper's case

Blandin's cases (in 1794)

Huten (Mem. de Med. Mil., t, xliv)

Brownrigg (Elvas, 1811)

Wedemeyer (Bull, de Ferusa?, t, iii, p. 161) . .

Letulle (Siege d' Anvers)

Clot Bey (Legouest's table)

Jubiot (idem)

Guyon (Alceria, 1840)

Sedillot (Annales de la Chir., t, ii, p. 279)

Rachel (rfournees de Juin, 1848)

Robert (idem)

Guersant (idem)

Vidal (idem) . . .'

Band ens (Traite des Plaies d' Armes a Feu)

Schleswiek Holstein cases

Langenbeck's case (Schleswick Holstein)

Two operations in the English army, in the Crimea, by the

Director General

A soldier of the 33d English regiment

Two other cases prior to April, 1855, in the English army in the

Crimea

Seven enlisted men and two officers (Med. and Surg. Hist, of

British army in the Crimea)

Twelve primary cases in the Trench army in the Crimea

Mounier's case at Dolma Batchi

Legouesfs case (really recovered and died of cholera)

Four other secondary cases in the French Crimean hospital

Bertherand's case after the engagement at Novara (Campagne

d' Italie de 1859. p. 37)

Jules Roux cases at Toulon (all secondary)

Primary cases in the late war (U. S.)

Secondary cases in the late war (U. S )

6

1

1

1

1

3

2

1

1

1

3

1

5

1

1

1

1

1

6

1

2

1

2

9

12

1

4

1

4

2

2

7

1

11

11

92

9

12
3

1
4

1
6
9

12

103

From an examination of the results of the preceeding
table, and from a careful analysis of all the cases of hip joint
amputations during the late war, Surgeon Otis concludes
that there are but three conditions under which early ampu-
tation at the hip joint is admissable in military surgery, viz:
when nearly the entire thigh is carried away by a large
projectile, when the totality of the femur is destroyed by
osteomyelites, and, possibly, when, with comminution ot the
upper extremity of the femur, the femeral vessels are
wounded.

122 Circular No. 6, War Department U.S.A. [July,

The experience of M. Jules Koux, in the Italian war, seems
to prove conclusively that secondary amputations at the hip
joint are less dangerous than primary ones.

As to the method of operating, it may be observed that
the anterior single nap procedure has of late been generally,
performed, pp. 48-53.

'Excisions. The number of excisions after gunshot injuries
that have been transcribed from the reports, has been given
on page 104 of this review, and indicates that this branch
of conservative surgery was largely practiced by the medical
officers of the United States army during the late war.

We shall extract from the report the statistics and obser-
vations upon the more important excisions.

Excisions of the Wrist. The thirty-five cases included in
this category were all examples of partial excision. In
twenty-seven, the ends of the radius or ulna, or of both,
were removed, and, in some instances, shattered fragments
of the upper row of carpal bones. In eight cases, the
greater part of the carpus was encised. Death took place
from pyamiia, and twice from exhaustion from protracted
suppuration and irritative fever; twenty-six cases are re-
ported as recovered. In two cases, amputation of the fore-
arm became necessary. The reports are unsatisfactory in
relation to the amount of mobility left in the hand, and the
cases are now under investigation with reference to this
point, p. 54.

Excisions of the Elbow. The returns from three-fourths of
the entire period give 315 cases of excision of the elbow,
and the results are ascertained in 286 cases. In sixteen
cases, amputation of the arm became necessary ; sixty-two
cases terminated fatally, or 21.67 per cent., which is a
mortality a fraction greater than that resulting from am-
putation of the arm. p. 55.

Excisions of the Shoulder Joint. Nearly all of the cases
that have been reported during the war have been recorded.
The following are the results: In 252 primary operations,
fifty died, 160 recovered, and in forty-two cases the results

1866.] Circular No. 6, War Department U.S.A. 123

are undetermined; in 323 secondary operations, 115 died,
183 recovered, and in twenty-five the results are still unde-
termined.

The percentage of mortality is 23.3 in primary cases, 38.59
in secondary cases, or a mean ratio of 32.48 per cent, in the
aggregate of 575 operations.

The ratio in amputations at the shoulder joint is 39.24, a
per centage of 6.76 in favor of excision.

Of thirty-six cases of gunshot fractures of the head of the
humerus, selected as favorable cases for the expectant plan,
and treated without excision or amputation, sixteen died,
or 44.4 per cent., a ratio in favor of excision of 11.96 per
cent. p. 55.

Generally the operation has been done in cases in which
the head of the bone was alone implicated, and consisted
simply in a decapitation of the humerus. Partial excisions
have been seldom practiced. The method commonly pre-
ferred was that by a single vertical incision, though some
operators raised a V shaped flap, and all endeavored to
include the wound made by the ball in the incisions. It is
frequently mentioned that the long tendon of the biceps was
preserved. In twenty-nine cases, portions of the clavicle, or
of the coracoid and acromion processes and neck of the
scapula, were excised, as well as the head of the humerus.
Only four of these cases terminated fatally, and the average
result in the recovered cases was as satisfactory as the
ordinary result in decapitation of the humerus. When the
shaft of the humerus has been extensively shattered, the
United States' surgeons have not been deterred by the pro-
hibition of Guthrie, but have frequently removed the head
with even five or six inches of the diaphysis. p. 56.

Excisions of the Ankle Joint. Of twenty-two recorded
cases, eight were excisions of the tibio-tarsal articulation,
and the remainder were nearly all ablations of the tarsal
bones ; of eighteen terminated cases, twelve recovered, and
six died. p. 57.

Excisions of the Knee- Joint. Prior to the present war,,

124 Circuit Xo. 6, War Department U.S.A. [July,

there were but seven recorded examples of excision of the
knee for gunshot injury. During the late war, complete
excision of the knee-joint has been performed eleven times.
Dr. Otis furnishes interesting abstracts of each case; two
cases of recovery and nine deaths are reported, the mortality
being precisely the same as in the same number of cases
reported before the war.

Excisions of the Head of the Femur. There were on
record, previous to the late war, twelve cases of this opera-
tion, with one suecess. Experience having demonstrated
the uniform fatality of gunshot fractures of the head or
neck of the femur when abandoned to the resources of
nature, and the excessive mortality of amputations at the
hip-joint for gunshot injury, the highest authorities in mili-
tary surgery were then unanimous in advising, under suita-
ble conditions, excision of the head of the femur, until, as
Baron Hippolyte JLarrey expressed it, the experiments of the
future proved more discouraging than the experience of the
past.

Surgeon Otis gives a tabulated statement of 32 cases of
excision of the head of the femur, and from this we gather
that 26 deaths occurred, to the three recoveries; one case is
reported as doing well, and the result is not stated in the
remaining two cases, pp. 61-75.

Excisions in the Continuity of the Long Bones of the Ex-
tremities. The great Surgeons who have done most toward
substituting excision for amputation in gunshot injuries of
the joints have almost unanimously condemned excisions
of the continuity of the long bones in the treatment
of gunshot fractures. The surgical histories of the Cri-
mean war, of the Schleswick-IIolstein campaigns, and of
the Italian mutiny, record a few successes in resections
of the shafts of the humerus, the tibia, and the bones of the
forearm; but this class of operations could scarcely be con-
sidered as admitted among the established and approved
procedures of Surgery. The late war has furnished ample
materials for arriving at definite conclusions on this subject,

1866.] Circular No. 6, War Department U.S.A. 125

and for determining how far these measures can claim to
be included in that true conservatism which has for its first
object the saving of life, and refuses to jeopardize lives in
order to save limbs.

These materials are yet to be thoroughly analyzed. So
far as examined, their evidence is, on the whole, unfavorable
to incisions in the continuity.

A synopsis of the results at present attained is presented
in the following table :

TABLE, giving the number of Cases of Excisions for Gunshot
Injuries in the Continuity of the Bones of the Extremities,
from the Commencement of the War to July, 1864, and the
Eesults as far as ascertained.

o

9

a

s
Z
5

c
<

J

o3

"3
en
o

%

r-

% 3

Excisions
Excisions
Excisions
Excisions
Excisions
Excisions
Excisions
Excisions
Excisions
Excisions

in the Continuity of the Humerus

in the Continuity of the Radius . . .*

in the Continuity of the Ulna

in the Continuity of both Radius and Ulna .

of the Metacarpal Bones

in the Continuity of the Femur

in the Continuity of the Tibia

in the Continuity of the Fibula

in the Continuity of both Tibia and Fibula,
of Metatarsal Bones

TOTALS 140 524

133 1 7

23

79 261
67 174
51 170
10' 40
IS 50
24 1 62
20 84

93

24.00
10.57
13.79
17.24
6 25
84.21
18.64
20 00
25 00
19.23

975 26.71

After excisions of portions of the shaft of the humerus
for gunshot fractures, a number of patients have certainly
obtained very useful limbs. But the mortality after the
operation is 3 per cent, greater than after amputation of the
arm.

Excision in the continuity of both bones of the forearm
has a larger mortality ratio than amputation of the forearm.

The specimens at the Museum and the records afford em-
phatic arguments against formal excisions of the shaft of
the femur. With one exception, the few cases that recovered
were those in which, after the removal of detached frag-
ments, the least amount of operative interference had been
practiced.

126 Circular No. 6, War Department U.S.A. [July,

The mortality rate after excisions of the tibia and fibula
is less than after amputation, as the statistics stand ; but
the number of cases in which the result is still pending is
unusually large, p. 76-77.

LIGATIONS.

The following table exhibits the number of cases of liga-
tion of the larger arteries, from the beginning of the war to
March, 1864 :

O v O'S

.2S

Common Carotid.
External Carotid.

Subclavian

Axillary

Brachial

Kadial

Ulnar

Common Iliac . . .

Internal Iliac

External Iliac . . .

Femoral .

Profunda . . .'

Popliteal

Anterior Tibial . .
Posterior Tibial . .

Peroneal

All others

AGGREGATE 163 240 403

12 37

49 | 75.71

100.

35 80.

87.50

17.18

1428

18.18

100.

100.
87.50
76.85
85.71
75.
31.25
31.57

100.
26.66

pp. 78-79.

We pass by the division of this report " on the Medical
Staff and the Meteria Chirurgica," and conclude with the
observations of Surgeon Otis on Anaesthetics. There have
been consulted, in regard to the employment of anaesthetics,
the reports of 23,260 surgical operations performed on the
field, or in general Hospitals. Chloroform was used in 60
per cent, of these operations, Ether in 30 per cent., and in
10 per cent, of the cases a mixture of the two was adminis-
tered.

At the general Hospitals, the greater safety of ethe r sis
an anaesthetic was commonly conceded. It was often em-
ployed, and no fatal accident from its use hay been reported.
In the field operations, chloroform was almost exclusively
used. The returns indicate that it was administered in not

1866.] Summary Sick and Wounded C. S. Army. 127

less than 80,000 cases. In seven instances fatal results have
been ascribed with apparent fairness to its use." p. 87.

We hope to review the remaining portion of this Circular
prepared by Assistant Surgeon J. J. Woodward, in the next
number of this journal.

The extracts which we have given from the report of
Surgeon George A. Otis, present all the important facts
which will prove of value to the Surgeons of the late Con.
federate Army for reference and comparison, in the study
and record of their Surgical experience during the recent
revolution.

ELECTIONS

ARTICLE I.

Grand Summary of the Sick and Wounded of the Confederate
States Army under Treatment during the Years 1861 and
1862.

The immense mass of reports from the Army Medical Corps for the first
two years of the war has been carefully winnowed and digested under the
supervision of the Surgeon-General, and a general summary laid before
Congress at its last session. Necessarily imperfect as these statistics are,
they show, at a glance, the herculean labors performed by the Medical
Staff. Gathered up as the Army was from homes of peace to meet the
throng of the invading enemy, the amount of sickness surpasses anything
on record, while the ratio of mortality is far below the usual average.
The Medical Department without resources of any sort without organi-
zation, without hospitals or the furniture to equip them, without transpor-
tation, self-depending and almost self-sustaining assumed the enormous
burden which is reached in the accompanying figures, containing a few
of t the leading diseases of the years 1861 and 1862, and faithfully
conducted their task to a satisfactory conclusion. We should be prepared
to make every allowance for the many imperfect statements and confused
or irregu'ar reports consequent on the confusion attendant on these
faithful public officers, whilst fighting manfully, and but half equipped,
with such a torrent of disease. In our next issue, when the more complete
records of the year 1863 will be presented to the reader, a comparison, not
without interest to all, can then be instituted.

128 Summary Sick and Wounded C. S. Army. [July,

GENERAL RESUME.

From all the reports now on file in the Surgeon-General's Office for the
years 1861 and 1862, exclusive of the few scattering ones which have
reached us from the Trans-Mississippi Department, we are enabled to
sum up the sickness and mortality occurring in our Armies, as follows :

Continued Fevers. Field Reports, 36,746 cases and 5,205 deaths.
Hospital Reports, 40,565 cases and 7,020 deaths.

Paroxysmal Fevers. Field reports, 115,415 cases and 848 deaths.
Hospital reports, 49,311 cases and 485 deaths.

Eruptive Fevers. Field, 44,438 cases aud 1,036 deaths. Hospitals,
32.755 cases and 1,238 deaths.

Diarrhcea qpid Dysentery. Field, 226,828 cases and 1,696 deaths.
Hospitals, 86,50|> cases and 1,658 deaths.

Pulmonary Affections! Field, 42,204 cases, 3,534 deaths, and 4,538
discharges from service. Hospitals, 36,988 cases, 4,538 deaths, and 1,135
discharges.

Rheumatism. Field, 29,334 case's and 1,142 discharges. Hospitals,
30,438 cases and 700 discharges.

Gun-shot Wounds. Field, 29,569 cases, 1,623 deaths, and 493 dis-
charges. Hospitals, 47,724 cases, 2,618 deaths, and 742 discharges.
Killed in battle, 8,087.

All other Diseases. Field, 324,321 cases and 2,278 deaths. Hospital,
123,402 cases and 1,802 deaths.

Whole number of cases exhibited in the Field Reports during 1861 and
1862 was 848,555 ; of which 16,220 died and 10,455 were discharged
from service. There were admitted in Hospitals, for the same period,
447,689 cases; of which 19,359 died and 6,485 were discharged.

We learn, also, from these Reports that of all the cases represented as
originating in the field, but 108,068 were sent to General Hospitals. If
this be so, the large number received into Hospitals, as shown by their
own returns, can only be accounted for in the repeated transfer of patients
during convalescence from one Hospital to another.

It is greatly to be regretted that the interest naturally felt in medico-
vital statistics, when based on accurate and reliable data, can scarcely be
claimed for what is offered in this paper. Still, if it have but the effect of
directing the attention of Medical officers more closely and carefully to
the reports required of them, it will not be altogether without good results.
This is but a beginning, and the next Annual Report, that for 1863, will
doubtless embody many facts of a much more useful and interesting
character. -Confederate States Medical and SurgicalJoumal, September,
1864.

1866.] Sorrel on Gun-Shot Wounds. 129

ARTICLE II.

Gun-Shot Wounds Army of Northern Virginia. An Ex-
tract from, a Report on the Sickness and Mortality in
the Armies of the Confederate States for 1863. By F.
Sorrel, Surgeon and Inspector of Hospitals.

GUN-SHOT WOUNDS.

The proportion of these was less than that of last year by two percent.;
that is to say, while gun-shot injuries, during the period covered by the
Report of last year, amounted to 9.8 of the whole number of cases reported,
for 1863 they only reach 7.7. It will be remembered that the campaign
of 1862 was conducted with the utmost vigor, and that the army fought,
in quick succession, many sanguinary battles, commencing with that of
Williamsburg, and ending with that of Fredericksburg ; including between
these two the battles around Richmond, Cedar Mountain, Manassas and
Sharpsburg, each of which resulted in a heavy list of casualties to the
troops engaged.

The mortality from these causes, as might be expected, was not nearly
80 great during this year as it had been during the one previous. The
men had become hardened and better able to resist the influence of
climate and exposure, and the battles which occurred during the year,
transpired at a season far more favorable to recoveries. Thus, instead of
being crowded together in hastily extemporised Hospitals during the
intense heats of mid-summer, as they were in 18G2, the battle of Chan-
cellorsville, fought early in May, gave to its wounded the benefit of a most
delightful and salubrious season for treatment and recovery, while that of
Gettysburg, still later, sent to our Hospitals the more slightly wounded,
leaving the grave cases in the hands of the enemy to die, or to be other-
wise accounted for in a manner not known to our reports.

The Surgical Operations performed on the field at Chancellorsville did
remarkably well. Generally, the wounded reached the Hospitals in this
city in a condition favorable to recovery, and, as before stated, the excel-
lent condition of our Hospitals seemed to repress all tendency to the
prevalence of Erysipelas or Gangrene. Indeed, never before or since have
they beeu so entirely free from the presence of these diseases, as they
were during the Summer and Fall of this year.

In the Hospitals, the mortality from wounds during the year 1862,
amounted to 11.2$ in 1863, to 2.3; and this difference is really increased
still further in favor of the latter year, by the fact that the wounded from
the battle of Fredericksburg gave most of its mortality to the year 1863,
without adding at all to the number of cases for that year these having
been already embraced in reports for 1862.

The figures, as we have them in our Reports for this year, exhibit 42,885
cases of Wounds treated in Hospitals, and 999 deaths this yields a mor-
9

130 Sorrel on Gun-Shot Wounds. [July,

tality of 2.3. Bat, in order to arrive at a more accurate estimate of the
proportion really dying from Wounds in the Hospital, it will be well to
assume that the number reported from the field were all that were treated
in Hospitals, and this being 27,206, and the mortality 999, we have a
per centage of 3.7, which, it is believed, approaches nearer the truth.

Adding the number dying in Hospitals to those reported from the field,
we have an aggregate of deaths for the year in field and in hospital, from
Gun-shot Wounds, of 1,723, or 2.4 of the whole number of cases reported.

This, however, is much too small, because it is impossible, as before
stated, with our present form of Reports, to avoid the frequent multiplica-
tion of cases by transfer, etc.

During this year, one case of successful Amputation at the hip-joint was
reported. It occurred on the person of James Kelly, Private Company
liB," 56th Pennsylvania, aged 23, and by occupation a Farmer. He was
wounded April 29th, 1863, near Fredericksburg, sustaining Compound
Comminuted Fracture of the Femur. Disarticulation, byantero-posterior
Haps, was performed the same day on the field. He fully recovered, was
paroled and sent North, July 14th, 1863. (Operation performed by
Surgeon E. Shippen, U. S. A.)

It is proper to remark, also, in this connection, the many successful
cases of Amputation, especially of the upper-third of the thigh, occurring
in our Reports. Among them may be mentioned Lieutenant-Generals
Ewell and Hood (the latter now General Commanding Army of
Tennessee), both of whom have been restored to duty, in the full vigor of
health, with thighs amputated just a little short of the hip-joint. Added
to these are many others, of less distinction, it is true, but not the less
attesting the skill and ability of Confederate Surgeons in the performance
of an operation regarded heretofore as almost uniformly fatal. Indeed, so
much had this come to be regarded the case, that recently an order
emanating from the Federal Surgeon-General, forbids such operations on
the field, not only at the upper-third, but any where along the continuity
of the thigh.

This question of Conservative Surgery in Compound Fractures of the
Femur, is one which is receiving the most earnest attention of Military
Surgeons, and though it has been to some extent, decided in the United
States, we are obliged, in balancing the merits of the two methods of
treatment, to adopt a different opinion. With us, the results, as elicited
from our Reports, exhibit a slight per centage in favor of the operation
itself on the field. Thus, of 77 cases of Primary Amputation of the Thigh,
at the upper-third, 40 recovered, and 37 died. The same favorable results
are also found to have attended the Conservative Method of treatment in
similar cases; for, of 221 cases, where Amputation was not resorted to,
116 recovered.

These results are, indeed, remarkably favorable ; far surpassing, in this
way, any heretofore reported or known to the Profession.

1866.] Sorrel on Gun-Shot Wounds, 131

As between the two modes of treatment, the difference in the results is
'out slight, as shown by the figures given above, and as will be more
perfectly understood when the tables annexed shall be examined.
Guided, then, by our Reports, it may be safely accepted as a rule, that
the better plan, in general, is to operate on the field. The greater
readiness with which the patient can be transported from the field; the
greater ease and comfort realized, under these circumstances, when the
limb has been removed ; the tesser time required in Hospital for recovery ?
would all seem to point to its adoption as the wiser policy. Still, in these
and in all other questions of Surgical interference, the Medical Officer
should be governed by the peculiar circumstances attending each<case.

Many Eesectiohs were performed during this year, and while, in very
many instances, with results altogether favorable, so far as recovery alone
is considered, yet, we are inclined to think, in nearly all cases, leaving
limbs of very doubtful utility. Indeed, when it is considered that these
operations are much more fatal than simple Amputations, exposing the
patient for a much greater time to the evil influence of Hospital atmos-
phere ; involving, more frequently, too, attacks of Erysipelas, Gangrene,
aud Pyaemia, it may be well questioned if our Surgeons do not too often
resort to them.

The shoulder joint, we sometimes think, is the only one in which
Resection promises all the good results claimed for it. In the elbow, if
the entire joint be removed, no possible effort of nature can supply the
lost motion ; and the slight prehensible power of the fingers, which may
continue, can scarcely atone for the awkward, useless and ungainly limb
remaining.

Exsection of the knee joint we cannot help regarding as positively
reprehensible on the field, and scarcely less" so in Hospital. But one
successful case is reported during the year (Surgeon J. B. Read), at last
accounts (September, 1864) the patient was fully recovered, but with a
limb shortened by several inches, and union only ligamentous. Amputa-
tion has been asked for by him, and -will be performed as soon as the
condition of his health may justify it.

One successful case of Resection of hip joint has likewise been reported
by Surgeon J. B. Read, and though the leg will never be of any use, yet
it is fair to say, that to this, operation may be due the preservation of the
patient's life, which might have been more seriously imperilled by disar-
ticulation.

Frequent cases of Gun-shot Wounds, healing by first intention, have
also been reported. It is difficult to understand how this can be so, when
all our theories of repair and restoration of lost tissues have been based
on inflammatory action, leading, of course, to suppuration and granulation.
Still, the evident care and truthfulness which accompany the report of the
cases attest the fact beyond all doubt; and it is hoped that future investi-
gations on the part of the Medical Staff will, in time, yield much that is
interesting and instructive in this connection. Already, it has been

132 Sorrel on Gun-Shot Wounds, [Jul}>

proposed (by Surgeon J. J. Chisolm) to convert all Gun-shot Wounds into
simple incised wounds, by paring the ragged edges and nicely adjusting
the lips by means of sutures or straps, excluding the atmosphere, and
thus effecting a cure by absorption and re-modelling, without the aid of
suppuration.

TETANUS.

In reviewing carefully all the circumstances connected with Gun-shot
Wounds, as exhibited in the Reports before us, it would be singular did
we not remark the occasional occurrence of Tetanus.

This complication of Gun-shot Wounds, so obscure, so fearfully fatal,
and so much to be deplored, is fortunately seldom met with. Indeed, it
has always been a source of wonder to all writers on Military Surgery that
it so rarely occurs. In our Reports for 1861 we find that in 1,750 cases
of wounds of different characters, there were thirteen cases of Tetanus
0.75, or one case of Tetanus in 134 cases of Wounds. Of these, only three
are reported as having ended fatally, giving a ratio of mortality of 2.3, or
one death in four cases a result which clearly proves the inaccuracy of
our earlier Reports.

In 1862, the consolidated Reports from Hospitals, present 45,974 cases
of Wounds, and only 53 cases of Tetanus 0.11, or one case of Tetanus
in 867 cases of Wounds. Of these 53 cases, 28 terminated in death 52.8y
about one death in two cases, a much larger per centage of mortality than
in 1861 but still we have reason to suspect, very much below the truth.
Many of the cases reported Tetanus are, doubtless, mere cases of
Tramautic Spasms ; hence, such apparently favorable results.

Tetanus was, doubtless, of more frequent occurrence in our Hospitals .
than would appear from the Reports, as it is well known that cases are
generally reported under the disease they first enter with, which ordi-
narily is " Vulnus Sclopeticum." It is only recently that Surgeons
have been reporting "supervening diseases." In referring to our special
reports of gun-shot injuries involving Tetanus, covering the whole period
of the war up to the present time, and which are evidently drawn up
with great care, we find 66 cases recorded. Of these, six only recovered^
giving a mortality of nearly 91 per cent.

Assuming, then, that these constitute the entire number of cases of
decided Tetanus which have occurred on the whole number of Gun-shot
Wounds treated (56,775), we have the proportion of one case of Tetanus
to every 860 cases of Gun-shot Wound.

McLeod, in his Surgery of the Crimean War, does not give the pro-
portion of Tetanus to wounds, but he says he could only hear of thirteen
cases of Tetanus in the English army throughout the Crimean War.
These were all fatal with only one exception. In the last East India
Y\rar, nineteen cases are reported, and only one recovery. Alcock gives
the proportion of cases of Tetanus to wounds as one in seventy-nine.
Stromyer states, that during the Schleswig-Holstein W^ar, the proportion
was three in 1,000. In 1830, of three hundred and ninety cases of Gun-

1866.]

Sorrel cm Gun-Shot Wounds.

133

shot Wounds, there was only one case of Tetanus in the Hotel Dieu at
Paris.

The following tables will exhibit the general results of amputations
and resections thus far collected, and carefully prepared from reports
throughout the Confederacy :

RESECTIONS.

Shoul'r

Elbow

Wrist

Hip

Kr.ee

TOTAL

Primary-

28
13

20
7
2

22
3

23
6

7

2
1

1

1

2

1
1

52

IS

Secondary

46

Unsuccessful. . .

15
9

TOTAL

70

61

8

2

4

140

DISARTICULATIONS.

Shoul'r

Elbow

Wrist

Hip

Knee

TOTAL

Primary

54
25

9
20

1QS

3
1

2
1

7~

5
2

7~~

1
2

2
3

6

65

33

Secondary

11

Deaths

27

TOTAL

3

11

136

AMPUTATION OF THIGH.

UPPEB third

Middle Third

LOWER THIRD

m

O

GO

m

s
O

DC

cq

o

1

'Circular-
Primary

Secondary

Flap-
Primary

Secondary

Method not stated-
Primary

Secondary

TOTAL?"

19

11

33

14

42

27

3

7

7

14

12

21

6

4

15

10

35

11

3

1

3

9

5

o

15

22

24

21

35

27

4

16

5

19

14

35

50

61

87

87

143

126

146
64

144
93

554

COMPOUND FRACTURE OF THE THIGH TREATED WITHOUT AMPUTATION.

Recove-
ries
116~~

Deaths
105

Days

Inches

Average Period of Recovery

104

255

41

52

185
1

'Greatest Period of Recovery

Least Period of Recovery

Average Period of Death

Greatest Period of Death

Least Period of Death

Average Amount of Shortening

1.9

Greatest Amount of Shortening

5.0

Least Amount of Shortening

0 5

is*

Statistics of the C. S. Army.

[July.-

CONSOLIDATED TABLE OF AMPUTATIONS.

Thigh

Leg

Arm

Fore-Arm

Shoulder-Joint.
Elbow-Joint. . . .

Wrist- Joint

Hip-Joint

Knee- Joint

Ankle-Joint.. . .

Tarsal-Joint. . . .

TOTAL

345

314

294

69

79

4

1

16

1142

PRIMARY

O

213

219

252

61

54

3

s

2
4
13

132
95

42
8

25
1
2
2
3
2
3

315

Secondary

162
150
140
45
28

546

262

ji

OJ

3

s

o

q

a.

119

73

74

49

53

37

10

.

20

71

1

6

100

1

12

281

51

[C. S. Med. & Surg. Jour., Oct., 1864.

ARTICLE III.

Amputation, Disarticulation and Resection Statistics of the
Confederate States Army.

Amputations of the Thigh, whole number, 507: Primary, 345; Re'
covered, 213; Died, 132; 38 percent. Secondary, 162; Recovered, 43;
Died, 119; 73 per cent.

Amputations of the Leg, whole number, 4G4 : Primary, 314 ; Recov-
ered 219; Died, 95; 30 per cent. Secondary, 150 ; Recovered, 76 ; Died,.
74 j 49 per cent.

Amputations of the Arm, whole number, 431: Primary, 294; Recov-
ered, 252 ; Died, 42; 14 per cent. Secondary, 140; Recovered, 87;
Died, 53 ; 37 per cent.

Amputations of the Fore-Arm, whole number, 114: Primary, 69; Re-
covered, 61; Died, 8; 12 per cent. Secondary, 45; Recovered, 35?
Died, 10 ; 22 per cent.

Disarticulations, whole number, 135: Primary, shoulder-joint, 79; Re-
covered, 54 ; Died, 25 ; 31 per cent. Primary, Elbow-joint, 4; Becovered,.
3; Died, 1. Primary, wrist-joint, 7 ; Recovered, 5 ; Died, 2. Primary,
hip-joint, 3 ; Recovered, 1 ; Died, 2. Primary, knee-joint, 5 ; Recovered,
2; Died, 3. Secondary, shoulder-joint, 28 ; Recovered, 8; Died, 20 ; 71
per ceut. Secondary, elbow-joint, 3 ; Recovered, 2 ; Died, 1. Secondary,,
knee-joint, 6 ; Died, 6.

Resections, whole number, 130 : Primary, shoulder-joint, 41; Recov-
ered, 28; Died, 13; 27 per cent. Primary, elbow joint, 25; Recovered,
22 ; Died, 3. Primary, wrist joint, 2 ; Recovered, 2. Primary, knee-
joint, 2; Died, 2. Secondary, shoulder-joint, 26; Recovered, 19; Died,.
7: 21 per cent. Secondary, elbow joint, 29 ; Recovered,. 23 ; Died, 6*.

1866.] Conservative Surgery in Compound Fracture. 135

Secondary, wrist-joint, 1 ; Recovered, 1. Secondary, hip-joint, 2 ; Recov-
ered, 1 5 Died, 1. Secondary, knee-joint, 2 ; Recovered, 1 , Died, 1.

Amputations of the Foot: Primary Chopart's, 16; Recovered, 13 ;
Died, 3 Symes', 2^ Recovered, 2 Pirogoffs, 4; Recovered, 2; Died,
2. Secondary Chopart's, 8 ; Recovered, 1 ; Died, 1 Symes', 4 ; Re-
covered, 4 (1 unsuccessful, requiring subsequent amputation above the
ankle-joint.)

A vast number of additional operations are received, but without
positive results, and, therefore, they have not been included in the above
list.

We may be well satisfied with the results of these statistics, which,
carefully excluding all doubtful cases, are compiled from those operations
only that have reached a positive conclusion. A general summary of
the above tables shows that the mortality after 1,814 operations, including
amputations, resections and disarticulations, amounted to 632, giving a
death ratio of 34 per cent.

By referring to the mortality tables after amputations, subsequent to
many of the great battles of modern days, taken from the pages of
Lagouest, which will be found in our chronicle for this number, the
reader will be able to draw his own comparisons.

The only statistics on this subject from the Federal army we find in
the United States Army and Navy Journal for November, 1863, which
gives the amputation statistics for September, October, November and
December of 1862, as follows: Whole number, 1,342; deducting 510
under treatment January 1, 1863 826. Of this number, 336 died ; a
mortality of 40 per cent.

The journal to which we owe the above observation gives the following
table: Whole number, 1,3411 ; Returned to Duty, 100; Furloughed, 25 :
Deserted, 11 ; Discharged, 350 ; Died, 336 ; Secondary Operation, 34 :
Under Treatment, January 1, 1863, 516.-0. S. Med. & Surg. Journal,
May, 1864.

ARTICLE IV.

Conservative Surgery in Compound Ft%acture of Femur.

The Military Surgeon has no question submitted to his discretion of
more importance than to determine upon the propriety of amputation in
compound fractures of the Femur, the result of Gun-shot Wounds.

The authorities, both French and English, teach us not to trust these
cases to nature, and broadly state that, in the operation alone, there is
hope ; but the statistics, particularly of the Crimean campaign and in
our own service, prove that the mortality after amputation is enormous,
and force us to consider the propriety of conservative practice in this
numerous class of surgical accidents.

136 Conservative Surgery in Compound Fracture. [July,

In various numbers of the Journal, the reader will find many interest-
ing observations bearing upon this question, and we submit at this
time a consolidated statement of compound fractures of Femur treated
without operation, compiled from the records in the Surgeon-General's
Office, from June, 1862, to February 1, 1864, inclusive. We have, in
summary, excluded all cases not positively determined, and hence, while
the number of observations is greatly reduced, the value of the conclu-
sion is increased in like proportions.

Total number of cases, 221 : Recovered, 116; 52 per cent.

Average period of recovery, 104 days greatest period, 255 days, and
least, 41 days. Average period where death occurred, 52 days greatest
period, 185 days least, one day. Average amount of shortening, 1 9-10ths
inches greatest, 5 inches, and least, half an inch.

When we compare directly the results of amputations with the table
of cases not operated on. we feel still more disposed to rebel against the
authority of Guthrie, McLeod, Larrey, Percy and Dupuytren, and at
least hesitate before condemning the shattered limb to instant ablation.
Our own statistics are as follows :

507 cases amputated ; 250 recovered ; 50 per cent*

221 cases not amputated ; 116 recovered; 52 per cent.

The chance for life being more than equal, the value of the leg saved
should be considered, and che table throws important light on this point
the average shortening is less than two inches.

Submit these facts to an intelligent soldier " your thigh is broken by
the ball your chances of life are even, whether amputation is performed
or not without the operation, if you live, you will suffer an average of
104 days if you die, it will take 52 days and when you recover, you
will have a leg two inches shorter than the other." It is easy to imagine
his reply to this simple statement of the facts " Give me a chance for
life and limb."

The very important remarks on this subject from the most recent
French authority on Military Surgery, published in the chronicle for this
number, corroborate forcibly the position which is assumed in this article.
The reader's careful attention is called to this interesting translation, but
for the sake of condensation, we group his statistics with those collected
from various sources during the war.

Legouest.
1,664 cases amputated ; Recovered, 123; 7 per cent.
337 cases not amputated ; Recovered, 117 ; 31 per cent.

Chimborazo Hospital Statisticsfirst and second numbers of this

Journal.

31 cases not amputated ; Recovered, 19 ; 61 per cent.

These observations bring us to conclude, that whenever, in compound
fracture of Femur, the result of Gun-shot Wound, there is no doubt as

1866.] Thomas on Ligation of Arteries. 137

to the propriety of amputation, that we give the leg the benefit of the
doubt the chances of life being at least equal, and the value of the
limb, after recovery, being worth the effort to save it, C. S. Med. &
Surg. Jour., June, 18G4.

ARTICLE V.

Cases of Gun-shot Injury Requiring Ligation of the Artery.
[From Reports in Surgeon-General's Office.] Collated
by H. L. Thomas, M. D.

Carotid.

Case 1. B. Creecy, company "E," Forty-Second Virginia Regiment,
wounded May 3, 1863, by a Minie ball, passing through the larynx above
the vocal chords and carrying away the epiglottis. The common carotid
of the left side was ligated on the 12th for excessive arterial hemorrhage.
No chloroform could be administered. Patient fainted during the
operation. On the morning of the 18th the right common carotid had
to be ligated. Patient died thirty eight hours after second operation.
No brain symptoms supervened, and the heat of the head was retained.
Autopsy : the hyoid artery of the left side was wounded ; both carotids
had been effectually secured.

Case 2. J. W. Jones, Company "E," Twenty-First Mississippi Regi-
ment; wounded May 3, 1863; ball entering left ear, fracturing the
superior maxillary bones, and escaping at the right angle of the mouth.
The wound began to slough on the 3d of June, and on the och, 6th and
7th hemorrhage occurred. Carotid artery was tied on the 7th, and patient
died same day.

Case 3. Richard Kelley, Company "C," Sixth Louisiana Regiment ;
wounded July 3, 1863. Division of external carotid by Minie ball.
Common carotid ligated July 13, 1863. Left at Williamsport, Md.

Case 4. Moses Hutts, aged 35. The lower jaw was badly shattered,
and the tongue injured. The right common carotid was ligated June
7th ; hemorrhage did not recur; patient died on the 8th.

Case 5. J. H. McGuire, Company "K," Twenty-Fourth Mississippi
Regiment; wounded September 26, 1863. Ball entered lower portion of
the left mastoid process and lodged. Ligation of common carotid artery
at upper third, October 10th, 1863. Died on the 24th inst.

Case 6. Daniel Shockley, Company "I," One Hundred and First
Indiana Regiment ; was wounded September 20, 1863, by a round musfeet
ball entering the face about an inch from the corner of the mouth, passing
downwards and backwards, across the upper part of the neck, badly
fracturing the lower jaw in its passage. The ball was extracted near
transverse process of third cervical vertebra. The patient had hemor-
rhage from the entrance wound amounting to one quart on the 25th of

138 Thomas on Ligation of Arteries. [July,

September; hemorrhage recurred again on the 30th. Three other
hemorrhages, of October 6th, 9th and 10th, respectively, so reduced the
strength of the patient that the common carotid artery was ligated. The
ligature separated on the 29th of October. Recovery perfect.

Case 7. M. W. Smith ; wounded May 5, 1864; ball entered the left
temple just above zygoma, ranging downwards and backwards beneath
the ear and immediately under the mastoid process, and passing out
through the soft parts of the neck. On the 12th of May secondary
hemorrhage supervened, which was cntrolled by pressure. It occurred
from day to day until the 21st, when the common carotid was ligated.
The hemorrhage was controlled, but the condition of the patient was
anaemic, and he died in twenty-four hours, evidently from the want of
supply of blood to the brain. *

Case 8. E. F. Lilley, Company "G," Eighth Texas Cavalry, aged 24 ;
was wounded May 9, 1864, by a Minie ball in the face. Secondary
hemorrhage, to the extent of one pint, occurred on the 16th, apparently
from wound in right side of the mouth. At six o'clock, P. M., there was
a repetition of the hemorrhage, amounting to about three pints, from
same point. The right primitive carotid was ligated in the inferior
triangle, in the usual way, and with very little additional loss of blood.
Chloroform was not used, and the patient bore the operation well. The
operation was successful to the extent of arresting the hemorrhage, of
which there was no recurrence. The patient died May 16, 1864, with
well marked cerebral symptoms.

Case 9. G. "W. Nelson, Company "K," Twelfth Georgia Regiment;
was wounded June 6, 1864, the ball entering posteriorly to left ear,
passing upwards and forwards, and emerging at the infra-orbital ridge,
fracturing the zygoma. The wound was extensive, and the hemorrhage
considerable. The cavity was plugged after the.removal of loose bone,
but the hemorrhage returned the next day, and the external carotid was
ligated. Hemorrhage recurred two days successively, in the last instance
produced by patient's tearing off the dressings in his sleep. The patient
died on the 19th.

Subclavian.

Case 1. Corporal G. M. Caughman, Company "K," Thirteenth South
Carolina Regiment, aged 25 ; wounded July 3, 1863, the ball passing
through upper part ot the chest, wounding the lung and the subclavian
artery where it passes between the clavicle and first rib. The subclavian
was ligated on the inner side of the clavicle. The operation was suc-
cessful ; the patient was furloughed, with the wounds entirely healed, but
with the left arm paralyzed.

Case 2. J. II. Kitrell, Company "D," Third Tennessee Regiment ;
wounded July 12, 1863, the ball fracturing humerus, and primary ampu-
tation being performed through surgical neck. The stump was progressing
well until July 20, when slight hemorrhage occurred, which was controlled

1866.] Thomas on Ligation of Arteries. 139

by pressure. Hemorrhage recurred again on the 28th, and digital
pressure was diligently applied up to August 2d, when the hemorrhage
again took place more copiously than ever. Effort was then made to
expose the bleeding vessel by tearing open the flaps, but the adhesions
were too firm, and, the hemorrhage proceeding from two points, it was
determined to ligate the subclavian at its third division. The patient,
under chloroform, bore the operation well, but required stimulation,
having lost largely of blood from the stump, but none from the operation
itself. The separated flaps re-adhered, and the ligature came away on
the 4th of September. The patient was furloughed the latter part of the
month.

Case 3. John T. Endy, Company "F," Fifth North Carolina Regiment,
aged 23; wounded July 2, 1863, the ball entering one-and-a-half inches
below the scapula, ranging forwards, but having no exit. There was
great tumefaction and effusion about the shoulder, while the wound under
the deltoid region was filled with clots of blood. Hemorrhage supervened
on the morning of the 16th, but was controlled by pressure and styptics:
it occurred again the evening of the same day, and was controlled in like
manner. On the morning of the 17th, very profuse hemorrhage took
place, which could only be controlled by pressure over the subclavian
artery. Exploring the wound failing to detect the bleeding vessel, it was
determined to ligate the subclavian in its third division. The operation
was performed without any untoward accident, but, while the hemorrhage
was lessened, the flow of blood could not be entirely arrested in the
wound, even with the assistance of styptics ; it was therefore decided to
ligate also the suprascapular artery, which had been exposed in the
operation ; this being done, the hemorrhage immediately ceased. The
patient was put to bed with the arm warmly wadded, and at night there
was sufficient temperature in the parts below the seat of ligature. The
ligature from the suprascapular came away on the tenth day, and that
from the subsclavian on the thirteenth day. The patient got well without
any bad symptom, and was furloughed on the 31st of August. The ball
was not discovered.

Case 4. W. S. Averitt, Company "H," Fourteenth Tennessee Regi-
ment; wounded August 9,1862. Arm amputated just below surgical
neck. Excessive hemorrhage having supervened, the subclavian was
ligated at usual point. Died January 26, 1863.

Case 5. A. C. Howard, aged 19; wounded May 31, 1862. Ball passed
through left shoulder, injuring the spine and producing paralysis. June
7 ligation of subclavian artery in consequence of hemorrhage. Died
June 18.

Case 6. J. W. King, Company "C," Twenty-Ninth North Carolina
Regiment; wounded September 19. 1863, the ball passing through
shoulder joint, fracturing and detaching head of humerus. The ball
entered near the coracoid process and passed out over the spine of the

140

Thomas on Ligation of Arteries.

[July,

scapula. The accident was followed by a high degree of swelling and
inflammation, extending from the seat of injury down the forearm;
suppuration copious and offensive, with high irritative fever. On the
10th of October there was hemorrhage from the anterior wound, which
was arrested by pressure ; on the 11th, the hemorrhage recurred copiously
from both wounds, and the subclavian was ligated in its external third.
There was no further hemorrhage, but gangrene attacked the wound of
operation on the 20th, and the patient died the next day.

Case 7. Result fatal. [This case is reported in full in the February
Dumber of the Journal, by Surgeon Browne.]

We give below a tabular statement of the rest of the cases of ligation,
including those detailed above :

Vessel

Carotid

Subclavian

Axillary

Brachial

Arteries of Forearm

Femoral

Profunda

1'opliteal

Arteries of the Leg

All others, including Facial, Temporal and Occipital.

Cases

Re-

Death

covery

9

1

7

7

3

4

7

2

5

43

30

5

16

14

1

S3

24

24

3

1

1

2

1

1

11

5

4

6

3

3

157

&4

55 1

Undeter-
mined
1~
0
0
8
1
5
1
0
2
0

TOTAL.

18

In giving the above report, it is not pretended to include all the
ligations performed, but simply all that have been reported. Medical
officers can look over it and see to what an extent the deficiency lies at
their own doors. That the bloody work through which the army has
passed in four campaigns has demanded only 157 ligations, and many of
these of only a trivial vessel, is an estimate which cannot be adopted.
Certainly more operations of this character have been performed, for the
number reported does not bear a respectable ratio in th chapter of gun-
shot accidents. The presumption is, they have not been reported, and
are sleeping in the case-books of the Hospitals. Gentlemen may see to
what a desirable use full reports of each special branch of surgery may
be put namely, the laying of them before the profession at large, and
especially before those officers whose experience has not yet brought them
in contact with such cases.

Even in many of the reports the data are so meagre as not to furnish
any satisfactory conclusion with regard to the gravity of the case. Brevity
is a very commendable feature in clinical reports, but should not be
pushed to the extent of robbing the case of its interest. " Alexander
died Alexander was buiied ;" but there are some people who would be
curious to know how he died and when he was buried ; and it is a lean
obituary that does not give these small items. Some of the reports,
indeed, seem to have been based upon the editorial warning that "funeral
notices of more than lines will be charged for as advertisements.*'

I860.] Maughs on Conservative Treatment 141

But we are satisfied there is room enough in the Surgeon-General's Office
for reasonable and instructive post-obits, and if they are transferred to-
the pages of this journal, disquisitive platitude may be modestly re-
trenched, but deficient data cannot be supplied, C. &. Med. & Surg*
Jour., 1864.

ARTICLE VI.

Conservative Treatment of Compound Comminuted Fracture
of the Femur. By G. M. B. Maughs, Surgeon P. A.
C. S.

Case 1. C. S. Sheffield, private 15th Mississippi Cavalry, aged 17, of
feeble constitution, power of reaction very low, was wounded at Tishi-
mingo Creek, June 10th, 1864, transported some thirty or forty miles in
an ambulance to Rail Road, and thence in cars some 130 miles, to
Lauderdale Hospital, where he was admitted June 15th, 1864; compound
comminuted fracture of Femur at juncture of middle and upper third
comminution very severe. Treated by Smith's anterior splint ; but little
effort at reparation ; suppuration excessive. Died August 1st, 1864, of
hectic and exhaustion.

Case 2. M. B. James, private Company "H," First Kentucky Cavalry ,.
aged 19, wounded at Tishimingo Creek, June 10th, transportation as case
1st, admitted in Hospital June 19th, 1864, compound comminuted
fracture of Femur at upper third, the ball in its oblique course passed
through the bone as high up as the trochanter major. Treated by
position ; attempted union by free provisional callus ; doing well until
the middle of August, when he was attacked with continued fever, of
which he died September 9th, 1864.

Case 3. W. H. Ray, private Newsom's cavalry, Company "H," aged
24, wounded at Tishimingo Creek, June 10th, 1864, admitted into the
Hospital June 19th, 1864; compound comminuted fracture of Femur at
middle third. Treated by Smith's anterior splint; cure perfect; no
shortening or deformity.

Case 4. E. H. Powell, private New3om's Cavalry, Company "H,'T
aged 49, wounded at Tishimingo Creek, June 10th, 1864, admitted June
19th, 1864; compound comminuted fracture of Femur at middle third.
Treated by Smith's anterior splint ; recovered with three inches short-
ening.

Case 5. W. B. Davis, private Sixth Mississippi Cavalry, Company
"F," wounded at Harrisburg July 14th, admitted at Lauderdale Hospital
July 18th ; compound comminuted fracture of Femur at middle third.
Treated by Smith's anterior splint ; union perfect ; shortened one inch ;
no deformity otherwise.

142 Maughs on Conservative Treatment. [July,

Case 6. D. C. Crouch, private Twentieth Tennessee, Company "F,"
aged 19, wounded at Harrisburg, July 14th, 1864, admitted July 18th,
1864; compound comminutad fracture of Femur at middle third; exten-
sive comminution. Treated by Smith's anterior splint. ; furloughed
October 12th, 1864; perfect union; shortened three inches.

Case 7. J. Posten, private First Kentucky Cavalry, Company "C,"
aged 18, wounded at Harrisburg, July 14th, 1864, admitted July 18th,
1864; ball passed through both thighs ; compound comminuted fracture
of left Femur at upper third at trochanter. Treated by Smith's anterior
splint ; furloughed September 26th ; cure perfect ; shortening scarcely
perceptible.

Case 8. J. H. Shelley, private Third Kentucky Cavalry, Company
"L," aged 20, wounded near Tishiraingo Creek, June 9th, 1864, admitted
June 14th; compound comminuted fracture of Femur at the juncture of
middle and upper third. Treated by position. The cure in this case
has been greatly retarded, and the limb rendered useless by the meddle-
some surgery to which he was subjected, in incising the soft parts and
removing the broken fragments of the Femur. Union complete ; will
recover with great shortening.

Case 9. J. W. Martin, private Seventh Kentucky Cavalry, Company
*\K," aged 19, wounded at Tishiraingo Creek, June 10th, admitted June
14th; compound comminuted fracture of Femur at the junction of
middle and upper third ; extensive injury to soft parts; died June 16th,
1864.

Case 10. J. L. Lawrence, private Eighth Kentucky, Company "C,"
aged 25, wounded at Tishiraingo Creek, June 10th, 1864, admitted June
14th; compound comminuted fracture of Femur at upper third; died
June 16th, 1864.

Case 11. N. L. McNight, private Fourteenth Confederate Cavalry,
wounded at Harrisburg, July 15th, 1864; compound comminuted frac-
ture of Femur at upper third. Treated by long, straight splints ; died
September 9th, 1864.

Case 12. N. L. McGoodwin, sergeant-major Third Kentucky Cavalry;
compound comminuted fracture of Femur at junction of middle and
upper third ; extensive comminution. Treated by position ; union
complete ; shortened two and a half inches ; wounded at Harrisburg,
July 14th, 1864; furloughed September 16th, 1864.

Case 13. J. T. Tindell, Eighteenth Mississippi Cavalry, Company
''K," aged 19, wounded July 15, 1864; compound comminuted fracture
of Femur at upper third, the ball passing up to the joint; extensive
comminution, wih great injury to soft parts: died September 18, 1864.

Case 14. A. Latten, Morgan's Command, wounded at Harrisburg,
July 15th, 1864; compound comminutad fracture of Femur at upper
third, near hip-joint: injury to bone and soft parts very severe; wound
sloughed extensively. Treated by long splint; died of pyaemia September
1st, 1864.

1866.] Maugiis on Conservative Treatment. 143

Case 15. J. Malone, Morgan's Command, aged 21, wounded at Har-

, risburg, July 15, 1864; compound comminuted fracture of Femur at

middle third. Treated by long splint; partial union of bone ; wound

doing well, when he was taken with pysemia, and died September 17th,

1 1864.

Case 16. V. T, Bynum, Third Kentucky Cavalry, aged 23, wounded
at Harrisburg, July 15th, 1864; compound comminuted fracture of
Femur at lower third. Treated by position ; union complete ; shortening
two inches ; gone home.

Case 17. J. H. Stevens, Third Kentucky Cavalry, Company "D," aged
20, wounded at Harrisburg, July 14th, 1864; compound comminuted
fracture of Femur, upper third; treated by position; had pthisis pulmo-
nalis ; died August 3d, 1864.

Case 18. H. Jenkins, private Company "H," Mississippi Partizan
Rangers, wounded at Harrisburg, July 14th, 1864, aged 23 ; compound
comminuted fracture of Femur, middle third ; treated by position ; cure
I perfect ; shortening scarcely perceptible.

Case 19. W. T. Ivy, private Nineteenth Mississippi Cavalry, aged 40,
wounded at Harrisburg, July 14th, 1864; compound comminuted fracture
of Femur, upper third ; ligation of arteria profunda ; treated by position ;
union complete ; shortened one inch.

Case 20. W. W. Shophire, Thirty-Eighth Mississippi, Company <'D,"
aged 28, wounded at Harrisburg, July 14th, 1864; compound commi-
nuted fracture of Femur, junction of middle and upper third ; very great
'comminution; attacked with erysipelas; recovered; union complete;
; shortening one inch; furloughed August 12th, 1863.

Case 21. Yankee Lieutenant, wounded at Harrisburg, July 14th,
I 1864; compound comminuted fracture of Femur, upper third; during
treatment femoral artery sloughed and was ligated ; complete recovery ;
has been exchanged.

Case 22. A. Boy, attached to the army, was admitted for wound of
1 Femur, middle third, compound comminuted ; treated by position ; union
> complete ; but little deformity ; gone home.

Here we have twenty-two cases of compound comminuted fracture of
I the Femur, treated without amputation ; not selected to make an argu-
ment, but consecutive cases, and include, with a single exception, all the
cases so wounded and so treated at these Hospitals, during the time
included within this report. And we have not extended the report
through a greater time, or hunted up isolated cases because others might
have been wounded at the same time, of whom no record was preserved,
' thereby rendering the statistics incomplete and worthless.

To the statistician, these twenty-two cases are worth more than a
thousand would be, gathered up from different sections, where in each
section a few cases had been omitted, and the result in others was not
known. Such statistics are like native offerings in heathen temples, they
tell but a partial story.

144 Maugiis on Conservative Treatment [July,

The excepted case is that of a private, wounded at Harrisburg by a
grapeshot through both thighs near the hip-joint, with great destruction
of the soft parts, tearing out the testicles, and bruising the perineum. It
was not expected that this unfortunate man could survive even a few
days. His testicles were removed, the wounds dressed, and his mangled
limbs placed in the most comfortable position ; stimulants and nourishing
diet were administered. He lived for six weeks, during which time one
of the wound3 healed up, the bone united, and considerable progress had
been made in the other limb, when he sank, worn out with the extensive
suppuration.

This case is mentioned and fairly stated to show that it could not have
been included with those given in this report, as the object of this paper
is not to prove that wounds of the Thigh may not be of such a nature as
to require amputation. Would, however, the most reckless advocate of
the knife have used it in this case?

Our object is to prove that in all compound comminuted fractures of
the Femur, with the artery intact and no very great destruction of soft
parts, conservative surgery not only gives the patient the advantages of a
natural over an artificial limb, but also gives him a better chance for his
life than amputation would. And all of this we think this paper estab-
lishes.

Of these twenty-two cases nearly all were subjected to circumstances
most unfavorable to recovery. The patients from the Tishimingo battle,
treated by Assistant-Surgeon S. Kennedy, were hauled over rough road3
for thirty or forty miles, and then transported some hundred and thirty
miles by Rail Road, being constantly disturbed and their wounds fretted
for eight or nine days before their arrival at Lauderdale Hospital.
Several of the patients from the battle of Harrisburg were subjected to
nearly the same transportation and frequent change of place ; the delay,
however, in their arrival at the Hospital was not so great ; some of the
others were necessarily removed three or four times during their treat-
ment. The Surgeon in charge, Dr. Hoyle, thinks the death of more
than one of these clearly attributable to this untoward circumstance.
Cases 9 and 10 died soon after their admission, never having re-acted
from the shock. Case 17 had pthisis pulmonalis, of which he most
probably died ; admitting, however, that he did not really die of this, it
can not be denied that it rendered his recovery from any serious injury
most improbable. Case 2 was progressing favorably when attacked with
continued fever, at the time prevailing in the Hospital, of which he died.
While, therefore, there would be much justification for excluding cases
2, 9, 10 and 17 from the report, as their deaths were only indireetly the
result of their wounds, yet we will give the advocates of amputation the
benefit of them.

We have then recovered, cases 3, 4, 5, 6, 7, 8, 12, 16, 18, 19, 20, 21, 22
total, 13, or 59.1-11 per cent. Died, cases 6, 2, 9, 10, 11, 13, 14, 15,
17 total, 9, or 40.10-11 per centum.

1866.] Maugiis on Conservative Treatment 145

Now, let us see what would have been the result had amputation
! been performed in all those cases. In cases 2, 7, 13, amputation must
! have been at hip-joint; disarticulation, all of whom would have died.
That a case does now and then survive this formidable operation does
not affect the rule that of ten or twenty so operated upon all will die.
Dr. Macleod never saw a successful case in Military Surgery. We have
heard of but one that of a private wounded by a shell at Fort Pembcr-
ton, and operated upon by Surgeon W. M. Compton, and afterward
attended by Surgeon Green in Hospital at Yazoo City.

In cases 1, 8, 9, 10, 11, 12, 13, 14, 17, 19, 20, 21 total, 12amputa-
tion must have been high up in upper third, through or near the trochan-
ters ; of these, nine, most probably ten, would have died. In the other
seven cases, amputation could not have been lower than the middle
third ; of these, lour would have died, giving for operative surgery, deaths
16, or 72.8-11 per cent.; recoveries 6, or 27.3 11 per cent., or more than
100 per cent, in favor of conservative, under the most untoward circum-
stances, over operative surgery, under circumstances the most favorable.
And this proportion, we doubt not, but for the meddlesome interference
of the Surgeons, would hold good throughout the Confederacy, or even
jibe greatly increased, as it would scarcely happen that a concatenation of
I circumstances so unpromising would again be met with. It will be
observed that in all of these cases, with a single exception, and that
greatly to the detriment of the patient, the treatment was eminently
conservative. No excisions of ike Femur, no incisions of soft parts
for the removal of loose pieces of bone, no formidable display of ma-
chinery to keep the limb in place and the patient^/nwi sleep.

The wounds were carefully examined, and all foreign bodies, including
spiculse of bone immediately in the track of the ball, removed. The
'limb was placed in Smith's anterior splint, or what was preferred, placed
in positian and retained there by soft cushions or pillows, and all un-
necessary probing or handling carefully avoided.

By even late authorities, the experience of the Crimean campaign and
Dr. Macleod's observations have been quoted to prove that ordinary
(fractures from rifle balls, above the knee (of the Femur), demand ampu-
tation. These give only eight per cent, recoveries for conservative
surgery under the most favorable circumstances, with selected cases, and
' only thirty two per cent, for amputation. This is indeed an alarming
fatality, and as frightfully dangerous, as it shows amputations of the
thigh to be two to one against recovery, as it is four times more success-
ful than conservative treatment, would of course establish the rule to
amputate. But against such a rule our paper is an unanswerable
demurrer; and as it reverses the result, and proves that by saving the
jlimb we save twice as many lives as could be saved by amputation, by
'the same parity of reasoning it must also reverse the rule, and establish
Ithis. As a general rule, ordinary f-actures above the knee, from rife
balls, should never cause primary amputation. [C. S. Med. & Surg.
Jour., January, 1865.

10

146 Sutton's Observations mi Cholera. [July,

ARTICLE VII.

A Summary of Observations on Cholera. By GEORGE Suttgn,
M. D., of Aurora, Indiana.

As the pages of the Reporter have been open for the opinions
and observations of physicians on the subject of cholera, I will
present a summary of conclusions which I think can be sustained
by conclusive arguments, and which appears to me to explain
much of the obscurity which has attended this disease. Some of
these conclusions were presented to the Indiana State Medical
Society in the year 1853, and are published in the proceedings of
the Society for that year. They are based upon an extensive
experience with cholera under various aspects having observed
the progress of the disease as it spread through a sparse popula-
tion in our rural districts, which gives the physician a favorable
opportunity of tracing the connection, if any exists, between the
different cases that occur also having seen cholera assume, as it
were, a local character, and present its most malignant form in
certain small localities within our city, and sweep off more than
half their inhabitants; again presenting an opportunity of exam-
ining why these localities (which are the most healthy and ele-
vated in our city) should be so severely attacked by the disease
and also having had the experience of being prostrated from a
severe attack of cholera myself, and while confined to the bed, see
my family stricken down, my son die after only a few hours'
illness, and other members of my family reduced to the lowest
stage of collapse from which the system could recover an expe-
rience with me in cholera which has led to a careful observation
of facts, and an anxious endeavor to unravel and account for the
diversity of phenomena which the disease presented, as it pre-
vailed in this section of country.

Physicians Lave recently presented the theory that cholera-
poison may emanate from evacuations, as something new. This
theory was advanced by myself in 1853, in the report alluded to
(and I am not aware that the theory was ever advanced before), to
account for the cause of the disease being so malignant in certain

I866v] Sutton's Observations on Cholera, 147

localities in the city of Aurora. It was shown in that report that
the alimentary discharges, from their watery character, were
generally emptied upon the ground, and that in one locality the
bedding known to have been saturated with the discharges during
the last stages of a fatal case which I attended, was thrown upon
a vacant lot and became, as I supposed, the first point from which
emanated the infection that produced a local malignancy to the
disease. (See the same Report, pages 162, 163 and 166.) The
idea is also advanced in that report, that cholera, like many other
diseases, is capable of assuming different grades of violence, and
that under the form of a mild diarrhoea, it may be spread over the
country by persons who are scarcely aware that they are unwell.
(See pages 160 to 175.)

The conclusions which we present may be summed up as fol-
lows and if found not to be altogether correct, we think is an
advance in the proper direction :

1st. That cholera is unlike any other disease, and is governed
by laws peculiar to itself.

2d. That its cause is an organic poison, which is reproduced
within the human system, and is diffused by human intercourse.

3d. That for the development of cholera on this continent, there
must first be cholera-poison, nest, a community susceptible to its
influence.

4th. That the susceptibility to cholera resides in the organic
nervous system, upon which the poison first makes its impression,
producing innervation and altered action of the capillaries, giving
rise, in many instances, to profuse exhalations, also morbid secre-
tions from the mucous membranes, from which probably the
infection arises as we see in hydrophobia, a nervous disease,
associated with poisonous secretions from the salivary glands or
glossopharyngeal mucous membrane.

5th. That this susceptibility to cholera is not alike in all
persons, but exists to the greatest extent in a community that has
never been under its influence.

6th. That temperature, or season of the year, humidity, modes
of living, and other local and physical causes, increase or diminish
the susceptibility of the community to the disease.

148 Sutton's Observations on Cholera, [July,

7th. That cholera, like other diseases, may assume different
grades of violence, and may also prevail under different forms.

8th. That it may prevail under the form of a diarrhoea. That
where predisposition, season of the year, or other causes favor the
development of dysentery, that cholera assumes this form of dis-
ease. That it may prevail as a mild cholera-morbus, and the
malignant form is the name that we would give to those cases
where there is failure of the circulation, blueness of the skinr
cramps, etc., etc.

9th. That when cholera-poison was introduced upon our conti-
nent, in 1832, in the North, and in 1818, in the South, it was
the cause of these four forms of disease spreading over the
country in many places intimately associated, and in others
appearing only as an epidemic diarrhoea which we consider not
merely a " symptom" of cholera, or the "premonitory stage," but
the cholera itself in a milder form. Why call this diarrhoea that
accompanies cholera the premonitory stage, when a large majority
of cases proceed no further ? And at what period of the attack
are we to consider true cholera as commencing ?

10 th. That the disease may be spread by each one of these
forms, and by the diarrhoeal form, even if only one person out of
ten is susceptible to its influence. Consequently, no other disease
known can be so easily diffused over the country as cholera, and
no other disease so difficult to trace the manner of its diffusion.

11th. That the malignant form of cholera is favored by a variety
of causes, among which are predisposition, tendency to diarrhoea,
modes of living, mental depression, probably fear, but more par-
tii-ularly than from any other cause, upon the accumulation of
infection, which overpowers vital resistance before the system has
acquired the power to tolerate the disease, as we see from the
i>ame cause, in certain malarial districts, a simple disease assuming
the fatal and malignant form of congestive fever.

12th. That the principal cause of the accumulation of infection
13 from the evacuations, which from their watery character are
generally emptied upon the ground, and from which the infection
is capable of spreading through the atmosphere, and gives a local
malignancy to the disease. (See Report to Ind. S. M. S.)

1866.] Sutton's Observations on Cholera. 149

loth. That this accumulation of infection takes pTace when
cholera is introduced under favorable circumstances into large
crowds of human beings, or poorly ventilated places, or in cities,
or on low damp situations during stillness of the atmosphere
and particularly where the sub-soil is of clay or limestone forma-
tion, while upon a dry and sandy soil, which rapidly absorbs
moisture, the infection seldom accumulates. (Pettenkoffer's
theory might have some foundation if the disease did not appear
so fatal on board our steamboats and ships, thousands of miles
from the soil or land, which he considers necessary in connection
with the evacuations, to develop the cholera germ.)

14th. That season of the year or temperature has a marked
influence upon the progress of cholera, and that during the Winter
it may prevail in our cities as a mild form of diarrhoea, to re-
assume its malignant form as Summer and other causes favor its
development.

loth. That the system soon tolerates tlte poison, and that attacks
of either of the forms of cholera and frequent exposure to the
infection, removes in a great measure the susceptibility to the
disease, which is probably acquired again in from 15 to 20 years.
This power in the system to tolerate the poison is the reason the
disease leaves the country, and seldom attacks a city or town
severely the second time.

16th. That when cholera-poison is once introduced upon our
continent, the most certain prophylactic in our northern climate
(in connection with proper sanitary regulations) against the malig-
nant form of cholera in the Summer, is frequent exposure under
favorable circumstances to the infection during Winter, by which the
susceptibility to the disease may in a great measure be removed.
We are well aware that cholera prevailed in Russia, Scotland, and
parts of England during the Winter, but we think that these
facts, when properly examined, have but little weight against the
correctness of our conclusion.

Now we think that we have a very extensive array of arguments
to sustain each one of these conclusions, a summary of which, in
as few words as possible, we will present at another time ; merely
stating at present that the first conclusion that cholera as an infec-

150 Sutton's Observations on Cholera, [July,

tious disease is governed by laws peculiar to itself, we consider as
self-evident, and requires no argument, if the other conclusions
we present are correct. Physicians tell us that cholera cannot be
contagious, because it differs from all other contagious diseases.
This assertion, we think, is without foundation, because we do
know that contagious diseases are governed by different laws
hydrophobia, for instance, is a contagious disease communicated
by inoculation, like small-pox, and capable of reproducing its
poison in different species of animals, even in the human system,
according to the experiments of MM. Magendie and Breschet;
but hydrophobia differs from all other diseases, and is governed by
laws peculiar to itself, and differs as much in its nervous symptoms
and indefinite period of incubation of its poison from sniall-pox,
as cholera does from other infectious diseases.

Could the virus of hydrophobia rise into the atmosphere like
the infection of rinderpest or of small-pox, and many other dis-
eases (and why should it not assume an serial character ?), and
produce its specific effects upon the human system through the
respiratory organs as it does now by inoculation, it would then in
its mode of communication resemble cholera, and be by far a more
terrible disease, perhaps the most terrible disease upon our globe,
incurable in its nature communicable to different species of
animals, which would reproduce the infection from innumerable
sources; and, like cholera, this infection having no definite period,
of incubation, it would be still more difficult to guard against it
by quarantine than cholera, and in time, like cholera, it might
desolate extensive portions of the globe. By merely changing
then the physical properties of the virus of a well known conta-
gious disease, we should have a malady probably more terrible
than cholera, which unlike all other diseases, would be then, as it
is now, governed by laws peculiar to itself. It is highly probable
that future discoveries may show that several theories of the for-
mation of contagion are correct, and that organic poison germs
may originate, 1st, from zymotic agents, or poisons which arc.
capable within the blood of re-development. 2d, from morbid
secretions, which by a natural selection for the organs from which
they were secreted, cause the reproduction of a similar secretion ;,

1866.] Daniell on Rice Culture. 151

and also, possibly from morbid secretions becoming poisonous from
their union with the elements of matter, either in the earth or
atmosphere. Is there anything unreasonable in supposing that
certain vitiated secretions, which are probably in the form of cells,
when introduced into the blood of another system through the
respiratory organs, have a natural selection or tendency to produce
morbid or specific effects on those organs, membranes or cells, from
tvhich they were secreted, so as to reproduce a similar secretion or
re-development of poison germs. This action being influenced by
an excited or irritated condition of the nervous system of the
part, produced by the poison itself as we know that many of the
secretions are excited and changed by nervous influence. That
poison germs are reproduced by secretions without the blood being
contaminated, is a well known fact as we see that an application
of gonorrheal poison to a mucous membrane, or the poison of
purulent ophthalmia applied to the conjunctiva reproduces a
similar poison without poisoning the blood, while in small-pox,
measles, scarlatina, and some other diseases, we have the evidence
of blood poisoning; and in gonorrhoea, purulent ophthalmia, hy-
drophobia, cholera, and probably hooping-cough, we have reason
to believe that the poison germs depend upon morbid secretions.
Then again we see the different effects which these specific poisons
produce upon the nervous system, as in hooping-cough, hydropho-
bia, and malignant cholera. Medical & Surgical Reporter.

OR,IGH3SrA.L correspondence.

ARTICLE I.

History of the Dry Culture System on the Rice Lands near
Savannah, tvith Observations on the Effects of Rice Culture
upon the Health of this City. By W. C. Daniell, M. D.

Athens, Ga., October 2d, 1865.

Joseph Jones, M. D., Professor of Medical Chemistry, in Medi-
cal College of Georgia : Augusta.

Dear Sir : Some necessary writing and the unusual heat of

the Summer have delayed my fulfilment of a promise to supply

you with whatever my memory may furnish of the history of the

152 Daniell on Rice Culture. [July,

Dry Culture system on the rice lands near Savannah, first pur-
chased by the city at forty dollars per acre, and afterwards
extended by legislative authority and confirmed by the Supreme
Court of this State.

It is now my purpose to make such memoranda, from day to
day, as my recollections will call up, that I may suppose will
interest you.

The idea of getting rid of the rice culture, around Savannah,
had been previously agitated, but was fully considered in the
early part of 1817 and established in 1818. The late Mr. John
Bolton, then an eminent merchant of Savannah, was at the head
of the movement, and we owe the establishment of the dry culture
system to his perseverance and address.

Some of the proprietors of the land to be subjected to the
system accepted the measure in the best spirit, among them was
Dr. 3S". B. Bayard, I believe. One of the proprietors, I think
the largest, positively refused to subject his lands to the system
in other words to relinquish the cultivation of rice. He was a
Scotchman who had acquired his property by marriage with
a wealthy widow, and who did not purpose living much longer in
this country; indeed, he removed, some years after, to Scotland.
Several of the proprietors, unwilling to sell and equally indisposed
to incur the public odium by refusing to concur in a measure so
eminently conducive to the health of the city, yielded a condition-
al assent. They would sell the right to cultivate rice on their
own land, provided all (amounting to some eight or ten) would
sell. There must be unanimity or a failure of the measure. Mr.
Bolton came to the conclusion that this conditional consent was
given in the conviction that the Scotchman would adhere to his
solemn declaration, so repeatedly made, that under no circum-
stances would he sell. The measure which the city had so much
at heart was to be defeated, and the conditional consent of so
many of the proprietors would be unavailing, because of the
obstinacy of the Scotchman. He wasconsequently responsible;
on his single head would fall the execrations of an indignant and
incensed community, foiled in its efforts, at great cost, to give
health to their homes. How, or by what means, I know not, Mr.
I

1866.] Daniell on Rice Culture. 153

Bolton inspired the Scotchman with the conviction that the
proprietors who had placed their consent to the proposed measure,
on the condition that he would also consent, had done so in the
full belief that he would stand by his declaration; and that
whilst these proprietors were as opposed to the measure as
he was, they had so managed that all the odium of the refusal
should fall on him, and they would be held up as willing to do all
that the occasion demanded. Once satisfied on that point, in an
agony of rage he avowed his determination to defeat and punish
the d d rascals, and yielded to passion and resentment, what
neither reason nor the wants of the city could win. Thus are,
occasionally, the evil passions of men made the means to accom-
plish a great good.

In the course of the year the contracts were made and the
money paid, and the dry culture system went fully into operation
the following year (1818) which was certainly and decidedly the
most healthful year I have ever known in Savaunah. The late
Dr. George Jones, whose father accompanied General Oglethorpe
to Georgia, in reply to my inquiry how to account for the number
of Charleston names to be found recorded as possessors of city
property in Savannah, told me that at an early period, and before the
clearing of the tide swamp immediately around the city, Savannah
was resorted to as a Summer residence by many Charleston ians on
account of its greater healthfulness.

The dry culture system was a measure to restore Savannah to
its early salubrity; it was a measure of self defence adopted by
the citizens for protection against injury, originating from the
pursuits of a few of the citizens, exercised to the injury of the
whole community. Instead of rising up in their power and
abating the nuisance, the people of Savannah acting under a
commendable respect for individual rights, preferred to compen-
sate the proprietors of the offensive culture, and paid to them
two-thirds the value of the lands so employed for their right to
cultivate rice, conditioned that they should keep their lands well
drained and not irrigate them during the warm months.

Some of the proprietors of the dry culture lands, after a few
years, became dissatisfied with their bargains; and an effort was

154 Daniell on Bice Culture. [July,

made by application to the city authorities to have them annulled,
upon the ground that the change of culture had not proved
beneficial to the health of the city, and that it had caused great
loss to the proprietors. The latter proposition was doubtless true,
but whether owing to the intrinsic qualities of the soil or to want
of enterprise and energy of the proprietors, need not be here
discussed.

The first proposition was of a different character. It had two
sides, an affirmative and a negative, and was of a character to
require research, investigation, and analysis. Apparently con-
flicting facts were to be reconciled by investigating remote and
secondary causes ; indeed, it was one of those questions which, in
this country, every man undertakes to judge of, and of which, not
every tenth man is capable of forming a reasonable opinion.
Three years had elapsed under the dry culture system. The first
had been very healthful; I mean 1818, the only year during my
practice there in which I did not sec a case of yellow fever. The
year 1819 was fatal to strangers who came out in great numbers in
the Summer, in consequence of financial embarrassments North.
They were chiefly of the laboring class, and were Europeans.
1820 was visited by yellow fever, as an epidemic, and carried off
over one-fifth of the white population. The city had been visited
by an extensive fire in its heart, and the foreign population which
had been constantly pouring in, were necessarily crowded into
small houses, and they supplied the main element to fill the bills
of mortality.

Whilst, therefore, the proprietors could cite the experience of
the three years as proving the inutility of the dry culture system
so far as 1819 and 1820 were concerned, the friends of the
measure saw nothing in the past to discourage them. The city
authorities referred the question of the abandonment of the dry
culture system to the citizens. If the proprietors had proffered
to return the money received by them in consideration for giving
up the culture of rice, I believe they would have prevailed, but
they refused this, alleging that their losses had been so great as
fully to cover what they had received in payment ; as it was, the
citizens, by a small majority sustained the system. In speaking

1866.] Daniell on Rice Culture. 156

of the proprietors of the dry culture lands, I refer to a. portion of
them and not to all ; some of them, from first to last, yielded their
cordial support to the dry culture system. The small majority of
citizens by which it had been sustained imposed great caution on
the friends of the measure. The dry culture committee of the
City Council made occasional reports, censuring the delinquent
proprietors, but dared not ask the approval or adoption of them by
the board. Appeals were made through the city press to the
community against these reports, which only embodied the sub-
stance of the Inspector of dry culture reports, and reasoned from
them. Of these appeals no notice was taken by the party assailed.
It was deemed most wise to let the dry culture system silently
work out its own vindication.

Whilst this was going on, some zealous friends of the measure
had a prosecution instituted against a citizen of another State,
who owned rice land near the city, which he cultivated. I believe
no proposal was ever made to him to purchase his right to its
culture. The prosecution failed, as had been predicted, and that
land is still cultivated in rice. I believe it is farther removed
from the city thas any tract of land contracted to dry culture.

About eight years after the dry culture system had been in
operation, and when the community had become fully assured of
its importance to the health of the city, a law was passed by the
General Assembly, prohibiting the culture of rice within a speci-
fied distance of the city, and its jurisdiction so enlarged as to em-
brace the dry culture lands, and heavy penalties were imposed on
violators of the law. The main purpose of this law was to supply
a prompt and efficient remedy against violations of the dry culture
contracts, and to repress the culture of rice upon abandoned and
recently opened rice lands. Prosecutions were soon after insti-
tuted against some violators of the law. They failed, the pre-
siding judge having been taught by learned counsel that the
omission of the numeral "one," before "hundred dollars," vitiated
the penalty in other words, that the absence of the. adjective
nullified the presence of the substantive. This decision led to
some curious results; proprietors became partial to the cultiva-
tion of rice as a dry culture crop, and most strangely wherever

156 Daniell on Rice Culture. [July,

(or in many cases) rice was so cultivated, such was the
affinity of the cherishing mother, water, that it would thrust a
chunk or billet of wood between the outer mouth of the trunk
and the door, and creep in and cover the thirsty rice, and closing
the door on the inner mouth of the trunk, would remain with its
nurselings, to the proclaimed astonishment of the proprietor.-
This foster mother of rice was as promptly extending its work
of beneficence as proprietors became enamored of the dry cultiva-
tion of rice, and it soon became apparent that the dry culture
system was about to be most mysteriously overthrown by new
agencies never dreamed of by the original contracting parties.

In this dilemma the city instituted prosecutions against some of
the proprietors under the law already referred to, and which had
been overruled by the grammatical decision of a most exemplary
judge. I understand that it was proven to the satisfaction of both
court and jury that the cultivation of rice was per se injurious to
health, which it may be supposed was founded upon the remark-
able affinity of water for growing rice, as already referred to. The
party was convicted, and an appeal was taken to the Supreme
Court, which sustained the finding of the court below. Thus,
after a long protracted struggle for existence, the dry culture
system has vindicated its salutary influence upon the health of
the city of Savannah, and its inhabitants are unanimous in its
support, and I believe all the proprietors of the dry culture lands
now acquiesce in good faith in the measure.

I might earlier have stated that before and after the vote was
taken, some of the contractors, sometimes from inability and some-
times, perhaps, from pervcrseness, did not comply with the condi-
tions of their contracts. The friends of the system doubting the
results of any attempt at their legal enforcement, were content to
rely on hopes of future amendment, and promptly accepted the
abandonment of any dry culture lands, in the belief that their
natural growths and the flux and reflux of the tides on them,
which followed such abandonment, approximated in influence
upon the health of the city to the most ample fulfilment of
the contract, and I believe that experience has fully justified
this judgment. Such abandonment, by the prompt growth of

1866.] Daniell on Bice Culture. 157

a dense cover of bushes, briars, and weeds would measurably,
and to that extent, restore the soil to the condition in which
it was when Charlestonians sought in Savannah a more health-
ful climate than their own cherished city then supplied, and
when Hugh Bryan sold Hutchinson's Island for a bowl of
punch, which was, of course, before the introduction of slave
labor into Georgia.

On my settling in Savannah, in the Fall of 1815, I found in
fall practice there Dr. Samuel Kollock, a gentleman not less
remarkable for his social virtues than for his colloquial powers.
He told me that he always was advised of the rice harvest by the
graver character of the fevers that immediately followed the
letting off the harvest water.

I also found in Savannah, W. B. Bullock, then late Senator in
Congress, from which he had retired, that he might no longqr be
deprived of the enjoyments of domestic life. He told me that
forty-five was a good old age in Savannah* and that Robert Bolton,
who had died at the age of 38, as stated on his tombstone, had
been called old Mr. Bolton for some years before his death. Mr.
Bullock died at an advanced age, I think above eighty.

When I went to Savannah to live, many respectable families
lived on Bay street, which lies next to and parallel to the river.
It was the custom of such families to remove into the centre of
the city in the Summer, and Broughton street was then preferred.
After the introduction of the dry culture system, Bay street, I
considered, at least, as healthful as Broughton street.

It was said (and I believe truly) that during the destructive
pestilence of 1820, not one case of yellow fever originated south
of South Broad street. The great fire of that year had not
extended south of Broughton street.

During my practice in Savannah (that is up to 1834), usually
in August, sometimes earlier, intermittent fever prevailed in the
last and next to the last range of houses south. As the city
advanced south, these fevers advanced pari passu in the same
direction, having abandoned their previous localities.

I believe, my dear sir, I have written all that occurs to me that

158 Daniell on the Introduction of Shad. [July,

may be useful to you. I may have repeated somewhat that I have
published, which you will excuse, as I have no means of reference.
I am conscious that I may have done little in fulfilment of your
wishes; if so, please take the will for the deed.
Very truly, yours,

W. C. Daniell.

ARTICLE II.

Introduction of Shad into the Southern Rivers emptying into the
Gulf of Mexico. By W. C. Daniell, M. D.

Savannah, May 22d, 1866.

Professor Joseph Jones, M. D., Augusta, Ga.

Dear Sir : I am gratified to say that I have fully established the
White Shad in the Alabama River, where they are as large and
as fine as our own Shad.

Xow that it has become a fixed fact that the Shad prosper at
the mouth of the Alabama River, we may readily infer that they
will equally prosper at the mouth of the Mississippi River, and
probably of all the rivers discharging into the Gulf of Mexico.
I hope to test this another year. I would have done so this
Spring, but that my fisherman disappointed me. As soon as 1
was satisfied that there were distinctive, though minute, differences
between the Shad of the Savannah and the Ogeechee Rivers, I
felt confident of establishing the White Shad in the Alabama
River. These differences were pointed out by our fishermen in
1846, and in 1848 I planted the fecundated eggs in a small
tributary of the Etowah, and in 1851 or '52 the fish were taken
in the traps at the foot of the falls at Wetumpka and Tuscaloosa.

Yery truly yours,

W, C. Daniell.

1866.} Discussion on Cholera. 159

ARTICLE III.
Petroleum Operations in Alabama. By Rev. J. L. Bogers.
Gadsden, Ala , April 25th, I860.

"Dr. Joseph Jones, Augusta

My Dear Sir : Your favor, containing a report on the Coal and
Iron Ore that I sent you, came to hand in due time. I ought to
have acknowledged it long since, but I have been off here in the
back woods, very busily engaged in starting our operations for
Petroleum. I think our prospects of success are very good. The
indications we have already are very encouraging. Our practical
well- borers from Oil Creek seem very confident we will succeed.
We have passed through about ten feet shale immediately under
the surface soil of four feet, then nineteen feet hard limestone,
strongly bituminous, then slate and soapstone, sixty-seven feet,
limestone again, three feet, then the first sandstone which we have
entered, eight or ten feet. It is strongly bituminous, and the
borings smell quite like the oil. At about sixty-five feet we struck
what the Pennsylvania men call the "Black Soot" Oil, and which
they say is considered in Pennsylvania one of the surest indica-
tions of a good well. I have very little doubt that this region
will afford oil. Yery truly yours,

J. L. Rogers.

TRANSACTIONS OF SOCIETIES.

ARTICLE I.

Discussion on Cholera. New York Academy of Medicine, Stated
Meeting, March 21, 1866; Dr. Alfred C. Post, Vice-Presi-
dent, in the Chair.

Mr. T. McElroy, by courtesy of the Academy, exhibited the
model of a very unique surgical table, and also an invalid bed,
after which

Dr. Herzog continued the discussion by referring to an epi-
demiological map prepared by the War Department of Bavaria,
and which he had brought with him for the inspection of the
Fellows of the Academy. This had been very carefully prepared

100 Discussion on Cholera. [July,

from the most authentic sources, since a commission representing
nearly every branch of science had been appointed, with ample
powers, to investigate the laws which governed the epidemic there
of 1854. Bavaria, he would remark in passing, represents a
population of five millions, confined to comparatively a small area,
and at the time presented peculiar opportunities for the study of the
various causes at work in the progress of this scourge. The artist
in the map represents what, for convenience sake, we shall style
local epidemics, by red lines, sporadic by green, and mere chole-
rine by those of a bluish tint. By this device the eye is very
readily addressed, and our facts very easily marshalled into line.
The commission to which I have alluded embraced, among others
equally celebrated, such names as Liebig and Pettenkofer. They
performed their duty ably, zealously, and thoroughly. They
observed that the epidemic attacked some localities and avoided
others, in obedience to other laws than those which govern portable
diseases; that certain persons or certain vessels were not respon-
sible for the introduction of this destroying power; or, in brief,
that human travel had very little, if anything, to do with the
question. They found that the direction of the winds or of the
water-courses was a matter of no importance. Why, then, they
inquired, as they narrowed down the results of their observations,
are these choleraic visitations confined to certain streets, sides of
streets, and even certain houses ? This led to the search after
specific causes, and we have the summary of their conclusions that
a dry, solid, rocky, compact soil is uniformly exempt from the
infection ; while a wet, oozy, soft soil especially invites the in-
vasion. The water underneath the surface of the ground is con-
tinually seeking different levels, and in its recession leaves the
debris of various offending substances, which ferment and decom-
pose in obedience to well known laws. The only requisite for the
spread of the disease in a locality permeated by those underground
streams, is the contact of choleraic stools.

The power of the excrements in the causation of the malady
was well exemplified in the case of the laundresses employed
about cholera hospitals; they were peculiarly susceptible to attack,
and the attack almost invariably terminated in death.

1866.] Discussion on Cholera. 161

Dr. Hutchison, for the sake of giving the discussion a practical
turn, wished to hear the experience of his brethren in the matter
of treatment. He had acted his part in two epidemics. The one
of 18-19 he was in the Mississippi Valley, and that of 1854 in this
vicinity; and he had come to the conclusion that the preferable
plan was to disturb the patient with as few medicines as possible.
He had adopted the practice of free vomiting by stimulating
emetics, such as common salt and mustard. These agents, he
found, controlled the vomiting attendant upon the disease, after
the production of their immediate therapeutical effect, much
more certainly than creasote, hydrocyanic acid, or any of the
salts of opium. They seemed to thoroughly clear the stomach of
all offending substances; he remembered a case where the ejection
of a piece of lemon-peel, dislodged from this organ by a mustard
emetic, gave almost immediate relief. The vomiting of the dis-
ease he would set down as rather of a regurgitative character, and
as indicative of what nature was striving to accomplish. He also
aimed to procure bilious stools by the exhibition of calomel in
one-grain doses every hour ; in fact, he looked upon nature as an
excellent indicator of the plan to be pursued, and had early
learned to regard free vomiting and purging as very hopeful signs.
For the cramps, he knew of no better plan than the forcible and
continuous extension of the muscles say, for instance, that if the
arm were implicated, he would subdue them by putting the
extensors upon the stretch. He thought also that some benefit in
these cases had been derived by the use of anaesthetics and hot-air
baths. He rather favored the method of introducing saline
solutions into the circulation, notwithstanding the want of satis-
factory results ; he had adopted the method in five cases, all of
which terminated fatally ; none of these, however, were fair tests.
Indeed there were many niceties involved in the question of
failure; the mode of operating, the quantity, quality, and relation
to each other of the materials, the specific gravity and temperature
of the solution, etc. The formula he had employed in his earlier
cases was as follows : Alcohol 3 i., chlor. sodium 5 iii., and water 1
pint. One or two pints were injected into the median basilar vein.

He afterward employed the solution recommended by Dr. Gull,,

11

162 Discussion on Cholera. [July,

which was composed as follows : Chlor. sodium 40 parts, chlor.
potassium 6 parts, phos. sod. 3 parts, and carb. sod. 40 parts; 140
grains were dissolved in 40 ounces of water, and injected at the
temperature of 100, 115.

The solutions employed are intended to represent the fluids
discharged from the blood, minus the organic materials. He de-
sired to see this method of treatment more thoroughly ventilated.

Dr. Herzog's experience coincided with Dr. Hutchison's; he
had known of no recovery where this plan had been adopted. In
reply to the question regarding the conclusions of the Bavarian
Commission in the matter of disinfecting the evacuations, he
would state that chloride of lime was an unreliable agent, and
that the most satisfactory results had been derived from the use
of the sulphate of copper; an instance or two being quoted where
the epidemic was arrested in the residence of the patients imme-
diately after the occurrence of the first case. The sulphates of
iron or zinc had also been tried, and were highly extolled.

One part of sulphurous acid and ten parts of water was like-
wise a good combination. In this the soiled clothing was purified,
and by it also the evacuations deprived of their noxious properties.

Dr. Harris had verified in his hospital experience the observa-
tion of Pettenkofer, that almost all the first cases were rapid in
progress and uniformly fatal; that these conditions prevailed
until, to use the language of Dr. Blair, "the complement of
mortality had been attained, when the type became milder and
more amenable to treatment of any kind." He entertained the
opinion that the disease was in some way portable, since, notwith-
standing the maintenance of a cordon almost military in character,
to prevent the communication of patients in buildings isolated
some one hundred or two hundred yards apart, and the exercise
of the utmost care in the disposal of the choleraic stools, the
epidemic had spread from building to building. Here there was
certainly no such thing as personal contact.

Dr. Herzog was reminded also that, according to the statements
of the Commission, a local epidemic spent its force in twenty-five
days. By the term local he meant certain districts, streets, or
neighborhoods; and not, of course, a large aggregation of dwell-
ings like New York City, or even towns of smaller dimensions.

1866.] Discussion on Cholera. 163

Dr. Hamilton favored, upon the whole, the expectant plan of
treatment, and his experience, like that of many present, em-
braced the observations of two epidemics ; these he saw in tho
City of Buffalo. He had no faith whatever in the beneficial
results of morphine or opium in the stage of collapse. He had
also exhibited large doses of quinine without any favorable effect ;
he could recall two cases of recovery after thorough emesis, and
would adduce as examples of the success attendant upon the
administration of calomel in full doses, the salvation of many
patients by a German practitioner not over scientific, but possessed
of a good stock of strong common sense.

He would lay much stress upon a change of location as an
element of success ; he attributed quite a number of recoveries in
his experience to the early adoption of this method.

Dr. Stiles recited his experience while assistant physician to the
Kings County Hospital. He had there observed that many
patients had died almost upon the instant that the limb was tied,
as a necessary preliminary to the operation for introducing the
saline solution. The medical staff then adopted friction in the
direction of the venous circulation, with, as they conceived,
happier results. He would warn against the danger of heat,
which increased with the rise of the temperature ; he had been
led to this conclusion by certain experiments upon the lower
animals. He would show the futility of the ice-bag plan of
treatment, by merely reminding his hearers that there was a
continual stream of warm blood coursing in the neighborhood of
the spine which required some time to be cooled ; and cooling the
spine was claimed to be effected by the advocates of the method.

Dr. Foster gave his experience in the epidemic of 1832, at
which time he was a practitioner in Scoharie County. He and
his colleague had employed with manifest advantage large doses
of calomel, larger perhaps than necessary, in conjunction with
injections of warm starch, retained through the medium of towels
applied to the anal orifice.

He was led to adopt this latter procedure by observing that the
rice-water stools were very low in temperature.

The meeting then adjourned. Medical Record, i\r. Y.

164 Editorial [July,

EDITORIAL.

SOUTHERN MEDICAL AND SURGICAL JOURNAL.

Our journal was established thirty years ago, by Dr. Milton
Antony, the founder of the Medical College of Georgia. The
volumes already issued, embrace over sixteen thousand closely
printed pages, containing more than sis hundred original com-
munications from professional men throughout the Southern
States, besides an immense number of valuable articles repub-
lished from its ample list of American and foreign exchanges.

It has been claimed for the Southern Medical and Surgical
Journal, that under the conduct of its able editors it has ac-
complished a good work in diffusing valuable medical and scientific
information, and that it has contributed materially to the advance-
ment and elevation of the medical profession by furnishing a
medium for the communication of the valuable experience of
Southern physicians.

At the close of a bloody and disastrous civil war, we have re.
established this journal, with the earnest desire that it may still
live as an honored medium for the communication of the discove-
ries and advancing doctrines of science, and of all the depart-
ments of medicine. We cannot close our eyes to the facts that
our armies were vanquished in the field by superior numbers and
by starvation, and our records of honor as a people, captured and
burned; and that our houses and lands are desolate, our cities
burned, and our people distressed and afflicted.

Even in Pagan Rome, the Triumph was accorded only for victo-
ries which enlarged the territory, and never for those which only
recovered lost ground no Triumph in civil wars, for in such case,
whatever might be the success, the Roman considered it always a
subject for public mourning. It would be well for Americans in
the distracted state of their country to consider the advice of a
noble Roman to the Senate : " All who deliberate upon doubtful
matters, ought to be uninfluenced by hatred, affection, anger or
pity. When we are animated by these sentiments, it is hard to
unravel the truth ; and no one has ever been able to serve at ones

1866.] Editorial 165

his passions and his interests. Free your reason of that which
beclouds it, and you will be strong ; if passion invades your mind
and rules it, you will be without strength. It would be here the
occasion to recall to mind how many kings and peoples, carried
away by rage, have taken fatal resolutions ) but I prefer remind-
ing you, how our ancestors, unswayed by prejudice, performed
good and just deeds."

Whilst acknowledging no geographical bounds to the operations
of science, and especially of medical science, we shall feel it to be
our duty as well as our highest pleasure to use the Southern
Medical and Surgical Journal as a medium for the communi-
cation of the facts and discoveries tending to develop the material
prosperity of the South, and especially for the recording and
preserving of the valuable medical statistics and observations of
the Confederate Surgeons during the recent revolution. It is
earnestly to be hoped, that the medical experience gathered
from the gigantic mass of suffering endured during four years by
the sick and wounded Confederate soldiers in Camp and Ilospitat
and in Prison, will not pass unrecorded. The medical officers of
the Confederate Army, who performed their arduous duties so
manfully in the face of unnumbered difficulties, should not con-
sider those labors in behalf of suffering humanity fully accom-
plished until they have been carefully recorded and placed in a
living form.

SPURIOUS VACCINATION.

Our journal opens with an interesting article upon this subject
from Dr. Habersham. During the recent civil war, untoward results
followed vaccination, and a number of deaths both amongst the
troops and citizens were directly referable to the effects of vacci-
nation. So great was the evil in the army, that it was made a
speeial subject of investigation, and a number of most interesting
reports were prepared by several of the medical officers, upon
what was most generally called in the army " spurious vaccina-
tion." Our friend, Surgeon Jackson Chambliss, in charge of Div.
No. 1 Camp Winder Hospital, Richmond, had examined and

166 Editorial [July,

recorded a large number of cases of " spurious vaccination/' illus-
trated with valuable drawings of the various local diseases and
skin affections. As far as our information extends, this valuable
mass of matter, relating to one of the most important subjects in
its bearings upon the welfare of the human race, was destroyed
during the evacuation of Richmond. If any of these reports are
still in existence, we shall be happy to be the medium of commu-
nicating them to the profession.

So common had accidents become after vaccination, and so
strong was the prejudice growing, both in the army and amongst
citizens against its employment, that we instituted a series of ex-
periments upon the inoculation of cows with small-pox matter, in
order to produce, if possible, cow-pox, from whence a supply of
fresh and reliable vaccine matter might be obtained. It was our
design to carry out an extensive series of investigations upon the
various secondary affections following vaccination, and to deter-
mine, if possible, what contagious principles could be associated
with the lymph of the vaccine vesicle. These labors were
brought to a sudden and unexpected close, by the disastrous ter-
mination of the civil war. As far, however, as our labors amongst
the Confederate troops extended, we were led to attribute the inju-
rious effects of vaccination to. the following causes:

1. Scorbutic condition of the Llood of the patients vaccinated
and, yielding vaccine matter.

Large numbers of the Confederate soldiers manifested slight
scorbutic symptoms, whrch were not sufficient to attract attention,
or to induce treatment, and as far as we could learn, no attention
was paid to this condition either in vaccination or in the selection
of vaccine lymph.

In scorbutic patients, all injuries tended to form ulcers of an
unhealthy character, and the vaccine vesicles even when they
appeared at the proper time, and manifested many of the usual
symptoms of vaccine disease, were nevertheless larger and more
slow in healing, and the scabs presented an enlarged scaly, dark,
unhealthy appearance. In many cases, a large ulcer covered with
a thick laminated crust, from one-quarter to one inch in diameter,
followed the introduction of the vaccine matter into scorbutic

1866.] Editorial 167

patients. Matter from these scabs and sores was frequently used
in vaccination, and this decomposing pus and blood acted as an
animal poison in some cases, and especially in constitutions debili-
tated by exposure, fatigue, and salt diet.

During the prosecution of the investigations which we insti-
tuted upon the diseases of the Federal prisoners confined at
Andersosville, the opportunity was embraced of investigating the
remarkable effects which followed the attempts of the Con-
federate medical officers to arrest the spread of small-pox by
vaccination. In a number of cases, large gangrenous ulcers ap-
peared at the points where the vaccine lymph had been inserted,
causing extensive destruction of the tissues, exposing arteries,
nerves, and bones, and necessitating amputation in more than one
instance. These accidents led to the belief amongst some of the
prisoners that the Surgeons had intentionally introduced poisonous
matter into their arms during vaccination.

After careful inquiry we were led to the conclusion that these
accidents were in the case of these Federal prisoners referable
wholly to the scorbutic condition of their blood, and to the
crowded condition of the stockade and hospital. The smallest
accidental injuries and abrasions of the surface, as from splinters,
or bites of insects, were in a number of instances followed by
such extensive gangrene as to necessitate amputation. The gan-
grene following vaccination appeared to be due essentially to the
same causes ; and in the condition of the blood of the patients,
would most probably have attacked any puncture made by a lancet,
without any vaccine matter or any other extraneous material. It
appeared also that the dried scab, resulting from the vaccination
of these scorbutic patients, was also capable of producing effects
wholly different from the vaccine lymph of healthy individuals;
and in some cases, these effects were of a most potent and injuri-
ous character.

2. The employment of matter from patients who had been
previously vaccinated and who were partially protected.

Whilst it might admit of debate, whether pure vaccine virus,
obtained from persons never before vaccinated, and who manifested
all the phenomena of the disease, and especially the characteristic

168 Editorial. [July,

febrile phenomena, ever becomes deteriorated or possessed of dele-
terious properties in its passage through numerous human bodies,
not suffering with such a contagious disease as syphilis ; on the
other hand, it cannot be denied that the protective power of vac-
cination has been impaired to a lamentable and almost incalculable
extent, by a succession of imperfect vaccinations.

Vaccination may be rendered imperfect by the development of
febrile and other diseased states after the introduction of the
virus into the system, arising from the action of cold or some
cause producing constitutional disturbances, differing essentially
from the febrile phenomena which mark the progress and perfec-
fection of the vaccine disease, as well as by its imperfect and
altered course in those who are partially protected by previous
vaccination.

In the isolated condition of the Southern Confederacy, cut off
from the surrounding world, and denied even vaccine matter, as
"contraband of war?' with the necessity of turning out the
entire fighting population to repel invasion, and with the necessity
of employing all the available medical aid, good, bad, and indiffer-
ent; and with the progressive increase of small-pox, it is not
strange that the process of vaccination was not as carefully
watched and tested as it should have been : and that consequently
much imperfect material circulated as vaccine matter, which not
only afforded little or no protection against small pox, but also
proved positively deleterious.

3. Dried vaccine lymph, or scabs, in which decomposition had
been excited by carrying the matter about the person for a length
of time, and thus subjecting it to a warm moist atmosphere.

The effects of such decomposing matter, resemble those of the
putrid animal matter received in dissecting wounds. The practice
of some physicians to mix a considerable portion of powdered
vaccine with water upon a glass slide, and to use this in a number
of vaccinations from house to house, is not unattended with
danger, especially during warm weather. In the warm climate of
the Southern States it is impossible to preserve vaccine matter
for any length of time, without more or less putrefaction. The
length of time which the vaccine virus will retain its active

1866.] Editorial 169

properties will depend upon the temperature and the moisture of
the climate.

4. Dried vaccine lymph, or scabs, from patients icho had suffered \ j
icith erysipelas during the progress of the vaccine disease.

In several instances death resulted from phlegmonous erysipelas,
following vaccination in apparently healthy patients, in both civil l\
and military practice. It was supposed that in some cases the * \
poison of erysipelas was conveyed along with the vaccine virus.

5. Fresh and dried vaccine lymph, or seals, from patients
suffering with secondary or constitutional syphilis, at the time and
during the progress of vaccination and the vaccine disease.

e examined at different times, during the progress of the
recent war, and also had under treatment, various skin affections, -
which presented the characters of the cutaneous diseases charac-
teristic of secondary syphilis, which were directly traceable to
impure vaccine virus. In several cases enlarged buboes in the
axilla and groin accompanied the peculiar skin affections induced
by spurious vaccination.

A number of the Confederate Surgeons took the ground that
secondary syphilis could be communicated along with the vaccine
virus, and especiaHy when the dried scabs were employed. In the
records upon this subject, which we examined in the Surgeon
General's Office in the Confederate Capital, this view was clearly
announced and supported by well recorded facts. Surgeon 0.
Kratz, in an interesting article upon vaccination, published in the
July number of the Confederate States Medical & Surg iced Journal
(vol. i., 1804; p. 104), boldly announced and supported the view
that secondary syphilis could be communicated through the
medium of the vaccine virus On the other hand, many of the
Surgeons entertained views similar to those announced by Dr.
Habersham in the present number of this journal.

Up to the commencement of the recent civil war, the belief
was almost universal, that secondary syphilis could not thus be
communicated by vaccination.

This question is of vast importance in its bearing upon the
human race, and should not be settled dogmatically in fact it is
not in any manner a question of belief, but of fact. Intimately

170 Editorial [July,

associated with this question is that of the possibility of inocu-
lating secondary syphilis.

Some of the older writers appear to have entertained no doubts
with reference to the possibility of communicating constitutional
syphilis. The following testimony is from William Clowes, who
wrote more than two centuries and a half ago :

I have also knowne divers persons infected, who have had in all other
parts of the bodie manifest signes thereof, as dolors, tumors, ulcers, and
venemous pustules, &c. And yet in the parts aforesaid, no paine, or any
signe thereof: so that their opinion is not to be observed, which affirme,
that this disease is ingendred onely, by the company of uncleane persons:
for I have knowne not many yeares past, three good and honest Midwives
infected with this disease, called Lues Venerea, by bringing abed three
infected women, of three infected children, which infection was chiefly
fixed upon the Midwives fingers and hands, &c. What should I speake
of young sucking children, whereof divers have beene grievously vexed
with this disease, and some of them a moneth, two, three or foure moneths
old, and some of them a yeare old, some foure or five yeares old, and
some of them sixe or seaven yeares old, amongst which sort, I thought
it good here to note a certaine wench, the daughter of one Sare, of
twelve yeares of age, the which I cured, in the yeare of our Lord 1567,
who was greatly infected with this sicknesse in many parts of her body,
having thereon painfull nodes or hard swellings and ulcers, with corrup-
tion of the bones, and yet no signe in the most suspected parts, neither
by reason of debilitie was able to have committed any such act, but it is
not to be doubted, but that she received the infection, either from the
parents, the which cure of some is supposed uncertaine, whether children
begotten by infected parents, may bee cured or not : or else she was
infected, as divers are, by sucking the corrupt milke of some infected
nurse, of whom I have cured many, for such milke is ingendred of in-
fected bloud, and I may not here in conscience overpasse, to forewarne
thee good Reader, of such lewde and filthie nurses : for that in the yeare
1583, it chanced that three young children, all borne in this citie of Lon-
don, all of one parish, or very neere together, and being of honest pa-
rentage, were put to nurse, the one in the countrie, and the other two
were nursed in this citie of London : but within lesse than halfe a yeare,
they were all three brought home to their parents and friends, grievously
infected with this great and odious disease, by their wicked and filthy
nurses : Then their parents seeing them thus miserably spoiled and
consumed with extreme paines, and great breaking out upon their bodies,
and being so young, sick and weake, unpossible to be weaned, were
forced, as nature doth binde, to seeke by all meanes possible to preserve
these poore silly infants, which else had died most pitifully. To be
briefe, ere ever those children could be cured, they had infected five
sundry good and honest nurses: I cured one of the children, and the
nurse which gave it sucke, the other two children and their nurses were
also cured by others, but one of the children lived not long after, as I
was given to understand. Also friendly Reader, I read of late in a cer-
tain history, written by Ambrose Pare, in his 2. book, intreating of the
causes of Lues Venerea, which history indeed is worthy the rehearsall :
"An honest Citizen saith he, granted his most chaste wife, that she
should nurse the childe which she was lately delivered of, if she would
keepe a nurse to be partaker of the traveil and paines : the nurse that

1866.]

Editorial. 171

she tooke by chance, was infected with Lues Venerea, therefore she did
presently infect the foster childe, and he the mother, and she the hus-
band, and he two children which he had daily at his table and bed, not
knowing- of that poison which he did nourish in his ov/n body and intrals.
But when the mother considered and perceived, that her childe did not
prosper or profit by the nourishment, but continually cried and waxed
wayward, desired me to tell her the cause of that disease, neither was it
any hard matter to doe, for his body was full of the small-pocks, whelkes,
and venereous pustules : and the brests of the nurses and mother being
looked on, were eroded with virulent ulcers : and the body of the father
and his two sonnes, the one about three yeares, and the other foure yeares
of age, were infected with the like pustules and swellings that the childe
had : therefore I shewed them that they were all infeeted with Lues Ve-
nerea, whose beginnings, and as it were provocations, were spred abroad
by the nurse that was hired, by her maligne infection. I cured them all,
and by the helpe of God, brought them to health, except the sucking
childe, which died in the cure : and the nurse being called before the
magistrates, was punished in prison, and whipped closely, and had been
publikely whipped through all the streets of the citie, if it had not been
for the honors of that unfortunate family." Thus we see children infected
by filthy nurses, and sometimes nurses be infected by giving sucke to
such infected children. And now to returne to my former purpose, the
disease, as saith Nicholas Masa, whose counsell and direction in the
cure of this disease I have greatly observed. The disease because it
hath a flowing matter, being once entred into any part of the body, pro-
ceeded on from part to part, never resting until it hath corrupted the
liver, with the ill disposition of this infection especially. When it touch-
eth any such part, as hath in it an apt disposition to admit such infection,
as when the action or force of the agent is wrought and imprinted in the
patient, fitly affected to receive the same forme, and so it disperseth it
selfe through the whole bodie : likewise this sicknesse is many times
bred in the mouth, by eating and drinking with infected persons, and
sometimes and sometimes onely by breathings: and Almanor a learned
Physition setteth downe for a truth, that this disease may be taken by
kissing, and sometimes by lying in the bed with them, or by lying in the
sheets after them : also it is said to come by sitting on the same stoole of
easement, where some infected person frequenteth, and sometimes such
as have been cured of this disease, fall into it againe by wearing; their
old infected apparell : all which causes of this disease I rather set downe,
for that I would thereby admonish as many,, as shall read this treatise, to
be carefull of themselves in this behalfe, and to shun as much as may
be, all such occasions. A Profitable and Nccessarie JBooke of Observa-
tions for all those that are burned with the flame of Gun-powder, &c. :
By William Clowes, London; M. Dawson, 1637. pp. 151-2-3.

Gideon Harvey, in his " Yenus Unmasked," published two

hundred years ago, expresses similar views :

4. Probl. How many vario-us ways doth the Pox exert its Contagion?
No external part is impowered to transmit its infection immediately,
except where its suscepted : so we observe the Venereal parts to be in-
fectory immediately upon the su&ception of virulency, but not through
kissing, sucking of the breast, by sweat, or through any other parts but
themselves. So the mouth that's infected by kissing, or sucking a thorow
pockified whores tet, is capable immediately of infecting anothers lips by
kissing, or any other part by sucking it, because the pocky Miasms are

172 Editorial. [July,

neer ; but not by copulation, or sweat, &c. because the contagion cannot
be crept so far. Experience verifies this dictate. Is it not an ordinary
trick of Wenchers (as Musa relates) to suck whores tongues, and tets of
their breast, and yet those, whom they know have been pockified many
years about their lower parts, and for that reason though their appetites
are furious, yet dare not be dabbling, but the other they reiterate a thous-
and times over without the least hazard? An instance for the other
part of the dictate, which I had from my first master in Physick, that
wonder of Physicians Prof. Job. Antonid. vander Linden, p. m. the pro-
foundest Commentator on Hippocrates and Celsiis, that ever any age
presented, whom I heard that most famous Projessor Begins Gaido
Patin intitulate the Dutch Hippocrates. He during his luculent practice
at Amsterdam, had a Merchants Prentice in cure of an Gonorrhe, and a
blistered, or cankered like mouth ; both symptoms he confest to have
started upon him at the same time. The excellent Professor being
curious, and admiring at the rarity of such distant symptoms emerging
at once, extorted an ingenuous confession irom his Patient, upon pre-
tence that it would facilitate and abreviate the cure : the other without
any longer suspense impudently told him, his tongue was as unfortunate
as his tayl ; a sort of Diabolick fatyrism, outvying Aretius Jlagello de
Principi, and very like a Dutch invention. Whatinsued? this bastard
at a Besoeck (an invitation thats usually made to young folks, preliminary
to all Weddings) accosted himself to two pretty Damsels, and being
planted between them, oft flanckt to the right, and in a kiss pledged his
right hand man, and so to the left, and performed the like duty there.
But the tragick evident may imprint a dread upon all young women. A
short time after their lips felt hot, inflamed, grew sore, and ulcered, one
named it the thrush, another a sore mouth ; vulgar applications rather
promoted than checkt the evil, wherein they persisted so long, that acces-
sory accidents, as sordid ulcers of the palat and tonsils, nocturnal pains,
&c. moved a jelousie of the fowl disease. Here you may remark, how
innocently these poor lasses pessundated their fortunes. The reflexion
of this relation upon the latter part of the dictate I commit to your own
thougLts.

2. A Wench or Monsieur by that time they are thorow pockified, are j
infectious in any part where ever the Pox bursts out, because the virulent
seminaries are propagated quite through the body, which exhaling at the
places affected, transport the contagion. What the thorow-pox is expect
below; so that when the malady is tumefyed to so high a flood, its time
for Nurses, Physicians, and all visiters to stand off: upon such occasions
a person may be infected by drinking out of the same vessel (provided
the spittle adhering be warm still), as we have heard of many; [Lcoaar- |
dus Botallus adduceth an observation of a patient of his, of a chast
and religious converse, who was stigmatized by a peculiar pledging of
his familiar, then under a sore affliction of a thorow-pox. His lips in-
flamed, afterwards ulcered, his jaw bone grew carious, and was miserably
raekt with nocturnal arthritick pains.) By trying of a warm Pocky
Glove ; by succeeding a virulent Patient on a close-stool ; by shifting of
him, or making his bed whilest the sheets continue warm ; as Nicol.
Massa's friend and Patient, who incurred this evil, by touching the
sheets, one lay in, that was lame of a Neapolitan ulcer in his legg ; and
that old woman in Ilorsfs observ. aged fifty six, tending a Pocky fellow j
in his lying in, was seized of the same disease in as furious a degree as
her Master: and by kissing, witness Faventinus, who knew a young man, i
that contracted this evil by oft kissing a fowl slut. The initial symptoms
appeared about his mouth j his privities, which otherwise might have

1866,1 Editorial 178

Din suspected, appearing free from all contagion. To this I'l parallel
mother ; one Mrs. &c. then a pocky inhabitant of the Hague, having run
;he gantlop of several cures, Hydrotick and Mercurial, at last proved
rvith child ; her reckoning being expired, she was brought to bed of a
Monster, in all particulars resembling a living child j saving the skin,
cwbich was abominally ciphered with spots and botches. This object of
nercy upon us was committed to the care of a Nurse, the Infant aspiring
X) higher things, bad the world adieu. But the unhappy Nurse had
:ause to curse her late Foster-child, her breasts and head ulcered, a
Caries got into the cranium, the Pox took possession of the poor wo-
ttians carcase, for want of a purse to release her. The pocky original
Mistris &c. was proclamed barbarous by a whole Jury of Matrons, for
-efusing relief to the disastered woman. In all these transactions the
Pater Familias stood it out vigorously with a fresh countenance, no sign
contradicting his pancratick health. Just such another mischance Musa
Brasovolns, tells us, befell a nurse that suckled one Sr. Orobo's child,
:,borowly eonspurcated with the Pcx. The observation hereupon infers
-his a thorow-pox, and consequently mu3t prove infectious in all parts of
Uie body. Physicians in this case run a great risk in feeling pulses, and
Approaching such Patients iu their sweats, Venus Unmasked, or a Jiore
lExact Discovery of the Venereal Evil, or French Disease : By Gideon
-Uirvey, London; T. Grismond, 1GG5. pp. 94-5 0-7-8-9.

In like manner Daniel Turner in his work on Syphilis, published
:.n 1717, maintains the contagious nature of constitutional Sy-
philis :

And this I intend shall suffice for its Chronology/ or Time, the Topology
r Place, and the Histriograyhy or Account of the Disease in general j
' ich, with some other Writers thereon, we shall now define, A venomous
r contagious Distemper, for the most part contracted by impure Coition,

least some Contact of the Genitals of both Sexes, or some other lewd

d flthy Dalliance beticeen each other that way tending.

I said for the most part, because it is beyond Controversy, the Infec-
.ion is also communicated by other ways, a3 from Pocky Parents by
Inheritance; by sucking an infected Nurse, to the Child; suckling a
diseased Child, to the Nurse : lying also in Bed with the Diseased, with-
out any Carnal Familiarity ; by which, though it may be possible for
strong and vigorous Bodies to escape, yet are the tender ones, especially
t>f little Infants, very likely to be contaminated, as I have more Reason
$0 believe than by bare Imagination.

i There are several other more uncommon "Ways of giving as well a3
receiving the Venereal Venom ; some of which I have already imparted
io the World in short Remarks upon a Quack Libel, Printed several
-.tYears past : But the Thought of such vile Monsters, and their execrable
Practices, is too shocking (unless to the Dregs of humane Nature) to
-bear even a Repetition of Circumstances, and fit only for a detestable
-Gonologium or Collection of Smutt aud Obscenity, in which I am told,
'they have been inserted, as some of the Author's own Observations.

A? for those fancied Ways of batching: it by common Conversation,
^drinking after one, sitting on the same Close-stool, drawing on a Glove,
[wiping on the Napkin or Towel, after the infected Person, with a hundred
he like Stories ; I believe in our time (whatever may have happened
formerly) there is no great Danger: Yet we find in one of our late
/Chronicles, that 'these and such like Imaginations, were so strongly
tted in Mens Minds at that time, even those of the better and more

174: Editorial. [July,

learned sort, that it was one of the Articles against a noted Cardinal,
That he had breathed on the itiag, when he, the said Cardinal, had this
Disease upon him : Which yon will find in Baker's Chronicle, and of
which Passage Dr. Harvy has also taken Notice. Hildanus likewise
tells us of a young Gentlewoman, who contracted the same, by only
putting on the Apparel of a Gentleman (that it seems was pox:d) at a
Masquerade, of which, through Modesty concealing her Illness (which
first of ail had seized the Pudenda) till she was past Recovery, she de-
ceased. The good Man's Credulity, at least his Charity, might however
be abus'd in this Relation, as the young Lady perhaps was also after the
Masque, otherwise than by simply putting on the Habit. But were it so
as the Case is stated, there is nothing therein much more admirable than
what the same great Man recites of a whole Family he knew infected,
viz. the Wife with three Children and a fourth in the Womb, as also a
Maid Servant, by the Husband, who had got the Distemper in their Ab-
sence only by sleeping in the same bed with his Man Servant, whom he
after understood was broke out with this Distemper

The Relation of Horst. and Hornung. are yet more strange, of several
People infected in the Bagnio, by having the same Scarificator apply'd
after Cupping, as had been used to a Venereal Patient: Which seems a
like credible with that of the Priest .poxed at his Ear, in the time of
confessing a wanton Nun ; the venomous Breath from her Mouth defiling
the holy Father : But enough of this. Si/philis; A Practical Disserta-
tion on the Venereal Disease: By Daniel Turner, London; R. Bonwicke
<D Co., 1717. pp. 10-11-12.

John Hunter, in his Treatise on the Venereal Disease, gives a

number of instances of the communication of secondary syphilis,

from which we select the following:

A lady was delivered of a child on the 30th of September, 1776. The
infant being weakly, and the quantity of milk in the mothers breasts
abundant, it was judged proper to procure the child of a person in the
neighborhood to assist in keeping the breasts in a proper state. It is
worthy of remark that the lady kept her own child to the right breast,
the stranger to the left. In about six weeks the nipple of the left breast
begun to inflame, and the glands of the axilla to swell. A few days
after, several small ulcers were formed about the nipple, which, spreadiug
rapidty, soon communicated and became one ulcer, and at last the whole
nipple was destroyed. The tumour in the axilla subsided, and the ulcer
in the breast healed in about three months from its first appearance. On
inquiry, about this time, the child of the stranger was found to be short-
breathed, had the thrush, and died tabid, with many sores on different
parte of the body. The patient now complained of shooting pains in
different parts of the body, which were succeeded by an eruption on the
arms, legs, and thigh, many of which became ulcers.

She, was now put under a mercurial course, with a decoction of sarsa-
parilla. Mercury was tried in a variety of forms : in solution, in pills
internally, and externally in the form of ointment. It could not be
continued above a few days at a time, as- it always brought oji fever or
purging, with extreme pain in the bowels. In this state she remained
till March lGth, 177D, when she was delivered of another child in a
diseased state. The child was committed to the care of a wet nurse, and
lived about nine weeks ; the cuticle peeling off in various parts, and a
scabby eruption covering the whole body. The child died.

Soon after the death of the child, the nurse complained of headache

.866.] Editorial 175

,nd sore throat, together with ulceration of the breasts. Various reme-
lies were given to her, but she determined to go into a public hospital,
/here she was salivated, and after some months she was discharged, but
lot cured of the disease. The bones of the nose and palate exfoliated,
tnd in a few months she also died tabid.

Of the various remedies tried by the lady herself, none succeeded so
veil as seabathing. About the end of May she began a course of the
liisbon diet-drink, and continued it with regularity about a month, dress-
ng the sores with laudanum, by which treatment the sores healed up ;
md in September she was delivered of another child, free from external
narks of disease, but very sickly ; and it died in the course of the month.

About a twelve month after, the sores broke out again, and, although
mercurial dressings and internal medicines were given, remained for a
twelve month, when they began again to heal up. *;-#*' '- '*

The third case was of a gentleman, where the transplanted tooth
remained, without giving the least disturbance, for about a month, when
the edge of the gum began to ulcerate, and the ulceration went on until
the tooth dropped out. Some time after, spots appeared almost every-
where on the skin; they had not the truly venereal appearance, but
were redder or more transparent, and more circumscribed. He had also
a tendency to a hectic fever, such as restlessness, want of sleep, loss of
appetite, and headache. After trying several things, and not finding
relief, he was put under a course of mercury, and all disease disappeared
according to the common course of the cure of the venereal disease, and
we thought him well; but some time after the same appearances returned,
with the addition of swelling in the bones of the metacarpus. He was
now put under another course of mercury, more severe than the former,
and in the usual time, all the symptoms again disappeared. Several
months after the same eruptions came out again, but not in so great a
degree as before, and without any other attendant symptoms. He a
third time took mercury, but it was only ten grains of corrosive sublimate
in the whole, and he got quite well. The time between his first taking
mercury and his being cured was a space of three years. The Works of
John Hunter, with Notes, edited by James F. Palmer. Vol. ii.. p. 475-
476 ; p. 484.

We might greatly multiply such facts from various authors, but
this appears to be unnecessary, as the experience of the authors
just quoted covers nearly three centuries; and we are justified iu
affirming that it is now clearly established that constitutional
syphilis can be transmitted by direct inoculation with the secre-
tions of secondary sores.

And more recent experiments have shown that the blood of

persons affected with constitutional syphilis is capable when

inoculated on healthy subjects of giving rise to syphilitic disease.

Waller succeeded in inoculating a healthy boy fifteen years old,

1 with this disease, by applying the blood of an individual affected *

i with secondary syphilis to incisions made by a scarificator on the

] "body of the boy. Well marked and unmistakable symptoms of

econdary syphilis followed this experiment. Other experimenters

176 Editorial. PW,

have arrived at similar results, but the best conducted experiments
appear to be those performed by Professor Pelizzari,* of Italy.

As this subject is of great interest, and as we have been cut off
from the main sources of information upon this and other medical
questions, we present the account of these experiments, as well as
of the most recent and circumstantial facts illustrating the trans-
mission of secondary syphilis through the vaccine virus, as it is
contained in one of the most recent works on Yenereal Diseases :

This physician inoculated two medical students with the blood of a
syphilitic patient with a negative result. On the 6th of February, 1862,
he resumed his experiments, three physicians, Drs. Bargioni, Rosi, and
Passagli submitting themselves to his investigations. The blood of a
female patient, aged twenty-five, affected with constitutional syphilis, and
who had undergone no treatment, was used for the purpose. The blood
was drawn, with a new lancet, from the cephalic vein. The patient was
at the time affected with mucous papules on the left labium, at the place
where the chancre had existed; mucous tubercles surrounded the anus,
and the inguinal glands were indurated and enlarged. A confluent
syphilitic eruption existed upon the body, the posterior cervical glands
were enlarged, and there were pustules on the head. At the point on the
arm from which the blood was drawn there was no sign of any eruption,
the skin of the part was well washed, and the surgeon washed his own
hands. The bandage was new, as was also the vessel in which the blood
was received. As the blood escaped from the cephalic vein, some of it
was received on a piece of lint, which was placed on the upper part of
Dr. Bargioni's arm, where the epidermis had previously been removed,
and three transverse incisions made. A similar operation was performed
on the other two gentlemen, but in the case of one the blood was cold,
and in that of the other it had coagulated.

After twenty-four hours the dressings were removed, and nothing was
observed but the crusts formed by the effused blood. Four days after-
ward all traces of the inoculations had disappeared.

On the morning of the third of March, Dr. Bargioni informed Prof.
Pelizzari that in the center of the inoculated surface he had noticed a
slight elevation, which produced a little itching. The arm was examined,
and at the point indicated Prof. Pelizzari found a small papule of a
roundish form, and of a dull-red color. On the eighth day the papule
had augmented to the size of a twenty-centime piece. On the eleventh
day it was covered with a very thin adherent scale, which became denser,
and on the second day commenced to crack in its central part. On the
fourteenth day two axillary glands became enlarged to the size of nuts.
The papule remained indolent, and there was no induration at its base.
On the twenty-first the scale was transferred iuto a true crust, and the
part beneath was ulcerating. Slight induration was more evident. On
the twenty-second the crust was detached, leaving a funnel-shaped ulcer,
with elastic and resistant borders, forming an annular induration. There
was but a small amount of secretion from the sore, and the pain was
trifling. On the twenty-sixth the ulcer had become as large as a fifty-
centime piece, and the surrounding induration was considerably increased.
Up to the 4th of April the ulcer remained stationary, but at that date

* Lectures on Syphilis, etc., by Henry Lee, 1SG3; p. 198.

1866.] Editorial. 177

its base appeared to be granulating. The axillary glands remained
swollen, hard, and indolent. Slight nocturnal pains occurred in the head
about this time, and the posterior cervical glauds became somewhat
enlarged. On the 12th of April spots of an irregular form and of rose
co'or appeared on the surface of the body. The eruption extended
itself, and during the succeeding days became more confluent. No con-
stitutional disturbance, heat of skin, or pruritus accompanied it. On the
twentieth the cervical glands had increased in size and were harder.
The chancre maintained its specific character and exhibited no tendency
to cicatrization. On the twenty-second the color of the eruption was
decidedly coppery. Small lenticular papules were now perceived to be
mixed with the erythema. The edges of the chancre had begun to
granulate. Mercury was now administered.

This case is of itself sufficient to prove the inoculability of syphilis
through the blood of an infected person. But the evidence does not
stop here.

In a very interesting memoir, M. Viennois* has collected many cases
of the transmission of syphilis by vaccinatiou, and has summed up his
conclusions from the data on hand. From his observations and researches
it would appear that syphilis cannot be communicated by vaccine virus
taken from a subject affected with the disease unless a portion of the
blood of the individual is also inoculated. Thus he says:

' When the vaccine virus of a syphilitic subject, pure and unmixed
with blood, is inoculated on a healthy individual, a simple vaccine pustule
is obtained, without any near or remote syphilitic complications being
produced.

' On the contrary, if, with the vaccine virus of a syphilitic individual
who either has or has not at the time constitutional accidents, a healthy
person is vaccinated, and the point of the lancet be charged with a little
blood at the same time as with the vaccine virus, both diseases may be
transmitted by the one operation the vaccine disease with the vaccine
virus, and syphilis with the syphilitic disease.'

M. Viennois also coucludes that in such cases the vaccine vesicle 13
developed first, and that after undergoing its incubatory period the syphil-
itic ulcer, with all the characteristics of a true chancre, appears.

These views of M. Viennois have recently received the most ample
confirmation from the tragedy which occurred at Rivalta, in Italy, by
which forty-six children and twenty nurses had syphilis communicated
to them through vaccination, and of which several of the children died.
The full details of this remarkable event are given in a memoir by Dr.
Pacchiott;,j of Turin, and I condense the following summary from his
report.

On the 21st of May, 18G1, Sig. Cagiola vaccinated Giovanni Chiabrera
with lymph contained in a tube sent from Acqui. The operation was
performed in the usual manner and with a perfectly clean lancet. The
child was eleven months old, and in good health at the time. Forty-six
other children were, ten days subsequently, vaccinated with lymph taken
from the vesicle of this child ; and ten days after this, seventeen children
were vaccinated with lymph taken from the arm of Luigia Manzone, one
of the forty-six first vaccinated.

Of these sixty-three children, forty-six thirty-nine of the first lot and
seven of the last were within two months attacked with syphilis. On

*De la Transmission de la Syphilis par la Vaccination. Archiv. Gen. de Med., Juin. JuiUet,
et Septeinbre, 18(50.

f SifiHde trasmissa per Mezzo della Vaccinazione in Rivalta, presso Acqui. Gazzelta delta
Assoeiazone .Med., Ottobre 20, 1861.

12

178 Editorial. [July,

the 7th of October seven of them, including the little Manzone, were
dead, three were yet in danger of dying, fourteen were recovering under
the use of mercury and iodine, and one was well.

A medical commission was now appointed to inquire into all the cir-
cumstances connected with this fatal event, and they proceeded to the
execution of the duty assigned them.

Twenty-three children were examined in full ; the others were not so
accurately noticed, as their parents had neglected to avail themselves of
medical aid in time. In the forty-six children who were affected, syphilis
appeared at periods varying from ten days to two months after vaccina-
tion, the average time being twenty days. The initiatory symptoms were
variable. Sometimes just as the vaccine vesicle had healed, it became
surrounded with a red, livid, and copper-colored areola, and ulcerated
again. In other instances an ulcer would form on the cicatrix, and
become covered with a scab, which in a few days would fall off to make
room for another, and so on. In others the vaccine vesicles had an un-
healthy appearance from the first, and were accompanied by a general
eruption.

The principal symptoms observed by the commission were mucous
tubercles in the vicinity of the anus and on the genitals, ulcerations of
the mucous membrane of the lips and fauces, engorgement of the lym-
phatic glands in the groin and neck, syphilitic skin diseases, alopecia,
deep tubercles, gummy tumors, etc.

In two subsequent papers, Dr. Pacchiotti* continues the detail of his
investigations. On the 8th of February, twenty of the mothers or nurses
of the forty-six children had become affected with symptoms of syphilis.
He ascertained, too, from a revaccination of five of the children, that the
ccurrence of syphilis had not destroyed the efficacy of the first vaccina-
tion. But he also discovered the source of the infection. It appeared
that a year and a half previously a young unmarried woman had had
syphilis, and that she was syphilitic at the time Chiabrera was vaccinated.
This woman was the mother of a child which had died syphilitic three
months after its birth. After the death of the child she was in the habit
of having her breasts drawn by the little Chiabrera, and gave him the
clothes which her own child had worn. Another child nursed by this
woman, but who was not vaccinated, also became syphilitic, and this
child infected its mother just as little Chiabrera did his mother. It is
therefore shown that the vaccine virus used on Chiabrera was not at
fault, but that all the other forty-five children were infected through the
lymph taken from his arm. It is also shown that blood was on the lancet
when several of the children were vaccinated.

Dr. Pacchiotti, as the results of his investigations and those of the
commission, gives the following rules to be observed in vaccinating:

1st. Examine the child from whom the lymph is taken.

. 2d. Inquire into the state of the parents' health.

3d. Take the lymph in preference from those children who have
<1 the fourth or fifth month, as hereditary syphilis appears in general
before that time.

1th. Do not use lymph taken from a vesicle which has passed its
eighth day, because on the ninth and tenth days the lymph becomes
mixed with pus, which latter may be of an infectious character.

5th. In taking the lymph, avoid hemorrhage, as there is less danger
with lymph free from blood.

oth. Do not vaccinate too many children with the same lymph.

*L'Uuion 3Iedicalo, Fey. 8eme et Avril 3emc, 1862.

1866.] Editorial. 179

In consequence of the publication of the details of the lamentable
affair at Rivalta, Dr. Marone concluded to relate the particulars of a
similar event which occurred- to him, and in regard to which he had
thought it advisable to maintain a discreet silence. The particulars are
given with sufficient fullness by Mr. Lee, whose excellent work I have
already referred to several times.

It seems that in November, 1856, Dr. Marone obtained some vaccine
lymph, with which he vaccinated a number of children at Lupara. The
lymph was contained in glas3 tubes, and Dr. Marone noticed that it was
mixed with a little biood, which affected its transparency. Of the num-
ber of children vaccinated with this lymph, notes were preserved in
twenty three cases. All these were affected with syphilis, and the disease
likewise manifested itself among the mothers, nurses, and even the
servants who were brought in contact with them. The symptoms with
which the children were affected consisted chiefly of eruptions of a
syphilitic character, and subsequently of mucous tubercles at the angles
of lips, around the anus, and on the vulva. The post-cervical and inguinal
glands were enlarged, and there was emaciation, in degree varying with
the severity of the syphilitic symptoms.

Besides these cases, eleven nurses of the number who suckled these
children gave the disease to eleven other children who were not vacci-
nated.

In some of the cases the syphilitic phenomena continued till April,
1859.

Dr. Marone draws the following conclusions from his experience:

u That the syphilitic virus was really transmitted in the above recorded
cases by means of vaccination.

ft That the children vaccinated suffered first, and became the means of
transmitting the disease to others.

"That the lymph used for the purpose ot vaccination was impure,
being mixed with blood, and that the result shows how necessary it is to
abstain from using lymph of that description/' Lectures on Venereal
Diseases: Btj Wm. A. Hammond, M. D. Philadelphia: J. B. Lippiti-
cott & Co., 1*864. p. 208-217.

The experience of the Confederate Surgeons, establishing the
possibility of communicating constitutional syphilis by vaccina-
tion ; the experiments of Waller, Pelizzari and others, establish-
ing the possibility of communicating secondary syphilis by
inoculation of the blood from patients suffering with the con-
stitutional symptoms of this disease into healthy individuals : the
cases collected by M. Viennois illustrating the transmission of
syphilis by vaccination: and the unfortunate tragedy of Rivalta
in the district of Piedmont Italy,/where syphilis was previously :
unknown )(forty-six children of various ages being simultaneously
attacked with well-marked syphilis, proceeding in all cases which
could be properly examined from the action of vaccine virus which
produced chancre on the arms, followed by buboes in the axilla,
and all these children had been vaccinated directly or indirectly

V

180 Vaccine Matter from the Cow. [JuljV

from a single child, who was subsequently proved to have con-
tracted syphilis from a wet nurse, and these children transmitted
the disease to a number of women, their wet nurses and mothers,
and even to children who played and nursed with them, and the
women so infected, in turn infected their husbands, and finally the
disease yielded in all cases to the usual remedies for syphilis) :
these, and other similar facts, as the infection of the infant at the
breast with secondary syphilis, and the communication of syphilis
from the infant inheriting the disease from its mother or father,
to a healthy nurse, all demonstrate the possibility of transmitting
constitutional syphilis by inoculation of syphilitic blood, or vaccine
virus, from patients poisoned with syphilis : and each such fact,
of itself is sufficient to overthrow the dogma, that " Primary
syphilis alone is capable of being inoculated, and that secondary
affections and the constitutional disease cannot be communicated
from one individual to another, by any means as vaccination, or
the direct inoculation of syphilitic blood."

Vaccine Matter from the Caw*

M. Lanoix has read a paper on this subject before the Academy
of Medicine at Paris. This physician, after studying the subject
at Naples, is founding in the capital of France an establishment
for such vaccination. In the paper it is stated that out of 820
revaccinations practiced in different schools upon children from
seven to thirteen years old, 21 per cent, succeeded. The figures
respecting a more advanced age are as follows : From fourteen to
twenty years, 71 revaccinations, 31 effectual j from thirty to forty
years, 200 revaccinations, 97 effectual; from forty to fifty-five
years, 30 revaccinations, 7 effectual ; from fifty to sixty years, 5
revaccinations, 2 effectual. The author considers that the trans-
mission of vaccine matter from heifer to heifer i3 always possible,
the quantity obtained being quite adequate to very numerous
operations; that the matter does not lose in activity in passing
through animals as it does in passing through human organisms;
that vaccinations are always or almost always successful; the re-
vaccination with animal matter succeed more frequently than with
matter obtained from human beings ; that vaccination with heifer
matter is extremely easy; and that such vaccinations are highly
useful in epidemics of small-pox, as larger supplies of vaccine
matter may rapidly be sent to extensive tracts of country.
London Lancet.

1866.] Medical College of Georgia, Augusta. 181

MEDICAL COLLEGE OF GEORGIA, AUGUSTA.

The exercises of this good old institution having been suspended
during the late war, were resumed on the first Monday in November last.
The class in attendance, in consequence of the disastrous effects of our
conflict, was very small when compared with the full benches of former
years* It numbered, however, forty-seven young men of fine promise, of
which thirty-seven were from Georgia, four from South Carolina, one
from Alabama, one from Louisiana, one from Kentucky, and three from
the United States army.

The following named gentlemen having complied with all the rules of
the College, were graduated Doctors of Medicine :

Fontenoy A. Beall, of Augusta, Ga.

William W. Bussey, of Clumbia County, Ga.

Louis A. Cormick, of Augusta, Ga.

John W. Johnston, of Scriven County, Ga.

David S. Mclver, of Newnan, Ga.

Benjamin B. Palmer, of Richmond County, Ga.

Robert G. Solomon, of Gordon, Ga.

Beverly H. Washington, of Louisville, Ky.

Amos G. Whitehead, of Burke County, Ga.

Dr. Frank J. Moses, a graduate of the Medical College of South
Carolina, and Dr. Virginius G. Hitt, a graduate of the Medical College
of Richmond, Va., were admitted ad eundem gradum.

This is one of the oldest Medical Colleges in the South, and its Faculty,
Library, Museum, and Laboratory, will compare favorably with any in
our country. We may therefore reasonably expect for it a career in the
future as prosperous as it has been in the past, when its classes numbered
from one hundred and fifty to one hundred and seventy-five. The deplo-
rable condition of Southern finances may render recuperation slow, but
the merits of this institution must secure to it a return of its former
prosperity if our people are true to themselves.

The next session will be commenced on the first Monday in November
next, when we have every reason to believe that the class will be mate-
rially increased.

182 Process of Disinfection. [July

Process of Disinfection.

A memorandum on disinfection has been issued by the Privy
Council (Great Britain). In view of the approaching epidemics,
we give its main points, after the Chemical News and Druggists?
Circular :

(1. For artificial disinfection, the agents most useful are chlo-
ride of lime, quicklime, and Condy's manganic compounds. Me-
tallic salts perchloride of iron, sulphate of iron, and chloride of
zinc are applicable. In certain cases chlorine gas or sulphurous
icid gas may be used ; and in other cases powdered charcoal or
fresh earth.

'2. If perchloride of iron or chloride of zinc be used, the com-
mon concentrated solution may be diluted with eight or ten times
its bulk of water. Sulphate of iron or chloride of iron may be
used in the proportion of a pound to a gallon of water, taking
care that the water completely dissolves the sulphate of iron, or
has the chloride of lime thoroughly mixed with it. Condy's
stronger fluid (red) may be diluted with fifty times its bulk of
water; his weaker fluid (green) with thirty times its bulk of
water. When the matters requiring to be disinfected have an
offensive smell, the disinfectant should be used till this smell has
entirely ceased.

1 3. In the ordinary emptying of privies or cesspools, use may
be made of perchloride of iron or chloride of zinc, or of sulphate
of iron. But where disease is present, it is best to use chloride
of lime or Condy's fluid. Where it is desirable to disinfect, before
throwing away the evacuations from the bowels of persons suffer-
ing from certain diseases, the disinfectant should be put into the
night stool or bed-pan when about to be used by the patient.

< 4. Heaps of manure or of other filth, if it be impossible or
inexpedient to remove them, should be covered to the depth of
two or three inches with a layer of freshly burnt vegetable char-
coal in powder. Freshly burnt lime may be used in the same
way, but is less effective than charcoal. If neither charcoal nor
lime be at hand, the filth should be covered with a layer of some
inches thick of clean dry earth.

1866.] Process of Disinfection. 183

1 5. Earth near dwellings, if it has become offensive or foul by
the soakage of decaying animal or vegetable matter, should be
treated on the same plan.

1 6. Drains and ditches are best treated with chloride of lime,
or Condy's fluid, or with perchloride of iron. A pound of good
chloride of lime will generally well suffice to disinfect 1000 gallons
of running sewerage ; but of course, the quantity of disinfectant
required will depend upon the amount of filth in the fluid to be
disinfected.

1 7. Linen and washing apparel requiring to be disinfected
should without delay be set to soak in water containing per gallon
about an ounce either of chloride of lime or Condy's red fluid.
The latter, as not being corrosive, is preferable. Or the articles
in question may be plunged at once into boiling water, and after-
ward, when at wash, be actually boiled in the washing water.

' 8. Woollens, bedding, or clothing which cannot be washed,
may be disinfected by exposure for two or more hours in chambers
constructed for the purpose to a temperature of 210 to 250 de-
grees Fahrenheit.

1 9. For the disinfection of interiors of houses, the ceilings and
walls should be washed off with quicklime water. The wood
work should be well cleansed with soap and water, and subse-
quently ^washed with a solution of chloride of lime, about two
ounces to the gallon.

1 10. A room, no longer occupied, may be disinfected by sul-
phurous acid gas or chlorine gas the first by burning in the room
an ounce or two of flowers of sulphur in a pipkin; the second by
setting in the room a dish containing a quarter of a pound of
finely-powdered black oxide of manganese, over which is poured
half a pint of muriatic acid, previously mixed with a quarter of a
pint of water. In either case, the doors, chimney, and windows
of the room must be kept carefully closed during the process,
which lasts for several hours.' Journal of Materia Medica ;
Boston Medical and Surgical Journal.

184 Books, Journals, etc., Received. [July, 1866.

BOOKS, JOUKNALS, ETC., RECEIVED.

Outlines of Surgical Diagnosis. By George H. B. Macleod, M. D., etc.

Bailliere Brothers, 520 Broadway, New York : 1864.
Practical Observations on the Generation of Statical Electricity, by the

Electrical Machine. By Col. George W. Rains,
Essay on Osmosis. (Extracted froni the American Journal of the Med-
ical Sciences, for July, 1865.)
Report of the Surgeon- General of Massachusetts, Dec. 1st, 1865. Boston ;

Wright & Potter: 1866.
Successful Removal of the Uterus and both Ovaries, by Abdominal Sec-
tion, etc. By Horatio R. Storer, M.D. Boston; David Clapp & Son : 1866.
Instructions in the Preparation, Administration, and Properties of Ni-
trons Oxide. Ry George T. Barker, D. D. S., etc. Philadelphia;

Rubencame & Sockton : 1866.
Priced Catalogue of Standard Books. By Smith, English & Co., No.

23 North Sixth street, Philadelphia : 1866.
A Comprehensive Medical Dictionary: containing the Pronunciation,

Etymology, and Signification of the Terms made use of in Medicine

and the Kindred Sciences. By J. Thomas, M. D. Philadelphia ; J. B.

Lippincott & Co.: 1864.
An Essay on Agriculture. By J. H. Cocke, Sr., Bremo Bluff, Fluvanna

County, Va.
Revue DeThtrapeutique Medico- Chirurgicale. Par A. Martin Lauzer.

Paris : April, May.
Outlines of the Chief Camp Diseases of the United States Armies. By

J. J. Woodward, M. D., Assistant Surgeon U. S. A., etc. Philadelphia ;

J. B. Lippincott & Co.: 1863.
Propriety and Necessity of Compulsory Vaccination. By J. M. Toner,

M. D., Washington, D. C. Philadelphia; Collins, Printer: 1865.
A Catalogue of Medical Works on Cholera, in the Library of J. M.

Toner/M. D., Washington, D. C: 1865.
The Medical and Surgical Reporter : A weekly journal, S. W. Butler,

M. D., Editor; 115 South Seventh street, Philadelphia: vol. xiv.
The Boston Medical and Surgical Journal : Edited by Samuel L. Abbot,

M. D., and James C. White, M. D. Boston : April, May, Juue.
The Chicago Medical Examiner: Edited by N. S. Davis, M.D., Chicago:

March, April, May, June.
The Dental Cosmos : Edited by J. H. McQuillen, D. D. S., and George

J. Ziegler, M. D. Philadelphia : April, May, June.
Buffalo Medical'and Surgical Journal: Edited by Julius F. Miner, M.

D. Buffalo : May, June.
Atlanta Medical and Surgical Journal: Edited by Drs. J. G. & W. F.

Westmoreland. Atlanta, Ga. : May.
The Savannah Journal of Medicine : Edited by Drs. J. Harris, J. B.

Read and J. G. Thomas. Savannah, Ga. : February, March.
The Richmond Medical Journal: Edited by Drs. E. S. Gaillard and W.

S. McChesney, M. D. Richmond, Va. : June.
The Medical Recorder. William Wood & Co., New York: April.
Southern Cultivator. Athens, Ga. : May, June.
Catalogue of the University of Virginia : 1866.
The Field and Fireside: W. B. Smith & Co., Editors and Proprietors.

Raleigh, N. C. : May, June.

SOUTHERN

^Jafemiu^

AUGUSTA, GA

Vol. XXL] SEPTEMBER AND OCTOBER, 1866. [Xo. 2.

ORIGINAL COiVIMIU^srC^TIONS.
ARTICLE VI.

Report en Wounds of Large Joints made to the " Confederate
States Association of Navy and Army Surgeons" Rich-
mond, Vcl-, 1864, By J. B. Read, M. D., formerly
Surgeon in the Provisional Army of the Confederate
States.

{Concluded from p. "28, Xo. 1. July. IS66.]

Incised wounds of the joint made by trenchant instru-
ments, as the knife, sabre or scythe, often heal kindly,
and are not so invariably followed by traumatic arthritis
as in the case of gunshot wounds. Such incised wounds
are often made by the Surgeon for the extraction of car-
tilaginous growths, lying free in the synovial sack. It
is worthy of notice, that in these cases the joint and the
foreign body are manipulated so as to make the incision
into the sack, valvular, to prevent entirely the entrance of
air.

In a war conducted as this has been, in a wooded, hilly
country, unfavorable to the action of cavalry in their
13

186 Read's Report on Wounds of Large Joints, [Sept.,

proper arm, incised wounds of joints have rarely been
under the treatment of Surgeons in our service. We
find no statements of any such cases in the records of the
Surgeon-General's Office, and we presume there are none.
Macleod mentions the, case of a dragoon, who was cut
across the elbow, of his sword arm, by a Russian horse-
man, at the heavy cavalry charge at Balaklava, The
olecranon was completely detached, and the joint opened.
The wound was immediately closed, and the arm placed
in an extended position, and cold employed to allay in-
flammation ; little more was done, and the divided sur-
faces quickly adhered, and an arm remained, which,
although not as free in its motions at that joint as it
formerly was, yet most useful, and would, I doubt not,
become more so in time. Other cases are mentioned by
authors on military surgery, in which the joint had been
opened by incised wounds, and those produced by sharp-
pointed stylet-shaped weapons, rapidly uniting, when at
once closed and the air perfectly excluded.

Shell wounds of joints in many cases, are of the nature
of incised wounds, but can hardly be treated as such. In
some cases, when the bones and articular cartilage are
not injured, and the wound in capsule is large enough to
permit of the free outflow of the fluids secreted, they do
well and heal with ankylosis.

But one instance of incised, or rather it was a penetra-
ting wound, produced by a sharp spike of glass, has come
under our observation during this war. A medical officer
being at dinner in a room on the ground floor had occa-
sion to leave the room. He stepped out of the window

' on an iron grating, which gave way and precipitated him
into an area some eight or ten feet deep, on some rubbish
and broken bottles. He fell 'upon his knee; beyond

\the. general discomfort that would ordinarily be produced
by such an unexpected descent, he experienced neither

1866.] Read's Report on Wounds of Large Joints. 187

pain nor annoyance. In a short time lie walked up to the
Capitol Square, to see the evening parade and listen to
the music of the band ; and at that time, whilst resting
on one of the benches, he first felt pain in the knee. Thi3
was not acute enough to direct his attention especially to
its condition. After parade he walked to his room, say
one-half mile off; his knee now became very painful, and
medical aid was solicited. Two hours after the fall, he
was found in his bed in a state of great alarm, and stated
that he had a piece of glass in his knee-joint. On exam-
ining his knee, a small opening of about a quarter of an
inch was found just below the under edge of the patella
in the line of the joint on the outer side ; no synovia had
escaped from the wound, nor could any connection with
the interior of the capsule be detected. Passing the
finger carefully over the articulation, a small, unnatural,
projecting point was detected, more than an inch below
the wound, in the skin. The skin was carefully drawn
down, so as to make the wound correspond to the pro-
jecting substances, and with a fine pair of forceps, a
wedge-shaped piece of crown glass, an inch long, was
extracted; a few drops of synovial fluid, streaked with
blood, followed this. The skin was at once allowed to
return to its normal position, and the lips of the cut were
nicely adapted and hermetically sealed by adhesive plas-
ter. The leg was fixed so as to prevent all motion of the
joint, and he was removed to General Hospital ISTo. 4, for
treatment. The articulation was kept cool with a solution
of muriate of ammonia in whiskey and water ; morphia
was administered to procure sleep, and absolute rest di-
rected. No inflammatory action ensued ; there was little
fever, and no pain worth mentioning; there was some
tenderness upon pressing over the joint. The wound
healed readily, united without suppuration, and in six
days the patient was able to bend his knee and exercise.

188 Read's Report on Wounds of Large Joints. [Sept.,

In wounds of this character we are then encouraged to
hope for the best results, and that there will be no loss of
the motion of the articulation.

The treatment consists in the speedy and perfect adap-
tation of the edges of the wound through its depth, as
far as possible, by compresses on each side of it. The
wound should be perfectly closed, to the total exclusion
of the air, by collodion; or if this*be not at hand, by
adhesive plaster, varnished over as advised by Mr. Aber-
nethy, with a solution of sealing wax in spirits of wine,
which hardens in a few minutes. The solution of gutta
percha in chloroform would answer a better purpose, as it
will not crack and fissure. The joint must be carefully
adjusted in some immovable apparatus, so that the edges
of the wound may be kept perfectly adapted, and such
means must be employed as to restrain the hypersecretion
of the synovial fluid, which will certainly come on with
the increased action in the vessels of the wounded part.

Bleeding, general and local, and the constant application
of cold to the part, must be resorted to, for we must 'bear
in mind that if this inflammatory action be not restrained,
the life of the patient may, or rather will, be placed at
hazard.

If, despite all our efforts to the contrary, the joint be-
comes painful and swollen; if rigors and high constitu-
tional excitement supervene, we suggest that the joint
should be freely incised, and then treated as other wounds
of joints in which traumatic arthritis exists.

John Bell says we may take the united experience of
all Surgeons, which has established this as the true prog-
nostic, that "wounds of joints are mortal." The diction
of so great a man and distinguished Surgeon, although
not really correct, will show how serious such injuries
are; how grave the " prognostic, " and how much anxiety

1866.] Eead's Report on Wounds of Large Joints. 189

they should excite. We, at this late day, after the expe-
rience of the recent and present* wars, are probably better
instructed as to the treatment of such injuries ; and as a
rule, there are probably no wounds in the body occasioned
by the accidents of war, in which so much is to be ex-
pected from the skill of the Surgeon, and from the exer-
tions of which such favorable results follow; or on the
other hand, if he have not such skill, or having it, neglect
to employ it, for the benefit of the patient, no class of
wounds are more mortal.

"Wounds of the orbicular are not of so serious a char-
acter as those of the hinsce-ioints. Their less com-
plexity of structure accounts for this. The results of joint
wounds in the upper and inferior extremities differ,
owing to the less size of the articular facets of joints
of the same character, and to the same law of nearness
to the centre of circulation which governs the result
of wounds and injuries and of anrputations in the two
extremities. The larger joints of the superior extremity
may get well, as far as the closing of the wound is
concerned, but with ankylosis and deformity. It is rare
for the two larger joints of the inferior extremity to re-
cover without aid from the Surgeon. No cases of recovery
from wounds implicating the hip-joint are noted in our
records, save where the resection of the head of "the
femur has been employed. The experience of Surgeons
of, the Allied army before Sebastopol was unanimous that
all cases where the knee-joint was distinctly known to be
injured were fatal, when amputation was not resorted to.
Macleod states that in 1854 he saw forty cases in the
French Hospital, and all died except those primarily
amputated. In the Indian reports, the same gentleman
found nine cases in which the knee was penetrated, and
the injury so slight as to induce attempts to save the limb,
and yet all died. Alcock has stated the proportion of

190 Read's Report on Wounds of Large Joints. [Sept.,

eases in which the articulation was wounded, to other gun-
shot wounds, as between four and five per cent., nearly
one-half of which were in the knee. Out of thirty-live
cases in which the knee was more or less implicated,
twenty-two lost their lives, and eight their legs. After
such results, he says it is little to say, that the fiye who
recovered preserved good and useful legs.

We have forestalled, the discussion of injuries to the
joint, in order to explain the extraordinary record* we have
before us, compiled from the data in the office of the
Surgeon-General. These records give, in regard to this
special joint, statistics far different from any ever before
published.

Should'ri Elbow ! Wrist

Hip I Knee Ankle

No. of Cases

Recovery

Ankylosis

Motion ^.

Deaths

No result

Cases still under treatment*

17

52

25

9

99

11

47

23

45

5

32
2

25

40

6

5

2

8

54

G

13

12

14

8

7

2

1

24

*Of which the result can only be surmised. Those of the knee and hip are reported as
doing badly.

INCISIONS INTO THE

CAVITIES OF JOINTS.

1 Should'ri Elbow

Wrist

Hip

Knue

Ankle

2

8

2

11

25
2

17
6

14
2
9

5

Primary

3
8
1
5
5

3

7

8
3

3

2

Deaths

1
3

Under treatment

1

The 'appearance of the external wounds give no indica-
tion in many cases of the actual damage sustained by the
articulation. In some cases that have come under our
observation the position of the orifice of entrance and
exit of the bullet, and the absence of pain in the joint,
and the patients stating that they had used the limb after
the injury, and in cases of knee-joint wounds, having
walked some distance, we did not suspect any serious
injury to the articulation ; yet subsequently traumatic

1866.] Head's Report on Wounds of Large Joints. 191

arthritis, with profuse suppuration having been estab-
lished, the joints have been opened, and great destruction
of the ends of the bones entering into the formation was
found to exist.

It is a fact well established by the experience of most
Surgeons conversant with military surgery, and fully
borne out by the records we have consulted, that at a
variable period after the reception of the wound, the joint
becomes inflamed, and profuse suppuration comes on, and
that at this time severe and dangerous symptoms set in.
We find only the records of a single ease in which this
result did not come to pass, in which a wound through
the elbow healed speedily without suppuration. Reported
by Surgeon Habersham, of Chimborazo. This case can
only be explained by the small size of the ball, and its
having passed through the joint at its greatest possible
momentum, thus making a clean cut through without
iujury to the articular cartilage or the bone. It may be
also in this case that the change of position in the limb,
after injury, permitted the skin to cover up the wound in
the synovial sack; or again, the sack itself may not have
been penetrated, and the ball taken an outer course
around the joint itself; for the description of the case
does not mention more than the wound and the result.

The length of time that in many cases intervenes be-
tween the reception of the wound and the beginning of
the suppurating stage, is a source of great danger. From
the description already given of the course pursued by
traumatic arthritis, and its destructive effects on the ar-
ticulation itself, we can readily conceive that this may be
the brooding time for great detriment to the patient.
This arthritis must ensue, sooner or later, when the air
is admitted to the synovial membrane, which is always
the case in gunshot wounds of these parts. When this
condition is established, we think but one resource

192 Head's Report on Wounds of Large Joints, [Sept.,

remains to us, in order to preserve the patient's life. The
joint should be fairly opened, and a free vent given to all
the retained and fetid purulent matter contained in it. It
should then he kept clean and free from all such collec-
tions, "by frequent injections of lukewarm water ; and a
suitable immovable apparatus, if not already in use in the
case, should be at once adjusted to the limb. If sinuses
and burrowing of pus, have been permitted to form in the
adjacent tissue, by neglect in not opening the joint in
time to prevent these, they should also be washed outy
and injected by some agent that will modify the diseased
action in the parts. For this purpose, Tinct. Iodine in.
water has been highly recommended. Of late years the
Tinct. of Coal Tar has established for itself a reputation
with the French Surgeons in the treatment of these
cases. It is claimed for this preparation, that it destroys
the- fetor of the secretion, and modifies and diminishes
the amount of pus. The walls of the sinuses should be-
compressed together by suitable bandages,, and kept
empty, as far as may be, by position.

"When this destructive process has once been establish-
ed, it goes on to- the complete destruction of the articular
cartilages of the joint, and in some eases induces inflam-
mation, and subsequent necrosis of the bone. The ques-
tion naturally arises : are we quietly to await the destruc-
tive traumatic arthritis which invariably comes on in
bullet wounds of joints, induced by the constant contact
of air and pus from the tract of the missile, with
its attendant disintegration of the cartilages and dis-
ease of the bone ? In many cases, indeed we may say
in all cases,, when the large joints, as the knee and hip
are implicated, this leads to the setting up of hectic
fever, and the death of the patient; or can we fore-
stall the condition by operative interference? As this
state of things so destructive to life always comes on,,

1866.] Read's Report on Wounds of Large Joints. 193

why should w.e not open the joint at once by free inci-
sions, and expose the whole of its cavity ? By this pro-
cedure the fibrous investing capsule and the tough
ligament of the joint will be freely divided, all irritant
discharges will find vent, and more than this, a correct
knowledge of the actual injury the parts have sustained
will be come at, and we can then sagaciously determine
what subsequent treatment ought to be pursued in the
case. No injury can be done either to the part or the
patient, for we at once place the articulation in the condi-
tion it must invariably come to at some subsequent period,
and this too under more propitious circumstances. The
patient will be stronger, and better able to resist the
profuse discharge that will ensue at this time, than if he
waits for a week or more, and the articulation will be
opened before these discharges have had a chance of
forming and producing deep burrows in the tissues
around. In this way much sufFering and great consti-
tutional irritation will be avoided.

The incision into large joints immediately after the
receipt of the injury, has been strongly advised by Mac-
leod in cases of penetrating ball wounds of the knee-
joint; and as this is a joint injury frequently followed by
los3 of life, when treated on the expectant plan, the
advice will with equal force be applicable to wounds of
other articulations. It has also received the sanction of
Stromeyer, who in the Schleswick-Holstein war, once
opened the joint with satisfactory results. "We have not
had an opportunity of putting this in practice, but for the
reasons given, would certainly do so, should the opportu-
nity present itself. [During the campaign of '64, this
practice was freely resorted to by myself and others, with
encouraging results.] Some primary incisions have
been made in Atlanta, Ga., by Surgeon Westmoreland,
but the result of the cases at this time have not come to

194 Head's Report on Wounds of Large Joints. [Sept.,

hand ; at last report they were doing well. The synovial
sack and the articular cartilage will be destroyed, but this
invariably occurs when the articulation is entered by a
ball, and in this case the disintegrated detritus will have
free outlet, and not be pent up by strong unyielding tis-
sues.

In dvil practice, in some of the diseases of these closed
sacks, the serous cavities, we are in the habit of injecting
Iodine and such allied remedies, with the avowed inten-
tion of creating a new action in them. Now would not
good accrue in the joint cases, where only incision has
to be practiced, and the endeavor of the Surgeon is turned
solely to the producing ankylosis from destroying the
synovial membrane at the time this primary incision is
made by caustics of some suitable kind? The total
removal of that membrane is recommended in cases of
resection of the joints. By the caustic treatment, we
will get clear of much profuse discharge from this mem-
brane which it rapidly secretes, until life is destroyed by
the violence of the inflammation excited in it by free
contact with air. After this invasion the limb should be
tixed, as indeed is advisable in all joint injuries, and
should be constantly cleansed from all irritant secretions.
The antiphlogistic treatment should be rigidly enforced.

We have in confirmation of this method of treatment
cases in which the wrist and ankle-joint have been freely
incised to facilitate the removal of spicule of bone ; as a
rule, these cases have resulted well. We are not prepared
to state that the employment of passive motion in these
cases, where the articulation is opened and the ends of
the bones not injured would not restore partial motion to
the articulation, for we are aware of cases from disease,
where the articular cartilages have been eroded; the
bones hardened and cburnatcd in their facets, in which
the joints were moderately useful.

1866."] Read's Report on Wounds of Large Joints. 195

Incisions into articulations, with the results, will be
found in the table appended to this report, and just read.

Different results are to be desired and sought for in the
superior and inferior extremities. An ankylosed joint in
the one is almost useless, and in the other is next to
perfect motion, the best result that can be hoped for
giving good and useful support to the body, infinitely
better than any artificial appliance.

It is not proposed in this report to discuss the merits of
amputation and of the efforts to save useful limbs. In
the arm, experience in this and other wars has amply
proven that not only is the operation of resection of its
articulations less fatal than amputation of the part, but that
there often result false joints of great use to the individ-
ual. If, then, the main blood vessels and nerves are
uninjured, in these joint wounds, amputation should not
be resorted to. In his decision on this subject, the
surgeon should be guided by circumstances. The gene-
ral health of the wounded man, the amount of fatigue he
has previously undergone, his freedom from scrofula or
secondary syphilis, and his " surroundings," or in other
words, the conveniences for subsequent treatment of the
cases; and last, but not least, in the chain of circumstances,
the amount of injury to the soft parts must be taken into
serious consideration. In superior extremities, in most
cases where the main vessels are uninjured, the effort to
save the limb and form an artificial joint, should always
be made, if no impediment to a successful result exists in
the patient himself.

The injury inflicted on the bone, and the amount of it
shattered will always influence the decision. Where,
from the result of experience, we are led to hope that
artificial joints may be formed, this is not of so much
moment. But in those joints where we desire ankylosis,
any great extent of destruction, extending through and

196 Read's Report on Wounds of Large Joints. [Sept.,

beyond the epiphysis of . the bone, would at once necessi-
tate the resort to amputation.

In the shoulder, as many as six or seven inches may be
ablated, and a limb remain of great utility, with perfect
use of the forearm, and a certain power of contracting the
loose tissues that hold the lower portion of the bone in
connection with the shoulder. This is beautifully exem-
plified in a case reported by Assistant Surgeon "Wilson,
of Camp Jackson hospital. In this case the motion of the
forearm is perfect, and when the patient had a splint
bandaged on to the arm and shoulder, slight power of
bringing the arm forward over his chest. Six inches of
bone had been ablated in this case, and no contraction, or
very little, had taken place. The arm could be twisted
round on itself, yet there was some little power in the
muscles that had attached themselves to the skin in fixing
the forearm. This case has been reported at length in
the C. S. Journal, and is doubtless familiar to all. In the
elbow a considerable portion of the humerus may be ex-
cised and a useful joint remain, and so long as the
attachment of the biceps remains to the radius, there
seems to be no limit to the amount that may be removed.
We have had under observation a case in which the
distance between the ends of the bones was four inches,
and the arm was strong enough to raise a bucket of
water. In the wrist the importance of preserving, if
possible, the use of the hand and the play of the finger
muscles, induces us in most cases to attempt its preserva-
tion by resection of the carpal ends of the radius and
ulna, and even of portions of the carpal bones.

The question with regard to the Coxo-femoral articula-
tions hardly admits of a doubt. It is either between
certain death or possible recovery, that the selection is to
be made. The records before us and those reported by
surgeons in other wars, teach us that all wounds inrpli-

1866.] Read's Report on Wounds of Large Joints. 197

eating this articulation, and treated on the expectant plan,
without surgical interference, are fatal. Hardly a better
result than this can be said to follow from amputation at
this joint; an exceptional case may recover, but we must
not be governed in our decision by results of this kind,
that are, from their rarity, almost miraculous. Resec-
tions of this joint, during this war have as far as our
information goes, been made three times, twice in the
Confederacy, and once by a- Federal surgeon on the
person of a Confederate soldier. Two of these cases
recovered with useful limbs; the third case was unsuc-
cessful; the condition of the part, owing to over work
and to the crowded state of the wards of the hospital
were not recognized until the strength of the patient was
sapped too far. But even in this case the excrutiating
pain experienced by the patient was entirely relieved, and
he sank quietly and painlessly to his grave. In the
Crimea, all cases of this wound, not treated by resection,
died; and of the six resected, one lived, with a useful
and strong limb.

The operation of resection in penetrating wounds of
the knee joint have not generally found favor with
military surgeons. The size and complexity of the
articulation, and the absolute need of perfect and con-
tinuous adaptation of the divided ends of the femur and
tibia, and the wearisome length of time requisite for the
treatment of the case, have always induced them to
resort to amputation in the lower third of the thigh. So
few resections of the knee joint have been accomplished
in our service that no facts can be deduced from them ; of
course the most desirable result in these cases is bony
union in such a position as to be useful to the patient for
walking ; for this purpose bony or strong fibrous union,
which finally may change with time, is sought to be
obtained. The difficulty of this perfect adaptation and

193 Read's Report on Wounds of Large Joints. [Sept.,

retention of the ends of the bones in apposition, we hope
to do away with by the method to be described, when
treating specially of resection of this joint. It seems to
us that as this operation of resection of the knee has re-
sulted so favorably in civil practice, it is well worthy of a
more extensive trial than has been accorded to it in this
war. Macleod mentions but one resection of this joint in
the Crimea, and this went on favorably, and partial union
took place between the divided bones ; the discharge
diminished in quantity, and the external wound looked
healthy, and had nearly healed across the front. The
restlessness of the patient, naturally a reckless person,
caused some difficulty in preserving the immoveability of
the limb. This patient, after doing well for some time,
succumbed under an attack of diarrhoea and Vomiting.
He had not the appearance of a man suffering with
pyaemia, but seemed simply to die exhausted by sickness
and diarrhoea.

The chairman of this committee has resected the knee
joint three times during the war, with two deaths and one
cure. The fatal cases were secondary, and when the
operation was made, were suffering from the exhaustion
of profuse suppuration. The resection was selected in
preference to amputation, which, from the disorganized
condition of the thigh, would have been made in the
middle third as a less grave procedure, and one in
which there would not be so much shock or nearly so
great a loss of blood; the patients also strenuously
objected to amputation. Had they been submitted to
amputation they would hardly have left the table
alive. The cases resulted fatally, but they lived and
suffered so slightly from shock, and had so light a re-
active fever, that great encouragement was felt to resort
to such operations in future, especially as secondary
amputations of the thigh for. knee joint injuries had

1866.] Read's Report on Wounds of Large Joints. 199

resulted fatally. In the other case, the operation was
secondary to the reception of the injury, but primary as
to the condition of the joint and synovial membrane, for
traumatic arthritis had just manifested itself, and no
suppuration had yet taken place in the articular cavity.
The patient recovered in one hundred and twenty days ;
the external wound was closed, the cicatrix was firm, and
no sinuses existed. There was firm fibrous union of the
two ends, which in time will doubtless ossify. The want
of osseous union at this time results from several causes.
The necessity that existed of changing the apparatus used,
which was constructed hastily, on the 4th or 5th day of
the treatment. By this movement the precise adaptation
of the ends of the bones was interfered with, and some
granulations injured, as was shown by a hemorrhage, that
came on soon after, for at this time the granulations
could be seen cropping out from the two bones. The
result of this case is encouraging. A full report has
been sent to the Surgeon General.

These operations in joints should always be primary, or
if secondary, after suppuration has been fully established
and the system has become somewhat accustomed to the
injury it has received. Intermediary operations are
inadmissible. Interference at any time during the stage
of acute arthritis, except to let out the putrid contents of
the synovial sack, will only increase the constitutional
disturbance. After the seven days' battles around Rich-
mond we saw two fatal results from excision of the
elbow joint, during the intermediary stage. "We must in
such cases see that free incisions are made to let out the
secretions, and quietly bide our time for interfering. It
is established by the records of military surgery that all
excisions of joints should be complete, that is, all the
articular cartilage in the joints should be ablated, and
experience teaches us that better cures in cases result

200 Read's Report on Wounds of Large Joints. [Sept.,

when this is done, for the cartilage, if not removed by the
operator, must be always, by a much slower and more
tedious process, that of disintegration from want of nu-
trition. In joints where motion is preserved after these
resections, the ends of the bones become rounded off and
covered by a strong fibrous envelope.

Baudens

JSchleswiek Holstein War. .
Crimea.

Knglish Army

French Army

Confederate States' Reports.

Total.

S3
4)

TO

h

I

"2

TO
V

e

o>

09

w

85

<y

c

4)
O

hi

fc

(-<

ce

Q

PM

U

Q

w

14

1

7.1

19

7

10

8

36.9

38

21

18.8

66

41

13

55.3!

180

46 25.6

26

r

89.061

66

246

20 1 29.6
66.26.09

The results of these operations are very satisfactory.
The hand preserved most of its movement, and the arm
in many cases could be moved slightly forward and back-
ward, there was little power, however, of abducting the
arm, owing, we surmise, to most of these cases having
been performed by the circular section through the
deltoid. There can be found in our own records many
cases reported as resected, in which no result has been
given ; those, of course, have been omitted in the report.
Comparing the result of these cases with that of wounds
of this articulation treated without excision, we find
seventeen; three cures, six deaths, and five useless an-
kylosed limbs, and six cases in which the result is not
stated. The percentage' is less than that given for ampu-
tations at the shoulder joint, and has the advantage of
leaving a most useful member.

Gunshot wounds of the Scapulo-humeral articulation
are to be resected in all cases in which the head of the
bone is injured, and the blood vessels and nerves that
pass to the arm are intact. The glenoid cavity and the

t366.~| Read's Report on Wounds of Large Joints. 201

:iead of the humerus, if injured, should be resected at
the same time. These resections are usually partial, that
is to say, the articular cartilage is not usually severed
Prom its adhesion to the scapula. It is difficult to place a
limit to the length of the piece of the humerus that may
be taken away and still a limb useful for many purposes
remain. In the reports of cases we find that as many as
six inches have been ablated and good results obtained.
We refer again to the case reported by Dr. Wilson as
in point.

In the cases we have examined, some time after the
healing of the wound, only a to and fro motion could be
given to the arm, and no elevation from want of a fixed
point for the humerus to work against. Desault says,
" The simplicity of an operation is its perfectness."
Various incisions have been, and are, employed by sur-
geons in the performance of this resection ; many, after
Stromeyer, make a semi-circular, horse-shoe-like, cut
jthrough the deltoid, severing the muscle entirely in two ;
others prefer the simple vertical incision through the
deltoid, extending from the acromion as far as such case
may require, and if this be not found sufficient to permit
the head of the bone to be dislodged from the glenoid
cavity, from the lower edge of this incision another may
je made, carried backwards and upwards, making a
josterior flap with its apex downwards. In our opinion,
inuch of the subsequent utility of the arm will depend
(upon the incision made, so as to expose the articulation.
The single verticle incision certainly possesses advan-
tages over any other, for if the bone be sawed through
above the insertion of the deltoid muscle, by avoiding the
(transverse section of its fibres, we preserve all the power
iof the contraction of the muscles, and have the end of the
bone drawn up to the glenoid cavity. Stromeyer's state-
ment, that the lower portion of the cut deltoid attaches
14

202 Read's Report on Wounds of Large Joints. [Sept,

itself to the glenoid cavity, is not sustained by onr
observation.

We have had the opportunity of examining many of
the resections of the shoulder, performed both by the
curved section across the fibre of the muscle, and the
straight one, made longitudinally with its fibres. The
difference in these cases was striking. The curved in-
cisions leave a large, deep, ugly cicatrix, which has a
tendency to ulcerate by the rubbing of the patient's
clothing ; there was no attachment of the muscle to the
head of the scapula, but all the muscular fibres seemed
to run into the cicatrix; the shoulder was flat, and the
acromion prominent. The deltoid was evidently atro-
phied. Where the vertical cut had been used, the arm
was shortened, if the section was not below the insertion

of the deltoid muscle. The roundness of the shoulder
was better preserved, and the cicatrix instead of being

exposed was depressed and protected from pressure.
! Some stress has been laid, that the line of the incision

should, if possible, include the wound or wounds; this,
we belive to be of minor importance. In a case of
secondary resection of the shoulder, performed at General
Hospital IsTo. 4, a single straight incision was made, and
neither the orifice of entrance or exit were included, and
the head and one inch of the humerus removed. The
lips of the wound were nicely adapted with ordinary
sutures. The wound healed by the first intention; the
discharge from the joint continued from the wound of
exit, situated behind. The case resulted happily, and
there remained a most useful limb. When the patient
was discharged he had slight use of the deltoid, in
abducting the arm. I have no doubt much more power
was subsequently developed by time and use.

In all resections of joints, we think it highly injudicious
to compress the main artery, for by so doing we deprive

1866.] Read's Report on Wounds of Large Joints. 203

ourselves of the important knowledge of its locality,
communicated to the fingers by its pulsations, while we
are dividing tendons and muscles in its vicinity; more-
over, secondary hemorrhage is one of the most usual
accidents that follows resection. By thus compressing
the main artery, the articular and circumflex branches
divided, do not bleed, and the subsequent handling of
the part, during the operation, prevent their spurting
when the pressure is removed, and thus they are not
ligated, and when reaction comes on start afresh.

The operation itself is simple and easy, a straight
incision is made of the required length for the acromion,
down to the head of the bone, and as far as needed along
the shaft, by one cut of the scalpel the parts are easily
separated. The long head of the biceps pushed inwards
out of the way, the capsule is opened, and the head of
the bone dislocated by manipulating the arm, or if this
be impossible, by seizing the upper portion of the bone,
with the lion forceps all spicule of the bone, are now to
be carefully picked out of the wound. The upper and
lower part of the incision may now be closed with
sutures, and if there be a posterior wound, the whole line
may be closed, and an attempt made at union. A soft
pad well covered with oiled silk, or rubber cloth, should
be placed under the arm from the axilla to the elbow, and
the arm and forearm, then bandaged closely to the chest
when the wound has nearly healed up again, motion
must be resorted to.

RESECTION OF

THE

ELBOW JOEST.

IS'o. of Pri- i Sec-
cases : mary ondary

Deaths

Per

cental?

Shieswick

40
20

45

13

3

22

'4

6
3

4

3
6

15.0

Partial recovery

3r."

Confederate States Reports < ' '

20

204 Read's Report on Wounds of Large Joints. [Sept.,

The results of the operation are highly satisfactory, for
if useful joints do not always remain, the ankylosed joint
can always be placed in the position that renders it most
useful to the patient, and the perfect use of the hand is
preserved. Both articular facets should be removed, for
although good joints have followed partial resections of
the elbow, the experience of surgeons runs, that complete
resections heal more rapidly and are attended with better
results. Macleod states: "Partial resections, of which
there are a great many cases, did not, I think, turn out as
well as complete ones; they were more tedious, more
liable to fail, and less satisfactory when they succeeded,
than when the whole articulation is removed." In these
cases it is proper to remove more than the articular facets,
although they alone be injured, in order to prevent anky-
losis ; a large extent of bone may be removed from the
lower end of the humerus, but of the radius, if possible,
the insertion of the biceps should be preserved. The
vertical incision fulfills all the indications required; it
should be free, and made directly through the tissue at
the back of the joint, at one cut, down to the bone, the
soft parts should be carefully cleared away, and the ulna
nerve sought for and pushed out of its groove to the inner
side. Wounds of this nerve may be followed by atrophy
of the forearm, and at least will be attended with less
sensation of the little and ring finger. The ordinary care
of protecting the soft parts and vessels from the saw must,
of course, not be omitted. Stromeyer states that the joint
should now be fixed on a splint and not be removed from
this whilst being dressed, and it must be elevated so as to
prevent oedema of the forearm; it must be flexed at an
angle of 130 to 140.

Early passive motion must be resorted to as soon as
suppuration has diminished, and before cicatrization is
complete. Little reaction ensues in these cases; cold

1866.] Read's Report on Wounds of Large Joints. 205

dressings should be applied as long as the condition of
the part indicates their use. By judicious after treatment
an amount of motion is obtained but little inferior to the
natural joint. In the fifth volume London Lancet, page
231, 1855, Mr. Syme reports the appearance of an elbow
joint nine years after resection. The ulna was found
united to the humerus by ligament, the end of the radius
was polished off and played on the ulna and humerus, a
material something like cartilage, being interposed. The
ends of the bones of the forearm were locked in by two
processes, projecting downwards from the humerus, and
posterior ligaments bound them to the latter bone. Mr.
Robert states, in these cases, that flexion is a compound
movement, the forearm being first drawn up to the
humerus by the triceps and then flexed by the biceps.
This action we have observed in three cases that we have
examined two years after operation. In some cases
flexion cannot be made unless the arm be fixed by a
weight in the hand.

RESECTIONS OF THE WRIST.

JNo.of

cases

Primary

Secondary

Deaths

Sorrel's reports . . .

1

3

2

1 1

1

Cases of

gunshot

injury

of

the

wrist

joint reqi

liring

resection are of rare occurrence. In the majority of cases
the enlargement of the wound for the removal of shattered
bone suffices, as for this purpose lateral incisions on the
outer side of the bones may be made, through these
incisions the ends of either the radius or ulna may be
turned out and cut off with the saw or bone plyers.
When we take into consideration how closely the tendons
are bound down by the annular ligament, we will at once
recognize the extreme difficulty of pushing them out of
the way of the saw. Legouest and others, on this account,
and because of the stiff and useless state of the fingers

206 Read's Report on Wounds of Large Joints, [Sept,,

that remain, advises against the operation. We have
ourselves no experience thus far, and find nothing in the
surgical reports bearing on this subject. Should this
operation be performed, great attention should be given
to the early use of passive movement, so as to keep the
tendons from forming adhesions.

INFERIOR EXTREMITY "HIP JOINT."

I No. of] Pri- | Sec-
I cases I inary | ondary

Deaths

Per

centage

Crimea

Sorrel's reports.

83

"We find upon recurring to our table of wounds of the
joints treated by the expectant plan, that eight cases thus
treated died, and that there were no recoveries. This
was also the experience in the Schleswick Holstein war,
and in the Crimea. Three cases in the present war were
submitted to resection, two with admirable results, and
the other, although terminating fatally, with great tem-
porary relief to the patient. Looking at these facts, and
at the almost equally fatal results of amputation of the
coxo-femoral articulation, we must come to the conclusion
that when the head of the femur is injured by a ball, the
only chance of the sufferer lies in prompt resection of the
joint. The useful limbs that are retained after this
operation would, other things being equal, give it the
call over amputation, and the expectant treatment, which
at best, could only result in an ankylosed joint, with
sinuses from carious bone. In the Crimea, O'Leary's
case recovered with a very useful joint.

Of the two cases reported by the chairman of this
committee, one recovered after the resection of the head
of the femur and over six inches of the shaft of the bone.
As will be seen by a letter just received, and part of which
is now submitted to the association, his limb is near six
inches short, but has tolerable motion and strength. The
other case will be found reported in the journal, and must

1366.] Read's Report on Wounds of Large Joints. 207

be familiar to all, as the person has been seen by many,
walking about the city with a useful leg. Jarret promises
to be in Bichmond early in May, and if possible, will be
presented to the association for examination. The case
that resulted fatally has also been reported.

An analysis of the cases in the Crimea, quoted by
Macleod, shows that of the five cases that died, two died
from exhaustion, one from pyaemia, one doing well up to
his seizure with Asiatic cholera, at that time prevalent in
the camp, and one from some cause unknown. Another
remarkable fact, perhaps worthy of note, is that in but
one of these cases was the capsule of the joint opened, or
did the fracture extend to the ephysis of the femur. The
same condition existed in Jarret's case. In the case of
Tony, who died, the ball was in the cotyloid cavity,
between the head of the femur and its wall. This case
was noticeable from the extreme pain that existed in the
whole leg, until after the head of the bone and the ball
were removed, the articular cartilage in the cavity was
loose and came off readily by traction with the finger
nail.

Taking into consideration the deplorable results that
ensue from compound comminuted fractures of and above
the trochanter, and the great length of time they take in
treatment, the necrosed bone left for years, if they ever
do recover, would it not be safe surgery in these cases to
excise the head of the bones ? Instructed by the disas-
trous results of these cases in our hands, and encouraged
by the cases of O'Leary and Jarret, we have been think-
ing seriously, that in fractures of this sort, resection is
perfectly justifiable, and even demanded. "We can at this
time call to mind one case that was brought to General
Hospital Xo. 1, in this city, from some other hospital, in
which the patient had been bed ridden for many months,
over a year certainly, and in which the end of the femur

208 Eead's Report on Wounds of Large Joints. [Sept.,

was drawn upon the outer and posterior portion of the
illium near to its crest. The condition of this man was
deplorable to behold ; the end of the bone was necrosed,
and with the most fortunate result that could happen to
him, the limb was useless. The articulation to be opened
is not a large one, although it is deeply seated; it com-
pares only with the shoulder. The results of resection
are so encouraging, and we can see no reason why, taking
into our estimate the greater danger in the lower extrem-
ity of all capital operations, it should not in many cases
succeed. The danger in these hip joint wounds is not
primary, but is the result of exhausting suppuration, and
pyaemic poisoning. These accidents are in a great meas-
ure avoided hj resection of the head of the femur.
Traumatic arthritis and its dangers are, by this ablation,
put entirely out of the way, and the purulent secretions,
instead of burrowing under and between the tissue, have
outlet through the incision made, and the chance of saving
life is increased. By the expectant plan there is certain
death ; by resection, a possibility of recovery with a use-
ful limb.

Various flaps and incisions have been advised and
practiced in this operation. The simple vertical incision
answers all purposes. The patient should be placed on a
table of convenient height, lying on his sound side, his
face turned to the edge of the table, or outward. The
surgeon standing at the opposite side of the table at the
patient's back, makes with a strong scalpel, an incision
over the edge of the trochanter major down to the articu-
lation. The length of this incision varies with the
amount of the femur to be excised with the head of the
bone ; it should be at least five inches in length, extend-
ing two or three inches below the trochanter, the joint
should be reached by this incision, the capsule must then
be opened ; an assistant standing in front of the patient

1866.] Head's Report on Wounas of Large Joints. 209

now places the joint on the stretch and dislocates it back-
wards, by seizing the extended leg, rotating it strongly
inwards, and then pushing it from him under the edge of
the table. This places the joint fully on the stretch; the
surgeon now divides the ligamentum-teres. If it be pos-
sible to divide this, the muscular attachments to the tro-
chanter and its fossa must be cut, and all difficulty will be
overcome. The bone must now be divided with the saw,
and all loose spiculae, many of which may be found drawn
into the surrounding tissues, should be carefully picked
out ; little bleeding occurs, and no ligatures are usually
required. The ends of the incision may now be closed,
but a large vent must be left for the escape of the secre-
tions. If the acetabulum be found injured, the loose
portions must be taken off with the forceps. In case of
the head of the bone being separated from the shaft,
great difficult}' will be experienced in separating the
round ligament. The head of the bone must be seized
by the " lion forceps " and dislocated by means of them.
Many lay great stress on fixing the parts immoveably.
This does not seem of great importance ; all that is
requisite is to apply a bracketed splint so as to prevent
the end of the femur from pushing against the wound,
and this must be so applied as not to interfere with the
contraction of the muscles, which tend to shorten the
limb, by drawing the end of the bone up to the acetabu-
lum. The wound should be often washed out with warm
water, or some preparation as suggested before, that has
a tendency to restrain the excessive suppuration. Bag-
ging of pus must be prevented by the suitable adjustment
of pads and pillows. The double inclined plane has been
advised, but seems objectionable, for it prevents the
needed contraction of the thigh muscles.

210 Read's Report on Wounds of Large Joints. [Sept.,

RESECTION KNEE JOINT.

I No. of Pri-
I cases | mary

S.ec" I Deaths I Re-
ondary | | covery

European Surgery 35

Confederate States' Reports

Per
centage

"97.01""

In the Crimean war, one case only of resection of this
articulation is mentioned by Macleod. The patient for
some time did well, but succumbed to an attack of intes-
tinal derangement, induced by eating apples. "VVe find
in the tables given of wounds of joints, recovery without
surgical interference, ninety-nine cases of knee joint
wounds there set down, with forty-five recoveries and
fifty-four deaths. These statistics show also twenty-four
cases of knee joint wounds, said to be doing badly.
These it will be fair to put down as dead by this time, as
no subsequent note has been made of them. Macleod
states that in the year 1854 he saw forty cases in the
French hospital, all of which resulted in death, save
when primarily amputated. In the Indian reports, he
states, in a "note," that he has been able to find the
particulars of nine cases in which the knee was pene-
trated, but the injury was apparently so slight as to lead
the attendants to try and save the limb ; every one died.
Alcock has stated, as before mentioned, that the propor-
tion of cases in which the articulations are wounded, to
other gunshot wounds, are between four and five per
cent, nearly half of which were in the knee ; of thirty -
iive cases, in which the knee was more or less implicated,
twenty-two lost their lives and eight their legs. After
such results he says : " It is little to say that the 1aye who
recovered preserved good and useful limbs." These re-
sults are very different from those shown in our table,
and correspond so little with the experience of all the
surgeons with whom we have had occasion to speak on
this subject, that we are forced to conclude that either
the successful cases being wonderful are reported, and

1866.] Read's Report on Wounds of Large Joints. 211

the dead not numbered, or that they were peri-articular,
the joint itself not being implicated.

In civil practice, the resection of this joint for disease,
has been attended with the most favorable results, as to
life and the subsequent utility of the limb. The mortal-
ity is less, according to Mr. Ferguson, than after amputa-
tion in the thigh for disease of the knee joint. AYe have
lately had the pleasure of meeting a surgeon from
London, and in discussing the subject, he stated that a
few days before he left that city, at a clinique of Mr.
Ferguson's, he had seen three cases, in which resection
of the knee had been performed some time before, and
that the gastroc-nemei muscles were developed in propor-
tion to the time that had elapsed from the operation in
each case. The great mortality in field practice can
satisfactorily be accounted for by the surroundings of the
soldier, and the want of necessary appliances for the
treatment. The nice adaptation of the divided ends of
the bone; the perfect fixedness of the parts; so as to pre-
vent the least motion ; the assiduous attention to nourish-
ment, and correct diatetic regulations; and the perfect
repose of a separate apartment, cannot be obtained in the
field, where, after the operation, the patient may have to
be moved many miles over a rough road, in jolting
ambulances and crowded cars. Mr. Ferguson justly sums
up the advantage of this operation in civil practice. The
wound is less than an amputation of the thigh; the bleed-
ing seldom requires more than one or two ligatures ; the
loss of substance is less, and probably on that account
there is less shock to the system ; the chances of second-
ary hemorrhage are scarcely worthy of notice, as the main
artery is left untouched ; there is, in short, nothing in the
after consequences more likely to endanger the patient's
safety than after amputations, while the prospect of re-
taining a useful and substantial limb, should encourage

212 Read's Report on Wounds of Large Joints. [Sept.,

both patient and surgeon to this practice. Were all the
conveniences for treatment in the field as in private
practice, the reasons would be equally forcible. The
patient not being a sickly, puny, scrofulous child, but in
the full vigor of manhood, would have more strength to
resist the shock, and more recuperative energy for the
building of the connective tissue.

It certainly appears right that conservative surgery
should be attempted in some of these cases ; for the ruth-
less amputation for all gunshot injuries to the knee joint,
is an opprobrium to military surgery. When the acci-
dent happens in the neighborhood of good hospital ac-
commodations, and the injury is confined to the articular
ends of the bones, and does not extend beyond the
epiphysis of the bones, it seems worthy of trial, as the
limb that results is superior to any artificial appliance.
Moreover, we have seen that where the articulation is
opened, and slight injury only has been inflicted on the
ends of the bones, or rather the articular cartilages, pri-
mary incisions have been attended with good results, and
that in all these cases, as far as we know, ankylosis
results from the destruction of the cartilages of the joints,
and that the union between the ends of the bones is
fibrous, or better still, osseous. It is certainly rational to
think that this danger would not be aggravated by saw-
ing through the epiphysis of the bones and bringing their
raw facets in immediate contact, so that the granulations
that rapidly spring up from healthy bone when cut, could
speedily cover the ends and unite the opposing granula-
tions. In disease, and when the joints are opened, before
this union can take place, destructive ulceration of the
cartilages must occur.

The following case is taken from Macleod, illustrating
the post mortem examination of the knee joint after re-
section for gunshot wound : " Death twenty-seven days

1866.] Read's Report on Wounds of Large Joints. 213

after resection ; post mortem fourteen hours after death.
Before removing the body to the dead tent, the orderlies
had taken off the splint, and the limb had been allowed
to hang down, so as to destroy any points of union there
might have been. The wound had healed, except its
extremities, the granulations of which had shrunk and
assumed a black appearance (post mortem). The oppo-
site surface of the bone presented a very similar appear-
ance, and there was no sign of dead bone. They had
become moulded to one another in shape. Whether
there had been any union towards the centre was not
evident ; at the circumference there were appearances of
adhesion having been broken. The cavity of the joint
contained only a small quantity of pus. The abscess in
the outer part of the thigh had almost healed, the viscera
healthy."

One case of resection of the knee has resulted well in
General Hospital, ~No. 4, in the case of Capt. Knowlton,
wounded in the battle of Payne's farm. This case has
been reported in full to the proper authorities: and we
will only mention here some of the leading points that
bear on this subject. The leg was strongly flexed upon
the ham, where impinged upon by the ball (a minnie),
which after touching the articular cartilage and opening
the synovial sack, turned up, and was removed on the
field, by an incision near the upper edge of the patella ;
it had formed a groove in the outer condyle of the femur,
and barely touched the cartilage. There was no discharge
of the synovia, and up to the tenth day after admission ;
the twelveth after the injury no serious symptoms ensued;
on the tenth the joint became painful and swollen, he had
two slight rigors, and some slight febrile excitement on
the eleventh day. These symptoms being on the increase,
and traumatic arthritis being imminent, with the advice
of Surgeons Gibson and Michel, it was decided to excise

214 Read's Report on Wounds of Large Joints, [Sept.,

the joint. The secretions of the capsule were found thin,
turbid, filled with fibrous flocculi. The synovial sack
was slightly reddened, the cartilages and bone were
healthy; about two and a half inches were sawed off, in
the endeavor to cut away the groove made by the ball,
the patella was dissected away. The section of the bone
was made obliquely downward and backward for the
femur, and the reverse for the tibia, so that when brought
into apposition the leg would be slightly bent, and the
toe inclined forward and downwards. The ends of the
bone were snugly fastened together with silver sutures,
no vessels were ligated, and before the patient was moved
from the table the leg was placed in a long fracture box,
extending from the nates to below the foot. This box
had moveable sides. The leg was well padded under the
knee so as to prevent the bones breaking out the wire
sutures by their weight, being unsupported in the popliteal
space. After some days this box was removed and the
leg merely adapted to bracketed splints. This patient's
general health and temper rendered him peculiarly un-
suited for such an operation. He was naturally irritable
and discontented, and subject to hepatic derangement.
In four months the internal wound was closed, one of
the wire sutures remaining in the limb, but seemed to
give no trouble. The union between the ends of the
bone is firm, but permits of slight motion,, when the limb
is taken between the thigh and leg. It can support itself
to be lifted up from the heel. The patient left the
hospital with the leg strengthened by a leather splint.

As resection of this joint under favorable circumstances
has so seldom been performed in this war, your commit-
tee will not hazard at this time an opinion as to the com-
parative results of resection and amputation for injuries
that penetrate its cavity, without inflicting much damage
on the articular ends of the bones, we, however, in view

1866.] Read's Report on Wounds of Large Joints. 215

of the great advantage of the limb retained, even if stiff
and slightly shortened, over the artificial limb that muct
be used in its place, are much inclined to resection when
the condition of the patient or his age will warrant, in the
surgeons opinion, such proceeding, and suitable appli-
ances are at hand. In many cases, as in Capt. Knowlton's,
the synovitis does not set in for days, and there is gene-
rally plenty of time to send the wounded man to some
neigboring hospital for treatment or operation, fixing the
joint for this purpose firmly in the bracketed splint, that
will shortly be described. It would be safe and judicious
practice in the field to examine all wounds of the knee
joint, or in its vicinity, enlarging the opening freely for
this purpose, so as to ascertain clearly the exact condition
of the articulation. If this be found to be much impli-
cated, with destruction of epiphysis of the bone or the
splitting of the shaft in the joint, no harm is done, and
the case can be completed by amputation. If there be
found but slight injury to the articulation, so that a section
of the shortened ends will not take off more than two and
a half inches from the length of the limb, or open the
medullary cavities, and if the vessels and nerves be
uninjured, then resection may be attempted with prospect
of success. If on the other hand it be found that only
the sack be opened and cartilage uninjured, the free
incision will expedite the treatment of the case.

The horse shoe incision is the one generally used in
this resection, extending from one condyle to the other
over the front of the joint under the patella. The tendon
of the extensor muscle is now divided, and the flap
containing the patella turned up. The joint is then
opened by flexing the leg strongly on the thigh, the ligr-
ments are divided and the bones cleansed of the soft
parts as far as necessary, care being taken not to injure
the vessels running along the back of the joint through

216 Read's Report on Wounds of Large Joints. [Sept.,

the popliteal space. The soft parts should now be pro-
tected by a wooden spatula or a piece of leather drawn
over them, and held out of the way by an assistant. The
end of the femur must now be divided with the saw,
taking care to make the section in such direction as to
insure the after adjustment in the way that will best
conduce to the production of a useful limb ; the tibia is
now to be divided by the saw, in these sections we must
be careful to conform ourselves to the epiphysis of the
bones.

The removal of the patella is still a mooted point, some
Surgeons taking it away and others allowing it to remain.
In Knowlton's case it was removed. If it be not ablated
it must be twisted over, and its articular cartilage shaved
off with the scalpel, and we must attempt to procure
union between it and the anterior aspect of the ends of
the femur and tibia. In civil practice we find an average
gain, in the treatment of cases in which the patella is cut
away, of thirty days. In Dr. Hodge's tables, the duration
in the treatment of forty-eight cases in which the patella
was removed is stated to have been 225 days ; where it
was not removed 255. The average duration of treat-
ment in these cases was eight months. In Knowlton's
case the time was four months, or just one-half of the
time required for the treatment of cases in civil practice.

If the ends of the femur and tibia after this first section
are not perfectly adjustable, then sections must be made
until this is secured. These two bones should be then
firmly tied together with sutures of strong silver or ar-
nealed iron wire ; the ends of the wire should be left long,
and be carried out of the side incisions, rather at the bottom
of the wound, as the part that will heal last. The little
instrument devised and employed by Surgeon Bolton for
ununited fractures, would answer admirably for this
purpose, by being placed on each side of the joint,

1866-1 Read's Report on Wounds of Large Joints. 217'

and then by the use of the screw, the ends of the
bones could be pressed firmly and perfectly together.
The incision through the skin should be closed by su-
tures, taking care to leave room enough for that dis-
charge to pass through at the lower edge of the wound.

The limb from the foot to the knee should now be
covered with a double layer of cotton wadding, or sheet
tow, over which an uninterrupted bandage should be
applied. The same should be applied to the thigh from
the groin to the knee. As these dressings are to remain
untouched for a long time, they should be guarded from
soiling near the wound by oiled silk. A well padded
posterior splint, extending from the middle third of the
thigh down to the tendon of posterior muscles of the
leg, cut out so as to be narrow under the knee, and
padded so as to fill up the popliteal hollow, protected
here likewise with oiled silk, should now be firmly fixed
to the leg. A Smith's wire splint, bent up to an angle at
the foot, may be bound tightly to the splint, and will
answer all purppses of a foot board, and will keep the
foot from twisting the knee by any lateral motion. By
means of this posterior splint, bent so as exactly to fit, we
can keep pressure on the leg, and so hold the edges of
the bone in contact. Two long splints, interrupted at the
incision opposite the joint, are now to be placed on either
side of the limb, extending from the upper side of the
thigh to the sole of the foot. These must be nicely
padded, and may be held in position by strips of bandage
tied at different points, so many as may be needed. The
limb may be suspended from a Salter's apparatus, or by
some extemporaneous contrivance.

Dr. Howell Thomas, of this city, on duty for some time

at General Hospital, "No. 1, under charge of Surgeon

Gibson, has ingeniously adapted Smith's anterior splint

to the purpose of bracketing the long straight splint, by

15

218 Bead's Report on Wounds of Large Joints. [Sept.,

bending them into suitable shape and bandaging them
firmly to the splint, which are then cut out corresponding
to the elbow made by the wire. The ends of the wire
splint, if too long, may be bent laterally on the sole of the
foot, then placing this in a firm wire box. This arrange-
ment preserves perfect immobility of the limb, and per-
mits the dressing to be applied and changed as often as
may be requisite. They are readily extemporized and
might be of use in wounds of joints in the field ; if sus-
pended from the roof of the ambulance, or car, the
patient could travel without much jar or jolting.

A Mr. Jones is mentioned in Erichson, who was in the
habit of excising the knee without dividing the legamen-
tum patella, but he began his operation by making the
ordinary horse-shoe cut in the skin.

The Chairman of this Committee, appreciating the im-
portance of preserving the tendenous attachment of the
anterior muscles of the thigh, so that it might act antagc*-
nistically to the ham-string muscles, has twice of late, on
a dead subject, performed resection of the knee on this
wise : From the lower edge of the patella, whilst the leg
is extended, an incision is made through the skin into the
joint and carried down to the ham-string tendons ; this is
done on both sides at its middle this is crossed by a ver-
ticle incision, two inches in length; these flaps are dis-
sected back. The knee is strongly flexed, and the lateral
and crucial ligaments are divided, cutting from below
upwards. The soft parts are carefully and slowly cleared
away from the back of the femur with the finger and
handle of the scalpel and perhaps a few touches of the
knife, keeping the edge near the bone. This part of the
operation must be carefully proceded with and the pulsa-
tions of the artery should be sought for so as to keep the
edge of the knife away from it. A piece of soft leather
being now passed under the condyle of the femur, the

1866.] Read's Report on Wounds of Large Joints. 219

soft parts are strongly depressed by an assistant ; another
assistant, by means of a strong piece of bandage, holds up
the patella and its ligaments. The blade of Mr. Butcher's
saw is now passed in, the handle attached, and the bone
divided, cutting from below upwards. This is repeated
for the head of the tibia, and the patella being everted
and its cartilage being sheared off, the operation is
complete.

Resections of the ankle joint for gunshot wounds pene-
trating the articulation, are rarely performed. Most Sur-
geons, owing to the complex arrangement of the synovial
membrane of this joint with the tarsal articulations, and
the bad results that have often ensued from the wounds,
have inclined to have recourse to amputation. Macleod
states, however, that penetrating wounds of the ankle did
well, although they demanded long treatment. This, he
says, is opposed to usual experience in such injuries; and
he further remarks that where the openings were largest
the patient did best.

We find in our table of incisions of joints, five cases
with one death, which support this statement.

If resection be determined on, a straight incision on
either side of the joint will enable us to throw out the
ends of the tibia and of the fibula, and saw them off.
Generally speaking, however, the simple enlargement
of the wound, and careful extraction of loose pieces,
will fill all indications. The foot, during treatment,
should be permanently fixed, as ankylosis must result.
On two occasions during this war after months of assid-
uous care, we have been compelled to amputate at the
lower third of the leg.

220 Jones on Treating Pneumonia* [Sept.,

article rir.

Relations of Pneumonia and Malarial Fever ; with Practical
Observations upon the Antiveriodic or Abortive Method of
Treating Pneumonia. By Joseph Jones 1 M. D., Profes-
sor of Chemistry in the Medical College of Georgia.

The great mortality caused by typhoid' fever and pneu-
monia in the hospitals and armies of the Confederate
States, invested these diseases with peculiar interest and
importance.

After a careful examination of the official reports, on
file in the Surgeon-General's office at Richmond, Ya., we
established the important fact, that up to the time of this
examination and consolidation of the sick reports, and
mortuary records (September, 1863), pneumonia and
typhoid fever had caused one-half of all the deaths from
all causes, gunshot wounds included, in the field and
general hospitals. We were led to draw up extended
reports, presenting the results of our investigations upon
the causes, nature and treatment of the most fatal dis-
eases. The manuscript volumes thus prepared for the
use of the Medical Department of the Confederate States
were captured or burnt at the time of the evacuation of.
Richmond.

In the report upon pneumonia, we urged that each
medical officer cf the Confederate army, should as far as
possible, test the value of the different modes of treat-
ment before the profession. Whilst there existed no want
of theories, of positive assertions, and of unbounded
confidence in special remedies in the treatment of pneu-
monia; unfortunately, however, the experience of which

1866.] Jones on Treating Pneumonia, 221

we heard so much, availed but little in the accurate de-
termination of practical questions, involving as was care-
fully and fully demonstrated, the lives of a great propor-
tion of those afflicted, and in truth, of thousands of the
brave defenders of their country. It is customary to
dignify with the title extensive experience, the use of one or
more remedies for a series of years amongst a number of
patients, regardless of the intelligence which selected
those remedies, regardless of the fact whether those
remedies were selected as the result of education, or of
accident or prejudice, or as the result of careful and
conscientious investigation and comparison of the relative
effects and value of different modes of treatment. It was
urged, that under all circumstances oT peace or of war,
and especially in a contest in which the entire community
was emptied of its male population, from boyhood to old
age, and from the statesman to the day-laborer, such
investigations should be considered of the greatest mo-
ment, and should be conducted with the most scrupulous
accuracy and honesty ; and the belief was expressed that
with concert of action, amongst conscientious and compe-
tent observers, results of great value would be achieved.

In medical science, as well as in sciences of more exact
observation, no other method except that of strict induc-
tion from well observed facts will result in the establish-
ment of fixed and general principles, which will express
with truth the operations of nature, and enable man to
guide and direct them in fixed modes for the accomplish-
ment of useful ends. Hypothetical discussions of disease,
and of the action of medicines, apart from established
facts, are worse than useless they are positively injurious,
by calling off the mind from rigid experiment and from
the careful observation of nature.

In Therapeutics we need above all things, rigid obser-

222 Jones on Treating Pneumonia. [Sept>

vations upon the effects of the different agents on the
duration, progress, effects and termination of particular
diseases.

In every inquiry in Therapeutics, the physician should
endeavor to determine

1st. The natural progress of the disease when no reme-
dies have been used : What is the natural history of the
disease: "What are the tendencies of the disease to
recovery, or to death. The relative mortality to the
total number of cases and to other diseases: When
recovery takes place what is the process ; and when death
takes place, what are the antecedents, and the immediate
causes. The effects of variations of climate, of previous
habits, of diet and of age, as well as the extent and
severity of the inflammation or disease should be accu-
rately noted ; also the effects of various modes of diet
and stimulation.

The results of such investigations will form a standard
by which the value of different remedies may be deter-
mined. Every conscientious physician desires to dispense
with all needless medicines ; and if it were possible to
treat certain diseases by aliment alone, with more success
than with drugs, it would be the duty of the physician to
conform the treatment to the established course of nature.

2d. "Whether the remedies used diminish the rate of
mortality in particular diseases, and thus contribute to
the safety of the patients.

3d. Whether the remedies abridge the course of the
disease.

4th. Whether they lessen the sufferings.

5th. Whether they leave any injurious results.

6th. The modes in which the remedies assisted nature
in the relief of the disease.

1866.] Jones on Treating Pneumonia. 223

"With a number of physicians, thus acting in concert,
even if each one experiments with and records his expe-
rience with only a single remedy, and that his accustomed
and favorite one, it will be possible, in the course of time,
to determine with an approach to accuracy, the most
efficacious remedies and modes of treatment

In the report referred to, the various modes of treating
pneumonia were classed under the following heads :

1st. Dietetic System.

2d. Rational Treatment designed to further the natural pro-
gress of Pneumonia towards recovery.

3d. Antiperiodic, or Abortive Treatment of Pneumonia.

4th. Antiphlogistic System of Treatment

The following table was drawn up from the official field
and hospital reports, with the design of comparing the
results of the treatment of pneumonia by Confederate
Surgeons, with the mortality under different systems of
treatment :

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226 Jones on Treating Pneumonia. [Sept.,

The important fact illustrated by this table, is that the
mortality from pneumonia, in a large number of Confede-
rate hospitals (those entered upon the table were selected
without any reference to the character of the statistics),
was far greater than the mortality in this disease under
different modes of treatment in European hospitals.

The mortality in these Confederate hospitals has been
twice as great as that under tartar emetic in large doses,
and about four times as great as under the dietetic system,
in which the powers of nature are simply supported, and
drugs abandoned. These facts are surely sufficient to
excite an earnest and diligent inquiry into the relative
merits of the different modes of treating pneumonia, now
in use by Southern physicians.

In the present paper we propose to consider the

Antijperiodic or Abortive Treatment of Pneumonia. These
terms are used, not so much to indicate the true nature
of this plan of treatment, as to express the views which
have led to its employment by various practitioners in the
Southern States.

Southern physicians, have for a number of years, used
quinine in the treatment of pneumonia ; and previous to
the recent civil war, a number of articles have from time
to time appeared in the various medical journals, extolling
the virtues of quinine in the treatment of this disease, and
more especially in malarious regions. By many of the
advocates of the power of quinine to greatly modify and
even arrest the progress of pneumonia, the doctrine is
held that the disease arises from the same causes, is inti-
mately associated with malarial fever, and in fact is
nothing more than one of the forms of periodic fever.
The remark is not unfrequently heard, that pneumonia
should be treated as a malignant remittent. Those who
adopt the view of the identity of paroxysmal fever and
pneumonia, believe that quinine in full doses, is capable

1866.] Jones on Treating Pneumonia. 227

of arresting the latter, in the same manner that it arrests
or aborts the former.

"We might bring forth numerous quotations from the
older writers, to prove that the belief in the identity of
the causes and ultimate nature of pneumonia and pa-
roxysmal fever, as well as the treatment by bark and
quinine founded upon this view, are by no means so novel
as some of the modern writers, and especially American
medical writers, would have us believe. Our limited
space, however, will permit only brief references to some
of the most trustworthy authorities.

Jean Senac* in his celebrated and unsurpassed treatise
on the " Hidden Nature and Treatment of Intermitting
and Remitting Fevers," discourses in several chapters
upon the conversion of intermittent fever into pleurisy
and pneumonia ; and in his observations upon the method
of detecting or distinguishing intermittents, when dis-
guised under the mask of other diseases, relates a case of
intermittent pleurisy, cured by febrifuge remedies. Ga-
leatius, near seventy years ago, in a work on Peruvian
bark, pointed out the efficacy of this remedy in the cure
of pneumonia occurring in intermittent fever, and which
he considered as one of the manifestations of paroxysmal
fever. George Cleghorn, in his " Observations on the
Epidemical Diseases of Minorca, from the year 1744 to
1749," describes a fatal form of pneumonia and pleurisy,
with distinct remissions. " When those pleurisies," says
Cleghorn, " first became epidemical, their quick progress
and uncommon mortality surprised me greatly. I at-
tempted to cure them by bleeding, once or twice a day, if
the complaints were violent, as I had always used to do
in inflammatory fevers ; but the remissions in the morn-
ings sometimes induced me to omit the operation ; and

*De Recondita Febrium Intermittentium, turn Remittcntium Natura etde earum Curatione:
Variis ^xperimentis et obeervatlonibus illuatrata. 1169.

228 Jones on Treating Pneumonia. [Sept.,

the cessation of the symptoms, which generally happened
about the third day, made me imagine that the danger
was over ; so that before the patients were blooded above
two or three times, the exacerbation came on upon the
fourth or fifth day, and defeated all attempts by bleeding,
blistering, or otherwise to relieve them.

" Those unforeseen events startled me greatly, and led
me to review the whole progress of the disease, its symp-
toms and issue. I had observed that some escaped by
means of expectoration and purulent urine, without much
assistance from phlebotomy; and considering the peri-
odical revolutions of the fever, the quick transition of the
stitches from one part to another, together with the pre-
vailing color of the blood, as well as that of the spitting,
and other excretions, I was apprehensive that those were
what authors call bilious pleurisies, which they allege are
exasperated by large evacuations :* particularly Duretus,f
who exclaims with great vehemence against those physi-
cians who trust principally to bleeding in the care of those
diseases, without waiting for the natural evacuations."
Loc cit. p. 164-5.

Morton appears to have frequently detected the malig-
nant intermittent concealed under the mask of pneumo-
nia and pleurisy. This physician relates, among others,
the case of a man who was seized in the morning with a
violent shivering, and a pain in the thorax of so severe a
character as to render respiration scarcely practicable.
The pulse of the patient was small and rapid, his weak-
ness was extreme, and universal coldness overspread all
the limbs. Notwithstanding these symptoms, blood-
letting from the arm was employed as the necessary and
proper remedy for this spasmodic state of the respiration.

* Ballon. Epid. Sparsim. Biancb Hist. Hep. p. iii. $ viii. &c. Bagl. Prax. Med. 1, i. c. ix.
Lands Epid Kom c. vi.

j-0 homines republicae calamitosos atque funestos ! ipsam pleuritidem, quae sua sponte
nullius operis indigens cum tali sputo quiesccret, ex eventur redduut inortiferam. Duret ia
Traeiiot. Coac.

1866.] Jones on Treating Pneumonia. 229

"When, however, from the nature and return of the parox-
ysms, Morton detected a fever of a malignant character,
masked under the appearance of a peripneumony, he
made the bark the principal foundation of his treatment,
and succeeded in arresting the disease.

Lautter, as quoted by Alibert, in his treatise on malig-
nant intermittents, has recorded two similar cases in his
Hist. Medic, bienn. morb. rural, etc.; Casus v. & ix.

A labourer of Luxembourg, thirty years of age, of a
dry temperament, being engaged in threshing corn, was
seized, first with a trembling, and then with a violent
coldness, to which succeeded a short hot fit, and great
thirst. The principal symptom was an excessive pain in
the left side, which considerably impeded respiration.
Being obliged to quit his work, he took to his bed ; the
fever continued nearly eighteen hours in the same state,
and then underwent a perceptible remission. On the
morning of the day following, the patient was still better.
Although he was rather feeble, the stitch in his side con-
tinued, and he was certainly in some degree feverish, yet
he went to work again, but all the symptoms returning
toward evening, he again took to his bed. Lautter was
called in; he found his patient laboring under a high
fever, his pulse was hard, his respiration laborious, pain-
ful, and almost suppressed; the pain in the side was ex-
tremely acute; there was no cough. From the history
of the disease, the physician discovered immediately that
it was a malignant intermittent, masked by the predomi-
nant symptom of pleurisy ; not being able to strike* im-
mediately at the root of the disease, because the exacer-
bation was then at its height, he employed himself in
moderating the violence of the symptoms. He drew
from the arm of the affected side ten ounces of blood,
which was covered with an inflammatory crust, and
ordered an emollient cataplasm to be applied to the part

230 Jones on Treating Pneumonia. [Sept.,

where the pain lay, and to be frequently renewed. In-
ternally he administered barley-water with oxymel and
nitre ; the patient experienced relief, his respiration
became easier, and the pain in his side abated; yet he
passed a sleepless night with heat and great. thirst. On
the day following, his pulse was indeed less frequent, and
was not hard, yet he had a high fever ; the pain in the
side continued, the urine, which was very high colored,
deposited a lateritious sediment; the symptoms were now
much milder, but as they had not altogether disappeared,
the foregoing remedies were continued. In the evening,
the disease resumed completely its first state and appear-
ance. On the morning of the following day, there was
no remarkable change, except that the acute pain in the
right side disappeared for a short time, but soon returned
again ; the urine had undergone no change since the day
before, the skin was constantly cold, etc. Lautter dis-
covered immediately the malignant character of the fever.
He took advantage of the remission to. administer an
ounce of the bark in the space of twenty-four hours ; the
next paroxysm was a very moderate one ; and by contin-
uing the use of the same remedy, the disease was radically
cured.

A woman, sixty years of age, having her system greatly
heated by exercise, exposed herself imprudently to the
coolness of the evening. She was attacked by a cold fit,
which was followed by a fever of great intensity. A
severe pain occurred in the right side, extending round
to the spine; a dry and frequent cough added to its
acuteness; the respiration was short and laborious, and
the succeeding night was passed without sleep. Lautter
was called in ; he found the pulse greatly agitated, full
and hard, the tongue white and dry. Taking the disease
for a pleurisy, he drew blood from the arm of the side
affected, and laid an emollient cataplasm on the part

1866.] Jones on Treating Pneumonia. 231

where the pain was situated; the blood was covered
with an inflammatory crust. The symptoms became
milder.

On the same day, at one o'clock in the afternoon, the
shivering returned with a slight degree of coldness; the
febrile heat, the cough, the pain, etc., were all augment-
ed ; the pulse was as full and as hard as at first ; blood
was consequently drawn a second time, and exhibited
again an inflammatory crust. There was now a remis-
sion of the febrile symptoms. On the evening of the
day following, the cold fit returned ; the pain, the heat,
the cough, etc., increased considerably, in consequence of
which the patient passed a very bad night.

Xext day there was a remission; afternoon, another
exacerbation, ushered in by a cold fit. The physician
contented himself with repeating the application of cata-
plasms, and administering cooling drinks. He had no
further recourse to blood-letting, because the patient's
strength was greatly exhausted, and from the progress of
the disease and the copious sediment of the urine, it w^as
easy to discover a double tertian remittent lurking under
the mask of pleurisy. Lautter gave an ounce of a mix-
ture of bark to be taken previously to the return of the
paroxysm which was very near at hand. During the
succeeding night, the patient experienced only a great
heat, but the cough and the pain in the side did not
increase. On the following day, the same medicine was
continued, and there was scarcely even the shadow of an
exacerbation. By the continued use of the bark, the
patient was very soon restored. (A treatise on malignant
intermittents, by J. L. Alibert, translated by Charles
Caldwell, M. D.; Philada., 1807 : pp.46-50). Alibert in
the same connection recounts a similar case of intermit
tent pneumonia, occurring in a student of medicine in
Paris, which was successfully treated by wine and bark.

232 Jones on Treating Pneumonia. [Sept.,

Laennec observed the existence of intermittent malarial
pneumonia (pernicious pneumonic fever) in a muscular,
robust man, who had entered the hospital with a recent
syphilis. On the sixth day of his admission, the patient
suffered with a paroxysm of intermittent fever of consid-
erable violence, and he stated that he had had a paroxysm
two days before. A third paroxysm occurred on the
third day after, but it was entirely different from the
preceding paroxysm ; it commenced with a more consid-
erable chill, was accompanied with a violent headache,
extreme dyspnoea, and hemoptysis. Upon exploring the
chest during the middle of the paroxysm, the respiratory
murmur was found unaltered except at the root of the
lungs, where it was masked by a rale crepitant well char-
acterized, principally on the right side. Laennec, without
hesitation, declared the disease a double pneumonia in its
initial stage : tartar emetic, six grains ; sulphate of qui-
nine, eighteen grains, to be taken in three doses. The
patient vomited a little and had but one stool ; the next
day he thought himself cured. But as the rale crepitant
had not entirely disappeared with the cessation of the
febrile paroxysm, the two prescriptions were continued.
The following paroxysm was very short ; the rale crepitant,
was slightly developed, and the hemoptysis reappeared ;
but the fever had scarcely ceased, when all the symptoms
disappeared (that is to say, as soon as the disease ceased,
it no longer existed). The tartar emetic was discontined
on the fifth day, the respiration having become pure and
natural ; the sulphate of quinine was continued for some
days. The patient was now cured of the fever, and the
anti-syphilitic treatment, which had been suspended, was,
resumed. Three weeks after, the intermittent fever re-
appeared ; it was now simple and benign, and a few doses
of the sulphate of quinia entirely arrested it; the patient
remained six weeks longer in the hospital, and left in

1866.] Jones on Treating Pneumonia. 233

good health. In like manner M, Fleury records a re-
markable case of tertian pneumonia, which was attended
with almost complete disappearance of the distressing
pneumonic symptoms during the intermission of the
fever, and which was arrested by quinine and bark. (See
Physiological Pyretology; or a Treatise on Fevers, etc.?
by F, G. Boisseau, trans, by J. R. Knox, M. D.; Phila.,
1832; pp, 433-436.)

We might present the testimony of many other writers,
as Ramazini, Lancisi, Sj'denham, Hunham, Sauvages, and
Broussais, to show that the notion of the production of
pneumonia, by the same causes which generate the various
forms of malarial fever, has been not only long, but
widely held by the medical profession; but the authors
already cited are believed to be sufficient for the estab-
lishment of this proposition.

Without attempting at this time to settle the question
as to whom belongs the honor of first giving bark and
quinine in pneumonia and inflammations generally, we
have shown conclusively that the former remedy has
been freely used in the treatment of all fevers and inflam-
mations for at least a oentury; and as the principles
which led to its administration did not differ materially
from those which now lead to the use of quinine, and as
the bark necessarily included this constituent, if any
eredit is due to this method of treating inflammations, it
rests with the older writers.

We will endeavor in the next place to determine the
relations of malarial fever to pneumonia, by the appliea-
cation of those facts and principles which have been de-
veloped by our own investigations.

We shall content ourselves with the expression of only
those general results of our investigations which bear
upon the treatment of pneumonia. *
16

234 Jones on Treating Pneumonia. [Sept,,

1st. There is no necessary connection between pieumonia
and malarial fever.

In healthy, elevated non-malarious regions, pneumonia
is almost never complicated with malarial fever.

In malarious regions on the other hand, pneumonia is
frequently complicated with malarial fever. The local
inflammation frequently appears in those who are laboring
under the action of the malarial poison, and the disease
partakes of the paroxysmal character.

If the system of healthy individuals be reduced in ma-
larious regions, by any depressing agent or disease, as by
the amputation of a limb, or by the inflammation of some
organ, as of the lung in pneumonia, the malarial poison is
most likely to exert its effects. In such cases the par-
oxysmal character of the inflammatory disease is due not
to the pre-existing action of the malarial poison, but to
the fact that the system has been so depressed as to be
unable to resist the action of the malarial poison.

2. The malarial poison induces profound alterations in the
constituents of the blood.

Under its action, the colored-blood corpuscles are more
rapidly, and to a greater extent, destroyed than in any
other disease. The fibrin is diminished and altered in
quality. The albumen is in like manner diminished. The
extractive and coloring matters of the blood are frequently
increased. The unhealthy hue of the complexion in ma-
larial fever, appears to be due to both the destruction of
the colored-blood corpuscles and the presence of coloring
matters in the blood.

3. During the active stages of malarial fever, phosphorus
and the compounds of phosphorus in the nervous structures
and in the colored-blood corpuscles, as well as sulphur and the
compounds of sidphur in the muscular structures, undergo
more rapid changes than in the normal state, and phosphoric
acid and the phosphates, and sulphuric acid and the sulphates,
appear in increased quantities in the mine.

1866.] Jones on Treating Pneumonia. 235

The waste of phosphorus and its compounds in the
blood corpuscles and nervous structures during the active
stages of the fever, is far greater than the supply of
these elements through the food.

The nervous disturbances and debility characteristic
of malarial fever are in a measure, if not entirely, due to
these rapid changes in the phosphorescent materials of
the nervous structures and especially of the central gan-
glionic cells.

4. During tiie slow action of the malarial poison, as well as
during tlie active stages of the paroxysm, important changes
take place m the liver and spleen.

In both organs, the colored-blood corpuscles are des-
troyed in large numbers, and the coloring matter, resulting
from the disintegration of the red corpuscles, accumulates
in them, and in conjunction with other changes in the
nutritive processes of these organs, produce those charac-
teristic alterations of the normal color. In fatal cases,
cellulose is found in both the liver and spleen, whilst
grape sugar is absent from the liver. The bile is altered
both in chemical constitution and physical properties.

5. Thai the chemistry of the body is still farther deranged
in malarial fever, is evidenced by the changes in the excretions.

During the chill, and at the very commencement of the
hot stage, phosphoric acid disappears almost entirely from
the urine ; as the hot stage progresses, and the febrile
action and the heat commence to decline, there is an aug-
mentation of phosphoric acid.

But what is still more important in its bearings upon
pneumonia, the uric acid is either increased, or remains
at the normal standard, during the chill; disappears
almost entirely during the fever; and then increases
rapidly, and rises to a high figure, after the subsidence of
the febrile excitement, and often continues for days, two,
three, and even six times more abundant than in the
normal state.

236 Jones on Treating Pneumonia. [Sept.,

If it be true that the presence of a morbific material in
the blood, as uric acid, in gout and rheumatism, will often
prove an excitant to- inflammatory action, this tendency
in malarial fever to the generation of large* quantities of
uric acid during the intermissions, and even during the
period of convalescence, is important in its bearings, not
only upon pneumonia, but also- upon neuralgic affections.

I have in my own case observed changes in the urine,
and especially in the uric acid, during severe headaches
of malarial origin, similar to those observed in well-de-
fined cases of paroxysmal fever.

6. One of the most marked and important of the phenomena
of malarial fever, in its connection with inflammations- of
internal organs, is the congestion of important organs at stated
intervals.

It would even appear that, aside from the general de-
pressing effects of the malarial poison upon the heart
and circulatory system at stated periods, and the conse-
quent stagnation of the blood in the central portions of
the circulatory system, the altered blood corpuscles, and
the products of their death and disintegration, as the
coloring matter, may under certain conditions obstruct
the smaller vessels, and give rise to local and circum-
scribed congestions and even effusions.

It results from these effects of the malarial poison :

(a.) When inflammation is excited from any cause, in a
system subjected to the influence of the malarial poison, the
natural tendency is for the inflammation to assume a low form,
from the altered condition of the constituents of the blood and
structures, and from the derangements in the processes of nu-
trition, and of those physical and chemical acts by ichich the
nervous and muscular forces are developed.

It is well known that the causes which are most influ-
ential in the production of inflammation are such as
enfeeble the heart, impair the tone of the arteries, reduce

1866.] Jones on Trmtmg Pneumonia. 237

the activity of the secreting organs, and debilitate the
muscular and nervous forces.

Imperfect nourishment also, either in consequence of
the defect in the quantity or quality of the food, or of
incapacity of the digestive powers, impairs the powers of
the system to resist the effects of deleterious and depres-
sing agents, as cold; and produces a liability to low forms
of i inflammation and fever, and to various epidemic and
contagious disorders.

In malarial fever, even when the digestion is unim-
paired, the action of the poison, by impairing the consti-
tution of the blood, and by deranging the nutritive
processes of the different organs and tissues, and by
deranging and depressing the chemical actions concerned
in the development of the physical and nervous forces,
produces similar results to those witnessed in ill-fed and
iil-conditioned beings.

The process of inflammation, whilst including both
congestion and determination of blood, is essentially
more complex than either or both of these conditions,
and includes changes of the blood within the vessels, and
changes of the relations of the capillaries to the blood,
and of the blood to the surrounding tissues.

The character of these changes, as well as the extent
and progress of the inflammation, will depend upon the
constitution of the blood, the forces moving that blood,
and the condition of the forces active in the nutrition of
all the organs, as well as of the forces especially active in
the inflamed tissue. Thus, when the character of the
blood has been altered and the forces depressed, the solid
products of inflammation are less capable of organization,
the lymph effused possesses inferior plasticity, and the
effects of the local inflammation upon the general system,
in causing inflammatory fever, are more , depressing and
dangerous. As therefore the tendency of the malarial

238 Jones on Treating Pneumonia. [Sept.,

poison is to derange the conditions upon which the
maintenance of healthy nutrition depends, viz, : the
regular supply of healthy Mood possessing a definite
composition and relation of its elements, and of a certain
supply of physical and nervous force, and the healthy
constitution of the organs and tissues, it is evident, not
only that inflammation engrafted upon the system labor-
ing under the effects, or under the direet action of the
poison, must be correspondingly altered from its progress
in the healthy constitution, but also that the state of the
system induced by the action of the malarial poison is
conducive to the origin of inflammation.

(b.) From the destruction of the fibrin and red-blood cor.
puscles, consequent upon the action of the malarial poison, the
tendency of inflammations excited in systems under the influ-
ence of the malarial poison is to diffusion.

The increase of fibrin in the blood, and in the inflamed
structures, appears to be destined, in the economy of
nature, to limit and circumscribe the inflammatory action,
by the fibrinous matter thrown out within and around the
inflamed part.

The colored-blood corpuscles, which crowd the inflamed
part, appear to contribute by the chemical changes which
they excite, and especially by the increased oxidization of
the protein elements, to the formation of fibrin, which in
this view may be considered as one of the controlling
and limiting elements of inflammation. Whatever there-
fore tends to diminish the red corpuscles and fibrin, tends
to interfere with the natural processes employed by nature
in the limitation of inflammation, and directly promotes
the diffusion of the inflammation over a greater extent of
tissue, and in a corresponding degree renders it more
severe and dangerous.

We have in these facts an explanation of the sudden
and fatal character of many cases of pneumonia occurring

1866.] Jones on Treating Pneumonia. 239

in those who have been for some time under the influence
of the malarial poison.

We have had under treatment, and recorded at length
elsewhere, cases which were suddenly seized with pneu-
monia during the period of convalescence from malarial
fever. These patients were destroyed, or rather drowned,
by the rapid pouring out of serous fluid into the air cells
and bronchial tubes of the lungs. In such cases, the
capillaries of the blood, being in an enfeebled state, the
fibrin of the blood being diminished in quantity and
altered in physical and chemical properties, the colored-
blood corpuscles, being diminished in number and physi-
cally and chemically altered, the solid matters of the
blood having been diminished, and the physical and
chemical relations between the individual constituents of
the blood and capillaries having been disturbed by the
action of the malarial poison, healthy limited inflammation
was impossible.

Diffused inflammation of all the structures of the lung
resulted, the serous portion of the blood poured into the
air cells, bronchial tubes and trachea; the supplies of
oxygen were in a great measure cut off; the chemical
changes of the solids and fluids were in a corresponding
degree checked ; and the physical forces, heat, and
electricity, and the nervous force, developed by these
chemical changes, were, as a necessary consequence,
correspondingly diminished.

Broussais, in his history of chronic phlegmasia, has
recorded several analogous cases of fatal pleuritic and
pulmonic affections attacking those suffering with mala-
rial fever ; and Andral, in his " Clinique Medicate," has
given at length a fatal case of pneumonia, with pulmo-
nary oedema and double pleuritic effusion following and
supervening upon intermittent fever.

(c.) The liability of persons who have suffered with malarial

240 Jones on Treating Pneumonia. [Sept,

fever in (he Summer and FaU, to be seized with pneumoniar
in (he Winter and Spring, and the danger of these inflammato-
ry attacks following or engrafted upon paroxysmal fever, have
long been known to the public as well as to the profession.

In many cases, these inflammations engrafted upon
malarial fever, or following- its effects, are clearly depend-
ent for their excitation upon the vicissitudes of the
weather, and especially upon the agency of cold.

In healthy beings exposed to cold, there is at firstr
through the stimulating effects of the cold air inspired,
and of the chang-e of temperature upon the exterior, an
increase in the circulating and respiratory actions, more
oxygen is introduced and distributed, the chemical
changes of the system become more rapid, and the
temperature of the body, notwithstanding the increased
radiation and loss of heat, is maintained at the normal
standard by the increased chemical actions. As long as
the fixed normal temperature of health is maintained in
the trunk and important organs of animal and vegetable
life, no evil results follow. If, however, throngh the
prolonged action of the cold, the materials capable of
keeping up the temperature be exhausted, or if the
nervous and muscular forces be so depressed that the
respiratory and circulating actions are so impaired, that
the materials are not distributed with sufficient volume
and celerity to maintain the necessary chemical changes
to preserve a fixed temperature, the heat of the body
gradually descends, not only by progressive conduction
and radiation, from the exterior to the centre, as in an
inanimated cooling body, but the chilled blood circulating
in the vessels of the exterior, and in the capillaries of the
lungs, mingles with the mass of blood in the interior, and
still farther and more rapidly reduces the temperature of
the great central organs. At the same time, the con-
traction of the vessels distributed through the superficial

1866.] Jones on Treating Pneumonia, 241

structures, under the prolonged action of cold, forces the
blood inward toward the largest venous receptacles, and
thus induces a state of congestion in the central organs.

It is a well established fact, that a fixed temperature is
absolutely necessary to the maintenance of the healthy
nutrition of the tissues, to the proper performance of the
functions of secretion and excretion, and to the regular
and active development of the nervous and muscular
forces. Not only by the congestion of the internal organs,
but also by the disturbances induced in the chemical and
physical processes concerned in secretion and excretion, by
the loss of that amount of heat or physical force, which is
one of the essential conditions to those actions, do those
changes in the mutual relations and constitution of the
blood, and capillaries, and organs ensue, which fre-
quently result in the establishment of inflammation. And
it is not unreasonable to suppose that, during such dis-
turbances, chemical products may be formed, of a totally
different character from those of the healthy organism;
just as in the laboratory, with the same organic materials,
different products are formed under different degrees of
heat ; and also, that the excrementitious matters necessa-
rily resulting from the nutrition of the organs and devel-
opment of the forces may be retained in the blood and
structures, from the congestion of the kidneys, and the
impairment, if not total cessation of the function of
the skin consequent upon the constriction of its pores
and vessels, and diminution of its nervous supplies,
following the reduction of temperature ; and still farther,
that these altered products and excrementitious matters
may irritate certain organs and excite in them inflam-
mation.

As, therefore, the malarial poison destroys those con-
stituents of the blood and nervous system most intimately
associated with, and necessary to, the generation of heat,

r

242 Jones on Treating Pneumonia. [Sept.,

and of all the nervous and physical forces ; and as it
farther depresses the nervous and muscular forces, and
the action of the heart, and the tonicity of the arteries,
and tends of itself to induce congestions of the internal
organs, it is evident that it renders its victims, when ex-
posed to the vicissitudes of weather, and especially to the
prolonged action of cold, exceedingly liable to inflam-
mations.

(d.) The action of the malarial poison is attended, not only
with derangement in various nutritive processes, but also with
the generation of increased quantities of the urates.

In like manner, in inflammations existing in healthy
organizations, when resolution takes place, there is an
increased excretion of the urates.

If, therefore, the existence in the blood, and non-elimi-
nation of these excrementitious bodies in certain diseases,
as gout and rheumatism, tend to excite local inflamma-
tions, it is but reasonable to suppose that their non-elimi-
nation from any cause, as from the effects of cold, previ-
ously described, may, in like manner, tend to excite local
inflammations in those suffering from the effects of the
malarial poison.

(e.) After the excitation of Pneumonic Inflammation from
any cause, the periodic changes, and especially the periodic con-
gestions of the internal organs, induced by the action ofihe ma-
larial poison, tend to aggravate and increase the inflammation.

During the cold stage, the blood stagnates, and accu-
mulates in the capillaries of important organs, because
the blood has been altered by the malarial poison and
the changes which it induces : because the relations
between the blood and its containing vessels, especially
the capillaries, have been disturbed ; because the regular
normal chemical changes necessary for the development
of the forces which work the machinery are not gene-
rated with sufficient energy, or if generated, with even

1866.] Jones on Treating Pneumonia. 243

increased energy, they are not generated in the right
position and in the proper quantities, and the correlation
of the physical, chemical, nervous and vital forces is thus
deranged ; because the action of the sympathetic nervous
system which accompanies the blood vessels, and regu-
lates the circulation, and respiration, and secretion, and
nutrition, and excretion, and relates them to each other,
and to the cerebro-spinal system, has been disturbed by
the direct and .indirect action of the poison, by the direct
action of the poison upon the sympathetic and cerebro-
spinal nervous systems, or by the relations of the chemi-
cal changes induced, or the products generated in the
constituents of the blood by the malarial poison, to the
sympathetic and cerebro-spinal nervous systems.

From these facts and considerations, we arrive at the
following practical conclusions :

First. Whilst the malarial poison cannot be said directly to
produce pneumonia, still it is capable of inducing such changes
in the blood, and in the nutritive and excretory processes, as to
predispose the system to this and other inflammations. And
therefore,

Secondly. The physician should never in the treatment of
pneumonia, in those who have been exposed to the action of
malaria, lose sight of Us effects in complicating inflammation
of the lungs, and of the consequent necessity of arresting at
once, if possible, the farther action of the malarial poison.

As no remedy can compare with quinine for the accom-
plishment of this result, its use would in the present state
of our knowledge appear to be imperatively demanded in
the treatment of pneumonia arising in malarious regions,
and presenting well marked and recurrent paroxysms.

This remedy may be indicated even when the patient
has exhibited none of the symptoms of malarial fever,
before the appearance of the inflammation, for it is well
established that the malarial poison may be present in

244 Jones on Treating Pneumonia. [Sept.,

the system without manifesting any effects sufficient to
excite the attention of the physician or patient. Thus,
mechanical injuries in those who have been exposed to
the action of malaria are frequently attended with the
appearance of paroxysmal fever. Whilst the strength
was unimpaired, the system resisted the morbid influences
of the poison; but when the forces were reduced, by the
injury and the consequent inflammation, then the effects
of the poison were manifest. In like manner the de-
pressing effects of the pneumonic inflammation may so
weaken the forces as to bring the system under the
dominion of a poison, which it had before resisted.

Thirdly. In the treatment of imeumortia in malarious dis-
tricts, the physician should never forget the similarity, in some
important respects, between the effects of the malarial poison and
general blood-letting.

The malarial poison, whatever it be, destroys rapidly
the colored-blood corpuscles. Whatever, therefore, di-
minishes the colored-blood corpuscles, acts in concert
with the malarial poison.

General blood-letting more rapidly diminishes these
important constituents of the blood, so essential to healthy
nutrition, to the maintenance of the nervous and muscular
forces, and to the successful progress and resolution of
inflammation ; because the colored-blood corpuscles rush
along chiefly in the centre of the vessels, and are evacu-
ated more abundantly than the other constituents of the
blood.

The malarial poison also reduces rapidly the forces.

General blood-letting reduces rapidly the forces.

The two, in this particular, again act in concert.

We would not, however, deny that circumstances may
arise where blood-letting, and especially local blood-let-
ting, would be beneficial in malarial fever, and in pneu-
monia complicating this disease. Whenever blood-letting

1866.] Jones on Treating Pneumonia. 245

is used, it should be borne in mind that it does not, and
cannot, cure malarious disease ; its beneficial action is
only temporary, and so far from curing the disease, the
relief which it has temporarily afforded will vanish, if
other remedies, especially the sulphate of quinia, be not
used; and as a general rule, without these remedies, the
patient will be in a much worse condition than if the
blood-letting had not been employed.

In considering the use of general blood-letting in mala-
rial fever, we should ever remember that the cerebral
symptoms, the delirium and the torpor of the intellectual
faculties, and the congestion of the internal organs, are
not inflammatory; they are not due to an exaltation of
the functions, or to an irritation of the congested organs,
but rather to a loss of power in the circulatory apparatus,
heart, arteries, capillaries, and veins, and to disturbances
in the physical, chemical, and nervous forces. Hence,
therefore, in pneumonia, complicated with malarial fever,
we will best guard against those dangerous periodic
changes and congestions, not by depleting, but by stimu-
lating and anti-periodic remedies.

Fourthly. It results from all this, that stimulants and nutri-
tious diet are especially indicated in pneumonia, complicated with
paroxysmal fever.

The nutritious diet supplies the elements of the blood
which have been destroyed ; and the stimulants not only
arouse the depressed nervous system, and through the
sympathetic and cerebro-spinal ganglia, excite the circula-
tory system to a full and salutary action for the introduction
and distribution of the elements of nutrition and secretion
so necessary to the favorable progress and termination
of all inflammations, but they also preserve the elements
of the blood and tissues from too rapid chemical change
and destruction, by taking their places, and themselves
undergoing the chemical changes which are for the

246 Jones on Treating Pneumonia. [Sept.,

development of the physical forces which work the ma-
chinery.

Fifthly. Quinine may arrest inflammations, or promote their
resolution by other modes than its anti-periodic powers, as by
its sedative and excretory powers, or by its influence upon the
nervous system and capillary and general circulations.

If the value of this ascent in the treatment of inflamma-
tion depends upon some such powers other than its anti-
periodic effects, then the important result is reached, that
this remedy is valuable in non-malarious, as well as in
malarious regions.

Upon this question, however, we need definite experi-
ments and investigations.

We hope at some future time to present the results
of experiments upon the effects of quinine, both upon the
healthy and diseased organism, designed to elucidate
those important questions concerning its mode of action.

Finally. We need, above all things, careful records of the
results of the treatment of pneumonia with quinine in full doses.

As far as my knowledge extends, no well established
data exists by which we may determine the relative merits
of this agent in the treatment of pneumonia. I have
heard experienced and intelligent physicians affirm that,
in private practice, when this drug was used energeti-
cally in the early stages of the disease, not more than one
case in fifty would prove fatal. This is surely an extra-
ordinary result, and far different from the results of the
treatment of pneumonia in the Confederate hospitals,
which, it must be confessed, as shown by the hospital
records themselves, are bad enough; and in fact, no
better, and even worse, than the heavy mortality charac-
teristic of the rigid anti-phlogistic method with bleeding,
blistering, calomel, and opium, and tartar emetic. The
Confederate Surgeons did not use blood-letting to any
extent in the treatment of pneumonia, and in many cases

1866.] Joxes on Treating Pneumonia. 247

of this disease employed quinine, stimulants, and nutri-
tious diet.

In our own practice, civil and military, we have used
quinine freely in the treatment of pneumonia, and es-
pecially in those cases which were complicated with
malarial fever, and apparently with marked benefit and
highly favorable results, but we are inclined to the
opinion that a large share of this success was due to two
facts, viz : quinine, a comparatively innoxious, and at the
same 'time a tonic medicine, was substituted for the
heroic and poisonous drugs so extensively employed in
the treatment of pneumonia, and our patients were sup-
plied with nutritious diet, and the strength was sup-
ported; in other words, depressing agents were withheld,
the strength was supported, and nature was allowed to
have her perfect work.

The Confederate statistics demonstrate that but little
confidence can be placed in the dogmatic assertions of
practitioners, apart from a careful record of cases and the
23reservation of the actual statistics.

The careful determination of the value of quinine in
the treatment of pneumonia, as well as the best mode and
period of its administration, as well as the relative action
of this agent in malarious and non-malarious regions,
should engage the careful attention of Southern physi-
cians.

In the institution of any investigations into the relative
value of quinine in the treatment of pneumonia, the
following well-established facts are worthy of constant
consideration.

Uncomplicated pneumonia, especially in young and
vigorous constitutions, almost always gets well, if instead
of being lowered, the vital powers are supported, and the
excretion of effete products assisted.

248 Porcher's Suggestions. [Sept.,

From the accounts which have been published concern-
ing the natural progress of pneumonia, it would appear
that very slight cases of limited inflammation may be
convalescent on the seventh day; that the majority of
cases of medium intensity recover between the seventh
and fourteenth days, and very severe ones between the
fourteenth and twenty-first days.

In the report of the cases, the extent ani character of
the inflammation, together with the symptoms, progress,
complications, and termination of the disease, as well as
the exact period of its commencement and the establish-
ment of convalescence, should be noted with scrupulous
accuracy.

Without the careful record of these points, the value
of such investigations will be greatly impaired.

ARTICLE VIII.

Suggestions made to the Medical Department. Modifications
of treatment required in the management of the Co? federate
Soldier, dependent upon his peculiar moral and physical
condition ; with a reference to certain ptoints in practice. By
F. Peyre Porcher, M. D., Surgeon in charge City
Hospital, Charleston. Formerly Surgeon in charge
of the General (Naval) Hospital, Norfolk Harbor, and
the South Carolina Hospital, Petersburg, Va.

[This paper was prepared just before the close of the war, by direction of the
Surgeon-General. He is not responsible, however, for the opinions contained
in it, as it reached his office at a very late period, and could not be acted
upon by that able officer. Though written with a view to impress upon surgeons
greater attention to peculiarities which were believed to be characteristic
of the soldier of the Confederate army, and which could not be neglected in
his treatment without detriment, it is believed that many of the considerations
contained in it apply, not only to all those engaged in war, but to others
employed in civil practice.

In recalling to the memory some of those sad deficiencies which were as
fatally prevalent as they were easily remediable, it affords a warning to those
coming after j whilst it gives a medical officer an opportunity to pay a slight
tribute to the exceeding heroism of the Southern soldier.]

1866.] PoRCHEirs Suggestions. 249

I wish to make my remarks as brief as possible. I
enter upon them witli the greatest diffidence ; and would
most cheerfully commit the task to abler hands but the
-conviction is so strong upon me, the results of my own
experience strengthened by conversation with a number
of surgeons in the army, that I am induced to offer them
for the benefit of the junior members in the medical
department

Whatever follows is written for the good of the service,
and any personal allusions are disclaimed. The relations
of the writer to those he has had the honor to have under
his control, or with whom he was officially connected,
have very generally given him the greatest satisfaction;
and he is enabled to testify to the zeal, fidelity, and ability
with which they performed the duties entrusted to them.
Differences of opinion, nevertheless, on points connected
with therapeutical indications, pathology, or the policy of
measures, might sometimes very properly and naturally
arise and be discussed with advantage.

There are certain prime fundamental facts connected
with the soldier, as he offers himself for treatment, which
require to be brought to the attention of the surgeon, in
order that he may be thoroughly impressed by them ; and
that the sick and wounded under his care should contin-
ually feel their influence. They are of the very highest
importance, and therefore, life or death, recovery or tedi-
ous convalescence depend upon their constant observance.
That I undertake their presentation and recommend their
enforcement, is simply because no one else, at this late
date, has come forward to give expression to them.

The success of a medical man, or his want of it, depends
upon the doctrines he entertains. His theories, views,
abstract ideas even, govern and control his practice. For
this we have the authority of the greatest of English
philosophers, Lord Bacon, quoted by Mialhe: "Si les
17

250 Porcher's Suggestions. [Sept.,

experiences ne sont pas dirigees par la theorie, elles sont
avengles ; et si la theorie n' est pas sontenue par 1' experi-
ence, elle devient trompeuse et incertaine." Not only the
selection and administration of medicines, the therapeuti-
cal or surgical appliances, but also the general care which
he bestows, or sees that others under him bestow, upon the
sick, are determined by the opinion which he entertains
of their necessity. We must, therefore, endeavor to
modify his views respecting the relative importance of
certain agents employed by him, if, when carried into
practice, the results seem injurious or fataL I will first
invite attention to the secondary rank held by medicines
in comparison with other agencies.

Medicines are not the only agents that are successfully
used in the cure of the sick many things besides, a
knowledge of which is obtained by observation, reading
or experience, under the control of common sense, are
also absolutely necessary to their recovery.

The seeing to the proper observance of other general
and particular directions are equally as essential as the
administration of drugs at stated times. The surgeon, or
assistant surgeon, who merely visits his wards, examines
his patients, prescribes secundum artem, orders the rou-
tine administration, and dismisses the patient and attend-
ant until the usual hour for a repetition of his visit, has
only acted the part of a formalist, and he cannot be suc-
cessful. In the case of those critically ill, there are a
great many directions respecting the proper administra-
tion of food and stimulants, the maintenance of warmth,
avoidance of exposure, improper getting up, etc.; all in-
volved in the comprehensive word, management, that are
of the first importance, and need to be pressed most
forcibly upon the attention of nurses and wardmasters.
These are even more strongly the duty of the surgeon,

1866.] Porcher's Suggestions. 251

because they are likely to receive little regard from subor-
dinates, whose duty it is to carry them out, but who natu-
rally pay little attention to them in comparison to their
minds, the vastly more important consideration, of duly
administering the medicinal agents. However ward-
masters may look to them as supreme and the only
effective weapons, the sick cannot get well upon med-
icines only. They do not cure. They are essential in
the cure : for they tend to restore the diseased organs
to a condition of health through the purturbative influ-
ence in modifying secretions, acting upon glands, pro-
ducing catharsis, diuresis, diaphoresis, lessening pain and
irritability, checking secretions, etc. Thus removing
materies morbi, urates, phosphates, dropsical accumula-
tions, serum, and other effete substances, the products of
digestion, of metamorphosis of tissues, of destruction of
proteine compounds, combustion during fever, inflamma-
tion, and so forth.

But after all, food is the principal agent which assists
in the cure, and its administration in proper quantity and
quality is of prime and absolute importance, in compar-
ison with which all other means sink into insignificance.
If this is a truism, it has been singularly slighted in our
army, and the effects have been disastrous. Eecovery in
the great majority of cases is brought about through the
instrumentality of the digestive organs; by the restoration
of the activity of the absorbents, of the venous rodicles of
the gastric and mesenteric veins and chyle ducts, the
proper sucking up in the digestive track of the "raw
material of the blood," which must at all hazards be
supplied, and which alone is gifted with the power to
restore wasted muscle, blood, brain, nerve substance,
adipose tissue which, in a word, brings the patient back
to a state of health. The great object of all our thera-
peutical efforts in the large proportion of cases occurring

252 Porcher's Suggestions. [Sept.,

among soldiers is to restore the diseased organs, particu-
larly the intestinal canal and its appendages, to that con-
dition of integrity by which they can absorb and assimi-
late food, recuperate the exhausted and impoverished
system, and repair the waste produced during the course
of the disease. Even in purely surgical cases the sufferer
must ultimately depend solely upon the sustenance afford-
ed by the same set of organs to rehabilitate his frame, and
it is through the instrumentality of nourishment alone
that the drain produced by excessive suppuration is
neutralized. I do not magnify, therefore, the necessity
of maintaining them intact and of supplying the pabulum
required.

Food must be procured and administered, or all other
exertions prove futile. It should not be left to the
matrons or nurses to parade three times a day, at meal
time, to divide out and distribute the customary ration.
Those sick a long time with acute or wasting diseases, so
common among soldiers, should receive suitable nourish-
ment by an inexorable rule at frequent intervals, day and
night, even in small quantities, as the only means of their
rapid and effectual recovery. An attention to this point
is of greater importance than any other single considera-
tion which belongs to the treatment of the sick soldier.

Let us examine into the principles upon which these
views are based, and if correct, let them be urged most
strenuously upon the attention of every officer in the
service, who is by any possibility likely to disregard
them.

What is the most obvious and striking peculiarity of a
very large proportion, nearly all, indeed, of our soldiers
who are brought into an infirmary or hospital for treat-
ment ? The dominating fact which must impress and modify
the whole course of treatment to ivhich any judicious surgeon
would subject him, unquestionoMg is prostration. This is

1866.] Porcher's Suggestions. 253

accompanied by weakness, nervous irritability, loss of
flesh, the result of bad food, or of food insufficient in
quantity, and of unusual privation and exposure to cold,
to wet, and to depressing emotions. Chronic diarrhoea
has also previously existed, or is present, in- almost every
case. Exhaustion, then, is the great characteristic as well
as the essential element to be considered and combatted.
In the soldier it may very properly be called chronic
almost every act of his military life has tended to produce
it. Its repair must consequently be kept in view by the
surgeon at all times, at every moment, and in every pro-
cedure which he puts in practice for his relief. Surgeons
in the Confederate army will acknowledge this to have
been eminently the characteristic feature in the patholog-
ical condition of those brought under their care, and yet
many of them instituted no modification of treatment
based upon this prime fact in their history.

The medical officer of the present day, practicing in the
army, who loses sight of this; who is not thoroughly
seized and possessed with the idea of unusual prostration
and feebleness in the vast proportion of his cases ; who
disregards the essential previous and present condition of
his patient, so markedly adynamic, has committed a
grievous error. If adopting exclusively the teaching of
any favorite author, he will carry out upon such sufferers
the written instruction of works not devoted to the con-
sideration and treatment of the diseases incident to the
soldier, or which fail to recognize this feature of their
condition, he is pursuing a vicious and ruinous system.
If his mind is filled with the intention to test all those
long lists of prescriptions which he has been in the habit
of employing in civil practice the same sugar of lead and
opium, the same infallible calomel, five grains every three
hours, the same drastic cathartics, without a moment's
attention to the special peculiarity of the man before

254 Porcher's Suggestions. [Sept.,

him, is most grievously at fault, and his efforts must
prove unsuccessful or be attended with disastrous results.
The correctness of these cautions, the reality of the prin-
ciples upon which they are based, and the necessity which
exists for their dissemination, has been acknowledged to
the writer by nearly every intelligent officer with whom
he has conversed.

Of course, individuals differ, and varying degrees of
robustness, constitutional vigor, stamina, etc., are found
to remain in those coming under the care of the military
surgeon ; but even in cases apparently most favorable for
the use of a depletive, purturbative, or anti-phlogistic
course, there should be a reticence with respect to the
employment of active medicines. By an almost absolute
rule the mildest and least irritating should be selected
and used in the smallest quantities ; they should be
diminished or discontinued as soon as possible, and they
should be combined, or neutralized, by those agents,
dietetic,*medicinal, or regiminal, which support and give
tone to the system. Throughout the treatment of almost
every case nourishment, however small in quantity, should
be introduced at appropriate intervals. Even in control-
ing by medicines whatever amount of inflammation there
may be present, we must constantly seek to strike that
nice balance, that delicate boundary line, which marks
how far we can go and no farther. Here the judgment
of the experienced and enlightened physician is capable
of its finest displays and is exercised with the best results.
Let the surgeon be prone to employ external means as
substitutes for internal, to avoid all weakening, depletive
treatment, all irritating cathartics ; in cases of fever, let
him use cold effusions assiduously, mild, cooling, catalytic
agents, renal depuratives, salts of potash, chlorate of
potash, neutral mixtures, milk, eggs, beef tea, brandy,
milk punch, etc. Vegetable astringents, turpentine, etc.,

1866.] Porcher's Suggestions. 255

guarded by opium and demulcents may also be required ;
neither must he depend solely upon stimulants, and
attempt, at the last moment, to save life by them.

In treating ninety-nine soldiers out of every hundred
the great object of the surgeon should be to follow
Chomel's golden maxim and do him no harm. He must
strive to administer the remedial agents that appear to be,
and are necessarj^, in barely sufficient quantities to dimin-
ish the existing disease without impairing the integrity of
the digestive and assimilatory functions, through the in-
strumentality of which alone, he knows (if he thinks at
all), that he must depend for the subsequent restoration
of the patient. He must remember that the subject is
not a hearty countryman, recently let loose from " fresh
fields and pastures new," with rich and florid blood, and
actually suffering from an overabundance of phlogiston,
but on the contrary, that he is precisely in the opposite
condition. He has been reduced by all the usual priva-
tions of the soldier's life. These are aggravated by cir.
cumstances in the ease of the Confederate soldier, which
are almost peculiar to him, namely : want, exposure, its
attendant depression, and toil, oftentimes prolonged to a
degree from which he has finally succumbed through
sheer breaking down of the powers of life. If he must
be physiced, let it be done most tenderly and charily.

Let his remaining vital forces be husbanded by every
means in the power of the attendant. It is more impor-
tant that he be builded up, strengthened, and sustained
at every convenient opportunity by stimulants and nour-
ishment These should be secured by every personal
exertion of the surgeon in charge, and his efforts should
be directed to this all-important subject. He should
never content himself simply with making the usual
monthly requisition for medicines, but should devote every
energy to procuring what is so obviously of equal, if not

256 Toucher's SugjesiionSr [Septr

far greater importance,, namely: the proper supplies of
those articles of food, upon the judicious and timely
administration of which those under his care depend
more than upon any other means at his disposal. He
must send out agents; if need be, appeal to the ready
or reluctant patriotism of the rich huy, borrow, or beg
but they must be had. Those who take the trouble,,
generally succeed in obtaining what they wish.

If the sugeon is willing to content himself simply with
conforming to the Regulations, paragraph so and so, he
may neglect all this ; he may pass for an excellent officer
and may please all in authority over him who cannot look
into the daily operations of his charge : for he can hand
in at the end of every quarter the usual prescribed bill of
mortality, nicely drawn out by his clerk on clean sheets of
ruled paper but he will still be far from performing his
duty to his country or to his fellow-soldier. The chief
weight of his responsibility does not lie with the medical
department, the general regulations of which are impor-
tant to any well-ordered establishment, but it lies with
the great cause we are sustaining. A sacred and heavy
responsibility is in his own bosom toward the sick them-
selves. Their span of life, as far as human efforts go, is
in his hands; their parents, relatives, and friends look to
the surgeon, that under the direction of an ably-managed
and most admirably-conducted administration, he also
uses every energy, devotes his whole soul to cary out his
part of the duty he owes to those entrusted to his care.
To the sick soldier he stands in loco parentis. If he has
not entered eon amore upon his labors ; if, whilst looking
after a thousand personal interests, present or prospective,
he is lax, indifferent, and willing simply to save himself
by only obeying orders and shunning mere military
responsibility, he can get through very easily and seem
to be a model officer. Through a careless or ignorant

1866.] Porcher's Suggestions. 257

disregard of the things most essential to success, the object
and sole aim of his assignment to his post is entirely lost
sight of, which is : saving life, if possible, by every exer-
tion, and the returning to duty, in the shortest possible
time, tuto, cito, et jucunde, those temporarily under his
control. Our hospitals and infimaries, in a provisional
army constituted as ours is for an emergency, are not
military hospitals in every sense of the term, to be con-
trolled only by the stern rules of war ; nor are surgeons
enfants terribles, whose chief duty is to hold themselves
unapproachable and aloof, in a cold and forbidden isola-
tion, jealous of position, and hedged off by rank from the
ignobile vulgus of the sick. Our cause is sacred; the
common impulse is patriotism ; our patients are our
brethren, generally from the front, often with equal
social position. They are temporarily inferior in military
rank, only on account of the superior medical education
of the surgeon, who needs only to restrain them within
the bounds that military subordination, orders, and dis-
cipline have made advisable. The humblest private may
be the true hero, worthy of our tenderest care, and all
the kindness we can bestow upon him. In attending
upon the sick or wounded, no office can be too servile, or
degrade him that performs it.

We do not lose either in dignity, position or influence
by being always accessible at the proper time. It is a
painful spectacle to the humane surgeon to witness the
fear, almost approaching to servility, with which a sick
man, scarred by bullets, hesitates for days to approach
the medical officer, who should be his friend and coun-
sellor. Tor should we allow wardmasters, or other
attachees, to lord it unnecessarily over those who are in a
great many cases their superiors in every qualification
which distinguishes a man, a gentleman, or a soldier.

Some men seem rather to delight in human misery, so

258 Porcher's Suggestions, [Sept.,

that it be military ; and care not to smooth a path which
is rough enough at best. Others are advocates for the
enjoyment by every one of the greatest degree of happi-
ness and comfort which is compatible with the general
welfare. The Confederate surgeon should always place
himself in the latter class, and whilst shunning too great
familiarity or intimacy with subordinates, which generally
leads to bad results, he should endeavor to make his hos-
pital or infirmary a well-ordered asylum for the weary,
the wounded, and the sick. Every privilege or kindness
not conflicting with proper discipline and a safe return to
duty should be extended to its inmates, with the studi-
ous avoidance of everything like a multiplicity of petty
or worrying regulations, calculated only to distress or
harrass those who have enough hardship to endure, whilst
enjoying comparative health amid the dangers of the
field. When a soldier becomes justly entitled to the
privileges of a hospital, there should be a truce to all
suffering save what is inevitable.

The ambition of superior cleanliness, whether it be a
permanent or a spasmodic feeling, should not be pushed
to extremes, and be considered the one thing needful in a
hospital, lest it blind the eye to the absence of other
things which are more important. The possession of the
neatest and cleanest wards may co-exist with radical
defects of the gravest character for outweighing the
quality of mere cleanliness, which is very excellent.

All excessive medication, drastic purgatives, compound
cathartic pills, calomel in large doses or long continued,
should as a general rule be particularly avoided. Perse-
verance in medication, save that of the mildest character,
should be eschewed. Even the pure medicine expectante
system, which has been wittily styled a " meditation on
death," is better than the old heroic one in a very large

1866.] Porcher's Suggestions. 259

majority of cases, marked as they are by the debility
which I have described as the prominent characteristic.
Having devoted many years to studying and teaching
Therapeutics, the writer is far from uniting with the nil
admirari school ; he does not agree with either Forbes,
Holmes or Bigelow, or with those who consider it a mark
of superiority to deride all medical treatment as nugatory
or mere guess-work. He firmly believes in the great
value and essential importance of judicious and correct
medication ; and is of the opinion that Mialhe, Trousseau,
Headland, Billings, Wood and Stille, may be consulted
with profit both by students and practitioners of medi-
cine. To hold the doctrine, professed by some, but only
in theory, that medicines are not beneficial, or that they
do not either cure, or aid in the cure, is idle and not
worthy of discussion particularly before those who con-
tinue to order them so freely. Every case is susceptible
of good or bad management, and there is a vast differ-
ence between the two.*

I repeat, that though medicines are essential and neces-
sary, still they are not the only things necessary. In
using them, especially upon such subjects as those with
whom we are at present concerned, the doses should be
far less in quantity than are, I fear, usually prescribed;
nor should they be had recourse to so continually.

In giving calomel, for example, in alterative doses, ,
J or J a grain, with ^, J or J of ippecacuanha, Dover's
powder, or opium, three or four times, is amply sufficient

*M. Chomel, in his Elemens de Pathologie Generale, Troiserae Edition, p. 582, Paris, article
M Therapeutique," gives a most concise decision as to the effects of treatment. I commend
it to those loose talkers of both extremes, generally men of a speculative turn of mind, and
often without practical experience, who either decry or exalt the action of Therapeutical
means :

Nous voulons dire 6eulement que nos moyens therapeutique n'out pas une action directe
contre la maladie, qu'ils n'agissent qu'en determinant dans l'economie des modifications en
vertue desquelles s'opere le changement favorable qui prepare et acheve la guerison; rex-
traction des corps etrangers et la reduction des parties deplacees fout presque seules excep-
tion. En exposant cette doctrine, generalement admise aujourd'hui, nous n'enlevous rien a
l'importance de la therapeutique, et vous rendous a la nature ce qui lui appartient: egale-
ment elorgnes de ceux qui donnent exclusiTement l'honneur de la guerison, soit a l'art, soit a
la nature, nous croyous que la concours de l'un et de l'autre et toujours utile et souvent in-
dispensable.

260 Porcher's Suggestions. [Sept.,

for all purposes. The surgeon has to be particularly
careful how he saturates such systems with mercury, or
prolongs its use even in the minute quantities which the
writer has found abundantly sufficient. The Surgeon-
General of the U. S. Army probably did much more
good than harm when he entirely prohibited the use of
calomel.

Dr. Law's statement, that one grain of calomel in
twenty-four powders, given at sufficient intervals, will
produce as full or a greater effect than a larger quantity
not so minutely divided, and frequently administered, is
important, as it affords a practical deduction. For, as
Miallie describes its action, " Chimie appliquee a la Phy-
siologie et a la Therapeutique," it is through the instru-
mentality of the alcaline chlorides that mercury gains
admission into the system, and only a proportionate
amount is in a given period dissolved and absorbed. This
change is for the most part effected in the liver.

Besides the great tendency to gastric irritability in
many soldiers, the previous existence of chronic irritation
of the stomach and gastro-intestinal mucus membrane
renders an attention to this point respecting the quantity
used especially important, as it allows the surgeon the
earlier to retrieve the disastrous effects which so fre-
quently follow large doses of the drug.

My hospital experience alone of ten years has con-
vinced me that, however valuable, essential indeed, the
occasional use of mercury may be particularly when
guarded by small quantities of opium or Dover's powder
with the simultaneous administration of alcoholic
stimulants, yet when prolonged, even in small doses, it is
to the mercury we may justly ascribe the diarrhoea and
wasting discharges which very often carry off the patient.
The persistent use of calomel is very frequently the
direct and only cause of the irritation of the mucus

1866.] Porcher's Suggestions. 261

membranes marked by the " running off" at the bowels.
The insidious and fatal colliquative diarrhcEas sifpervening
in pneumonias, fevers, etc., are often the sole work of the
inordinate and prolonged drugging. They are never
beneficial; they diminish rather than promote the ac-
tivity of the absorbents; cause the surgeon to lose time
in the effort to arrest the discharges; and give rise to
the worst inconveniences, even where they fail to turn
the scale in the wrong direction.

I am not indulging in special pleading, or in the slight-
est degree pushing the advice to extremes, when I unite
my voice with others in urging the whole corps of army
surgeons who have not done so to test the use of mer-
cury in doses of one sixth to one half a grain. Let the
latter be the maximum amount when used for the altera-
tive effect, as in cases of peritonitis, pleuritis, uretis,
hepotigation in pneumonia, and other similar conditions.
Two grains is far too large a quantity to be repeated
every two or three hours for days, as it is not only
injurious but useless. The minimum doses when carried
to excess can be recovered from more readily by being
sooner eliminated from the system through the aid of
laxatives, the oxygen-bearing bodies, chlorate of potash
or other catalytic agents. I doubt extremely whether
calomel in ten-grain doses is ever borne by the Confede-
rate soldier. Its repetition in this quantity is scarcely
ever admissible, unless in an occasional case of obstinate
engorgement of the liver or violent constipation occurring
in a robust subject.

Let the idea be for ever exploded, especially in our
military hospitals and infirmaries, peopled as they are,
that each sick man is of necessity to have one or two
"bilious" evacuations each day or he must be' dosed
until he does. Such rules are bad enough even in the
rural districts and among highly-nourished civilians. The

262 Porcher's Suggestions. [Sept.,

ordering calomel indiscriminately and upon every occa-
sion for its supposed general applicability is simply
atrocious.

If ptyalism is ever advisable, and it sometimes cannot
be avoided, let it be only the very slightest mercurial
effect, and not carried so far as to produce salivation.
They remind one of the comparison instituted by the
Jewish women between Solomon and David ; the execu-
tion of each is great enough, though one may have only
slain its thousands.

I append an extract which I had quoted from Stille's
Therapeutics, v. ii., in my Prize Essay, published by the
South Carolina Medical Association in 1861.* Dr. More-
head's description should be written in letters of gold. I
endorse in full the doctrine it conveys, and believe their
adoption in practice would be a great boon conferred by
the practitioner of medicine upon the people. It was
only confirmed by my own previously-acquired experience
during six years service before the war, in charge of the
Marine Hospital, Charleston, in the General Hospital at
[Norfolk, and the S. C. Hospital, Petersburg, Va. :

" The cholagogue action of mercury is invoked in this
affection to relieve the overloaded liver, as it is in yellow
fever to stimulate the non-secreting liver. Leaving unat-
tempted here the task of reconciling these apparent
contradictions, let us endeavor to learn whether or not
experience has proved mercurials to be useful in bilious
remittent fevers. In reference to their 'purgative action, it
may be remarked that this is generally sought for at the
beginning of an attack, by the administration of ten
grains of calomel at bed-time, and some saline laxative,
or else jalap, on the following morning. But even at

Illustrations of Disease with the MicroscopeClinical Investigations aided by the Micro-
scope and by Chemical reagents, with Microscopical observations of Pathological specimens,
Medical and Surgical, obtained in Charleston, S. C, with upward of 500 original drawings,
made from nature ft'atura maxime miranda in minimis Linnaeus. Charleston, S. C,
C S.A.

1866.] Porcher's Suggestions. 263

this stage such treatment is unnecessary, unless the abdo-
men is full and hard, the tongue much coated, and the
alonic evacuations sensibly disordered. In this disease
the real remedy is quinia, and it is much better to obtain
its specific operation as soon as possible, feeling assured
that then the associated local derangements will be all
the more readily removed.

" It may be presumed that the employment of calomel
as a constitutional remedy in this disease, whether by the
daily repetition of slightly laxative doses, or the more
frequent administration of still smaller quantities, is still
the general practice in some portions of the United
States.* So far as these forms of the disease are con-
cerned which originate in the Middle States of the Union,
we have never found it necessary to prescribe mercurials
except as purgatives, relying for the cure of the disease
upon quinia alone. It is possible that the more inflam-
matory form of remittent fever met with in Southern
latitudes may call for a different management. [My own
experience has convinced me that it does not. It should
not be selected, even as a purgative in the case of the
Confederate soldier.] But the excellent reports of Dr.
Boiling, and several other Southern physicians, render
this supposition improbable. Moreover, if we turn to
the East Indies, whence the calomel treatment first ema-
nated, we shall find that it no longer holds its original
place in the medical creed of that country. One of the
most eminent of the East Indian practitioner's; Dr.
Charles Morehead, says :f 4 The practice, at one time too
common, of exhibiting calomel in doses of four or five
grains three or four times in the course of the day, with-
out any very definite object in view, and continuing it for
a succession of days, cannot be too strongly discouraged.

Compare Boiling, on rein, fever. Am. I. Med; S. C, July, 1840, p. 29, and Dickson's
Elems. of Medicine, p. 243.
fClinical Researches on Diseases in India, i., pp. 202-200.

264 Porcher's Suggestions. [Sept.,

Xot only is it unnecessary, but for the following reasons,
often positively injurious. In watching the progress of
cases thus treated, it is not difficult to detect a train of
symptoms much more fairly attributable to the treatment
than to the disease, because it is in cases thus treated that
this has been chiefly observed. The symptoms to which
I allude are uneasy feeling, sometimes amounting to pain,
with a sense of oppression or sinking at the epigastrium,
and occasionally griping of the abdomen, for which
leeches are not unfrequently applied, and purgatives un-
necessarily given. The frequent repetition of the calomel
keeps up also a foul state of the tongue, nausea and irri-
tability of stomach, aggravates the febrile excitement,
and produces an irritable state of the bowels, marked by
frequent watery discharges. The convalescence of cases
thus treated is always tedious, and frequently complicated
with diarrhoea and clay-colored dejections.' <I am of
opinion that an endeavor to induce mercurial influence in
remittent fever is erroneous in theory, and of no value in
practice;' not only so, but 'it is opposed to all rational
theory, and very injurious in practice. If it be true that
prostration of vital actions and a deteriorated condition of
the blood are pathological states to be much dreaded in
remittent fever, and if mercury deteriorates the blood
and favors prostration, on what principle of reasoning can
it be supposed that induced mercurial influence can have
any other than an injurious effect on remittent fever?'
The author further attributes to the mercurial treatment
so long prevalent in that country, the frequent occurrence
of a cachexia marked by asthma, dyspepsia, injured teeth,
pains in the side and loins, foul tongue, constipation, pale
faces, and depressed spirits."

From my experience in the Marine Hospital, where a
large number of the worst forms of malarial fever were
treated, with a very large proportion of recoveries (see

1866.] Porcher's Suggestions* 265

report In detail, Charleston Medical Journal), I ascertained
that, with the exception of an occasional dose, mercury
could be dispensed with. A few grains were given at the
inception of some cases, and occasionally, in combination
with a little Dover's powder, was administered at night to
others in whom there was not much prostration. Few or
none of the cases of bilious remittent fever, even of the
severest grade, require more than ten grains during the
whole course of the attack.

There is no objection to using two grains of calomel
with two or three of Dover's powder occasionally, in
cases of typhoid fever or typhoid pneumonia with dry
tongue ; and it has an excellent effect when given simul-
taneously with brandy or turpentine, one or both, and
chlorate of potash water as a drink. These, with nour-
ishment and revulsives (and cupping and poultices if the
case demands them) are pretty much all that are required,
where we conclude not to treat the diseases with veratrum
viride. By giving mercury thus, in combination with
Dover's powder at distant intervals when necessary, we
avoid its injurious effects. The stimulant will be found
still farther to neutralize and counteract any ill effects of
the medicine, besides being itself specially serviceable in
improving digestion and preventing depression of the
nervous centres. This employment of stimulants simul-
taneously with mercury I have found an important point
in practice.

I have also seen excellent results recently from a com-
bination of Dover's powder, three or four grains with
three of antimonial powder and one half of calomel, as
an alterative, expectorant, and diaphoretic in pneumonia
and to prevent the approach of hepatization of the lungs.

Turpentine also, which is so extensively used, need
never be given in doses larger than five to ten drops
repeated. It will sufficiently stimulate the intestinal
18

266 Porchek/s Suggestions. [Sept,

mucous membranes in this quantity; and with an occa-
sional mercurial and wine or brandy, will produce alhwe
expect of it in acting- upon the mucus surfaces, in pre-
venting depression of the nervous centres indicated by
dry tongue, delirium, etc.

I have established three or four rules whichr in my
opinion, may be regarded as general principles in medi-
cine, which I will state before passing to other matters :

1st. The natural tendency of disease is to recovery in
all fair cases when judiciously treated, not improperly
interfered with, and suitably nourished and supplied the
hygeinic conditions being also favorable. Bad treatment,
with defective management, will destroy even these.

2d. When the tongue continues dry, alcoholic stimu-
lants can and must be used repeatedly and freely till it
becomes moisty because it indicates want of glandular
and secretory action, caused by depression of the nervous
centres. The quick pulse is simply owing to the altered
condition of the blood and the defective innervation, and
stimulants are not contra-indicated. To administer pur-
gatives or mercury merely because the tongue continues
furred, is ruinous.

3d. At the inception, or even in advance of delirium,
apply blisters to the back of the neck and upper portion
of the spinal column. The stimulants may also be con-
tinued.

4th. Alkalies are serviceable-in the inceptive and early
stages of disease ; acids after the inflammatory symptoms
are subdued and the climax is passed or during the
decline of the disease following the protracted use of
depletive and active medicines. Acids with tonics are
universally applicable when the stage of excitement has
been subdued by active medication, and there is relaxa-
tion, weakness and prostration, and excessive drain from
any cause.

1866.] Porcher's Suggestions. 267

I would also inculcate upon the junior members of the
profession (as the result of my own experience repeatedly
acquired from experiments made with a view to testing
the question of its safety) that, when pushing any course
of treatment but particularly one whose possible ten-
dency is to produce irritation or diarrhoea it is best to
check the treatment, or to desist from it, even before its
full beneficial results appear to ensue. Let them inva-
riably err on the side of abstinence, and thus give nature
time to operate her own most excelling handiwork*
They will seldom, if ever, regret the "hands off" system.

It has often happened to the writer whilst carrying out
a cautious, non-purturbative course of treatment, as above
indicated, to question the policy of prolonging it to fear
that the diseased condition, a hepatization of the lung for
example, would be re-established, or an inflammation be
relit for want of more active measures. I have always
found that a favorable result followed the cessation of
treatment at the earliest possible moment earlier than
many would have supposed judicious, particularly when
aided by external revulsives, demulcents, salines, sponging
with cold water, etc.

Merely to extol the recuperative powers of Nature and
satisfy ourselves with the trite quotation "vis medicatrix,"
etc., is useless. Let us do what is better: believe in her
practically, give her a fair chance to assist in the cure
before organic changes have taken place, and the powers
of life are fatally compromised.

Among the general suggestions that I would respect-
fully offer, are the following :

If to superior judgment, skill and experience possessed
by one physician over another, there be added one habit
to be cultivated for its real practical effect in promoting
recovery, it is that of encouraging the sick. Let it be no
idle mannerism put on or assumed for effect. It is a

268 Porcher's Suggestions. [Sept.,

"third estate" in physic, and is ntext in importance only
to food and medicines. It is absolutely potent in its plain,
positive results, for the sick man, in his weakened state
with his nerves unstrung, is a prey to his diseased imagi-
nations, and depression of spirits greatly diminishes the
recuperative energies of the entire organism. He has the
"mens insana, in corpore insano." The fancy prone to
despondency, and inclined to look at the dark side of
things, has dethroned the judgment; and it is the busi-
ness of the surgeon to reinstate hope and cheerfulness in
his heart, on account of the influences which he knows
they have upon the vital functions, the secretions, the
appetite, and consequently the power with which he
responds to remedial agents. By a pious fraud, if neces-
sary, he should conceal from his patient all useless knowl-
edge respecting his pulse, tongue, amount of fever,
criticalness of condition, so long as the concealment
will tend to lift him out of his state of gloom, despon-
dency, or apathy, and will inspire him with anticipations
of recovery. The beneficial effects of instilling cheer-
fulness and hopefulness cannot be overestimated, and the
sufferer should never be left without some encouraging
word. We have all witnessed the sudden and extraordi-
nary revolution produced, even in the desperately sick or
wounded, by the anticipation of a furlough and the hope
of revisiting their homes. Revived hope, as with the
wand of an Enchanter, kindles new life in the worn-out
frame.

From the brief and imperfect description I gave of the
depressing and exhausting effects produced by the cir-
cumstances which surround the Confederate soldier, this
course of conduct becomes of the first importance in
reference to him.

The " Pathology of Shakespeare," as the learned, com-
prehensive and elegant Watson has called it, when he

1866.] Porciier's Suggestions. 269

speaks of " rasing out the written troubles of the brain,"
and " ministering to the mind diseased," may therefore
be observed by the surgeon with the greatest advantage.
Superadded to the prostration and general asthenic state
which I have asserted to be the dominant feature of our
sick soldiers, there is also very generally extreme apathy
as to results, however sombre may be their complexion,
or even fatal to their hopes, wishes, or lives.

The Confederate soldier resigns himself to his fate.
Once that it is decided that a return home is impossible
for him, and he must remain in hospital, the physiognomy
of his condition is admirably expressed by the Italian
phrase poco curante, which he carries in every feature of
his face, in his gait, and in his bearing. He really seems
to present the unusual spectacle of a man devoid of
either hopes or aspirations; or if he has them, they
are suppressed. When he entered the service, whether
from compulsion, or, as in nearly every instance, urged
by a noble patriotism, his mind was prepared for any
fate; the scenes of danger, also, through which he has
passed have strung his nerves to so high a pitch of tension
so much higher than mere sickness, which is far below
the battle-field in the stirring intensity or the elevation of
the emotions it excites that he is not impressed by his
present peril, however imminent may be the fate which it
threatens. He is therefore languid, careless and indiffer-
ent, and his mind needs to be aroused and stimulated.

There is no one so uncomplaining as the Confederate
soldier. Every surgeon who has seen active service will
confirm the truthfulness and accuracy of a picture drawn
without exaggeration. In your daily rounds to offer him
relief he gazes upon you, but does not complain that you
pass him by, asks for nothing, does not bemoan his fate,
nor murmur at the insufficiency of either food or attend-
ance. He may lie sick under a broiling sun, in a heated

270 Porcher's Suggestions. [Sept,,

tent, or wounded; he may languish in a hospital, amid
the dying and the dead, surrounded by everything to
appal even well men :

"Ubique luctus, ubique pavor
Et plurima mortis imago."

Yet the mere stripling possesses his soul unterrified,
and utters neither ery nor groan. There has always been
a courage, and a resolution mingled with his apparent
indifference, which has extorted my admiration, and has
compelled me involuntarily to recall the noble description
of the invincible Cato, whose unsubdued spirit soared
aloft when the world crumbled at his feet :

" Omne terrarum subacta,
Preter atrocero animum catonis."

In this display of his courage, there is an inexorable
sternness almost amounting to atrocity.

When the soldier, leaving friends, kindred and home,
delivers up his life for his country, he has paid the dearest
tribute that man can offer, and there is a moral sublimity
in the act which ennobles the very poorest. In every age
the sacrifice has been immortalized in verse and song, and
the divine Dante says of him :

" He goes in quest of Liberty which is so costly
As he knows best who suffered default of life for it.n*

I have always thought that the Roman maxim obsta
printipiis, expressed very finely the proper policy to be
pursued by the physician and surgeon in the treatment of
diseases or surgical injuries. Among the practical sug-
gestions of a general nature, I wish to give prominence
to it, as embodying a useful principle : for many surgeons
lose time and worry themselves, or become discouraged,
because they fail to manage successfully those who are
beyond the reach of art. Early treatment should be

Liber ta va cercaDdo, ch'e si cara,

Come sa chi per lei vita rifiuta." Purgatorio, ., p. 71.

1866,] Porcher's Suggestions. 271

regarded as almost a -sine qua non to suecess. In other
words, lose no time at the beginning of diseases, or as
soon as they are presented for treatment Then you can
arrest more easily and completely the spread of symp-
toms; for the danger of organic changes, of blood-poi-
soning, of passive congestions, of secondary accumula-
tions, of depression of the nervous centres with its results,
increase in a geometrical ratio the longer they are
permitted to remain unchecked. The surgeon should
never permit a hot, burning fever to continue, if it be
possible to prevent it by remedial agents, sedatives,
cooling applications, etc., for when the passive congestion,
coma, or delirium follows, it is too late. Let it be re-
membered that medicines are far more potent in prevent-
ing or arresting diseased states than in curing them when
fully developed, and it is especially difficult to do away
with the ill-effects of the secondary results of disease.
After surgical injuries, use cold water at the beginning
and continue it unmteruptedly, and do not wait till the
inflammation has run too high, or an hour even is lost
Do not strive so much to recover a patient after an
engorgement or a hepatization of the lung as to prevent
them. Anticipate these changes by energetic means
employed at the beginning. It is an easy matter to check
the cholerine ushering in an attack of Asiatic cholera,
but very hard to arrest the disease after it is fully de-
clared; and this is true with respect to almost every
ailment to which the human frame is liable.

In diphtheria, which is a blood disease with the charac-
teristic ashen appearance of the throat, fauces and nasal
passages, it is necessary to begin the treatment with mu-
riated tincture of iron, chlorate of potash, local applica-
tions, soft-boiled eggs, or other light and nutritious food,
brandy, etc., at the very earliest possible moment A few
hours delay will make all the difference as to the final

272 Porcher7s Suggestions. [Sept.,

result. Recent contributors speak of cerebrospinal me-
ningetis as a disease which is inevitably fatal. The only
hope will, in my opinion, be fonncl in full blood-lettiBg at
the very inception of the disease, when the mafaise is-
exhibited. This, with blisters to the neck and spine, cold
affusion to the scalp, veratrum viride, and possibly mer- .
cury, in small doses repeated, may, if used early, arrest
and prevent the secondary blood charges by lowering the
inflammatory action. Surgeon Miller informs me that
he has thus employed blood-letting successfully, Nearly
all recent writers recommend quinine and opium.

After surgical injuries, cold water by irrigation, or
continuously applied, should not be delayed an hour after
any danger from the shock is over. It must be applied
thoroughly or not at all. In a large hospital with a num-
ber of wounded, I have used dried gourds or squashes to
hold the water; they have not a very scientific appearance,
but they are light and easily suspended, and they can be
refilled without trouble. Empty tin cans will also be
found very convenient.

A course of treatment which has been found to be
generally successful when employed at the inception of a
disease, should not be abandoned by the surgeon because
it fails to relieve those who are beyond the reach of
assistance from any remedies. Watch the patient closely
when he enters, and before he becomes too sick; and
give explicit and full directions, with a view to prevent
the morbid changes that the surgeon knows are those
that will ensue. This is all resolved into the common
household maxim : that an ounce of prevention is worth
a pound of cure.

If the case is plainly one in which fatal organic changes
may have already occurred, do not attempt to combat
them by active medicines. The only hope is in the
mildest alteratives (and these are of doubtful utility),

1866.] Porcher's Suggestions. 273

rather trusting to the powers of nature, aided by the use
of the oxygen-bearing bodies, stimulants and revulsives.
Tartar emetic, calomel, etc., are not only ineffectual, but
they tend to impair whatever recuperative force still re-
mains. All terrific exertions over the concluding scenes
(attended by a great waste of whiskey) are out of place,
though very common.

There should be much more attention paid by the
surgeons, with such rich opportunities open to them, to
perfecting themselves in the art of auscultation and per-
cussion, as well as in the examinations of the renal secre-
tions, in order to assist in the more rapid and accurate
diagnosis of some of the most important and numerous
cases that come before them. The study and practice of
auscultation is to them more than ever a necessity.

It would be well, perhaps, that those known to be
skilled in it should be distributed as consulting surgeons
wherever soldiers are collected in any number, with au-
thority to aid by daily visits those who stand in need of
assistance. One specially qualified by his knowledge of
auscultation, or any other branch of diagnosis, should if
possible be a member of every Examining Board ; and to
this extent in their formation the military rule regarding
mere rank, age, or date of commission should be violated.
It is useless to say that it is expected or assumed that all
surgeons should be skilled in every branch of physic, and
competent to the performance of every duty required at
their hands.

It is well known that surgeons practice for the most
part, so far as reading is concerned, upon the capital stock
acquired before the commencement of the war. The
remark is not made in a derogatory spirit, for the excite-
ment, change to which they are subjected, want of books,
etc., are natural reasons why any prolonged application
to study is rather the exception than the rule. Many of

274 Porcher's Suggestions. [Sept.,

the most competent men, whether by reason of age, ex-
perience or attainments, were assigned to duty or ac-
cepted seats in high cathedral places, on boards, as
medical directors, inspectors, purveyors, etc., instead of
being placed in active service, where their practical and
previously acquired knowledge, or their manual dexterity
as surgeons, might have at once contributed to save the
lives of thousands who have been treated by the junior
and more inexperienced members.

But a transposition is fast being effected: for the juniors
in years, from being always in the front, in the field, in
the hospitals, or in some position of active responsibility,
have become the seniors by the practical experience and
the skill which they have acquired.

Every surgeon or assistant surgeon, who is competent,
should make it his business to examine each patient at
least once attentively and thoroughly. This should involve
his previous history and the separate interrogation of every
prominent organ implicated in the diseased condition. No
pains should be spared, for though in the end we may
only attain to an approximation to a knowledge of the
pathological states, yet this is far better than mere guess
work. By the use of all the means at our disposal,
through the instrumentality of the superior implements
of diagnosis, including the microscope, chemical reagents,
etc., greater acuracy is secured than by a mere casual in-
spection. Superficial or hurried examinations lead to
erronious conclusions, and the omission to perform them
properly is an act of injustice to the sick. Let every one
witness the difference between a complete and thorough
examination by an expert, and the careless, hurried,
superficial observation of one ignorant of his business,
and the proof of its importance will be too convincing
to be denied.

For this reason, assistant surgeons should not hurry

1866.] Porcher's Suggestions. 275

through their work. They should esteem their position
a privilege, and he glad to avail themselves of the oppor-
tunity for instruction, if not for the benefit of the siek, at
least for their own improvement. They are rewarded for
their services, and no private reasons or motives of self
ease should deter them from a full and faithful attention
to them without haste, which is inexcusable. They
should devote themselves specially to the very sick, and
not be cotented with two or three visits a day, as if this
was a matter of rule, or as if they were members of a
" square and compass club."

It has frequently struck the writer that everywhere in
the army the claims of relationship, or private friendship,
should be more studiously ignored. In a military service,
where all should equally endure the privations and suffer-
ings incident to a war for independence and for national
life, there should be no preferences, no partialities of any
kind, based on previous personal connections, extended
to one individual over another, whatever may be his rank,
title, or patronage. Every hardship should be equally
endured ; no greater favor should be granted to the most
influential than to the humblest private soldier. They
should stand upon precisely the same footing in any
decision that is made respecting them.

"With the power of exempting the sick from duty,
allowing him to remain in private quarters and granting
him a thousand privileges and advantages, the surgeon
should always endeavor to exercise the right with a strict
new to general equity founded solely upon the merits of
each case. No influences whatever, save these, should
control his actions. These principles are so closely allied
with integrity and true patriotism that the caution might,
with propriety, be dispensed with; but personal claims
are sometimes so hard to resist, and the practice of
yielding to them is so injurious to the general welfare,

276 Porcher's Suggestions. [Sept.,

that the writer need not claim indulgence for even
alluding to the necessity for their being rigidly observed.

Before closing this portion of my remarks, I beg leave
to make one observation to those officers who hold sup-
plies in their hands, and upon whom the surgeon mainly
depends for furnishing and supporting the sick.

Quartermasters, commissaries, medical purveyors, med-
ical directors, senior surgeons of posts, surgeons them-
selves, and I may add, paymasters, should remember that
the chief virtue does not consist so much in the collection
and hoarding of the greatest amount of stores as in their
proper, prompt, and equitable distribution, under suitable
restrictions, to those who require them. And yet how
few approached " the height of this great argument."
They cling to their stores as if they were a part of them-
selves, carefully preserve them at points remote from
battle-fields or beleaguered cities, and will rather see
them burned than used. There is no virtue in mere
storage, per se. The virtue consists in its judicious
distribution, for such is the only object of the accumula-
tion. The sick and wounded sometimes perish for want
of articles within their reach which are simply hoarded.
This is done from a failure to appreciate the true philoso-
phy of the matter, coupled with a certain amount of
indifference and " circumlocution." The supplies are so
difficult to get at that for all practical purposes they may
as well not exist. It '"goes without saying," however,
that some collection is necessary, or else there would be
nothing to distribute.

For stewards, matrons, attendants, and others in hospi-
tals to pamper and indulge themselves in waste and high
living, while those in the trenches have only the plainest
fare, is, to say the very least of it, indecorous, though
sometimes regarded by those who enjoy to the full the
benefit of their position with feelings of pride and full

1866.] Porcher's Suggestions. 277

satisfaction as if they were superior "because they provided
well for themselves. The surgeon should, under such
circumstances, rigorously enforce sumptuary regulations
and restrain within proper bounds those who, mistaking
the true relation of things, entertain themselves with
more than is their due share. There is not the slightest
reason why such disparity should be allowed to exist and
that all the advantage should lie on the side of those who
are certainly not more deserving of them. Let the chief
aim and motive of all be to minister to the wants of, even
to indulge, the sick the well will generally take care of
themselves. The inequalities which have pervaded our
armies in these respects are glaring and require to be
corrected. Inspectors of the highest character of the
antique Roman type, who will not swerve a hair's breadth
from their duty, could be employed with the greatest
advantage to examine into the "inner life" of commis-
sary, quartermaster, medical, and other departments.
But, alas! unless such are selected, the satirist is likely
to inquire, quis custo diet ipsos custodes !

I now invite attention to two or three diseases to which
the principles laid down are specially applicable, and
which have attracted my critical attention on account
of their importance.

There is nothing so common, so universally prevalent,
and so fatal in its effects upon the Confederate soldier
as chronic diarrhoea, particularly during the Spring and
Summer months. This is the great scourge of our
armies ; it coexists with almost every other disease with
which he becomes affected, and the best mode of man-
aging it is consequently of interest to us all. It may or
may not be, but often is, associated with a certain amount
of dysentery, and sometimes chronic dysentery is almost
as frequently met with as diarrhoea.

278 Porcher's Suggestions. [Sept.,

I would banish from the treatment of either that almost
universal recourse of every surgeon, acetate of lead and
opium. It is true that mineral astringents check the
discharges temporarily, and there is often an apparent
benefit following their use, but the relief is only fugitive.
They are injurious to the Confederate soldier in his im-
poverished, prostrated condition, inasmuch as he depends
upon the integrity of the gastro-intestinal surfaces being
preserved for the purpose of assimilating food as soon as
possible, in order to maintain a fair balance in his favor
in the unequal strife between life and death. The illus-
tration is very common-place, hut not less true, that it is
a question of plus and minus, and that he has of necessity,
whilst the disease is being checked by mild astringents,
to receive into his exhausted system enough nourishment
to counterbalance the drainage going on. He must
absorb and assimilate more than he loses, or he dies.

In the length to which this paper is limited, I cannot
enter minutely upon the mode of action of medicines, but
with reference to mineral astringents it may be briefly
stated : that they act directly upon 'the mucus membranes
by entering into combination with the albumen of the
tissues, thus materially interfering with their integrity,
disturbing the functions of absoption, and consequently
of digestion, which is of such prime importance, in this
respect differing in degree, if not essentially, from the
vegetable astringents. In the Confederate soldier, weak-
ened and exhausted as he is by his previous life, by
exposure and the circumstances which surround him, we
cannot afford still farther to impair his recuperative
energies by any but those agents which will barely
suffice to constringe the relaxed membranes and to
gradually diminish the discharges with the least possible
injury to the subsequent absorption of enough food to
nourish and sustain him.

1866.1 Porcher's Suggestions. . 279

Of the agents of this class, vegetable astringents, chalk
mixtures, with demulcents, milk, eggs, arrow-root jelly,
with small quantities of brandy or other stimulants, are
all that he can have. He must be trusted to time, rest,
the recumbent posture, to the recuperative powers of
his constitution and to nature.

I have been in the habit of using a tea made of the
root of the blackberry, which possesses the advantage
that it can be easily obtained in the vicinage of any camp,
infirmary, or hospital. The decoction made with an
ounce or two of the root in a quart of water boiled down
to a pint, may be given in wine-glassful doses, with a
little brandy or whiskey added, several times a day.
Two grains of Dover's powders, with half a grain of
calomel, may be prescribed at night. This, or some
similar harmless treatment, should be continued, pro re
nata, and be the only one used, with the simultaneous
introduction of suitable and easily-digested food in quan-
tities that will be retained and not prove hurtful. Its
applicability consists in its mildness. There should be
no castor oil, no purgatives, no continual alteratives,
repeatedly employed, for they fatally impair the digestive
functions, which are absolutely essential to recovery.

In lieu of the decoction of the blackberry-root or the
bark of the sweet gum (Liquidambar styraciflua), which is
both astringent and balsamic in its properties, I have fre-
quently advised and used largely, with the best effects,
an extemporaneous " chalk mixture," which possesses
the important qualities of being an absorbent, an astrin-
gent, and doing as little harm as any medicine can be
divested of. It is prepared thus : Prepared chalk,
one drachm ; Tinct. opium, two drachms ; Paregoric, one
drachm; Tinct. of kino or catechu, two drachms; Water,
six ounces ; a desert-spoonful after each operation.

280 Porcher's Suggestions. [Sept.,

Some surgeons inform me that they find Hope's mix-
ture beneficial, and others use a demulcent preparation,
with a little turpentine added. The latter is serviceable
where there is a tendency to dry tongue and distension.

M}' reasons for combining with two or three grains of
Dover's powders at night a small quantity of calomel is^
that I have considered the condition of the internal
organs in (chronic) diarrhoea somewhat analogous to the
diarrhoea of teething children, where the secretory func-
tions of the liver and the glandular system are impaired,
and where mercury and Dover's powders, in minute
doses, with vegetable astringents, change of air, and
proper food are now universally recognized as being
essential and the only treatment. Opium alone, or with
astringents, are ineffectual.

Assistant Surgeon Frierson informs me that in the
hospital in which he was employed, under Surgeon
Selden, where convalescents from protracted cases were
generally brought, they found great advantage following
the use of extract of nux vomica. The reasons of this
are obvious, viz : the loss of the accustomed tonicity in
the organs requiring a nervous stimulant. It is equally
useful in the opposite condition of constipation when
dependent upon the same cause. In very violent and
protracted cases accompanied with dysentery, and re-
sisting all other treatment, I must admit that I have seen
beneficial effects ensue after the use of nitrate of silver
with local applications.

Surgeon Fauntleroi, in charge of the' hospital, second
division, Danville, Va,, relies in such cases upon two or
three grains at a dose, and he cautions us against the
addition of opium, which confines its action too high up
in the digestive track.

It has been my plan also to apply blisters occasionally
on the left hypogastric and hypochondriac spaces, over

1866.] Porcher's Suggestions. 281

the descending colon. It is, of course, difficult to decide
to which particular agent used we are to ascribe most
good effects, but I use blisters invariably where there
is any dysentery present, for obvious reasons ; and the
point mentioned is selected because the pain and inflam-
mation is generally found in that locality. They should
not be large and exhausting, and should be followed by
poultices assiduously applied.

In the treatment of dysentery in the army, it is neces-
sary to use the same caution with respect to active medi-
cation. So necessary do I consider this, that as much
confidence as I place, after repeated trials, in the salts
and laudanum . mixture (Epsom salts, two ounces ;
Laudanum, two drachms; Water, a quart; two table-
spoonfuls after each operation, till the blood is checked),.
or that made with cream of tartar and Dover's powders
(Cream tartar, two ounces ; "Water, a quart : a wine-
glassful, with four grains of Dover's powders, every four
hours), yet I have scarcely even thought these prescrip-
tions warranted in the reduced condition to which most
of our soldiers are brought before entering a hospital.
So that in this disease I have been compelled to trust
to occasional doses of Dover's powder, two grains ; calo-
mel, half a grain ; given at night, for some mercury is
very beneficial, particularly in cases of dysentery depend-
ing upon, or connected with, hepatic enjoyment,, and
consequent reflux upon the mesenteric and hemorrhoidal
veins. Dover's powder, in three-grain doses, may be
given during the day, and chalk mixture and vegetable
astringents so soon as the inflammatory symptoms are in
the slightest degree subdued. This treatment can indeed
be used at almost any stage of the disease, employing
blisters, followed by repeated fomentations or poultices,,
and giving light food, with milk, rice, arrow-root, etc.
Bitter tonics and stimulants may be introduced at the
19

282 Porcher's Suggestions, [Sept,,

earliest possible moment, or simultaneously with the course
above mentioned. In other words, employ a mild, tenta-
tive, soothing treatment, with an avoidance of anything
active or calculated to irritate or arrest still farther the
digestive and assimilatory functions. In most diseases the
general management of the case, with the application of
a combination of means, external and internal, to secure
certain ends, is more effectual than the use of any partic-
ular remedy, though there is great room for selection in
these also.

I do not consider these directions as particularly novel
their chief merit, if they have any, is the general direc-
tion to which they tend, which will be found more salu-
tary than an opposite one. The surgeon must be cau-
tioned against a purturbative system, which is essentially
fatal and destructive, from the nature of the cases which
he has to treat.

Not merely for their utility during convalescence from
the diseases just mentioned, but for their general benefit,
there should be in daily use in all hospitals some vege-
table bitter tincture. The compound from the formula
in the Surgeon-General's office, known as Moore's tinc-
ture, or any preparation or infusion of the bitter barks,
wild cherry, willow, dogwood, poplar, one or more mixed
with a sufficient amount of whiskey to preserve it and add
to its efficacy, should be made in large quantities and
daily used in all hospitals, infirmaries, or camps. It must
not be left to the assistant surgeons to order their prepa-
ration at each time that they are wanted.

The thoroughwort plant, boneset (eupatorium), should
also be collected and kept in large amount in the apothe-
cary establishments attached to hospitals, in order that
the use of such simple and excellent preparations may be
facilitated. These, used as substitutes for mineral medi-
cines, will prove highly beneficial to the service. This is

1866.] Porciieh's Suggestions. 283

owing also to their intrinsic values in giving tone to the
system, increasing the appetite, or producing vomiting
and diaphoresis, laying aside any anti-periodic power they
may possess. These varying effects, as in the example of
the boneset, depend upon the form in which they are
administered, viz : whether cold, tepid, or hot

Gerhard, in his lectures on the diseases of the chest,
recommends very highly both the eupatorium and senega,
in decoction, in pneumonia and bronchitis, with the addi-
tion occasionally of sanguinaria. I have repeatedly used
them, and with great advantage. The employment like-
wise of neutral mixture, chlorate of potash, effervescing
draughts, or other cooling agents, is highly beneficial in
a hospital, as they take the place of substanees that are of
doubtful utility and more dangerous, or less innocuous,
in their effects upon the class of patients the army sur-
geon is called upon to treat.

In the declared pneumonia and bronchitis following
measles, for example, it is far preferable to trust to a
drink of chlorate of potash water (three drachms to a
pint), and the mildest alteratives of calomel and Dover's
powder, or morphia, a fourth to a sixth of a grain each,
with an anodyne diaphoretic at night ; if there is much
perspiration, to quinine and aromatic sulphuric acid, and
to nourishment, and the healing influences of time, than
to attempt to jugulate the disease by any active treatment.

Prof. Chambers, of London, in a recent paper on the
treatment of pneumonia by cupping and jacket poultices,
to the exclusion of mercury and tartar emetic, republished
in the Confederate States' Medical Journal, sustains an
opinion I have long and openly maintained as the result
of my own experience : that a case of pneumonia never
improves so long as there is running off at the bowels.
This is absolutely fatal in the disease of the chest conse-
quent upon measles, unless speedily checked. The

284 Porcher's Suggestions. [Sept,,

tendency to it should be anticipated by opiates and
stimulants.

Army surgeons, now-a-days, profess to cure sloughing
wounds, gangrene, etc., with the greatest facility with
nitric acid, mur. tinct. of iron,, and so forth. Some em-
ploy poultices. Guthrie (and those following in his
wake), condemns the latter out and out, in a wholesale
way, with most opprobrious epithets : " cover sluts "
and such like terms. One would suppose that Astley
Cooper, Liston, Dupuytren, and the great army of
able men of a past day, were either mere children, or
had been practicing the most egregious errors during
their whole lives.

After witnessing a large number of sloughing wounds
following the battles around Petersburg, but no gan-
grene, as this was prevented by securing-tents at all
hazards, and disgorging the wards into them, I have
endeavored to come to some conclusion as to the relative
merits of the agents tested. I find that some things are
required besides nitric acid, and that poultices are of the
very greatest service when judiciously applied not only
in sloughing wounds, but wherever the inflammatory action
is too high, or when we wish to determine to the surface,
as in cases of deep-seated matter or abscess. But surely
one would hardly be compelled to argue in favor of the
utility of any description of poultice in hastening the
maturation of a boil or whitlow, in soothing the pain, or
bringing matter to the surface. Cold water is applicable
and essential at a period when poultices are not, and vice
versa. There is no substitute for either. I would not
speak dictatorially when I say, in the first place, that in a
sloughing wound where there is a large amount of dead
matter, sometimes an inch or two thick, concealing the
sensitive parts beneath, which you wish your stimulant
or escharotic to reach and excite the granulations of, that

1866.] Porcher's Suggestions. 285

it hastens the process extraordinarily to use a pair of
scissors and cut it away outright. When you do this
(and I have repeatedly seen it save life), whilst giving
muriated tincture of iron, quinine, or other stimulating
tonics internally, you expose the sensitive layer supplied
by blood vessels, and then even nitric acid is hardly
needed; for any stimulant, turpentine, alum, sulphate of
zinc, muriated tincture of iron, yellow wash, is sufficient
to excite the parts to healthy action. Before the use of
the scissors, nitric acid, or the "fuming nordhausen" itself
are hardly sufficient to act upon the dead inorganic
matter, and time is lost.

A charcoal or yeast poultice is often also of the greatest
service in hastening the disengagement of the slough,
but particularly also in lessening the inflammatory action,
which often runs too high, and is the cause of the exten-
sion of the sloughing process. In any wound, sloughing
or not, where there is too great heat, redness, and inflam-
mation, the greatest benefit is derived from the applica-
tion of soothing poultices of any description ; but particu-
larly from those possessing the antiseptic and absorbent
properties mentioned above. This statement I have
demonstrated almost daily. Doubtless poultices of any
kind can be used too much. I have seen surgeons
continue them quite too long. After wounds, after
amputations, when the tissues are pale and relaxed, and
there is an absence of too great inflammatory action
(which is always destructive), poultices are injurious.
When employed too constantly, they are often the cause
of the flabby, relaxed condition which/prevents healthy
granulations, arrests the healing process, and produces
wasting discharges. The question of their applicability
or not is one easily decided.

Nitric acid or other active stimulants, as all admit, are
very serviceable in gangrene, with internal tonics which

286 Ford's Report of [Sept.,

constringe the cappillaries, employing also highly nutri-
tious food.

I introduced into daily use at the South Carolina hos-
pital, Petersburg, where several hundred wounded men
were collected, an agent which is an admirable substitute
for Labaraque's wash, Darby's fluid, or other disinfectant
or antiseptic preparation. It is a weak solution of com-
mercial copperas in water, which for local application to
stumps, sloughing wounds, fetid ulcers, etc., may be
made by the gallon. It is a very efficient antiseptic
and disinfectant, also a good local stimulant and astrin-
gent, and it has been long used in erysipelas ; its cheap-
ness, likewise, commends it to the surgeon during the
present exigency. My employment of it before the war,
in the marine hospital, Charleston, as a general disin-
fectant for yards, suggested the extension of its use to the
wards and for the wounded.

In concluding these somewhat desultory remarks, I
cannot but suppose that others may differ from me; but I
am fully convinced that the foregoing views are correct
in the main, having been found successful as far as my
observation extends, and after a good deal of careful
attention to the subjects referred to.

ARTICLE IX.

Gunshot Wound of the Spinal Cord, and the ball found in the
ascending Aorta. Patient lived ten days. By DeSaussure
Ford, M> D., Demonstrator of Anatomy in Medical
College of Georgia.

Mr. A., of South Carolina, thirty-eight years of age, of
full habit, in vigorous health, weighing one hundred and
eighty pounds, was shot on the 26th of May, 1866, and
I saw him, in consultation with Drs. Smith and Brooker,
the 28th, at 11 o'clock a. m. He was standing twenty-

1866.] Gunshot Wound of the Spinal Cord. 287

five feet from, and rather obliquely, with his back pre-
senting to a store, from which he was shot, the ball
passing through a pane of glass. He was suddenly
thrown down, there being instantaneous paralysis and
anaesthesia of the inferior extremities. The pistol sup-
posed to have been used, was the largest size Navy
Colt's, carrying a conical ball.

The ball entered to the left of the spinal column, oppo-
site the fifth and sixth dorsal vertebrae. The wound had
been repeatedly probed, but notwithstanding this, and
my aversion to probing wounds often, I used a large size
bullet probe, cautiously, which passed two inches deep,
obliquely downward, and almost parallel with, but rang-
ing toward the spinal column. I failed to discover any
fracture of the vertebrae or ribs. He complained of so
much pain in the left side, over the region of the heart,
that I examined carefully, by physical exploration, the
thoracic viscera, but nothing was discovered which indi-
cated any disturbance of these organs. His breathing
was somewhat labored, but the pulse natural and soft,
beating eighty-five, the skin pleasant and warm, tongue
coated heavily with a white fur, and hiccough, his spirits
low, and countenance very anxious. He had been cathe-
terized twice daily, but the bowels had not acted since
the accident, although enemeta had been administered
repeatedly. He was seen by one of the attending physi-
cians five minutes after he was wounded, who represents
that "his suffering was intense; was much prostrated;
considerable hemorrhage, say twenty ounces during the
first six or eight hours, after which it subsided, and re-
action in six or eight hours ; constant pain in the chest ;
great thirst."

In the consultation, I gave the opinion that the probe
failing to reach the bones of the spinal column in any of
the probings, the absence of any tenderness of the spine

288 Ford's Report of [Sept.,

proximate to the wound, with the absence also of crepi-
tus, and the paralysed parts having remained perfectly
warm and pleasant, with no increased warmth or coldness,
neither clamminess, and the pulse natural, that the ball
had probably embedded itself somewhere in the muscles
of the back ; that the cord had not been injured, and that
the paralysis was the result of concussion, rather than
either compression or laceration of the spinal cord, or its
membranes. "We determined to treat the case by repeat-
ing enemeta, small doses of sulphate of morphia, and
perfect quiet.

He rested quietly until the next morning, when the
enemeta failing to bring a discharge, a half ounce of
castor oil and ten drops of spirits of turpentine were
administered; before this had time for effect, he had a
copious faecal evacuation, but was not sensible of it. The
oil and turpentine commencing to act, he was rendered
so feeble that whiskey punch was administered freely.
The night of the 29th he rested quietly, and manifested
more comfort and cheerfulness. The pulse, during my
stay of two days, was natural, ranging from eighty to
ninety, except immediately after the large evacuations
from his bowels. The only uneasiness manifested was
the constant pain over the region of the heart, with oc-
casional hiccough, which was sometimes violent, but
draughts of solution of bicarb, of soda relieved him
temporarily; during these paroxysms of hiccough, he
complained of excessive oppression over the sternum,
and begged to be pressed forcibly at that point for relief.

My father, Prof. L. D. Ford, saw him for me the next
day, remaining with him the whole of it, observing only
this pain, the hiccough, and spasm of the diaphragm.
The bladder was still relieved by the catheter; his condi-
tion was considered favorable; was taking nourishment
%, and talking cheerfully. The sensibility of the

1866.] Gunshot Wound of the Spinal Cord. 289

paralysed parts was estimated by his attendants to be
returning. My father saw him again on the 1st of June,
finding him in a comfortable condition, cheerful, pulse
natural, appetite good, and although the hiccough still
annoying, the prognosis was favorable.

By advices from his attending physicians, he was rep-
resented as doing well, when we were summoned to him
on the 5th of June, a hemorrhage from the wound oc-
curring on the night before. The bleeding came from
the vessels of the spinal column. He was found cold,
pulseless, his mind wandering, in which condition he
remained until 9 o'clock of this day, when he died.

Post mortem examination was performed by Drs. Smith
and Brooker, my father being present, the morning after
death, before the coroner and his jury, and under other
circumstances not favorable for a critical examination.

The subject upon his face, an incision was made across
the wound, down to the vertebral column, and the track
of the ball discovered, which passed through the base of
the transverse process of the sixth dorsal vertebra, and
thence into its body, wounding the membranes of and the
spinal cord. To determine the further course of the ball,
a section of the vertebral column was removed, including
vertebrae below and above the wounded one, separating
this section from the aorta from above downward. It was
found that the ball passed through the body of the ver-
tebra, leaving some spiculae of bone in contact with the
membranes of the spinal cord. This section of the
column was then laid aside, and no course or track of the
ball was perceptible. The viscera within the thorax
were examined by free feeling; the ball not felt, the
opening in the posterior part of the thorax was enlarged,
by sawing off more of the ribs, and the viscera removed,
by dividing the aesophagus and trachea, and the vessels
at the top of the chest, and the pericardium cut through

290 Ford's Beport of [Sept,

in detaching these viscera from the diaphragm. This
disadvantageous mode of removal necessarily caused
much mutilation of the viscera; thus the pericardium
was necessarily opened, and some incisions made into
the heart itself at its apex. The lungs were crepitant
throughout. In examining the heart, the ball was felt in
the ascending aorta, which was taken out by making an
incision into the vessel ; the base of the ball was unal-
tered, but the apex was rough arid jagged. The cavities
of the heart were opened, and a eoagulum, ante mortem,
was found in the left ventricle, extending toward the
aorta. The inner surfaces of the ascending aorta and
its arch were of an intense, deep vermillion color, which
extended throughout the entire substance of the arterial
coats, and this remarkable pathological appearance was
also found in the arteria innominata, but left subclavian
and carotid arteries were natural in color. This color
was also present in the descending aorta, gradually di-
minishing in intensity, and confined to the internal coat.

At the base of the left ventricle, at the junction of the
pericardium with the aorta, there was an irregular open-
ing in the external tissues, and in the aorta corresponding
there was a slit of sufficient length to allow the passage
of the ball.

The upper portion of the heart, including the auricles
and parts of the large vessels leading from the organ,
was brought to the city for more careful inspection.
With the assistance of my friends Professor Dugas and
Joseph Jones, it has been determined that the ball entered
this irregular opening, of a circular form, which was in
the posterior portion of the ascending aorta immediately
beyond the semi-lunar valves, corresponding to the point
where the ball was found ; the external tissues about this
opening were bruised, the edges of it lacerated, and look-
ing inward, while the elastic coat had the appearance

1866.] Gunshot Wound of the Spinal Cord. 291

of having been incised, which must necessarily be the
case in wounds by balls of the elastic coats of large
arteries, the rent being in the direction of the fibres.

It is to be noted here as an important feature in this
case, the remarkable vermillion color of the aorta and
arteria innominata, indicating that this ball, probably, at
each contraction of the left ventricle was thrown forward
in the ascending aorta, by the advancing column of blood,
up toward the arch, which it did not pass, and by the
elastic reaction of the aorta, was then thrown back upon
the closed semi-lunar valves, and that here this ball was
dancing during the life of the patient, being a continual
source of irritation. Why the intense color was not
found in the left subclavian and carotid vessels I cannot
conjecture. This remarkable pathological condition about
the point where the ball was found, with the abiding
distress in the region of the heart, this occasioned proba-
bly by the coagulum, the formation of which may have
been due to the presence of this ball immediately beyond
the valves, is conclusive evidence that the ball rested in
the ascending aorta from the moment of the accident.

Wounds of the heart and its vessels, the subjects living
for days and even months, are not of such rare occur-
rence. Dr. Cristison reports a case" where a ball was
found in the left ventricle of the heart, yet there was no
opening through which it entered; "the patient lived
from April 14th to about the end of June, when he sud-
denly expired." A case is reported by Dr. Latour, chief
physician to the Due de Berg, where the ball was found
in the right ventricle, resting upon the septum medium.
There was great hemorrhage immediately after this
wound, but on the third day he was more comfortable,
and, at the end of three months, the wound cicatrized,
and he suffered with only occasional palpitation three
years ; six years after, he died. Post mortem examination

292 Logan's Report of Primary [Sept.,

disclosed a cicatrix in the right ventricle of the heart,
and the ball resting upon the septum medium. Dr.
James M. Green, of Macon, Ga., reports a case, in the
Southern Medical and Surgical Journal, 1855, of a wound
of aorta, the patient living a month, and then dying not
from its effects.

The case of the prize-fighter, Poole, of New York city,
is reported under the head of gunshot wound of the
heart. The ball lodged in the septum between the ventri-
cles, without symptoms indicating its presence. Another
case of spontaneous cure of a wound in the ascending
aorta is reported in the London Lancet, 1837 ; vol. xxxiv.
These cases I have referred to as noted in " Eve's surgi-
cal cases."

ARTICLE X.

Report of two cases of Primary Resection at the Knee-joint
for gunshot icound ; death resulting in both cases. By
Samuel Logan, M. D., Llemonstrator of Anatomy and
extraordinary Professor of Anatomy in the Medical
College of the State of South Carolina, lately Surgeon
in the Confederate States Army and Medical Inspector
for the Department of North Carolina.

Charleston, S. C, July 27, 1866.
Prof. Joseph Jones, M. D., Augusta, Ga.

Dear Doctor : Please receive my thanks for the copy
of the Journal as well as for your kind note accompanying
it. In accordance with my promise made to you at the
time when I had the pleasure of receiving your agreeably
remembered visit at Pocotaligo, during the war, I had
set to work in good earnest to condense, revise, and
arrange the medical statistics of the department of South
Carolina, Georgia, and Florida, having procured the
original reports from the Medical-Director's office for the
purpose. I had prepared over one hundred pages of the
manuscript, and was progressing in the work, when
the exigencies of the service in Virginia caused my
transfer, with most of the command, to that more active

1866.] Resection at Knee-joint. 293

field of operations. My work was thus brought to a
stand still, but hoping at a future day to be able to resume
it, I left the papers at my father's house, in Columbia,
where they, together with all my other manuscripts, and
my whole library, were destroyed by fire, by the " great
incendiary" of " our common country."'

1 had a few professional war notes with me in the army,
such as I had more recently collected, and had had no
opportunity to send home for safety, as I then supposed.
These I have saved, and from among them I have made
up a report of the only two cases in which I deemed
myself in the least justified in performing primary resec-
tion of the knee-joint for gunshot injury. The details are
rather meagre ; but as all such cases should be recorded,
1 send the report to you.

I congratulate you on the success, comparatively, of
your college. We have reorganized and somewhat reju-
venated our institution, and promise you to try at least to
hold our own. We were fortunate in losing very little
by the war.

With sincere regard, I remain, your's sincerely,

Samuel Logan.

First. J. p. Goforth, Private Co. K, 11th regiment S.
C. volunteers, aged about twenty-five years ; robust con-
stitution and in good health; was wounded June 24th,
1864, near Petersburg, Va.; was admitted into the "field
hospital" of the division, located in the city of Peters-
burg, about two hours after the receipt of the injury.

Pulse about ninety ; no shock or constitutional distur-
bance of any importance; general condition, indeed, calm
and good. Gunshot wound runs obliquely through left
knee-joint, tearing away both articular surfaces, but pro-
ducing no splintering of the cancellated structure or shaft
of either of the bones, merely making a groove along the
articular surfaces of the femur and fracturing the patella.

A general hospital, where he could be permanently
treated, being in the immediate vicinity not a quarter of
a mile distant and the case, on account of the nature of
the wound as well as the excellent state of general health,

294 Logan's Report of Primary [Sept.,

being considered as one in which the operation might be
regarded as justifiable, while at the same time the patient
preferring any risk to the loss of his leg, I determined
upon resection.

The patient being placed under the influence of chloro-
form, the operation was performed a few hours after the
receipt of the injury (June 24, 1864), by the H incision,
the cross cut including both orifices of the wound.

Nearly all of the contused soft parts were excised, with
the patella also, after the articular surfaces of the bones
had been sawed off beyond their contused portions. The
parts then seemed to present very favorable conditions
for speedy union.

I consider that the removal of the bruised soft tissues
contributes very materially to this result in this as in all
other resections for gunshot injury, and I have always
carried this principle into practice, except when a too free
excision of the soft parts would involve the injury of im-
portant structures. I think that with this precaution the
removal of such contused tissues should be adopted as
the rule of action in such cases.

The patient soon reacted from the effects of the chlo-
roform, and was sent to one of the general hospitals in
the immediate vicinity, a long splint having been applied
to the limb as a temporary expedient to facilitate his im-
mediate removal from among the crowd of wounded who
were awaiting professional attention.

June 28th. Had been too much engaged to go to see
the patient before to-day. Pulse now about one hundred
and ten; skin a little unnaturally warm,, but moist;
tongue almost natural ; feels tolerably comfortable ; ap-
petite good ; part slightly swollen, but not painful : limb
dressed in Smith's anterior wire splint, and suspended,
water dressing by irrigation being used.

1866.] Resection at Knee-joint 295

July 1st. Patient not doing so well as at last visit. He
is restless, and his skin is hotter ; face flushed ; pulse
one hundred and fifteen or one hundred and twenty,
and tongue rather dry ; parts much swollen and some-
what erysipeloid in appearance; suppuration commenc-
ing imperfectly. There has, however, heen some union
of the lips of the wound. Water dressing is still used.
Other cases of erysipelas have occurred in the hospital.

I regret that I was unable to see this patient again,
hut I afterwards ascertained that he had died within the
twentieth day after the operation ; I could not ascertain
the precise date.

Second. J. White, corporal, Co. I, 21st regiment S. C.
volunteers, robust-looking young man ; apparently about
twenty-five years of age ; admitted into the division field
hospital, in the city of Petersburg, Va., June 24, 1864,
about two or three hours after being wounded. General
condition good ; pulse strong, and about eighty-five ; skin
warm, and healthy in feeling ; no shock, or if there had
been any he had recovered from it.

Upon examination, a wound, probably from a conical
ball, had passed through the external condyle of the right
femur, laying open the joint freely, and knocking off a
portion of the articular surface. The tibia was uninjured.
He had also a slight flesh wound in his right arm.

The case being considered as one almost as favorable
as the last, and the external circumstances being precisely
the same, it was determined to give him also whatever
chance of saving the limb a resection might afford. I
accordingly performed the operation immediately, by the
H incision, removing both articular surfaces, sawing
through the femur at about one inch from the joint,
merely slicing off the top of the tibia, and removing all of
the contused soft parts.

296 Logan's Report of Primary [Sept.,

The recovery from chloroform was prompt, with a
healthy amount of reaction, and he was at once sent to
one of the general hospitals in the immediate vicinity,
with the limb bound, with tolerable firmness, to a long
external splint, as a temporary expedient and to facilitate
his comfortable transportation.

June 26th. Visited patient at hospital. The immense
crowd upon the capacity of the hospital has necessarily
lessened the degree of attention which he otherwise
might have received. His bed is not comfortable, and
the limb is still dressed in the temporary apparatus
applied at the field hospital, which is causing some
pain by its undue pressure. He is restless, with some
reactionary fever, though not a great deal. Pulse about
one hundred and fifteen; tongue almost natural; skin
healthy and soft, perhaps a little too warm; the leg is
somewhat swollen at the seat of operation.

June 27th. General symptoms much the same, but is
more comfortable, the dressing having been rearranged.
The limb is about as much swollen as it was yesterday,
but it is only a little above the natural temperature, and
gives him no pain.

June 28th. General condition much the same, but the
flesh wound in the arm is not doing well. It is painful,
and the parts around are swollen and red, presenting
somewhat an erysipeloid appearance. The leg is the
same as yesterday ; in almost a natural state, if we
except the slight swelling present; union appears to
be taking place quite healthily. He complains of the
arm, and not the leg. He still has on the same dressing.

July 8th. Have been unable until to-day to see the
patient since the 28th ult. He has been removed from
the tent he first occupied to a ward in one of the build-
ings. His general condition is rather favorable; pulse
about one hundred and ten ; skin moist ; appetite good ;

1866.] Resection at Knee-joint. 297

tongue soft and tolerably clean ; feels more comfortable.
The erysipeloid tendency in the wound of the arm has
disappeared ; the leg is somewhat swollen at and around
the site of the operation; the wound is suppurating freely
and the pus is healthy.

All retentive apparatus has been removed; nothing
but what was applied at the field hospital having been
ever used, and this had caused some excoriation. The
limb lies free ; thus every motion of the body, or foot,
disturbs the relations of the osseous surfaces, and pro-
duces friction between them.

I was unable to see the patient again, but I afterward
heard that he had died at some period before the 15th of
July, or within twenty-one days after the operation was
performed.

The notes on the above cases are necessarily imperfect ;
but it is believed that they are sufficiently full, though
wanting in so many details, to render it worth while to
report them.

The exigencies of my oflicial duties at the time, and
afterward, prevented me from procuring more full partic-
ulars, especially as the cases immediately passed from
under my professional care. This latter circumstance
will account for the absence of details as to the treat-
ment. In forming an opinion' as to whether the opera-
tion of resection at the knee-joint is ever admissible as a
primary operation for gunshot injury, it is very important
that we should have as many reports of cases as possible.
It is with this view that I have deemed it advisable to
hand in the results of my experience in the only two
cases coming under my hands during the recent was, in
which I considered that the condition of the patient,
coinciding with the favorable circumstances which I had
reason to expect would obtain, during the after-treatment,
warranted this attempt at conservative surgery.
20

298 Medical Society of Augusta. [Sept.,

In respect to the influence to be allotted to these cases,
in forming any generalizations on the subject, it is neces-
sary to qualify our judgment as to the results, by bearing
in mind that it was only in the case of private Goforth
that the favorable after-circumstances obtained, on the
presupposition of which the decision as to operating was
mainly based.

The circumstances attending the after-treatment of the
case of corporal White, whether avoidable or not, were
certainly not such, to say the least, as ought to be
expected to contribute to a favorable termination.

Taken by themselves, -these cases, of course, settle no
principle, but aggregated with others, it is hoped they
may contribute to that result.

TRANSACTIONS OE SOCIETIES.

Medical Society of Augusta, Georgia.

The Medical Society of Augusta was reviewed and reorganized
on the 23d of May, 1866.

The members have displayed commendable zeal, and a number
of interesting questions, as the possibility of communicating
secondary syphilis, through the medium of the vaccine virus,
the nature and effects of the malarious poison, and the pathology
and treatment of puerperal fever, have been discussed at the
bi-monthly meetings.

The following Essays, read before the Society, are published
in response to a resolution, requesting the editor of the Southern
Medical and Surgical Journal to open his pages to the
publication of the transactions.

The officers of the Society, as at present constituted, are :

President, L. A. Dugas, M. D., Professor of Surgery in the
Medical College of Georgia.

Vice-President, S. E. Habersham, M. D.

Secretary, Y. G. IIitt; M. I).

1866.] Brown on Diseased Teeth. 239

ARTICLE I.

Affections of Difficult Diagnosis Caused ~by Diseased Teeth. By
Dr. J. P. H. Brown, of Augusta, Ga. Read before the
Medical Society of Augusta, June 20th, 1866.

The presentation of this paper, for the consideration of this
Society, is done with no little diffidence and embarrassment
First, I have a consciousness of my inability to do the subject
justice; and, Secondly, occupying the position of a dentist, I
feel that the ground over which I must pass requires delicate
stepping, lest I may be thought transcending my sphere.

We must view man as a microcosm a little world made up of
many parts, which are so intimately united, and dependent upon
one another for integrity and existence, that when we ignore one
we not only mar the beauty and destroy the harmony of the whole,
but our knowledge of their structure must also necessarily be
imperfect.

A knowledge of structure forms the basis of all surgical and
medical practice, and is equally necessary for those who wish to
understand the nature and character of disease ; for without a
knowledge of the laws governing the life of a part all treatment
is empirical. Experience may sometimes enable us to treat suc-
cessfully a certain disease under certain circumstances, but expe-
rience, by itself, leads to mere routine and hobby practice. There
are many men in my own profession who are so pre-eminently prac-
tical that, by means of forceps and excavators, they have com-
pletely detached the teeth, if I may so speak, from all connection
with the living organism, and bidding adieu to all physiological
and pathological knowledge, have rode -their routine hobby into
charlatanism. These practitioners never stop to inquire how the
cure is really accomplished, and what is worse, they never deviate
from one set course of practice; and whatever may be the condi-
tion of the part, or of the patient, their treatment remains the
same.

The accomplished physician, surgeon, or dentist must possess
both experience and theor}', which includes not only a thorough
knowledge of structure; but also a knowledge of the application

800 Brown on Diseased Teeth. [Sept,

of those remedial agents brought into requisition in the treatment
of disease. For this seeming digression from my subject I hope
you will pardon me.

I trust you will not think it improper, or outside of my legiti-
mate province, if I ask your attention, for a few moments, to .a
brief but general consideration of some of the influences and
effects which the teeth, when diseased, may have upon the other
parts of the body and upon the general health. When we take
into account that the teeth are virilized structures, endowed with
nerves and blood-vessels, and, through these nerves, are intimately
connected with the great sympathetic nervous system, and through,
this with all the organs concerned in the production of animal
life, the varied influences they possess become an additional field
of observation. It must be apparent, therefore, to every medical
and dental practitioner, tliat a knowledge of the anatomy and
physiology of the fifth pair of nerves is indispensable to a proper
appreciation of those pathological conditions to which these nerves
are liable, and of their sympathetic derangements primarily in-
duced by dental irritation.

Dr. Bond, in his work on " Dental Medicine," when referring
to this subject, says : " As the body is a unit, knit by the closest
bonds, pervaded by one system of blood-vessels and nerves,
directed by one intelligence, and kept in a continual relation of
function and expression by an all-pervading law of -reciprocal
reaction and sympathy; as diseases of other parts, and those
which, in distinction to well-defined and limited affections, we call
general, are capable of affecting the teeth, it might be apparent, if
we had no particular facts in evidence, that the morbid condition
of the teeth may produce corresponding evils in other parts, and
may even involve the whole system in troubled and morbid
action.

" It might also be evident that severe and long-continued pain,
located in the immediate vicinity of the brain, and in parts little
accessible to soothing appliances, can not be less dangerous to
lieal th than pain in other organs situated at greater distances
from the nervous centres and more easy of access.

" It might also be perceived that sensitive organs, in immediate

1866.] Brown gu Diseased Teeth. 301

contact with the great living membrane of the thoracic and abdom-
inal cavities, and intimately connected with it by function, can
not be less capable of propagating disorder to it than parts located
far from it, and having no immediate relation to it."

In commenting upon the effects of diseased teeth upon the
system, Dr. Rush, one of the most comprehensive and accurate
pathological observers that ever lived, remarks : " When we con-
sider how often the teeth, when decayed, are exposed to irritation
from hot and cold drinks and aliments, from pressure, by mortifi-
cation, and from cold air, and how intimate the connection of the
mouth is with the whole system, I am disposed to believe they
are often unsuspected causes of general, and particularly of ner-
vous, diseases. When we add to the list of these diseases the
morbid effects of the acrid and putrid matters which are some-
times discharged from carious teeth, or from ulcers in the gums,
created by them ; also the influences which both have in prevent-
ing perfect mastication, and the connection of that animal function
with good health, I can not help thinking that our success in the
treatment of all chronic diseases would be very much promoted
by directing our inquiries into the state of the teeth in sick
people, and by advising their extraction in every case in which
they are decayed. It is not necessary that they should be
attended with pain, in order to produce disease ; for splinters,
tumors, and other irritants before mentioned, often bring on
disease and death, when they give no pain, and are unsuspected
as causes of them. This translation of sensation and motion to
parts remote from the place where impressions are made appears
in many instances, and seems to depend upon an original law of
animal economy."

As natural as these inferences are, and as important as they
must be to every reflecting mind, I hope you will pardon me when
I advance the opinion that the medical profession generally have
not paid that attention to this subject which its importance
demands. Without wishing to tire your patience, I will give a
few cases, showing some of the disorders that occasionally arise
from dental irritation.

302 Brown m Diseased Teeth [Sept.,

Case 1. Abscess and loss of a portion of the hard palate, caused
by the irritation of a diseased tooth.

This case came under my notice some seven years ago, in
Atlanta. The history was related by the patient himself. Some
four years previous to my seeing the case, an abscess formed in
the centre of the palatine arch, which was lanced by his physi-
cian, and a large quantity of pus discharged. The place did not
heal, but left a fistulous opening, which continued to discharge
small quantities of matter. Finally, the edges of the opening
inflamed and enlarged to the size of a filbert; the discharge con-
sisting of pus and sanies.

One of his central incisors becoming troublesome, it was ex-
tracted, when it was found that there was a fistula running from
the root of the tooth to the opening in the palate. The discharge
of pus soon ceased, but a portion of the palatine bone necrosed
and exfoliated, leaving an opening in the hard palate of the size
of a ten-cent piece, which communicated with the nasal cavity,
rendering the performance of the functions of mastication and
deglutition very difficult, and greatly impairing his speech.

For this gentleman I constructed an obturator, which he wore
with comfort and satisfaction. I will here remark that this
patient was free from syphilitic taint, but had what may be
termed a scorbutic diathesis. He informed me that caustic had
been freely applied to the abscess, and he had taken internal
remedies, but he could observe no improvement in his case . until
after the extraction of the diseased tooth. In subjects of this
constitutional indiosyncrasy, the slightest irritation of a dental
nerve may involve the death of the tooth ; or, the irritation may
be reflected to some neighboring part. The teeth of such persons
always require the most careful and thorough treatment.

Case 2. Sir Astley Cooper, in his " Surgical Lectures," has re-
corded the following cases as illustrating what he terms sympa-
thetic irritation.

A lady, in Essex, had for a long period been afflicted with a
fungoid granulation, which protruded through an ulcerous opening
in the cheek, and which had resisted the use of every means-

1866.] Brown on Diseased Teeth. 303

Upon stating one day that a tooth near the part was occasionally
painful, she was recommended to get it drawn ; the tooth was ex-
tracted, and the fungus quickly disappeared.

" A gentleman of my acquaintance," says Sir Astley, " had,
for many years, been exceedingly annoyed by an ulcer on the
chin ; every attempt to heal it having proved ineffectual, it was
considered incurable. At length, one of the teeth opposite the
wound becoming painful, it was extracted, when, to the delight
and astonishment of the patient, his malady disappeared."

The eruption of the dentes sapientise, especially those of the
lower jaw, is frequently attended by great suffering, and may give
rise to serious disturbance. Velpeau relates several cases in
which mal-position of the wisdom tooth was followed by necrosis
and exfoliation of large portions of the inferior maxilla, fungus
growths, immobility of the jaws, epilepsy, and insanity. The
nervous disturbance is sometimes so distant from the seat of the
primary cause as to present serious obstacle to a correct diagnosis.

Case 3. Hysteria from tJte eruption of a wisdom tooth.

Dr. B. W. Richardson, senior physician to the Eoyal Infirmary
(London) for diseases of the chest, in his lectures on " the medi-
cal history of diseases of the teeth," relates the following case :

" A girl came under my care in 1855, and remained as a patient
for many weeks. Her symptoms were those of hysteria, but from
the description of the fits which, according to the mother's state,
mefit, she suffered from, I judged that she must be subject to
epilepsy, or at least to severe epileptiform hysteria. I treated her
first with tonics, but no good having resulted, and feeling that
some local mischief must be at work, I gave purgatives on the
speculation of the presence of tape-worm or lumbricus. It was
clear that tonics did not relieve, and that depressants increased
the malady. Ultimately, there were general twitchings in the
muscles, not exactly amounting to chorea, but such as are seen
sometimes after the administration of strychnia. I was unavoid-
ably kept from dispensary work for a few weeks, and returning to
it was surprised to find a great improvement in this patient. She
had been in great pain and had cut a wisdom tooth, since which

304 Brown on Diseased Teeth [Sept.,

she had lost all symptoms of convulsive start. How I blamed
myself for carelessness in not having examined for this simple
cause of irritation, I need not say. How quickly I should have
examined for it had my patient been in her first, instead of her
last dentition, I need not explain. Suffice it, that I never meet
with hysteria now, of extreme kind, if the excitant seems to
be local, without asking in the most solicitous manner after the
wisdom teeth."

Dr. W. Tyler Smith, a medical writer of distinction, remarks
that : " Irritation of the tri-facial nerve seems, in rare cases, to
excite abortion. It happens when no cause can be recognized but
the appearance of the dens sapientia, and this phase in dentition
is known to produce considerable local and constitutional dis-
turbance. General convulsions may, in fact, be excited from this
source, either in the male or female subject. The reflection of
irritation from the tri-facial upon the uterine nerves, in young
pregnant women, is no more remarkable than the strangury
excited by teething in the infant."

I might enumerate cases of amaurosis, neuralgia, headache,
tetanus, rheumatism, and dyspepsia arising from dental irritation,
but the foregoing are sufficient to fully impress the mind with the
importance of the subject. I will close this paper with a quota-
tion from Mr. Liston, in his treatise on surgery : " From the
presence of carious teeth, or decayed portions of teeth, many
evils, both local and general, may ensue, besides inflammation and
abscess. They are frequently the cause, and the sole cause, of
violent and continued headaches ; of glandular swellings in the
neck, terminating in, or combined with, abscess ; of enlargement
and inflammation of the tonsils, either chronic or acute ; of ulce-
rations of the tongue and lips, often assuming a malignant action
from continued irritation ; of painful feelings in the face, tic-
douloureux, pains in the tongue, jaws, etc.; of disordered stomach,
from affections of the nerves or from imperfect mastication ) of
continued constitutional irritation, which may give rise to serious
diseases."

1866.] Rains on Malaria and Epidemical Diseases. 305

ARTICLE II.

The Probable Causes of Malaria and Epidemical Diseases. Read
before the Medical Society of Augusta, Ga., July lHth, 1866.
By Col. George W. Rains, formerly Professor of Chemistry
in West Point, U. S. A.

Mr. President, and Gentlemen of the Medical Society :

In speaking* on the subject for this afternoon's discussion, I
think it proper that I should first state my views as to the nature
of force, so far as to explain the term points of force employed in
the question proposed. To give a comprehensive definition, I
sliould say that Force is anything which can cause motion, either
in bodies or in the ultimate atoms of matter. This definition
would then include as forces sound, heat, magnetism, light, elec-
tricity and chemical affinity, actinic or photographic rays, nervous
influence and vital action, as well as gravitation, cohesion, etc.
These primary forces act in connection with the ultimate atoms of
matter to which they impart motion, and as each atom is supposed
to be indefinitely small, we may regard them practically as mere
mathematical points. What may be the actual dimensions of such
particles, is a question which has never been answered. We know,
however, that if we reckon them up in weight, in parts of a grain,
or in dimensions, in parts of an inch, we should have to employ
the term billions, at least, or more probably quadrillions; indeed,
the belief is entertained by many, and is daily gaining groundj
that they have no dimensions at all, but are truly mathematical
points, whence emanate attractions and repulsions. The air
around us is composed of such atoms, each one associated with
heat, light and electricity ; hence each atom may be regarded as
a mere point, from which radiate forces in straight lines, or rays
in all directions; or we may say the air is composed of points
radiating forces, or simply points of force.

The belief has generally been entertained that there are marked
differences and broad distinctions between the inorganic and
organic worlds, as well as between the vegetable and animal
kingdoms. I think, however, tkat to-day the certainty of such
conclusions is far less strong than it was considered some fifty

306 Eains on the Probable Causes of [Sept.,

years ago. Every day we appear to break down some of the
separating barriers, until some believe that after a time there will
be but slight obstructions left, if indeed there shall be any left at
all. Between amorphous matter and a highly organized vegetable,
there exists a deep gulf of separation; also between a tree and an
animal; but between the lowest vegetable structure and the highest
inorganic form the difference is not so striking; the lower organ-
isms mingle insensibly together, so at times it is difficult if not
impossible to say which is the vegetable and which the animal.

In the frosty forms on windows in freezing weather, we have
beautiful representations of some of the palm species ; and when
nitrate of silver is crystalized and viewed in the microscope, and
colored green by polarized light, it would be taken by any one not
acquainted with the facts to be a growing shrub or sprig of moss,
the representation being perfect. It is said that if bichromate of
potash be crystalized on a film of gelatine, not only is a tree-like
form produced, with its limbs and branches, but actually rhom-
boidal fruit appears to hang pendant in the foliage. Again,
granules of starch, which is a vegetable structure, regularly
formed by growth in the cells, when viewed in the microscope by
reflected light, looks very much like transparent rounded crystals.
The constituents of all organisms, whether vegetable or animal,
are mineral elements, and it was long supposed that the peculiar
combinations of those elements selected by the vegetable and
animal kingdoms could not be formed in the laboratory, but were
the exclusive results of life-action. It is now well established,
however, that this was an error, as not less than one thousand of
such organic compounds, such as urea and its compounds, acetic
acid, methyle, amylene, the alcohols, napthaline, glycerine, grape
sugar, etc., have been produced artificially or without the agency
of vitality.

All vegetables and animals are mainly composed of air and
water, the latter holding carbonic acid in solution, and only two
or three per cent, of other matters. Motion can not be held as the
characteristic of the organic world, since certain vegetable germs
have no motion, and finely divided matter diffused in liquids in
many cases has a distinct molecular movement, and the crystals of

1866.] Malaria and Epidemical Diseases, 307

camphor in small fragments move about on the surface of water
with considerable activity, closely resembling the movements of
some of the infusoria. Crystals grow in size by attracting such
particles in the surrounding solution as are suitable to their for-
mation ; the same thing is done by vegetable organisms. The hard
seeds of plants, when placed in a watery solution of such elements
as are required, will decompose, or its constitution will be broken
up, by attracting and assimilating the proper materials, and the
result is a shrub or plant. Also, if a piece of zinc be placed in a
solution of acetate of lead, it will partially dissolve, and at the
same time will attract the precipitated atoms of the metal in
solution, and the observed result will be the growth or formation
of a beautiful metallic shrub.

In making these comparisons, I do not pretend that we are
unable by examination to say which is the organic form and
which the inorganic structure, but merely to draw attention to
the fact, that the broad distinctions hitherto held as existing
between the organic and inorganic worlds no longer exist; that
as the animal forms imperceptibly pass into the vegetable, so those
of the latter, when our knowledge shall be more extended, may
also be found to gradually fade into inorganic structures.

The power which attracts the atoms of amorphous matter
together we call chemical affinity, or chemical or electrical force,
and that which holds togetker particles of the same kind we
term cohesive force ; crystalic force attracts and unites the atoms
into regular forms, and vital force attracts and unites the proper
atoms into organized forms. It is not seen why this latter force
should be considered as differing from the others, except in being
of a higher order. They are all means or agents in the hands of
the great overruling Intelligence to work out His designs and
fulfil His plans.

Having thus set forth in detail, as far as my limits will permit,
what I understand by the term force, and points of force, I will
now pass on to the consideration as to whether such points of force
may not exist intangible to the senses which may be capable of
self-division, equivalent to propagation or multiplication.

The first appearance of a new existence or formation, whether

308 Rains on the Probable Causes of [Sept ,

it be animal, vegetable, or mineral, is a minute transparent point
just perceptible to the highest powers of the microscope. As it
grows or expands by assimilating the suitable surrounding ele-
ments, if it be a mineral, it assumes some definite crystalic form ;
if an organism, it is observed to be more or less globular in form,
and consisting of an outer enveloping sac enclosing an albuminous
liquid or semi-liquid, and having a dot or nucleus in its centre.
In the earlier growth, in some instances, there appears neither
enveloping sac nor nucleus, but merely a rounded mass of gelatin-
ous substance. Such is the beginning of all life, from the
simplest photophyte to the varied and exceedingly complex struc-
ture of man, as is well known to those whom I now have the
honor of addressing. In the formation of the crystal the ultimate
composing atoms or points of force appear to act in certain direc-
tions with more energy than in others; and hence, in their associ-
ation, the resulting form is in general angular, or developed with
regard to certain fixed lines, axes, or poles. In the growth of the
organic structure, the vital or formative force appears to act or
radiate from the centre, in the primitive vesicle. If we suppose
a single point of force acting in all directions, but with power
lessening as the distance increases from the centre, and that to a
certain distance it is attractive to certain elements in the sur-
rounding medium, but beyond such limit the attractive force
becomes too feeble for such an effect, then there would result a
globular form of organized matter, or in other words a living
existence of the simplest kind.

In the further development of the simple organisms, a constric-
tion begins to appear apparently without cause, which, becoming
more and more defined, ultimately ends in dividing the cell or
individual into two perfect cells or existences. In this operation,
the point of force acting from the centre, and represented by the
dot or nucleus, began to divide itself into two parts simultaneously
with the first appearance of the constriction around the cell or
globule. It would thence appear that the division of the central
point of action into two parts necessarily determined the division
of the enveloping cell into two individuals. Each new cell thus
formed repeats the process of forming two separate cells, and thus

1866.] Malaria and Epidemical Diseases. 309

proceeding in a geometrical ratio until, within a few hours, the
number perhaps may be counted by millions.

In some cases, if two of the cells after separating touch each
other, the point of meeting dissolves away gradually, until the
two cells entirely mingle their contents, and a single cell is the
result. The product of such fusion or conjugation is remarkable,
for the compound cell dries up into a hard grain or spove, which
may last indefinitely, floating about in the air, or under favorable
conditions will develop cells similar to the original ones, which
by binary division will form new structures of agglomerated cells
covering extended areas. The growth of such plant is favored in
some cases by cold and damp, whilst the union of two separate
cells into one, or the act of generation resulting in the spove, is
promoted by heat and dryness. Thus, during the Spring and
cooler part of the Summer, such kind of vegetation may grow
luxuriantly, but it requires the hotter and dryer portion of the
season to develop the sporules, which, from their minuteness, are
carried off by every passing breeze. The size of the spoves in
some species of the cryptogamia is very small : thus I have
measured the average spove of the stysanus caput medusse and
found it about the one five-thousandth of an inch in diameter, or
so small that such a drop as would adhere to the point of a needle
would contain sufficient space for fifteen millions. Indeed, there
appears to be no limit to the smallness of size in the minutest
organisms of infusorial life, and as the power of the microscope is
increased it brings new, and before invisible, points of life into
view, just as the increased powers of the modern telescope
resolves into mathematical shining points the distant nebulae of
space. It is then clear that organisms capable of self-division
and propagation may and probably do exist beyond the utmost
powers of our best microscopes, and hence that countless sporules
may float in the air invisible to man, although assisted by the
highest powers of modern art. Such existences we may call
sporules, atoms, or points of force, and they may ever remain as
invisible as the particles constituting the various odors, and can
only be known to exist, like the latter, by their effects on the
exceedingly subtle nervous or vital forces.

310 Rains on (he Probable Causes of [Sept.,

I will now examine into the effects on the nervous and vital
forces produced by the introduction of sporules into the circu-
lating system, either by inoculation or by being drawn into the
blood by inhalation of the air in which they float. It will be
premised that the vital force of an organism attracts each atom of
its structure, or that each atom is enveloped by the vital force
precisely as it is enveloped or conjoined to the force of heat, and
when such atom shall be removed from the general system, it
carries with it its corresponding envelopes of associated forces ;
hence the loss of a certain number of atoms composing the struc-
ture of a living organism would result necessarily in the subtrac-
tion of an equivalent amount of vitality.

On the introduction of the sporule or germ into the blood, a
contest immediately arises between the vital forces of the spove
and those of the blood : the former endeavoring to attract to itself
the nutritious elements of the latter suitable to its development.
If the animal be in vigorous life, all the forces of its system are
in full activity, and the spove seeks in vain to overcome the
resistance opposing the disintegration of its constituents. # If,
however, the number of sporules or germinal cells introduced into
the blood be so great that their combined power exceeds the
resisting forces of the latter, or if from other cause the vital
force of the blood should have been previously reduced too low,
then the attractive power of the sporule will succeed in drawing
to itself such of the elements of the blood as it may require, and
the development of cells having commenced, proceeds with ac-
celerated rapidity by self-division and reproduction.

Thus the constitution of the blood is gradually disorganized ;
each removed atom has taken with it a portion of the vital force ;
the energies of the system become impaired; the portions of the
blood disorganized by the attractive forces of the sporules, with-
drawing some of its constituent elements, remain as foreign matter
which must be eliminated. Thus additional work is thrown on
the excreting organs, already weakened by the abstraction of a
portion of the vital force from the general system. The loss of
vital energy, and the deteriorated condition of the nutrifying
fluid, prevents its full normal action, and an increased waste of

1866.] Malaria and Epidemical Diseases, 311

tissues takes place, the components of which have also to be
removed from the system by excretion or combustion. This
disturbed condition of the general function of the system results
in fever, a particular discussion of which, as well as of the chill
which precedes it, does not immediately belong to the subject
under consideration.

"What is that which vitiates the air in particular localities, pro-
ducing intermittent, remittent, and bilious affections? has been a
question probably from the earliest ages of civilization. The bad
air or malaria of the Poretine marshes ages ago caused the wealth
and fashion of Rome to leave the pestilential atmosphere of the
city during the two warm months of Summer, and seek a purer
breathing medium in healthier localities.

Everywhere, when the warmth, moisture, and fertility of the
soil is favorable for the rapid production and decay of vegetable
and animal life and tissues, we find malaria. Thus marshes,
swamps, and stagnant water in warm climates, or during the warm
season of the year, infect the surrounding air, as is well known ;
even in healthy localities, if the firm soil for the first time is
broken up, thereby exposing innumerable vegetable fibres to rapid
decay, and perhaps also releasing imprisoned sporules and ger-
minating points, malarial influence is experienced. Thus in the
comparatively healthy districts of South Florida, in 1848 and
1849, I found in every case where the soldiers broke up the
ground, whether for the purpose of policing and dkching the
camps, throwing up earth-works, or in gardening, malarial fevers
ensued, notwithstanding every precaution was taken to preserve
health ; and when, at certain points considered very unfavorably

! situated, I took the precaution to prevent any disturbance of the
soil, the men under my command enjoyed good health for such
localities. Thus new agricultural countries must abound in ma-
laria, because of the breaking up of new soil, and old cultivated
districts become healthier, because of the gradual decomposition
of those organic matters which were peculiarly favorable for the

j generation of poisonous fungi, sporules, or exhalations. Hence
even in old districts the dwelling-houses should not be in the
midst of cultivated grounds, tut as far as practical removed from

312 Rains on the Probable Causes of [Sept.,

them; not the sides of hills or elevations fronting on plantations,
swamps, marshes, creeks, or rivers, but beyond the crests of such
rising grounds. The warm rays of the sun striking such elevated
places with more freedom than the shady bottoms, cause a rarefac-
tion of the air, which rising more or less vertically, has its place
supplied by the poisoned air of the low grounds. Thus, a dwelling
on the side of a hill, unless protected by a thick growth of trees,
would be exposed to a daily current of malarial atmosphere from
the bottom lands, and would be in a worse situation than if located
on the lowest adjacent land.

Warmth, moisture, and decaying vegetable matter are suitable
conditions for the growth, in general, of cryptogamia with the
rapid evolution of the innumerable sporules of the fungi. From the
circumstances attending the production of malaria, it would appear
to be either air containing floating sporules, germinal vegetable or
animal cells, points of force capable of propagation, or air mixed
up with the diffused gases arising from organic decomposition.

At Mont-faucon in Paris, there are extensive enclosures called
Huacker-yards, where thousands of animals are slaughtered as
worthless, or the dead bodies carried there to save the skins and to
allow the carcasses to putrefy for the purpose of manure. From this
mass of putrescent animal substances are evolved all the gases given
off by vegetable decomposition, and several others in addition, of
the most nauseous and disagreeable odors, involving ammonia and
the compounds of sulphur and phosphorus. Notwithstanding, the
numerous workmen with their families who live in the midst of this
most offensive effluvia preserve excellent health ; indeed, the family
of one of them named Friand, consisting of his wife and five
children, were in remarkably robust health, although they had all
the year round worked and slept in a place which was actually
unapproachable, on account of the stench, to the members of the
Commission appointed by the Government of Fiance to examine
into the matter. Moreover, these workmen live to be old men and
women, many above seventy and eighty years of age.

Again, all the gases given off by vegetable decomposition are
breathed at times in the laboratory of the chemist, in a more con-
centrated condition than ever takes place in the natural decomposi.
tion of such bodies, without any malarial effects whatever. It is

1866.] Malaria and Epklcmk-al Diseases. 313

true, the long breathing of carbonic acid and carbonic oxide, when
in appreciable amounts, will lower the vitality of the system, and
perhaps, in conjunction with other causes, may at times produce
typhoidal disease, like anything else which would diminish the
energies of the body whilst certain conditions prevailed ; but I
presume there exists no accredited case of a healthy person living
in a healthy atmosphere who has had malarial fever from the effects
of any single or compound gas.

In the matter of epidemical poison in the air, there is still less
foundation to suppose it results from the admixture of a delete-
rious gas or exhalation. It is well known that Asiatic cholera was
engendered in the Souderbund marshes of the Ganges in Indict,,
and thence spread through the English army in 1817, whence for
the first time it became the terror of the civilized world. la the
same district of country a pestilence like the plague, preceded by
cholera, arose in 1860, and for the three succeeding years swept
off many thousands of the inhabitants. Dr. Elliot, of the army,
who was sent to report upon the disease, attributed it to. malaria
and water filled with decaying organisms.

It is evident that, whatever may constitute epidemical poison, it
can not be gases, since it propagates itself, and extends from place
to place, far beyond the original locus. It must be, then, either a
peculiar propagating organism, propagating points of force, or an
electrical phenomena.

But how can electricity act ? It is a primary force like light
and heat, and like them is diffused in matter and throughout
space. It can indeed energize the oxygen of the air, into ozone,
and can diminish its normal activity into autozone, .and such
changes might doubtless- cause variations of health throughout
wide districts of country. But why should electrical action follow
particular streets of a city, or one side of a street, or one bank of
a river, or follow exclusively the lines of travel ? Electric force
can not be carried about in the clothes, or propagate itself from
house to house, or adhere to the stools of cholera patients, which
is said to be a main source of its propagation. It is well known
that electricity can be produced by friction of the clothes, or,
indeed, by any species of molecular disturbance, but who ever

21

314 Rains on the Probable Causes of [Sept.,

heard of such producing cholera, or any other disease ? The
important fact that the excrements of cholera subjects are the
principal sources of contagion, bears strongly on the probability
of the poison being organic points capable of propagation. It
may be asked, why could there not be minute poisonous atoms
floating in the air, or deleterious unknown gases, which would
thus poison the blood and cause disease ? Doubtless such may be
the case, but we must admit in epidemics such points or delete-
rious gases to be capable of propagation, otherwise the disease
produced would soon terminate for want of cause, and if propa-
gative, then they come under the definition either of organisms or
propagative points of force.

There are three ways of poisoning the blood, resulting in dis-
ease or death, viz. : First, by fermentation caused by the inocu-
lation or reception of bodies capable of producing such action
Second, by chemical combination with the foreign substance;
and Third, by what is termed catalytic action. Fermentation is
the breaking up of the constitution of the blood by organisms
which feed upon some of its elements, thus separating into new
compounds such portions as are acted upon ; the ultimate of fer-
mentation is putrefaction and dissolution. Some of the ferments
are vegetable, and some animal ; generally the decomposition of
animal tissues is effected by infusorial animalcules, the smallest
commencing the operation, viz. : the monas crepusculum, and
bacterium termo, according to the researches of M. Pasteur, a
distinguished French chemist. The size of these animated points
is so minute that the smallest specimens imperceptibly fade away
under the highest powers of the microscope, and are only known
to exist at certain points by the slight movement of the liquid
which surrounds them. Thus I have at first, in the sanguinious
matter from an ulcer, seen only a kind of motion in the seini-liquid
mass with a magnifying power of four hundred diameters, but with
a careful increase of power and arrangement of light, I have de-
tected countless thousands all in active movement. An idea ha*
been attempted to be given of the relative size of these excessively
minute organisms, by saying that thousands of them might sail
eide by side through the eye of an ordinary needle.

1866.] Malaria and Epidemical Diseases, 315

The poisoning of the blood by chemical combination with a
foreign substance fs well seen in cases of poisoning by arsenic or
corrosive sublimate, which unite with the albuminous tissues or
parts, and thus, rendering them solid, incapacitate them for further
vital operations. This action of these two substances renders
them virulently poisonous to all life, for every organized body
contains albuminous compounds essential to its structure. Thus,
arsenic, or chloride -of mercury, in solution, when given in small
doses, would completely destroy the malarial spoves or germinating
cells, which may have been absorbed in the blood. The blood
globules being larger, and hence supposed to have a larger amouufc
of vital resistance, would not be sensibly affected unless the
amount taken should be too large, in which case they also would
be killed.

What is called catalytic action is the production of a eertain
effect in compound bodies, without any apparent change in the
agent employed, and is probahly an electrical phenomena. Thus
a mixture of oxygen and hydrogen gases may remain perhaps
indefinitely without change, but on the introduction of a clean
piece of platina foil they immediately combine and form water.
If a piece of metal be in the slightest degree electrified, it will
cause the explosion of fulminate of silver. If the blood be inocu-
lated by an organic poison, as that of the snake, an immediate
action commences, and in a short time the vital force, as such,
is destroyed. This species of poisoning is entirely distinct from
that of fermentation or malaria, for whilst the latter find their
proper field of action in a debilitated, nervous condition of the
system, and consequent weak resisting power, tiie former acts
with greatest energy when the nervous force is in best condition.
Thus it is said to take less organic poison to destroy life in a
vigorous organization than in a feeble one. In other words, the
poison acts directly on the nervous and vital forces, and its action
is in proportion to their energy.

This would seem to indicate a possibility that those forces could
be so lowered in polarity, by being brought into contact with
certain agents, as to change their nature or become transformed
into others, just as light, heat, and electricity are corelative, or

316 Raixs on Malaria and Epidemical Diseases.. [SeptT

capable of being converted the one into the other. The fact
exists that the nervous and vital forces- gradually disappear under
the action of such poisons, and as it is held that no force can be
lost under any circumstances, the question arises, what has become
of them?

Alcohol, and the alkaloids, such as quinine, morphine, nicotine,
etc., also appear to act directly on the nervous force; their first
effects being stimulative, or increasing the energy of the nervous
power, they would hence appear as the antidotes of the above
kind of poisons. There must be floating in the air, in the
neighborhood of localities favorable for their propagation, a num-
ber, more or less great, of minute animal organisms, the dead
remains of which must be absorbed in the lungs, and there act in
some measure like particles of putrid blood, poisoning the system.
The same conditions, favorable for the development of vegetable
organisms, would favor the production of such animalcule, and
hence attending malarial poison of the blood would be the organic
poison affecting directly the nervous force. Hence, if arsenic,
mercury, etc., be used to destroy the vegetable germs, then
alcohol, quinine, morphine, etc., would be indicated as the proper
agents to neutralize the action of the decaying animal germs ; or7
as the two kinds of poison probably prevail together, then a mix-
ture of the two species of antidotes would suggest itself for
malarial influences, such as doses of arsenic and brandy, or arsenic
and quinine.

Arsenic, mercurial compounds, and the alkaloids, have long
been employed as the proper remedies for malarial fevers, and it is
interesting to trace out the chemistry of their use.

As regards the supposition that malaria and epidemics may be
caused by organisms floating in the air, I will here quote the sub-
stance of the remarks of Dr. G. Eobinson, ,in an address made to
the British Association, 1863. The author alluded to the circum-
stance of the analogy between many of the phenomena of fevers
and other zymotic diseases, and the ordinary process of fermenta-
tion having been perceived and recognized by Hippocrates and
the oldest writers on medicine. Their idea was, that a poisonous
ferment; existing in the atmosphere, entered the mass of the

1866.] T> u gas on Congenital 31 arks. 317

blood, and induced in it a series of elianges, whieh gave rise to
the excessive heat and other peculiarities of that class of disease.
At the present time, this doctrine, modified by the discoveries of
Liebig, and other ehemists, has been adopted by most physicians,
and forms the basis of the classification of disease framed by Dr.
Farr, and used by the registrar-general. It thus supposes living
germs to exist in the atmosphere, which, whea introduced into
the body, give rise to a specific and regular series of morbid
actions, pursuing a definite course in a definite time, as in small
pox, those germs being disclosed and multiplied, and producing
others eapable of reproducing in other bodies the same succession
of changes. (An. Sci. dis., 1864.)

I trust the foregoing remarks, however inadequate in elucida-
tion, will prove suggestive, and assist in drawing attention to a
subject of great interest to mankind.

ARTICLE III.
Remarks upon the supposed influence of the mother in the produc-
tion of Kscvi Materni, or congenital " marlcs" and other de-
formities. Read before the Medical Society of Augusta,
August 1st, 1866. By L. A. Dugas, M. D., Professor of
Surgery in the Medieal College of Georgia, and President
of the Medical Society of Augusta.

The love of mysticism and the vain desire to aecount for ever}
thing, have led men into some of the strangest vagaries with
regard to the origin, or immediate cause, o those olemishes of the
skin and malformations of the body so often* observed in new-born
infants. The most common interpretation of, these " marks " ir,
that they result from the longing desire of the mother, during
pregnancy, for some particular artiele of food, which article is
thought to be faithfully represented by the blemish on the skin j
and, as the color of these jnarks varies from a pink flush to a
reddish brown, they are most frequently supposed to be pictures
of strawberries, cherries, or other fruit; sometimes of roast beef,
ham, etc. Other marks and malformations are attributed to the
surprise or alarm of the mother at the sight of some hideous or
frightful object during her pregnancy. The locality of the mark
is said to be determined by the application of her hand at the time

318 Dugas on Congenital Marks. [Sepf.,-

to the corresponding part of her own body. Henee, the precau-
tion recommended in such eases, to apply the hand promptly to
some concealed part of the surface, in order that the mark of the
child may be covered by his garments and not be unsightly. Woe
be to the child if the mother carries her hand to her face when
she is "longing" for a dish of strawberries, or is shocked at the
sight of a toad, for the offspring will then be terribly disfigured I
These superstitions are so generally known, and, I may say, be-
lieved, that it is unnecessary to enter into a more detailed account
of them. Let us now examine the matter a little and see if there
are any grounds for the belief, or rather if it be possible for such
effects to be induced by such causes.

The only rational grounds for the belief are to be found in the
occasional coincidence between the alleged cause and effect. But
even these are so rare when compared with the countless number
of instances in which the effect fails to follow the cause, that they
must lose much of their force upon the slightest investigation.
Hideous objects have been known to frequent the thoroughfares
of London for many months without giving rise to a solitary well-
authenticated instance of deformity in anywise resembling them,
although they must have been seen by thousands of women, at all
stages of gestation. A cause so rarely followed by any effect can
scarcely be entitled to be considered as a spectacle carefully to be
avoided by women lest the foetus in utero be made to bear the
marks of their temerity. Again, was there ever a woman who,
under the influence of the derangement of the functions of the
stomach, and the capricious appetite peculiar to pregnancy, did
not, more or less, ardently -desire some article of diet she could
not obtain ? And yet how does the number of children born
with marks correspond to the number of those who come
into the world without the evidence of such longing? This
absence of sequence will become more striking if we bear in mind
that inasmuch as the mother must have, in every instance, desired
quite a variety of things, it can never be difficult to assign the mark
to some object it may be supposed to resemble.

But science furnishes us the strongest argument against this
superstition. The laws of foetal evolution have been so successfully

1866.] DuiAS on Congenital Marks, 319

studied during the present century, that we are now enabled to
solve many problems heretofore incomprehensible, with regard
both to the nevi materni and to the malformations or monstrosi-
ties, as they are technically called, which we occasionally meet-
Among the principles that bear upon our subject, the following
may be mentioned :

1st. That, with the exception of the heart and organs of diges-
tion, the early product of conception consists of two lateral and
symetrical halves, which subsequently come together and are
agglutinated upon the median line so as to constitute one body.

2d. That the process of evolution proceeds from the periphery to
the centre; those portions most remote from the median line being
formed first and the others last. Hence, the fingers are formed
before the hand, this before the forearm, and the arm proper still
later ; the ears exist before the eyes, these before the nose ; and
so also with regard to the trunk.

3d. That any arrest or cessation of evolution before it be com-
pleted must result in malformation, corresponding to the stage
of evolution at the time of its arrest. If, for example, after the
hand has been eked out of the body, the process of evolution be
arrested, the child will be born with a hand where the shoulder
should be, and consequently with neither forearm nor arm. If,
after the formation of the ears, head, and eyes, there be no farther
evolution, and the two halves become then agglutinated, the nose
and the central portions of the upper-jaw will be wanting at birth.
Cyclops are thus formed by the union of the lateral portions of the
head just at the time when the outer half of each eye had been
completed. The arrest of evolution leaving only one half of each
eye formed, these halves have come together so accurately as to
resemble one perfect eye on the median line. Cyclops can never
have a nose, because of the arrest of evolution and of the union
which has taken place before it could be formed.

4th. The failure to unite the two halves at any point of the
median line must leave fissures where none should exist. Hare-
lips and cleft palates are thus produced.

oth. Whenever two products of conception or distinct foetuses
become united during their evolution, the connection always

320 Dugas on Congenital Ma^iS. [Sept.,

occurs between homologous parts; or in other words, parts dissim-
ilar in the two never unite. Union takes place of face to face,
back to back, side to side, sternum to sternum (as with the
Siamese twins), shoulder to shoulder, etc.; but we never find the
face of one united to the back of another, nor the shoulder to
the hip, nor any union of parts dissimilar.

6th. The process of evolution may be excessive as well as in-
complete; when excessive in certain portions of the capillaries,
these blood-vessels, which are in the normal state too small to be
seen with the naked eye, now become so large as to carry red
blood and to impart to the locality (if in the skin) a correspond-
ing degree of redness. This is the way in which marks are
formed. An excess of evolution may also produce supernumerary
fingers or other appendages.

^Yith these principles in view, we must be prepared to admit
that if the emotions of the mother ever affect the feetus so as to
induce deformity, this must be done at the precise time at which
the deformed locality is undergoing evolution; for the difficulty
would much increase if we had to presume that, after the evolution
had been completed, the emotions of the mother would destroy it
and reproduce an anomalous one in its place. In the case of hare-
lip, for example, which is one of the simplest deformities resulting
from a failure of timely agglutination of the parts, to suppose it to
be induced by an emotion occurring after the formation of a
healthy lip, would be to admit the possibility of a destruction of
normal tissues and the extension of skin over the edges of the
newly formed fissure.

One of the most hideous deformities, and one unfortunately too
common, is that which results from an arrest of evolution before
the development of the brain and cranial bones. The child is-
then born with neither brain nor head proper, while the face is
fully developed, which gives it a monstrous appearance, not uufre-
quently compared to a toad or bull-frog. Would it not be taxing
the credulity even of a fanatic in such matters, to suggest that any
emotion of the mother could induce the destruction of such ex-
tensive and important organs after they had been formed ? The
cause, whatever it may be, which gives rise to such a deformity,

1866.] Dugas on Congenital Marks. 321

must be operative before the evolution of these portions of the
body; for it clearly results from an arrest of evolution. I may be
permitted here to cite an instance somewhat analogous, which was
attributed by the accoucheur, a physician of high standing and of
large experience, to the sight of a giraffe during the last month
of pregnancy. The child presented a deformity of the head,
which was said to assimilate it most strikingly to a giraffe. I re-
quested permission to examine the monstrosity with the gentleman
in attendance, and found it to be simply a case resulting from an
arres of evolution in the cranial bones ; but not in the brain.
The consequence was, that the hemispheres of the brain, not being
bound down by bony matter, stood up somewhat like cones ; and
these were the bodies supposed to correspond to the ears of the
giraffe ! In all other particulars the child was well formed, and
lived several days. Now, if the sight of the giraffe had had any-
thing to do with this deformity, it must have occasioned the
destruction of the whole scalp and of all the bones of the cranium
in the course of the few weeks which elapsed between the
unpleasant spectacle and the birth of the child. And yet it is
probable that this wonderful effect will be handed down from gen-
eration to generation among the credulous friends who witnessed
it, as positive evidence of the correctness of their belief! Almost
every family circle hoards up some story of the kind, in which the
most circumstantial details are given to establish authenticity ;
but although I have sought every opportunity to investigate the
correctness of the inferences, I have never yet seen one which
would sustain the belief in the slightest degree.

Is there any reason to believe that emotions of the mother's
mind can affect the evolution of the foetus in utero? This is an
interesting question to physiologists, and one that has engaged
their serious attention from time to time. In order to answer it,
we must first determine the ways, or means, by which communica-
tion is established and kept up between the mother and the fcetus.
There is between the two an obvious communication by means of
the blood; for it is through the mother's circulation that the
foetus is nourished. The placenta is attached to the inner surface
of the uterus, whence it continually derives nutritious blood from

322 Dugas on Congenital Marks. [Sept.,

the mother, and returns that rendered unfitted for this purpose by
its course through the foetal vessels. So far as the minutest ana-
tomical investigations may be relied upon, there is no nervous
communication whatever between the two. No nervous filaments
have ever been found running from the uterus to the foetus. I
believe that some anatomists have imagined that they traced
nervous filaments into the placenta, but I can just now recall none
who pretend to have followed them any farther. In the present
state of our knowledge, we can not admit that there exists any
other than a sanguinious communication between the mother. and
foetus ) and this seems to be all that is necessary for the well-being
of the product of conception. If analogy be worth anything in
settling such questions, we should observe that in oviparous repro-
duction all communication is cut off as soon as the egg becomes
encased in its shell. The chick is nourished and developed at
the expense of the pabulum enclosed in the shell. This yolk, or
pabulum, having been supplied by the mother in sufficient quantity,
all communication is cut off, and with it the nervous influence, if
any previously existed. It should also be remarked that mal-
formations are exceedingly' common in our domestic fowls, and
that they occur in strict accordance with the principles we have
adduced as governing them in the human family.*

In conceding that the foetus in utero derrves his nourishment
directly from the mother's blood, it follows that the development
of the foetus may be influenced by the quality of the food supplied.
But, while this might affect the development of the body as a
whole, it is not easily understood how it could affect only certain
localities, and, still farther, do so under the temporary influence
of a desire for special articles of diet, or of a sudden emotion,
however strong. A mother pining away under protracted de-
rangement of the functions of digestion, or long-continued grief,
which might likewise impair her functions of nutrition, might
give birth to a puny child; but this does not reach the cases
under consideration, in which the defects are altogether local.

* The Medical College of Georgia contains a very valuable collection of monstrosities, not
only human, but also representing nearly all our domestic animals. In every instance,
whether of single or double monsters, the same laws are observed, and the deformities of
the lower animals correspond exactly to those in the human subject. Will it be urged that
the mental emotions of the hen, the cow, the mare, the sow, etc., have occasioned thesa
moditications of development in their young.

1866.] Dugas on Congenital Marks. 323

Indeed, it is generally found that those who are born with mal-
formations, referred to an arrest of evolution in a certain locality,
are rather prone to an excess of evolution in the unaffected parts
of the body.

Finally, if the mental emotions of the mother ever reach the
foetus, this must be done through the nervous system, which can
alone convey them from the brain. We know of no other channel
through which the operations of the brain may be conveyed to the
other parts of the system. It is through them that the brain
receives the impressions made upon all parts of the organism, and
it is likewise through them that the mandates of the will are
transmitted to every muscle of voluntary motion. If there be no
nervous communication between the mother's brain and the system
of the foetus, and none has ever been detected, is it not preposterous
to attribute an extensive and most curious class of phenomena to
the influence of the mother's mental condition upon the intra-
uterine offspring ?

There is no denying the occasional occurrence of coincidences
well calculated to impress the unreflecting classes of society with
a belief in the superstition we are combatting. The case I have
cited, in which the sight of the first giraffe that was brought to
this city was followed by the birth of a child deformed in that par-
ticular manner, carried conviction to the mind of those who may
have doubted before ; and especially when sustained by the credu-
lous accoucheur. It is probable that any other deformity would
have met with the same interpretation in that case, for the mena-
gerie contained quite a large collection of wild beasts, some one of
which would have supplied the place of the giraffe if this had not
answered the demands of the imagination. If the child's skin had
presented a number of marks, the leopard might have been made
to father them.

I saw another striking case of coincidence, which occasioned
quite as much sensation as the one referred to. I was requested
to visit a little negro who was suffering with paraphymosis, at-
tended with retention of urine, and was waited upon by a negress
in her last month of pregnancy, who assisted me in drawing off
the urine with a catheter and in reducing the strangulation.

824 Dugas on Congenital Marks. [Sept.,

About a month after this a messenger came for me, stating that
this woman " was delivered the night before of a son who was
affected just as the other little negro was, and could not pass his
urine." I found accordingly that the new-born infant had a
fissure of the prepuce, resulting from an arrest of evolution, and
an occlusion of the meatus urinarius by mucous agglutination,
which prevented the escape of his urine. The meatus being
opened with a probe, the urine was immediately passed off.
Nothing could be more conclusive, and it is needless to add that
no argument I could adduce had the least influence in shaking a
faith so strongly confirmed. And yet, in this case, the foetus was
eight months old when the unpleasant sight was witnessed j his
genital organs were then, of course, fully developed, or rather
deformed, in the way in which he came into the world. If they
were not deformed at eight months, how could they become so at
a later period ? The history of dreams, and of coincidences in
general, is full of curious and inexplicable facts, which we must
admit, but which we should be careful not to invoke in support of
superstitions entirely at variance with sound knowledge and sub-
versive of all we know to be true.

We are now prepared to understand the philosophy of the
simplest, as well as of the most complex, deviations from the
normal evolution of the body; and if we can not fathom their
remote or ultimate cause, the reason is to be found in the law of
nature which fixes a limit to our understanding. We know the
ultimate cause of nothing whatever. Why does an apple fall to
the ground? Newton has discovered the law by which this is
effected, and answers that it is attracted by the earth. But why
is it attracted ? We can go no farther. The discovery of the
law is the limit of our abilities. We are continually asked why it
is that one person is born with blue eyes and another with black;
why is one person fair and another brown ; one with good teeth
and another with bad ones ! We know the laws by which all
these peculiarities are brought about, but can not divine why
these laws have thus controlled the evolution of each individual
so as to make it different from others.

Nevi materni may involve the blood-vessels, the pigment coat,

1866.] Dugas on Congenital Marks. 325

and the hair follicles separately, or jointly, and be slightly raised
above the general surface, or not at all so, giving very different
appearances to the "marks."

When the blood-vessels of a certain part of the skin are in a
state of hypertrophy, or of excessive development, the "mark"
presents various hues of red from a slight flush to crimson, ac-
cording to the different degrees of hypertrophy and quantity of
blood there concentrated. These marks are more florid in the
Spring and Summer, when the cutaneous circulation becomes
more active, which circumstance is attributed by the vulgar to
the relation the marks bear to certain fruit which ripen and turn
red at that time.

Although this condition of the blood-vessels usually remains sta-
tionary after birth, instances are not rare in which, if not excessive,
it gradually disappears. I have seen a number of children born
with slight florid marks on the face, which entirely disappeared in
one, two, or three years, without any interference. Sometimes they
are cured by the supervention of some disease. A child a few
months of age was brought here from the country with quite an
extensive red nevus of one side of the face and lips. A surgical
operation was proposed for its destruction, which I opposed, because
of the danger it involved. The child, fortunately, escaped the ordeal,
and "was taken home. Not very long afterward, the whole face
became invaded with crusta lactea, which ran its usual course, with
the exception that it was worse over the nevus than elsewhere, and
left the child completely relieved of her congenital deformity.

But sometimes the hypertrophy goes on increasing after birth, or
may begin to do so in the adult*,' so as to result in a very formidable
disease. They occasionally degenerate into malignant affections
more or less unmanageable.

An excessive or perverted action of the pigment coat, by which
the coloring matter of the skin is secreted, will produce patches
more or less dark j and if the hair follicles are also affected, these
marks may be covered with a more abundant growth of hair than
the adjacent surface. An arrest of the evolution of the pigment
coat in the whole skin of a negro will make him an albino. White
rabbits, white mice, white crows, etc., are all produced in like

326 Dugas on Congenital Marks. [Sept.,

manner; and it is curious that in all these cases the coloring
matter of the eyes is equally wanting ; hence the intolerance of
light, with which they suffer.

In some cases we find the development of the hair growth to be
excessive and general. The hirsute woman and children, who
exhibited themselves throughout our country some years ago,
were striking instances of this kind. Simply bearded women are
more common.

Harelip and cleft palate we have seen to be dependent upon an
arrest in the union of the lateral portions of the body before its
completion. This occurs occasionally in the spinal column. The
whole, or only a portion, of the posterior surface of the spinal
canal remaining open, the watery fluid, which fills the membranes
by which the spinal marrow is surrounded, accumulates. As
these membranes are not supported by the usual bony walls, they
gradually yield, until they form a large pouch projecting from the
affected region, and give rise to considerable deformity. This
is what we denominate spina bifida. It is not only a malforma-
tion, but a frightful disease, which goes on increasing, and is
necessarily fatal.

I have already noticed some of the most striking cases of defi-
cient evolution in the brain, cranium, and scalp. Children may
be born with imperfect hands, feet, and limbs ; sometimes without
any at all.

The most curious monstrosities are those which result from the
union of twins. In the case of the Siamese twins, so generally
known, it seems that their development went on naturally and
separately until they were brought in such close contact that they
adhered or grew together just at the lower end of the sternum or
breast-bone. Why did not the sternum of the one adhere to
seme other part of his brother? Simply because the law which
governs such cases forbids it. Instances are on record in which
twins have been thus cemented by the soles of their feet, others
by the crown of the head, some face to face, back to back, side to
side, etc. In all these cases the individuals were at one time
separate and distinct, and the subsequent union does not obliterate
their individuality, however great may be the apparent fusion of

1866.] Dugas on Congenital Marks. 327

both into one. Bitta Christina, extensively known in Europe,
had two heads and necks, four arms, and only two legs. From
the umbilicus down there appeared to be but one child a well
formed girl. While one head was asleep, the other might be awake
and playful, or crying. They lived upward of a year, when one of
them sickened and died; the other, in good health until then,
gasped and died, also, immediately. A post-mortem examination
showed that their brains, spinal marrows, and nerves were distinct;
that they each had a heart, but that these were inclosed in a com-
mon sac, or pericardium ; that the digestive organs were distinct
down to the large intestines, where they became merged into one
canal. It was thus explained why their appetite was distinct,
whereas .their desire to defecate was common or simultaneous. Pain
was perceived by the right head when the corresponding leg was
pinched, and by the left when the same impression was made upon
the other limb. Now, what had become of the missing portions of
each body ? They were absorbed or destroyed by the pressure by
which the individuals had been forced together, when the tissues,
being in a soft and almost gelatinous state, would readily lose their
vitality.

Sometimes tke pressure operates unequally upon the two beings,
and results in the destruction of a very large portion of one body
while the others have not suffered. We then have fragments of
one body attached to another, which is otherwise well-developed. A
cow was to be seen in our streets for a number of years who had
the fore-leg of a twin dangling from her shoulder. It is remarkable
that in all these cases the fragment, however large or small, obeys
the law already enunciated, and unites only to a corresponding
portion of the body of the other.

Having already extended these remarks far beyond the limits I
had intended, I will conclude by urging upon the members of this
Society an unbiassed and philosophical examination into every case
that may present itself of supposed maternal influence upon the
production of defective or anomalous evolution. A* well-kept record
of such investigations would be exceedingly interesting, for it is
only by the collection of facts that we can ever expect to demon-
strate the fallacy of the popular belief on the subject.

828 Habersham on Wounds of Knee-joint [Sept.,

ARTICLE IV.

Penetrating Wounds of the Knee-joint : treated at Chimlorazo
Hospital, Division i\x>. 2, Richmond, Va. By S. E Haber-
sham, M. D., Surgeon in charge, and Vice President of the
Medical Society of Augusta, Ga. Read before the Society July
18th, 1866.

The object of this paper is to call attention to the results of con-
servative surgery in gunshot wounds of the knee-joint, treated at
Chimborazo Hospital, Division No. 2, hoping that it may induce
other surgeons who may have the records of their own experience,
to publish them in vindication of the Southern medical man, whose
labors in the late sectional war should be a part of our glory, and
of which we shall be robbed, if their names remain buried in the
oblivion of private case-books. This mode of publication is the
more important, since all of the carefully-prepared records in the C.
S. Surgical Bureau were entirely destroyed by fire on the 3d of
April, 1865.

The number of cases here reported are too insignificant for the
purposes of statistics, yet they serve to show that, under favorable
circumstances, many wounds heretofore deemed cases for amputation
or resection may recover under the existence of favorable conditions,
to be mentioned hereinafter ; and though the writer does not pre-
sume to take issue with the eminent authorities and advocates for
operative interference in all cases of gunshot wounds of this joint,
yet he must believe that this rule will be somewhat modified when
the results of Confederate surgery are published to the world, which
can only be done through the voluntary contribution of every
surgeon who has matter in his possession. Already has the result of
conservative surgery in compound fractures of the femur somewhat,
materially shaken our faith in the application of European experi-
ence to this country, and the number of recoveries from wounds of
the knee-joint in all the divisions of Chimborazo Hospital, if they
could be obtained, would throw valuable light upon a question re-
quiring farther elucidation, before we can subscribe to the rule laid
down even by Dr. Hamilton, an American surgeon, who says :
"Gunshot wounds involving the knee-joint demand amputation in

1866.] Habersham on Wounds of Knee-joint 329

almost all cases. Guthrie has seen no recoveries from gunshot
wounds of the knee-joint, unless the limb was amputated. Wt
have seen a few recoveries, especially when the joint was penetrated
by round balls, or when the joint was slightly opened"

Against secondary or intermediary amputations we certainly put
in our demurrer, when the joint is simply perforated by the ball, or
is within reach of the bullet forceps, and can be extracted without
opening the joint too effectually. In support of which opinion the
following cases are submitted.

Before, however, introducing these cases, it will be necessary to
make a few preliminary remarks upon the hospital in which thes
results occurred, nor is it deemed irrelevant to the subject to consider
the material of which the medical staff was composed, as explana
tory of the cause why conservative surgery prevailed to so great an
extent as it did in the early part of the war. Many of the surgical
staff were called from the peaceful practice of their profession in
small country towns, where operative surgery was seldom practiced,
and when necessary, the more experienced city physician was gene-
rally consulted, hence it was very difficult for these men to bring
themselves to realize the full force of the necessity of amputation,
when the external appearance was simply a small slit, or circular
hole in the skin, therefore many operations were postponed which,
by the rules of art, should have been performed primarily on the
field. In many cases nature was allowed to do her part unaided,
save by such means as placing the patient in as comfortable a

position as possible, the maintenance of secretions, regulation of
diet, and removing such foreign bodies as presented at the orifice of
-the wound. Under this treatment, with careful nursing, many
wounds of the most serious character manifested decided tendencies
to recovery, so that the secondary operation was postponed from
day to day until there was no question of ultimate recovery. On
the other hand, there were those of more operative skill and expe-
rience in surgery who, appreciating the advice of military surgeons
being on hospital duty, were generally obliged to wait for the secon-
dary period or condition befoVe amputating, and when this condition
was obtained, it was deemedr'by them safe to subject the patient to

'conservative treatment, rather than expose them to the almost

22

330 Habersham on Wounds of Knee-joint [Sept.,

4 certain death which attended intermediary and secondary amputa-
tions in hospitals. Experiencing the same beneficial results of post-
ponement, they, too, became the advocates of conservative surgery,
particularly when compared with secondary amputations. In time
this influence extended to the field surgeon, who often, forced to
reserve many cases "for a more convenient season," only operated
upon those manifestly requiring immediately his attention, giving
the others the benefit of a doubt, which often resulted in good to
the individual, and saved, to many, useful limbs.

In a short time the experienced physician became an excellent
consulting surgeon, and before the war terminated I doubt whether
there could be found, in any army, more judicious, experienced,
intelligent, and successful practitioners than was the surgical staff
of the Confederate army ; and this the records of the staff would
show, could they be recovered from the ashes which has buried
for ever, I fear, these herculean labors, excepting when here and
there a few isolated cases may be published from the private records
of individual surgeons. In no department of the staff would this
have appeared more honorably than in the compilation of reports
made by that intelligent and industrious officer, Surgeon F. Sorrel,
General Inspector of Hospitals, and his able and hard-working as-
sistant, Surgeon Baehr, which, but for the untoward accident of
fire, would have enriched the field of military surgery, particularly
in data on the subject of the conservative treatment of gunshot
fractures of the femur and penetrating or perforating wounds of the
knee-joint. Could these records be exhumed from the ruins of the
War department, and published to the world, the Confederate
medical staff, with its able, working, and discriminating Surgeon-
General, would stand out as lovers of their profession and their
race, contending against disease and wealth with all their energies,
while the resources of their art were cut off by the cruel policy of
the Federal Government, which declared medicines contraband of
war, so that it was often, even in hospital, impossible to obtain a
single dose of morphia to relieve the most excrutiating pain. This,
however, is no place to recall painful associations, and this is only
mentioned here to show one of the many difficulties we had to
contend against in the treatment of the wounded.

1866.] Habersham on Wounds of Knee-joint 331

Situated on the eastern confines of the City of Richmond, upon
a plateau of ten acres (at least one hundred and fifty feet above
the banks of James river), terminating in a precipitous bluff on
the east, south, and west, and on the north in a wide cultivated
field, the site of Chimborazo hospital possessed all the advantages
of an eligible location. In addition to this favorable site, cool, stiff
breezes from the southeast, coming across a wide river and immense
extent of field and woodland, continually wafted the contaminated
atmosphere of the hospital into the fields beyond, while many springs
of cold, pure water, of 58 or 60 Fahrenheit, gave an abundant
supply of nature's most refreshing and healthful beverage, so essential
to the modern surgeon, and which has altogether supplanted the
fomitic poultice in military surgery. With ample room for the accom-
modation of our wounded, we were generally enabled to give each
patient from eight hundred to one thousand cubic feet of atmos-
phere, and when a purer air was deemed essential in any particular
case, our wounded were isolated in tents, furnished for the purpose
by the admired foresight of the Surgeon-General, which were
pitched in open areas, in proximity to the hospital. The beneficial
influence of this change was often manifested in the rapid improve-
ment of gangrenous wounds, and sloughing phagardena.

During the battles around tbe~cky in 1862, many of the wounded
were transported to the hospitals directly from the field, in private
carriages, comfortable hacks, and ambulance wagons, and being
immediately attended to upon their reaching the hospital, were thus
placed under the most favorable conditions for recovery. Some
cases, however, reached us in a moribund condition, having never
recovered from the shock of the wound, while others, quite numer-
ous, were transported long distances by rail or ambulance wagon,
and consequently suffered the unavoidable neglect incident to the
transportation of large numbers of wounded without a sufficient
medical staff to afford them proper assistance. This evil helped to
swell the mortuary report of the hospitals to a greater degree than
any other cause, for it is certain that many wounded lost their
lives who, under more favorable conditions of transportation, would
have recovered.

The abundant ration supplied to the army of Northern Virginia

832 Habersham on Wounds of Knee-joint. [Sept.,

in the first year of the war contrasted very greatly with that of the
period following the retreat of General Johnston from Manassas,
and the subsequent operations upon the Peninsula, around the
City of Richmond ; in consequence of which, the soldiers brought
into hospital manifested a decided tendency to all the diseases
growing out of an impoverished state of the blood, such as scor-
butis, purpura, sloughing ulcers, etc.; heDce, wounds seldom man-
ifested highly inflammatory complications, but on the contra^,
the reverse, requiring a tonic diet and stimulating beverages in
the outset to bring about sufficient action to resist the wasting and
prostrating effects of suppuration. Thus the advantages derived
from the favorable condition of the hospital, and the early removal
of our wounded from the field-ambulance, were very much counter-
acted by this evil of spare diet requiring the utmost attention and
discrimination in the attending surgeon, whose supply of stimulants
was very meager, and generally confined to impure new whiskey,
with an occasional bottle of brandy, reluctantly furnished by the
medical purveyor, who, I suppose, had very little in store.

ISTow, that the war is over, and we are enabled to contrast our
difficulties with the immense advantages enjoyed by the Federal
surgeon in his superior resource and unlimited supply of every
necessity, nay, every comfort for his wounded, the wonder is that
our results of treatment should compare even favorably with theirs,
and yet in several characters of wounds the credit would be in
favor of Confederate surgery.

In no character of gunshot injury was unexpected success more
manifest than those included in the following summary and history
of cases :

Total number of cases admitted from July, 1862, to April, 1865,
25 ; known to have recovered, 6 ; furloughed, but not heard from,
3 ; transferred as convalescents, 4 ; unaccounted for, 3 ; died in
Hospital, 6 ; in hospital April, 1865, recovering, 3.

We have, in the above summary, a known mortality of six cases,
or twenty-four per cent. Suppose, however, of the three fur-
lougKed but not heard from, four transferred as convalescents, and
three unaccounted for; twenty-four per cent, died, we then have in

1866.] Habersham on Wounds of Knee-joint 333

all a mortality of nearly twenty-seven per cent.; the three, how-
ever, who were furloughed were certainly in a fair way of recovery,
else the board would not have acted in their cases ; the three un-
accounted for may possibly have died, though this is not probable,
else the fact would have been mentioned in the copy of surgical
reports. It is, therefore, more probable that they were transferred
to some country hospital, and in the hurry and confusion attending
some of these 'transfers (of a hundred men at a time, in a few
hours after receiving the order), the clerk may have omitted to
mention the fact in the copy of report. But, even if we allow
among the two above enumerated the twenty-four per cent, of
deaths, we have a most favorable result, very much at variance
with the statistical records of all previous surgical experience, and
mainly attributable, no doubt, to very favorable hygienic influences
in the hospital; the persistent and judicious use of cold water,
and the tender care manifested for the sick and wounded by our
valuable matron, Mrs. Pember, who spared no pains in the prepa-
ration of the diet prescribed for them, often supplying from her
own stinted resources the deficiencies of the supply furnished by
the hospital department and city market.

Case 1. Penetrating wound of knee-joint, by conical missile,
causing pyemia and death.

I. P. B., private Co. I, 2d S. C. infantry, was wounded on the
2d July, 1862, and admitted to hospital on the next day, with
wound on external side of left knee ; synovia escaping ; ball ex-
tracted ; no fracture detected ; a high degree of inflammation re-
sulted in profuse suppuration, and pyemia terminated the case in
a few days.

Case 2. Penetrating wound of knee-joint by conical missile.
Pyemia; death.

T. B. S., Co. , 2d N. C. regiment, wounded June 28, 1862,
and admitted 30th, with penetrating wound of joint; synovia
escaping; no fracture detected; missile lodged, but not discov-
ered. Synovitis supervened on third day of receipt of wound,
and pyemia terminated life on the 11th July.

Case 3. Penetrating wound of knee-joint; synovitis, terminat-
ing in gangrene ; amputation and death.

334 Habersham on Wounds of Knee-joint. [Septy

W. P., Co. A, 34th N. C. artillery. Wounded June 27th,
admitted June 29th, with penetrating wound of knee-joint by
conical missile, fracturing patella, and lodging. Health good, and
quite an athletic man. At the time of admission there was so
little appearance of even external inflammation that it was thought
to be a glancing shot, confirmed by the statement of the soldier
that he had walked a mile without much pain after being wounded.
On the fifth day of admission synovitis supervened, and, on con-
sultation with surgeon McCaw, amputation was determined upon,
it having been discovered that the head of the tibia was fractured.
On the 9th day of July, free suppuration having been established,
and the patient being in a proper condition for secondary amputa-
tion, it was determined that the operation should be performed in
the cool of the afternoon. In an hour or two the wound was
attacked with gangrene, implicating the whole surface of the
knee, and amputation was performed before the prescribed hour,
by Assistant Surgeon Wall, the patient not losing more than two
or three ounces of blood, notwithstanding which, he commenced
to sink in a few hours after the operation, and died on the sixth
day after from suppurative discharge. An examination after am-
putation revealed fracture of head of tibia, with injury to external
condyle of femur.

This was the first case of true malignant or hospital gangrene
that occurred in the second division of Chimborazo hospital.

Case 4. Wound of the knee-joint by fragment of shell, opening
synovial sack and grazing external condyle of femur. Eecovery.

I. S. N". private Pegram's battery, aged 19. General health
good. Wounded May 24, admitted next day. Wound by small
fragment of shell, which entered at external edge of patella,
grazing external condyle of femur, and making exit through quad-
riceps tendon, with escape of synovia from lower wound. When
admitted, patient was suffering much pain, and the knee was much
swollen from synovitis. The limb was immediately elevated on
pillow, cold drip applied, and one quarter- grain tartar emetic
prescribed every two hours, until nausea occurred, then reduced to
one eighth-grain every two hours, or, in case this should nauseate,
to one sixteenth-grain. The former was suspended sometimes for
a few hours, and the latter occasionally omitted.

1366.] Habersham on Wounds of Knee-joint 335

Tenth day. Inflammation subsiding ; complains of drip use
wet rags instead ; tartar emetic suspended.

June 6. Discharge of synovia ceased ; lower wound granulating
on edge ; discharging serum as if from joint ; upper wound healed,
covered with white film.

June 16. Lower wound healed. Some enlargement of knee,
with pain upon motion ; some slight inflammation has occurred ;
return to cold drip.

June 18. Cold drip having proved uncomfortable, was suspended
after a few hours trial, and wet rags substituted ; knee natural in
temperature ; no pain upon slight motion of limb.

June 24. Patient being anxious to be on his feet, suspended
his leg by sling, passing under foot and around neck, and permit-
ted him to walk about the ward for a few minutes.

June 26. Patient brought before furlough board, and sent home
for sixty days in charge of a friend.

Case 5. Y. S. left knee-joint, by conical missile, entering an
inch below outer side of patella, passing into joint and lodging
against integument on its inner side, from which it was removed,
with one or two spiculae of bone, by incising integument.

"W. H. S., aged 23, Co. B- Pegram's battery. General health
good ; was wounded 24th May and admitted into hospital the
same day. Knee very much enlarged ; inflamed and very painful,
with profuse discharge of synovia ; high inflammatory fever ; limb
was elevated on pillows and cold drip applied ; tartar emetic as in
other case every two hours, and diminished according to effect ;
half-grain sulph. morphia at bedtime to insure rest and benumb
pain.

May 26. Knee not more enlarged ; external inflammation
greater ; synovial fluid still escaping from both wounds ; synovitis
acute. Continue cold drip ; canteen to be frequently filled with
fresh water from spring ; continue tartar emetic. Ten grains cal-
omel, to be followed ia six hours by half-ounce sulph. magnesia
in eight ounces water.

May 28. Wound attacked with erysipelas,- removed to tent;
suspend cold water ; paint with tinct. iodine ; stop tartar emetic
and substituted twenty drops mur. tinct. iron three times a day, in

336 Habersham on Wounds of Knee-joint. [Sept.,

half-tumblerful of water ; half-diet. This treatment was continued
for fifteen days, when the erysipelas had subsided and patient was
returned to his ward.

June 26. Discharge from joint has altogether ceased ; wound
of exit showing tendency to heal ; slight constipation, indicating
saline aperient; continue wet-rag application, which had been
used constantly after return to ward ; full diet.

June 30. Patient unusually cheerful upon promise of furlough;
pulse natural; temperature of joint natural; sleeps well, and eats
his full ration.

July 6. Swelling of joint nearly reduced ; inner wound nearly
healed; outer one discharging dark-colored serum; continue full
diet and water dressing.

From this time there was a gradual improvement, terminating
in recovery, with stiff joint, and he was furloughed by board some
time in July not stated, for sixty days. When he left hospital
joint was nearly of natural size.

Case 6. Y. S. left knee, by conical missile, entering on the
outer edge of patella, making exit at centre of politeal space, with
escape of synovia from both orifices, and recovery, with stiff joint,
in forty-nine days.

J. F. F., aged 25, private Co. B, 47th cavalry, was wounded May
7, 1864, and admitted into hospital on the following day, with
joint very much swollen, a deep inflammatory blush around articu.
lation, and particularly wound of entrance. This wound was ac-
companied with great pain. The patient was of strong constitu-
tion, in perfect health, and appreciated fully the danger of the
wound and the necessity of obeying implicitly the directions
given to his nurse. The limb was elevated upon a pillow, the
cold drip immediately applied, and continued unremittingly for
fifteen days, affording the patient so much comfort that he was
able to attend to it himself. On the fifteenth day a pustular
eruption appeared, covering the joint, no doubt the effect of the
continued use of the cold drip. This eruption resembled that
produced by tartar emetic ointment, and was extremely painful,
attended with the most intensely itching sensation. Upon the

1866.] Habersham on Wounds of Knee-joint 337

appearance of this eruption, the swelling of the joint immedi-
ately subsided, and wet-rag applications were substituted for the
drip ; synovial discharge ceased.

May 28. Wound healed ; swelling of joint nearly absent; pus-
tular eruption discharging, showing no tendency to resolution, and
still quite painful ; continue cold water application ; full diet ;
patient having been on half-diet.

June 13. Eruption disappearing; nearly absent; joint nearly
natural in size, but stiff.

June 21. Patient perfectly recovered, with stiff joint; furloughed
by the board for sixty days.

This patient reported at expiration of his furlough with stiff joint.
The revulsive effect of the eruption in this case, no doubt, expedited
recovery. It will be seen that the continued use of cold water was
the only remedy used ; that be was only on half-diet for twenty-one
days. When he appeared before the board he presented the appear-
ance of perfect health.

Case 7. V. S., left knee by conical missile, which entered at
inner edge of patella, passing into joint, comminuting end of femur
and lodging in popliteal space against integument ; was removed by
incision on the field. Escape of synovia from both orifices ; death
in fifty-three days after receipt of injury.

J. 0., private Co. G, 11th Va. infantry, of scrofulous tendency
, and leuco- phlegmatic temperament; was admitted on the 8th May,
1864, having been wounded three days before ; was suffering much
pain in joint when admitted, which presented all symptoms of acuta
synovitis and joint greatly enlarged ; pulse full and rapid. This
patient expressed great anxiety as to the result of his injury, and
seemed to have a fixed presentiment that he would never recover.
The cold drip was applied and the limb supported on pillows. Full
doses of morphia, to allay nervous excitement and produce sleep, and
the patient assured of his recovery, to allay mental inquietude. Here
I would remark, that this fixed presentiment of death is almost a
certain indication of an unfavorable termination, even in slighter
wounds than this, acting upon body as well as mind, he is left with-
out hope to sustain the body in its struggle to repair the injury.

338 Habersham on Wounds of Knee-joint. [Sept.,

Sixth day of admission. Profuse hemorrhage from upper wound,
easily arrested by elevation and ice applied to the wound. Not-
withstanding every means used to subdue inflammation, it did not
begin to subside for some days, when profuse suppuration set in, and
incisions were found necessary to give exit to pus in joint, which
flowed in enormous quantity, and subsequently burrowed along the
thigh, from which it was discharged by incision also. As no means
seemed to exert any influence in postponing the termination of this
case in death, I will simply state that the patient died from ex-
haustion on the 27th June.

In the treatment of this case, Smith's anterior splint was used,
and found to add very much to the comfort of the sufferer.

Case 8. V. S., left knee, by conical missile, which entered the
joint one inch above and external to patella, passing out at flexion
of joint near centre of popliteal space. Recovery in one hundred-
days.

W. H. U., private Co. E, J 7th Va. infantry, wounded May 16,
and admitted into hospital on the evening of the same day. Joint
much swollen and very painful, also profuse discharge of synovia
from inferior orifice of wound ; cold drip applied as in other cases,
and patient put upon light diet, which treatment was continued to
the twenty-sixth of May, when, from the peculiar appearance of the
discharge, seemingly an intimate mixture of pus and synovia, and
the great enlargement of the joint, it was thought advisable to
incise lower wound to give exit to pus. None, however, flowed, for
the discharge was of so tenacious a character as to block up the
incision as well as the superior wound. The general health of the
patient being very good, it was resolved, upon consultation with
the attending ward surgeon, to wait a few days and see the result
before incising again, and the wet-rag application was continued,
the limb being placed on its side.

May 30. Appearance of joint unchanged, excepting slight dimi-
nution in size; cold having proved disagreeable, warm water was
substituted for a few days, but a tendency to increased inflammatory
action induced us to return to the cold water dressing, with small,
not nauseating, doses of tartar emetic. It was not found necessary
to incise the joint again nor to suspend the cold water dressings

1866.] Habersham on Wounds of Knee-joint 339

during the progress of the case. Tartar emetic was discontinued in
twenty-four hours. Gradual improvement in joint commenced
about the 10th June and continued until the 25th day of September,
when he recovered with anchylosis, and was furloughed for sixty
days, but never returned to hospital.

Case 9. V. S., left knee by minnie missile, fracturing head of
tibia and making exit near external condyle of femur. Death from
pyemia.

W. G-. H., October 24, private Co. K, 44th Va. infantry. Gene-
ral health good ; wounded February 6, 1865, and admitted Feb-
ruary 9. The only record found of this case is, that the wound was
very painful, discharging synovia freely ; prognosis unfavorable ;
should have been amputated on field ; died March 14, of pyemia.

In connection with this case, which is only introduced to call
attention to the character of wound, viz : Fracture of the head of
the tibia, and the remark of the attending ward surgeon, " should
have been amputated on the field," I would remark that this com-
plication was considered necessarily fatal.

In the summary and above history of nine cases, are included all
the knee-joint wounds admitted from the 28th June, 1862, to the
3d of April, 1865, and I regret the loss of a second volume of man-
uscript, containing the history of the remaining cases from which
the summary is drawn, precludes the possibility of my continuing
the history of the cases.

The three cases unaccounted for were admitted during my absence
on a sick leave of two months, consequently no notes were taken in
their cases, and they simply stand upon the register as admitted
with penetrating wound of knee-joint, and some other insignificant
data. Even the fact of their transfer is omitted, and the probability
is, that they were so disposed of, since their deaths would certainly
have been mentioned. At the time of my absence, the exigencies of
the army called for a large number of assistant surgeons, and it so
happened that most of the officers attached to the second division
were those selected, while contract physicians were substituted, who
knew nothing about the routine duties of the hospital. Coupled
with this evil the clerk, whose duty it was to attend to the hospital
register, having no one to overlook him, neglected his duty, and

340 Habersham on Wounds of Knee-joint [Sept.,

finally deserted,* and then much valuable data was lost which might
have been collected under other circumstances. Enough, I trust,
however, has been shown in the above nine histories of cases to elu-
cidate the character of injury for which we claim the benefit of
conservative surgery.

When it is recollected that irritative fever and inflammation set in
sooner in wounds of the knee-joint than in any other cavity, ex-
cepting the lungs, that gangrene sometimes terminates the life of
the patient within five days of the receipt of the wound, the
necessity of prompt action on the part of the field surgeon is mani-
fest, and therefore the great importance of fixed rules, from which
there should be no departure, inasmuch as a few hours' delay might
result in irreparable injury to the individual and render nugatory all
the advantages of conservative surgery.

The hospital surgeon, who sees all of the above-mentioned evils
when too late to remedy them, and has learned too well the danger
of secondary amputation, or the long suffering and ultimate termi-
nation in death of a badly selected case for conservative treatment,
as was that of Oliver, No. 7, is probably the best judge as to the
character of wounds likely to recover under favorable conditions,
and therefore the greater the importance to be attached to his
opinion upon this class of injury.

4

The deductions drawn from histories of cases, by others, are not
to be compared in value with those convictions resulting from a
personal familiarity with the cases, and studying them from day to
day through the many phases of conditions likely to occur in their
treatment. I, therefore, trust that if, in suggesting the following
rules for amputation, there should appear aught of egotism, it may
be attributed to a desire to give the results of individual experience
and the opinions deducted therefrom, rather than the dogmatical
expression of an idea, which the observations and experience of
others may falsify. It is, therefore, with the hope of being corrected,
if wrong, that I am induced to offer the following rules for amputa-
tion in this class of injury :

* These remarks, of course, do not refer to Mr. W. Walker, of Virginia, who remained at
his post to the last day, and to whom I am indebted for valuable clerical services*

1866.] Habersham on Wounds of Knee-joint. 341

1st. That amputation should be promptly performed in all those
cases attended with laceration of the soft parts surrounding the
joint, and opening the synovial sack, or where the tibia or condyle
of the femur are either of them fractured. We say nothing of the
graver injuries to the joint, for here, as in the case of lacerated
wounds, the indications are too palpable. The patient should have
the advantage of conservative surgery, if the wound is simply a
penetrating or perforating one, grazing either of the condyles, but
the grazing of the head of the tibia is of more serious import,
necessitating amputation wherever it occurs. If the wound, then,
is simply a perforating or even penetrating one (providing the
missile can be extracted), and has not grazed the head of tibia, or
fractured the entire condyle, an effort should be made to save the
limb. When this is determined upon, the limb should be put in a
splint, as for fracture of the thigh, leaving the joint uncovered, the
object being to prevent the least motion in the articulation. Any of
the ordinary dressings may be used to the wound during the trans-
portation of the wounded man to the hospital, and the injuries of
this class should always be accompanied by a proper attendant, to
see that the physical comfort of the patient is attended to, and that
the irritating tendency of the wound is not aggravated by motion of
the limb or the want of ordinary dressings during the journey.
Opiates should also be given to benumb sensibility, for of all wounds
these are the most painful. If the above conditions obtain, and the
patient be of sound health, and not of strumous or cachectic habit,
an effort to save the limb will probably be attended with success,
but the case will require the utmost attention on the part of the
surgeon and nurses.

As to the treatment to be adopted in these cases, this must be
left to the judgment of the attending surgeon, who alone can decide
upon the indications of the case, which may arise from day to day.
He alone can determine when to use the- cold drip, or when to sub-
stitute the simple cold water dressingtfor it; when to administer
anodynes and when to withhold them ; when to administer sedatives,
such as tartar emetic, and when to incise. Hence, no one, however
great may be his experience, can lay down any fixed rule for treat-
ment in individual cases, and in the opinion of the writer, that

342 Habersham on Wounds of Knee-joint [Sept.,

surgeon who advocates free incision of the joint as a preliminary to
treatment is in error, as such a proceeding was never instituted by
any of the surgeons who had charge of the cases included in this
article.

The writer was induced to suggest the use of tartar emetic, as
adopted in some of these cases, from the very favorable influence it
has seemed to exert in arresting paronychia and pereostial inflamraa-
tions generally. In none of the successful cases were the joints ever
entered by probe or finger after admission to the hospital, it having
been taken for granted that the field surgeon had done his duty in
this respect ; consequently, we could only be guided by the direction
the ball had taken, as manifested by the wounds of entrance and
exit, the escape of synovia, the appearance of the ball (whenever in
possession of the man), and the escape of spiculse during treatment,
in forming an estimate of the amount of injury inflicted.

In the local treatment of highly-aggravated inflammation, I have
never had the objection to cold water common to many surgeons
of much greater experience than myself, for the reason that I have
always found it the most powerful means of controling local inflam-
mation when constanly applied. In those cases where it has done
harm, for I have seen many such, it was either applied too soon,
thus keeping down a healthy reaction in the part, thereby causing
sloughing or mortification, or had been continued too long after the
subsidence of inflammation. In either case the same result should
have been anticipated, since by its means the vitality of the part had
been kept too low for healthy suppurative action.

For information upon this subject, the reader is referred to some
very judicious remarks of Surgeon Reid, in an article upon wounds
of the large joints, published in the present number of this Journal,
and which was read by him before the Association of Army and
Navy Surgeons in Richmond. This very able paper is replete with
valuable information pertaining to the subject, and comprehends
everything which can be said on wounds of the knee-joint.

If, in presenting the above history of cases, the writer should be
instrumental in eliciting other contributions upon this subject, he
will feel amply repaid for any trouble its preparation has given him,
in the consciousness of knowing that he had added his mite of

1866.] Rains on Malaria at Fort Gibson. 343

information to the treasury of knowledge, and that the little light he
has been able, by its means, to throw upon the subject of Confede-
rate surgery, has not been hidden under a bushel.

The gentlemen immediately connected with the treatment of most
of the above cases, to whose skill and unflagging energies the happy
results may be attributed, were Assistant Surgeons Harrison, Yaidin,
and Upham, of Virginia ; Wall and Saball, of Florida, and several
other gentlemen who were connected for a short time with the
division. I was also indebted for much valuable advice, in consul-
tation, to Surgeon Seabrook, now of Richmond, Va.; Holloway,
Professor of Surgery in the Louisville School of Medicine (Kentucky),
and Surgeon Craig, also of the same State, who, from time to time,
saw many of the above cases, and who finally (as members of the
furlough board) had an opportunity of examining them before
leaving the hospital.

Erkata. First paragraph, seventh line, for names, read records.

ARTICLE V.

Facts bearing upon the Nature and Effects of Malaria and Dis-
eases at Fort Gibson, in the Fall and Winter of 1834. By
General G. J. Rains. Read before the Medical Society of Au-
gusta, Ga., August 1, 1866.

In the year 1833, the Arkansas river rose an unprecedented
height, overflowed all the bottom lands, and while it benefitted
some few places, it piled the sand three feet deep on others, before
fruitful, and rendered them barren and desolate.

During the year succeeding this great rise, September, 1834, I
joined my company at Fort Gibson, fifty seven miles west of Ar-
kansas. I had been on duty in the Indian department at the
Choctaw agency, in about thirteen miles from Fort Smith, and about
three from the Arkansas river, a thick growth of timbered land
intervening. The malaria had reached the agency before I left, and
I had been severely sick with fever, and was convalescing, when I
went to Fort Gibson, already noted, from medical statistics, as the
! most unhealthy post in the United States occupied by troops.

The post of Fort Gibson is situated on the east bank of the
Neosho river, about two and a half miles from its confluence with

344 Eains on Malaria at Fort Gibson. [Sept.,

the Arkansas, having a bottom land south and southeast, in juxta-
position to that post, extending to the river, having stagnant pools,
and a pond or lake, of about one half-mile in extent, in a thick
canebrake, in about three fourths of a mile distant, south. In an
easterly direction were the dragoon barracks, occupied by four or
six companies of dragoons, and Fort Gibson, with six companies of
infantry, composed of, officers and men, fifty two each in number
when full. The garrisons were found sickly and sickness increasing
rapidly, mainly congestive fever and dysentery.

We began to bury the dead with martial honors, until the mu-
sicians became sick, and notice made that the music and dead-
marches were going almost all the time. When that was stopped,
our whole business was to dig graves, make coffins, and bury the
dead. Out of about thirty officers there were soon but three for
duty, viz.: Adjutant Miles, who, I think, had been sick, and was
afterward General Miles, killed at Harper's Ferry, fighting against
us, Captain Dawson, who, cadaverous looking, was said to take daily
a dose of charcoal, and your humble servant, convalescing as said,
with diarrhoea, a check to which immediately brought on fever.

A singular case I must here mention. Lieutenant West, of the
Seventh infantry, some three or four years before, had taken the
venereal disease from an Indian squaw, and had been apparently
cured by Surgeon Pitcher, since of the Medical College at Detroit,
Michigan ; had married, and his wife had one child, diminutive and
sickly. He was down with the dysentery, and Dr. Hawkins in-
formed me that his old disease had again broken out with all its
violence, and it hastened his death.

Finally, we were burying the men all day, and the grave-yard
between the two commands had the prisoners of both dragoons and
infantry, with other details, almost continually employed digging
graves, and these accused one another of hooking their graves, the
term they used, as the first that came with a corpse put it into the
prepared pit.

Coffins were soon out of the question, only rough boxes were
made, and to supply plank for this purpose, all at the post was used
up, and the ceiling taken down from some of the rooms in the
barracks, for the boards. The dragoons suffered, if possible, worse

1866.J Rains on Malaria at Fort Gibson. 345

than the infantry, being nearer the swampy land, which was just
back of them, and I heard a discussion between Colonel, afterward
General Mason, and Captain Johnston, of the Quartermasters de-
partment, concerning a requisition made from the War department
for the number of deaths, which was stated, could not be told, as
the dragoon officers were all sick, and some men, not known, who
had deserted. It often occurred that two bodies were put into the
same grave together, the upper not being more than a foot from the
surface of the ground, and occasionally these deposits were made
after night, by candle or torchlight.

I have seen battle-scenes, but none so horrible as this, where it
seemed a man's business was to die. The diseases were of three-
fold character, viz. : dysentery, fever congestive, and a nameless
disease, which would commence in apparently a healthy subject,
as a very small aphthe inside the upper lip, which soon became a
sloughing ulcer, of portentous magnitude, before it destroyed the
man.

The cause of this singular disease was attributed falsely to
Surgeon Finley giving enormous doses of calomel to soldiers a
few months previous, when out on the Western prairies, as I had
several attacks myself, which I found in my case yielded to appli-
cation of sulphate of copper, and Cherokee Indians in the vicinity
of the fort had it also. An estimate of the number of deaths
may be inferred from a remark of Surgeon Bailey to me, that
from the building which he afterward had fitted up, and occupied
as quarters for himself and family, more dead bodies, of dragoons
alone, had been carried out of that house that season than, if
brought back again, would chink it to the roof. I examined the
locality, the evident source of this malaria, and found numerous
ponds of stagnant water left by the river the year before, with
much decaying vegetable matter all through the woods the water,
the earth, and the air replete with organic formations in a state
of decomposition, and the air visited by perfumes, the most per-
ceptible to the olfactory nerves being something like that of the
cucumber. The stagnant air, loaded with millions of dead infu-
soria, actually conveyed the idea that there was no such thing as
malaria proper, but that so called was loaded with death, to come

23

346 King on Asiatic Cholera. [Sept.r

in contact with the living fibre in the lungs and body of man.
To go in bathing, or in any manner to check insensible perspi-
ration for however short a time, was the certain passport to a
fever.

If remembered aright, calomel was the sheet-anchor in this
storm of death, and Surgeon B. M. Byrne, U. S. army, once told
me that he had never lost a patient from dysentery, which he
always treated with a dose of calomel, and demulcent food and
drinks, and he had probably a thousand cases in his time. He
considered the liver the locale of the disease, and a vitiated se-
cretion of bile the cause.

In the winter the diseases most prevalent were severe influen-
zas and pneumonias the former epidemic, the latter endemic, if
not contagious, as it seemed to pass rapidly from patient to bunk-
mate, so that but two or three days would elapse before the death
of both.

During the prevalence of the severe malarious diseases during
the fall and winter of 1834, at Port Gibson, it was observed
that the livers of both men and animals presented, after death, a
dark, slate color. The livers of all the animals slaughtered were
thrown away by the butchers, on account of their dark, unhealthy
appearance.

ARTICLE VI.

Is Asiatic Cholera Contagious ? Read before the Providence
Medical Association by H. TV. King, M. D., Surgeon-Gene-
ral of Rhode Island, and communicated for the Boston
Medical and Surgical Journal.

This question is now of public interest, in view of the
anticipated coming of the disease. Doctors disagree upon
it. This is no new phase in the history of medicine.
Doctors have disagreed as to the contagiousness of nearly
all diseases which are most strongly influenced by epidemic,
conditions. It is so difficult to determine which is the
prime source of disorder, when both contagious and epi-
demic causes are operating ! Hospital gangrene, puerperal
fever, yellow fever, scarlet fever, typhus fever, whooping
cough, and plague were for a long time held in doubt, and

1866.] King on Asiatic Cholera. 347

finally, after hot dispute, quietly found place, one by one, in
the list of contagious diseases.

Cholera is most promiuent among those of which we are
still in doubt, and about which we may dispute. I propose
briefly to examine a few of the reasons recently given to
the public why some "physicians cannot believe cholera to
be contagious," and to extend a few remarks upon the
subject of contagion.

First. On board the steamship Atlanta, which brought the
disease to New York last November, it was confined to the
steerage during the whole passage. The fact that the
disease did not spread to other- parts of the ship is relied
upon as evidence oi its non-contagious character. It would
seem to me, better evidence of its non-epidemic character.
This fact, which is thought too singular for a freak of con-
tagion, has had its parallel many times in the passage of
typhus fever to our shores, and no doubts are now enter-
tained as to the contagion of typhus.

Second. The Emperor of the French, holding the destiny
of the nation, " was permitted," recently, to visit the cholera
hospitals of Paris, and did not take the disease. This act of
the emperor is considered proof that both he and his medical
advisers believed the disease to be non-contagious; that the
possibility of his taking it was not even doubtful. Does it
prove so much ? The French once had another emperor,
who, with responsibilities as great upon him as ever rested
upon his nephew, was permitted to cross a bridge at Lodi,
swept by thirty Austrian cannon. Does this prove that he
and his military advisers were satisfied that there was no
danger in the passage ? that the possibility of his being hit
was not even doubtful ?

Third. In India, where the disease has become naturalized,
and has prevailed for a long time, the belief is universal that
it is not contagious. The same argument would prove the
plague to be non-contagious, while we all hold the contrary.
That, too, is a habitant of the East, and like views are enter-
tained of it there.

348 King on Asiatic Cholera. [Sept.,

Fourth. Cholera can be arrested in its progress by proper
medication, and the question is asked : "Is this true of small-
pox, or any other confessedly contagious disease ?" It may
not be true of smallpox, but it is true of many other con-
fessedly contagious diseases, among them itch, syphilis, and
porrigo.

Fifth. In cholera there is no definite period of incubation,
nor any regular stages of development in its progress and
decline, while it is asserted in all known contagious diseases
these stages are generally clearly marked. Is this state-
ment true ? Let us examine and compare it with the
teachings of one of the best of American authors. Dr.
Wood says of pertussis: " The period of incubation is from
two to thirty days;" of measles, "from one week or less to
three weeks or more;" of scarlet fever, "two or three days
to two or three weeks;" and of typhus fever, "from imme-
diately to several months." Each of these, in its progress
and decline, is as irregular as in its development, and these
are all well-known contagious diseases. The period of
incubation of the latter would seem indefinite enough to
correspond with cholera, or almost any other disease.

Sixth. " One attack of cholera furnishes no security against
a second." Neither does one attack of gonorrhoea, syphilis,
porrigo, frambcesia, or itch furnish security against a second
attack, and these are all contagious diseases.

Seventh. " Cholera remains quiet for a long series of years,
almost constantly existing at the place of its origin, and
does not extend beyond that region. Could this be true of
any strictly contagious disease ?" It is true of the plague,
and also true of typhus and yellow fever.

Eighth. It is stated that it is an established law of cholera
that the prevalence of the disease is in inverse ratio to the
height above the level of the sea, or large rivers, or bodies
of water in the vicinity, and the question is asked: "Was it
ever known or suspected that any such law of elevation
existed in relation to any strictly contagious disease?" I
answer, it is known that the same law exists in relation to
the prevalence of nearly all disease, both contagious and

1866.] King on Asiatic Cholera. 349

non-contagious. The exceptions are those diseases peculiar
to mountainous regions. This idea, now advanced by Dr.
Snow, was used by Dr. Kush in his argument against the
contagiousness of yellow fever. It is answered by stating
the fact, that the law of elevation in relation to the preva-
lence of disease follows the law of settlements. The popu-
lation of the world is so distributed.

Ninth. "Cholera is uniformly checked in its progress by
cold, and prevails most severely in hot weather. Smallpox,
on the contrary, and other contagious diseases, which do
not depend upon actual contact, prevail most severely in
cold weather."

How is it with yellow fever ? It is uniformly checked by
cold ; indeed, it requires a higher temperature for its exist-
ence than cholera. The question of the contagion of this
disease has been more fully discussed than that of cholera,
and the professional mind is generally settled in the belief
that it is contagious. This brings me to a point where
theory might be introduced into the argument. Do not all
contagious diseases dependent upon corpuscular origin pre-
vail most severely in cold weather ? And do not all diseases
dependent upon cryptogamous agency for their cause pre-
vail most severely in warm weather? The prevalence of
cholera in Russia during the winter might tend to prove
one part of this hypothesis. The life of the sporule may
have been protected in the underground huts, at a tempera-
ture where germination could go on, while in the clear, cold
air above no epidemic cause may have existed.

The most of the arguments advanced to prove the non-
contagion of cholera may be summed up in this simple
statement : Cholera is not contagious, because it does not
follow the same law that smallpox does; reasoning as though
smallpox were the type of contagious disease, and judging
all other diseases by it. As well might itch be taken for the
type, and other diseases judged by that. From what has
been shown, it would appear that cholera is not more ano-
malous than many other diseases known to be contagious,

350 King on Asiatic Cholera. [Sept.,

yet it is not contended that there is any general law gov-
erning contagious disease, forihere is none. Each is pecu-
liar to itself. There may be a resemblance in form, or kind
of substance producing disease, that may be classified. We
have contagious diseases that are known to be of animalcu-
lar origin, as scabies, dracunculus, pulex penetrans, etc. We
have others that we know to be of fungous origin, as favus,
sycosis, porrigo, etc.; and others that we believe to be of
corpuscular origin, as syphilis, hospital gangrene, smallpox,
etc. In thus classifying, we have a resemblance in the kind
of materies morbi forming each class, and here the resem-
blance ends. As the disease produced by the acarus scabiei
differs from that produced by the filaria medinensis, and as
the disease produced by variolous matter differs from that
produced by syphilitic matter, so may we expect cholera to
differ from other diseases, though produced by the same
class of contagious matter.

In many of the arguments upon this question of contagion
there seems to be wanting a clear idea of the definition of
the subject. The best definition that I have seen, and the
one that seems to me to convey a near idea of what is
generally understood by the word contagion, is that given
by Dr. Wood, in his Practice of Medicine. In this, conta-
gion is held to be nearly synonymous with infection, but
contagion is allowed a broader signification, and to embrace
the meaning of both terms, including contactual and remote
propagation. An agreement in the understanding of terms,
though we still might differ, would save many words in
dispute. With the microscope we may hope some day to
solve the mystery that now divides us. It seems no deeper
hidden than was the poison of malaria before Dr. Salisbury
discovered that, instead of its depending upon the decompo-
sition of vegetable matter for its origin, it has its source in
cryptogamic life. He or some one else may show that,
instead of cholera depending upon the "decomposition of
filth," vegetable organism must exist in choleraic air, and
that germ and human excrement are necessary for its
growth.

1866.] Medical Association of Georgia. 351

The Medical Association of Georgia.

This Association convened in annual session, in the City of
Atlanta, on the 21st of June last. The meetings of the i\.ssoci-
ation having been necessarily suspended during the war, it was
the first opportunity enjoyed by its members of communing as
a body since April, 1861. We were sorry to see so few present,
but are willing to attribute it more to the failure of receiving due
and timely notice than any want of interest in the Association.
The following officers were duly elected and installed : Dr. A.
Means, President; Dr. F. O. Dannelly, 1st Vice-President; Dr.
L. H. Orme, Recording Secretary; Dr. J. L. Moore, Correspond-
ing Secretary ; Dr. H. L. Wilson, Treasurer.

Through Dr. Means, Chairman of the Committee on Prize
Essays, an essay was reported on Diphtheria, with the motto,
u Sis subjudice" for which the prize of fifty dollars was awarded.
It was from the pen of Dr. E. L. Gaillard ordered to be pub-
lished so soon as funds could be obtained.

Dr. Habersham moved to amend the Constitution by striking
out that clause authorizing the admission of State licentiates
to membership in the Association. After some discussion, on
motion of Dr. Godfrey, the further consideration of the subject
was postponed to the next meeting of the Association.

The following resolutions were adopted :

Resolved, That the permanent location of the Association at some
suitable place, in the opinion of this meeting, is ealled for by the
highest interests^ and that, in view of said interests, we do invite
and call upon its members, in every portion of the State, to meet
with us at our next annual meeting, and settle definitely this question.

Resolved, That the sum of one hundred dollars be hereby offered
by the Association for the best Prize Essays $50 for the best, $30
for the second, and $20 for the third.

The next annual meeting of the Association will be held in
-Griffin, on the second Wednesday in April, 1867. Signet &
.JaiunaL

352 Bibliographical Notices. [Sept.,

BIBLIOGRAPHICAL NOTICES.

[From the large amount of original matter presented in this number of
the Souther* Medical and Surgical Journal, we are compelled to defer
the more elaborate reviews to another issue.]

ARTICLE I.

A Practical Treatise on the Diseases of the Sexual Organs of
Women. By F. W. Yon Scanzoni, Professor of Midwifery
and Diseases of Females, in the University of Wurzburg; Coun-
sellor to his Majesty, the King of Bavaria ; Chevalier of many
Orders. Translated from the French of Drs. H. Dor and A.
Socin, and annoted, with the approval of the author, by Aug.
K. Gardner, A. M., M. D., Professor of Clinical Midwifery
and the Diseases of Women, in the New York Medical College;
Author of the " Causes and Curative Treatment of Sterility ;"
Editor of Tyler Smith's "Lectures on Obstetrics/' etc., with
upward of sixty illustrations. New York : Robert M. DeWitt
publisher. 8vo. 670 pp.

It is to the study of specialties in medieine we owe, in a great
degree, the decided advances made during the present century in
our profession ; and the monograph before us abundantly illus-
trates the advantages of this system. The work is divided into
seven parts, devoted to the pathology and therapeutics of the
uterus ; of the ligaments of the uterus ; of the fallopian tubes ; of
the ovaries ; of the vagina ; of the external genital organs, and of
the breast. Each subject is elaborately treated, and the author
has diligently striven to make his work a complete compilation
and reflex of the present state of knowledge. We know of none
more calculated to be useful to the general practitioner, and
regret that we can not give it a more extended notice at present.

ARTICLE II.
Outlines of Surgical Diagnosis. By Geo. H. B. MacLeod, M. P.,.
F. R. C., S. E., eel. fac. phys. and surg., Glasgow ; Lecturer on
Surgery, Anderson's University ; Surgeon to the Glasgow Royal
Infirmary, and the Lock Hospital; late senior Surgeon Civil
Hospital, Smyrna, and General Hospital in Camp before Sebas.
topol, etc., etc. American edition, reprinted from advance
sheets. New York : Bailliere Brothers, 1864. 8vo. 505 pp.

As correct diagnosis is indispensable to safe and judicious
treatment, any contribution upon the subject should be gratefully

1866.] Bibliographical Notices. 353

received. While we cheerfully accord to the work before us a
high degree of merit, we can not withhold the expression of our
conviction that the great desideratum in diagnosis is simplicity as
well as unerring accuracy, and that the author would not have
sacrificed anything of intrinsic value by leaving out many of the
unimportant details, which tend rather to obscure the strong points
in each case than to add to their value. But this is the only
complete work of the kind in our language, and we cheerfully
recommend it.

ARTICLE III.
Clinical Lectures by Prof. A. Von Graefe, on Amblyopia and
Amaurosis, and the Extraction of Cataract. Translated from
the German, by Hasket Derby, M. P., Surgeon to the
Massachusetts Charitable Eye and Ear Infirmary, etc. Boston :
D. Clapp & Son, printers, 1866. 8vo. 86 pp.

The high authority of Professor Graefe in opthalmoiogy, and
the new light thrown upon the important topics of these lectures,
must make them peculiarly acceptable to those who devote any
attention to diseases of the eye. The Germans have latterly done
more than any other people toward the advancement of this branch
of medicine, and we therefore naturally look with much interest
to their publications on the subject.

ARTICLE IV.

A Comprehensive Medical Dictionary, containing the Pronuncia-
tion t Etymology, and Signification of the terms made use of in
Medicine and the Kindred Sciences, with an Appendix, com-
prising a Complete List of all the more important articles of the
Materia Medica, arranged according to their Medicinal Properties ;
also, an Explanation of the Latin Terms and Phrases occurring
in Anatomy, Pharmacy, etc.; together with the necessary direc-
tions for writing Latin Prescriptions, etc., etc. By JL Thomas,
M. D., Author of the System of Pronouncing in Lippincott's
Pronouncing Gazetteer of the World. Philadelphia : J. B.
Lippincott & Co., 1864. 'Pp. 704.

This work supplies a want felt by every one commencing the

study of medicine. The student will find in this medium sized

volume concise, clear definitions, and full explanations of the

etymology of the various words and terms used in Medicine and

the collateral sciences. Another feature of the work, of practical

354 Bibliographical Notices. [Sept.,

importance, is the pronunciation of the various terms given in the
Dictionary. " What correct spelling is to the writer, correct pro-
nunciation is to the speaker. If either should be wholly neglected,
the most perfect language would soon become a babel, and fall into
utter corruption.'' The Appendix contains matter of value to the
student, viz : table of Materia Aledica, containing the names of all
the medicinal articles of any importance, arranged according to
their medicinal properties ; table of doses ; synopsis of respective
nosologies of Cullen and Good ; method of writing prescriptions,
etc. The work is printed in the best style of the art, as is char-
acteristic of all the works issued by the liberal and enterprising
publishers, J. B. Lippincott & Co., of Philadelphia.

ARTICLE V.

Catalogue of the University of Virginia, 1865-66 (with Catalogue

of Sessions 1861-65 prefixed}.

Just before the close of the war, it was reported in this part of
the South that the University of Virginia had been sacked and
burned by the United States forces. The friends of this noble
institution will be gratified to know that it passed through the
recent civil war intact, without the loss of a Professor, or of a book.
The catalogue before us gives proof of the undiminished confidence
and interest of the public in this institution, which might well
serve as a model for every college in the Southern country. A
large number of the educational institutions of the South were
burned during the sectional war; and all of them have been, more
or less, prostrated and crippled by the subversion of the agricultu-
ral system of the South, and the wide spread financial ruin follow-
ing the triumph of the destructive measures of the Black Repub-
lican faction. In the face of all these difficulties, and at the close
of a bloody and desolating war, which expended its fury chiefly
upon Virginia, the class of the University numbered two hundred
and fifty-eight. Notwithstanding all their losses and deep dis-
tress, the Southern people have still left for them the development
of perfection of their educational institutes. It has been said
with truth that " man can not propose a higher or holier object
k'ov his study than education, all that pertains to education."

1866.] Bibliographical Notices. 355

During the recent war, the dormatories of the University fur-
nished comfortable hospital accommodations to hundreds, and we
might say thousands, of the wounded of General T. J. (Stonewall)
Jackson's army, during his celebrated campaign in the Valley of
Virginia ; and two of the Professors of the Medical School, J. L.
Cabell, M. D , Professor of Comparative Anatomy, and Physiology,
and Surgery, and J. S. Davis, M. D., Professor of Anatomy and
Materia Medica, conducted one of the largest and* best-ordered
hospitals in the Southern Confederacy.

The amount of valuable material for clinical instruction, gathered
by these learned and accomplished physicians, during their most
efficient and untiring ministrations to the Confederate sick and
wounded, must have been immense, and of incalculable value to
the University.

At the present time, when we are reviving our institutions, the
peculiar features of the Medical department of the University of
Virginia are well worthy of the attention of the physicians of the
Southern States.

" In nearly all the medical schools of this country, the usual
length of the session is from four to five months. In order to
embrace all the important branches of Medical science in a course
of instruction compressed in so short a time, it is found necessary
to employ the services of six or seven Professors, who deliver six
lectures a day. Under this arrangement the student, if they take
all the tickets, are required to spend nearly the whole day in
listening to lectures, delivered in rapid succession, and treating of
diverse topics. None but those who have had personal experience in
this matter can fully appreciate the troubles and difficulties which
beset a student when he first enters the school; the fatigue of
body and perplexity of mind which he inevitably experiences in
his painful efforts to hear every lecture and master every subject.
In attempting, after the close of the lectures for the day, to bring
in review the topics discussed by his teachers, he finds links in the
chain, here and there, broken; he flies from one subject of thought
to another without adequately mastering any, and confounded by
their number, and the utter impossibility of keeping pace in his
private reading at night with the lectures of six Professors, he

356 Bibliographical Notices. [Sept.,

despairs of doing more than retaining such portion of the facts
stated in the lectures as may happen to make the strongest im-
pression on the mind.

In the Medical department of this Institution, the length of the
session, which is nine months, enables four Professors to perform
all the duties which are elsewhere assigned to six. The students
attend but two lectures a day, and thus have ample time for private
reading, and#for pursuing their anatomical dissections. The sup-
ply of subjects is ample, and the Demonstrator devotes the whole
of every afternoon to his duties. He guides the labors of those
who are at work, and explains to them the structures which are
successively exposed. "

It is one of the peculiar advantages of the University Medical
School, that it unites the plan of private instruction by private
pupilage with that of public lectures ; while the length of the
session enables the Professors to pursue a philosophical order of
studies, and thus to afford the students an opportunity of master-
ing the elementary branches before attention is directed to their
practical application.

ARTICLE VI.

History of Florida. By L. D. Strickney, Florida Union, edited
by J. K. Strickney, Jacksonville, Florida.

We have derived profit as well as pleasure from the perusal of
the chapters of this valuable History of Florida, which are pub-
lished weekly in the Florida Union, and we hope that the author
will, at an early day, issue his labors in book form, and thus secure
them from the accidents of time. A most interesting feature of
this work is, that it embraces a wide field of study, and includes
extended and careful descriptions of the climate, soil, and natural
productions of Florida. We have always regarded such efforts at
the South with great interest ; and they are especially valuable at
the close of a desolating war, in which some of the most valuable
libraries of the South were either burned, destroyed, or "captured,"
and shipped out of the country.

1866.] Munroe on Anatomy of Cholera. 357

Pathological Anatomy of Cholera. Communicated for the

Boston Medical and Surgical Journal. By W. F. Munroe,

M. D., Boston.

In order to understand the theory of treatment of any
disease, a knowledge of its pathological anatomy is abso-
lutely essential. This fact is more often overlooked with
regard to cholera, perhaps, than to any other disease, and
for the very natural reason that no investigations in this
direction have as yet thrown much light upon the subject.
Still, to properly appreciate the numerous theories con-
stantly brought forward, the results, both positive and
negative, of the post mortem examinations should be present
to the mind. To bring together facts scattered through
many different treatises, has been the object of the present
resume.

There are some few cases on record where patients have
succumbed to the prodromic symptoms before the cholera
proper had declared itself; but as there have been preserved
none of the pathological changes, I shall pass at once to
those recorded after death during the second period, or that
of collapse.

In these cases, there is frequently a sudden elevation of
temperature ; invariably the body loses its heat, but slowly.
The muscular spasms often continue to a more or less
extent, and, in India, cases are reported in which the
attendants have been forced to secure the limbs of the
dead, so great was the moral effect upon the neighboring
patients. The blueness of the face and members remains ;
the subcutaneous cellular tissue is dry ; the muscles
are dark colored and but slightly consistent (excep-
tional, Yalleix). This bluish appearance is also noticed in
the greater part of the spongy bones, and even to the roots
and crowns of the teeth. The digestive canal is pale and
discolored in places, but in general offers a dark color, due
to the arrest of the blood. From the oesophagus to the
rectum, but particularly at the end of the ileum and in the
coecum and colon, is often found an eruption of hard, opaque

358 Munrue on Anatomy of Cholera. [Sept.,

bodies, about the size of the head of a pin, which are nothing
more than the swollen follicles, such as are often found in
other diseases where the serous exhalation is increased.
The stomach and intestines contain a variable quantity of a
flocculent liquid, sometimes acid, sometimes alkaline in
reaction, and of an insipid odor. Most authors deny the
presence of any bile, but Dr. J. C. Dalton and Niemeyer say
that the bile is present, but recognized with difficulty, from
its extreme dilution. In color this liquid varies from a
greyish white to a chocolate, the darker being more common
in the lower parts. Its nature is generally considered to be
that of the serum of the blood, although Andral and Bouil-
laud consider it mucous, and Bouillaud attributes to it some
specific qualities. The floceuli floating in it, as well as the
creamy, greyish-white membranes with which parts of the
entire digestive canal are covered, consist of epithetical
scales in different stages of perfection. Valleix, Bouillaud,
and several others have occasionally noticed in the gall-
bladder the presence of a liquid resembling that found in the
intestines, while J. Brown has usually found it turgid with
black blood. Virchow has signalized an enormous accumu-
lation of fat in the villi of the intestines, a fact attributed to
the ordinary occurrence of the attacks during the process
of digestion, when the vessels are loaded with chyle. In
other respects the biliary and lymphatic vessels are unal-
tered. The kidneys, particularly in their cortical substance,
are engorged with black, diffluent blood, and a certain
flaccidity of their tissue is noticed by Dr. Dalton, as well
as a peculiar smell, resembling that of molasses, which is
exhaled from their cut surface and replaces the ordinary
renal odor. The liver is congested with black blood; the
spleen is generally small and hard, while the other paren-
chymatous tissues are conoested and of a peculiar bluish
color j the bladder, ordinarily empty and retracted, but
occasionally containing a certain amount of altered mucus,
exhibits on its internal surface membranous patches similar
to those found in the digestive canal ; the lungs are usually

1866.] Mukroe on Anatomy of Cholera. 359

collapsed, flabby, and hardly obstructed rarely, however,
there is extensive congestion, and apoplectic centres even
ftave been found in them. Small patches of the whitish
membrane spoken of in connection with the digestive canal
are sometimes found in the bronchial tubes. The heart is
small, flabby, and easily torn; the right ventricle filled with
black, sticky blood, the left usually empty. Ecehymoses
are sometimes found on the pericardium and on the endocar-
dium of the left ventricle. The whole venous system is
engorged with the same black, sticky blood, which coagu-
lates very slowly and parts with but little if any of its
Berum. Upon exposure to the air, according to Eayer's
investigations, it oxidizes more slowly than in its normal
condition, owing to the absence of the saline substances
which favor oxygenation. Schmidt found the oxygen di-
minished more than one half. The fibrin, albumen, and
salts have been found deficient by most chemists, although
Robertson, of Edinburgh, states that the fibrin is usually in
large amount, and Andral that albumen is present in nor-
mal quantity. Becquerel concludes that the proportion of
the globules is increased; the serum, less abundant and
denser, contains an abnormally large proportion of extrac-
tive matters, salts, and particularly fatty matters. Micro-
scopic examination has shown the globules normal in
appearance, but Donne has remarked a certain viscosity,
which prevents them from slipping easily in the liquid in
which. they swim. Dr. Parkes has observed that, in some
cases, the addition of a few drops of the liquid taken from
the intestine would restore the arterial color of the blood.
The serous membranes are all more or less dry and sticky,
the peritoneum particularly so; the cerebral and cerebro-
spinal vessels are more or less engorged ; the cerebral
substance is likely to be congested, and even the nerves
and their ganglions may be in the game condition, although
the nerve-tissue is never altered. The semilunar ganglion,
thought by some authors to be the original seat of the
disease, has been found normal by the majority of pathol-
ogists.

360 Necrologies Notices. [Sept.,

In subjects who have died in the period of reaction, there
is less venous but more active and inflammatory congestion ;
the brain is dotted with puncta cruenta; the lungs are
sometimes inflamed or hepatized; the blood is redder and
contains more serum; the peculiar liquid has disappeared
from the digestive oanal ; the serous membranes are moist ;
the agminated follicles are occasionally a little swollen, but
without showing any of the characteristic appearances
of typhoid fever; the bladder contains a variable quantity
of urine,

Thus far the alterations given us by pathologists are : 1st,
the general injection of the venous system, giving the pecu-
liar color to nearly all the organs; 2d, the characteristic
liquid found in the digestive canal; 3d, the absence or
altered condition of the mucus in the different cavities which
are lined by a mucous membrane; 4th, the development
of the glands of the intestine evidently most insufficient
grounds for the basis of anything more than a purely spec-
ulative hypothesis.

NECROLOGICAL NOTICES.

James Hamilton Couper, >/ Glynn County, Georgia.

It was with feelings of deep sorrow, that we noticed in the
secular papers the announcement of the death of the distinguished
Naturalist, at his residence on St. Simon's island.

Mr. Couper occupied a distinguished position in science, and
was, perhaps, more widely known in Europe than in Georgia, his
native State. Many valuable contributions upon the Geology and
Natural History of the Southern States, from his pen, have been
published in the scientific journals ; and he has been the generous
donor of several splendid collections of fossil remains to the
museums of Washington, Philadelphia, Charleston, and London.

In 1861, Mr. Couper presented his entire cabinet of Conchology
and Palaeontology to the Museum of the Charleston College. This
magnificent contribution added greatly to the interest of these

1866.] Necrdogical Notices. 361

special departments, and stimulated many citizens to contribute
rare specimens from their private cabinets.

Possessed of a large fortune, and endowed by nature with the
highest social and intellectual qualities, Mr. Couper exerted a
most extended and useful influence in the world of science, and
attracted to himself the esteem and friendship of many of the
most distinguished savans in America and Europe. The estima-
tion in which ho was held abroad, will be shown by the following
extract from the travels in America of the distinguished English
Geologist, Sir Charles Lyell.

" December 31st, 1845. x\t the end of a long day's sail, our
steamer landed us safely at the village of Darien, on the sandy
banks of the river Altamaha. * * The next morning, while
we were standing on the river's bank, we were joined by Mr.
Hamilton Couper, with whom I had corresponded on geological
matters, and whom 1 have already mentioned as the donor of a
splendid collection of fossil remains to the Museum at Washing^
ton, and, I may add, of other like treasures to that of Philadel.
phia. He came down the river to meet us in a long canoe,
hollowed out of the trunk of a single cypress, and rowed by six
negroes, who were singing loudly and keeping time to the stroke
of their oars. He brought us a packet of letters from England,
which had been sent to his house, a welcome new year's gift, and
when we had glanced over their contents we entered the boat to
ascend the Altamaha. * * About fifteen miles above Darien,
on the opposite bank, we came to Hopeton, the residence of Mr.
H. Couper, where we spent our time very agreeably for a fortnight.
Much has been said in praise of the hospitality of the Southern
planter, but they alone who have travelled in the Southern States
can appreciate the perfect ease and politeness with which a stranger
is made to feel himself at home horses, carriages, boats, servants,
are all at his disposal; even his little comforts thought of, and
everything is done as heartily and naturally as if no obligation
were conferred. When Northerners who are not very rich receive
guests in the country, where domestic servants are few and ex-
pensive, they are often compelled, if they would ensure the
comfort of their visitors, to perform menial offices themselves. * *

24

362 Necrological Notices. [Sept.y

There is a warm and generous openness of character in the
Southerners which mere wealth and a retinue of servants can not
give; and they have often a dignity of manner, without stiffness,
which is most agreeable. The landed proprietors here visit each
other in the style of English country gentlemen, sometimes
dining out with their families and returning at night, or, if the
distance be great, remaining to sleep, and coming home the next
morning. * * * * * *

" I found, in the well-stocked library of Mr. Couper, Audubon's
Birds, Milhaad's Forest Trees, and other costly works on natural
history; also, Catherwood's Antiquities of Central America, folic
edition, in which the superior effect of the larger drawings of the
monuments of Indian architecture struck me much, as compared
to the reduced ones given in Stephens' Central America, by the
same artist, although they are also very descriptive/'

Dr. William Rushton, M. >.,

Died in New Orleans, after a brief illness, on the 21st day of
November, 1862, at the age of fifty-four years.

He was born near Bolton, Lancashire, England," in 1808. He
studied the profession of medicine in Edinbnrg, Scotland, and grad-
uated at the famous school of that city in August, 1827. In order,
however, to observe disease under the treatment of other leading
lights of medical science, he repaired to London, and continued two
years longer in the prosecution of his studies

The first professional duties to whieh Dr. Rushton devoted his
services was the position as surgeon to one of the East India Com-
pany's ships to Calcutta. At the conclusion of this voyage, which
occupied his attention for one year, be returned to England, and
immediately sailed for New Orleans, and arriving in this city in
1832, he determined to make his home in the great emporium of
the Southwest. After a residence of two years, he married Miss
Elizabeth West, a daughter of an estimable family, and connected
with many of the most highly refined and influential of our Creole
population.

1866.] Neurological Notices. 363

From the moment of the arrival of this young and enterprising-
stranger in this city he began a career of usefulness, and attained a
degree of eminence as a practitioner rarely enjoyed by medical men :
for he was affable in manner, intelligent in conversation, well versed
in the practical details of a learned profession, possessed of energy
and decision of character, and armed with these elements of success,
he so speedily entwined himself around the hearts of our people, as
to render his untimely loss a serious public calamity. Generous and
warm-hearted, he assisted the needy with his bounty, entirely free
from pride or ostentation. Taught by the pure waves and free
winds that bore him to these shores to love freedom of speech and
action, he became intimately identified with the manners, customs,
and institutions of our people ; and when political strife arose, he
mingled his sorrows with his friends, and grieved with profound
sympathy for the cause of those with whom he had passed a well-
spent life, and who had saluted him, a stranger in a strange land,
with: kindness. His heart was a fountain of goodness and benevo-
lence, and, going to his grave without an enemy, he "rests from his
labors, and his works follow him."

Though buried far away from the graves of his fathers, his bier
was moistened by the tears of affection, and his memory will be
long held dear by friends who saw within him the soul of honor and
generosity. May God comfort the bereaved hearts of those within
that home which knows him no more ! N. 0. Medical and Sur-
gical Journal.

Dr. Erasmus Darwin Fenner, M. D.,

Died in New Orleans on the 4th day of May, 1866. He did
not long suffer the pangs of disease, for a short illness quickly
severed the slender cords of life. Indeed, but few of our citizens
were aware that this man of energy was feeble in strength, and
that an abrupt period was about to terminate his career of public
service.

Dr. Fenner was a native of Franklin, North Carolina. His
father, who was a physician, educated him to the practice of the
medical profession, and he first entered upon the arduous duties
of his calling at Clinton, Mississippi. Seeking a wider field for

364 Necrological Notices. [Sept.,

the exercise of his talents, he made his residence in this city in
1840. His first undertaking that directed public attention to his
labors was the organization, in conjunction with Dr. A. Hester, of
the New Orleans Medical Journal, which was begun in 1844, and
from this effort originated the present New Orleans Medical and
Surgical Journal. His next effort for good was the establishment
of the " New Orleans School of Medicine," and since the termi-
nation of our disastrous political strife, he interested himself in
establishing the Southern Journal of Medical Sciences.

At all times ambitious of success, Dr. Fenner struggled to
attain an enviable distinction among his fellows. In order to
confer benefit upon his beloved section, he often attempted to
penetrate the mysteries surrounding the origin and cause of the
malignant febrile diseases of the Southwest. His efforts were
constantly directed to the improvement of the sanitary condition
of our city, and in the last paper given by him to the medical
profession, the lamented author sums up his observations in regard
to a question which is of present and paramount interest to the
people of New Orleans. He is discussing epidemic diseases and
quarantine, and says :

" All efforts hitherto made to prevent their extension by means
of quarantine and sanitary cordons have failed, and we have but
little reason to hope they will ever succeed. For twenty years we
and some others have labored to convince the people of New
Orleans that the only way to make the city healthy is to make and
keep it clean. But we have labored in vain. In the mysterious
course of events, the hand of the tyrant has been brought to our
aid, and the results are marvelous. Will our citizens profit by
this experience, and continue to enforce their health ordinances,
as the Federal authorities enforced them ? If they do not, the
consequences will surely be deplorable."

This is our lamented friend's last professional will and testament
to the people whom he loved so well, and of which, when reading
them over on his bed of sickness, he said to his associate: " The
future will prove these words to be true." New Orleans Medical
and Surgical Journal.

1866.] Disinfectants. 365

DISINFECTANTS AND HOW TO USE THEM.

[Advised by the Metropolitan Board of Health.]

(1.) Quicklime to absorb moisture and putrid fluids use
fresh stone lime finely broken; sprinkle it on the place to be
dried, and in damp rooms place a large number of plates filled
with the lime powder. Whitewash with pure lime, and not with
kalsomine.

(2.) Charcoal powder to absorb putrid gases the coal must
be dry and fresh, and should be combined with lime : This com-
pound is the " calx powder"

(3.) Chloride of Lime to give off chlorine, to absorb putrid
effluvia and to stop putrefaction : Use it as lime is used, and if in
cellars or close rooms the chlorine gas is wanted, pour strong
vinegar or diluted sidphuric acid upon your plates of chloride of
lime occasionally, and add more of the chloride.

(4.) Sulphate of Iron (Copperas) to disinfect the discharges
from cholera patients and to purify privies and drains : Dissolve
ten pounds of the copperas in a common pailful of water, and
pour a quart or two of this strong solution into the privy, water-
closet, or drain every hour, if cholera discharges have been
thrown in those places ; but for ordinary use, to keep privies and
water-closets from becoming offensive, pour a pint of this solution
into every water-closet, pan, or privy-seat every night and morn-
ing. Always sprinkle a cupful of chloride of lime or lime powder
in the same place and at the same time. Bed-pans and chamber
vessels are best disinfected in this way, by a spoonful of chloride
of lime and a spoonful of the copperas solution.

(5.) Permanganate of Potassa to be used in disinfecting
clothing and towels from cholera and fever patients, during the
night, or when such articles can not be instantly boiled. Throw
the soiled articles immediately into a small tub of water in which
there has been dissolved an ounce of the permanganate salt to
every three or four gallons of water. A pint of " Labarraque's
Solution of Chlorinated Soda " may be used for the same purpose
in the tub of water. Either of these solutions may be used in

366 Cholera. [Sept.,

cleansing the soiled parts of the body of sick or dead persons.
May also be used in bed-pans, etc.

PLACES THAT MUST BE DISINFECTED.

(a.) For water-closets, use 4 and 3; for privies, use 4, 3 and
2 ; for bed-pans and close stools, use 3 and 4 or 5 ; for cellars, use
1, 2 and 3 ; for vaults and stables, use 1 and 2, or 3 and 4, or any
of coal-tar powders.

(b.) For soiled clothing, bedding, and carpets boil whatever
can be boiled, if the articles have been soiled by cholera dis-
charges. Use solution of chloride of lime or chlorinated soda, a
quart of either solution to ten gallons of water, if the articles are
coarse and their colors of no consequence; but on fine clothing,
that has been soiled in cholera or fevers, use the disinfectants
described under No. 5, in the list above.

(c.) For sick-rooms, use 1, 2, or 3 ; for bed-rooms, ventilate ;
for closets, cleanse and keep dry ; for beds and bedding, ventilate
frequently in the sun.

(rf.) Finally : Let fresh air and sunlight purify every place and
thing they can reach ; open and dry your cellars and vaults ; flush
the water-closets and drains daPy before throwing in the disin-
fectants as directed; let there be no neglect of domestic and
personal cleanliness.

CHOLERA.

The Metropolitan Board of Health publish this simple state-
ment, and beg the public to give to it their earnest attention :

Cholera is generally a preventable disease, and in its early stages
can be arrested, if the habits be good. Study, therefore, temper-
ance in eating and drinking: do not believe that alcoholic stimulants
are useful in guarding you against an attack. Let the food be
nutritious, and keep the digestive organs in a healthful condition.
Use no stale or uncooked vegetables. Let your meet be fresh,
and your vegetables be well cooked, and all fruits be fresh and
ripe.

Cleanliness of the body is of the first consideration. Keep the
akin in a healthy stato by bathing the whole body, with a free use

1866.] Treatment of Cholera. 367

of soap. Cold bathing is best used in the morning never just
before going to bed. Dry frictions or the warm bath may be
more safely used just before going to bed.

Cleanness in your homes is of equal importance. Let your
apartments be dry ; never damp. Suffer no decayed vegetables or
stagnant water to remain in your cellars or yards. Any disagree-
able smell from privies, cess- pools, or sinks is a proof of their
unhealthfulness. Remove them by necessary repairs, lime, chlo-
ride of lime, or whitewashing. Ventilate well your houses and
apartments. Expose your bedding to the air and sun. Avoid
excessive fatigue. Keep regular hours in eating and sleeping.
Wear flannel next to the skin. A good plan is, if the bowels are
at all disordered, to wear a broad band of flannel (a belly-band)
around the body, reaching from the hips to the ribs. Maintain
the natural temperature of the body by sufficient clothing ;
especially keep the feet warm. Never, when heated, sit on the
grass or stone seats, or sleep under an open window. If exposed
to wet, change your boots and clothes as soon as possible. Take
no purgative medicines, except by direction of a physician.

By order of the Metropolitan Board of Health.

TREATMENT OF CHOLERA.

Cholera is almost invariably preceded by a painless diarrhoea,
and in all cases to be promptly treated.

When diarrhoea is present, go to bed and maintain a position
on the back ; use abundance of blankets, and send for a
physician.

A physician can always be obtained by applying to the nearest
police-station.

Stay in bed until you are well ; do not consider yourself well
until you have had a natural movement from the bowels. Abstain
from all drinks. Apply mustard plasters to the bowels.

In the absence of a physician, an adult can take ten drops
of laudanum and ten drops of spirits of camphor. A child
of ten years may take five drops of laudanum and five of
camphor. A child of five years may take three drops of
laudanum and three of spirits of camphor; and these doses

368 Books and Journals Received. [Sept., 1866.]

may be repeated every twenty minutes, so long as diarrhoea, or
pain, or vomiting continues.

This will save time, but in all cases send for a physician.

Do not get up to pass the evacuations, but use the bed -pan or
other conveniences. Never chill the surface of the body by
getting out of bed.

Remove immediately all the evacuations from your rooms.
Scald all the utensils used, or disinfect them with chloride of
lime ) scald also your soiled clothing.

By order of the Metropolitan Board of Health.

Medical Diagnosis with special reference to Practical Medicine. A
guide to the knowledge and discrimination of diseases. By I.
M. DaCosta, M. D., Lecturer on Clinical Medicine, and
Physician to the Pennsylvania Hospital, etc., etc. Illustrated
with engravings on wood. Second edition. Philadelphia: J.
B. Lipplncott & Co. 1866. 8vo. pp. 784.

The author tells that his chief aim in writing this work has
been to furnish advanced students and young graduates of medi-
cine with a guide that might be of service to them in their
endeavors to discriminate disease. He has accomplished his task
with decided ability, and his book can not fail to be eminently
useful, especially in this country, where so little attention is
usually given to the study of diagnosis. A clear perception
of the real condition of the system and of each organ is an
essential pre-requisite to correct prescription, and too much
attention can not be bestowed upon the study of the means
by which this knowledge may be attained. We, therefore,
commend Br. DaCosta' s treatise especially to the junior members
of the profession.

BOOKS AND JOURNALS RECEIVED.

BraithwaW 3 Retrospect of Practical Medicine and Surgery. New York,
VV. A. Townsend, 434 Broome street ; Part LIII : July, 1866.

Ihe American Journal of the Medical Sciences. Edited by Isaac Hays,
M. D., Philadelphia; Henry C. Lea : July, 1866.

The Medical Reporter, a Semi-Monthly Record of Medicine and Surgei-y.
Edited by J. S. B. Alleyne, M. D., and 0. F. Potter, M. D., St. Louis ;
March to July, 1866.

The New Orleans Medical and Surgical Journal. Edited by Warren
Stone, M. D., James Jones, M. D., S. E. Chaille, M. D., and W. C.
Nichols, M. D.: July, 1866.

Southern Journal of the Medical Sciences. Edited by Warren Brick well,
M. D., and C. Beard, M. D.: May, 1866.

Illustration of Diseases with the Microscope. Prize Essay. By Franci%
Peyre Porcher, M. D. Published by the South Carolina Medical Asso-
ciation; Evans & Cogswell, Printers: 1861. Pp. 133, plates 107.

SOUTHERN

ebical ^ Surgical Jfottrnol

AUGUSTA, GA.

Vol. XXL] JANUARY, 1867. [No. 3.

ORIGINAL AND ECLECTIC.

The Physical Geography of the North Pacific Ocean, the
Peculiarities of its Circulation, and their Relations to the
Climate of the Pacific Coast of the United States. By
Wm. Henry Doughty, M. D., Augusta, Ga.

The relations of medicine to the natural sciences are so
apparent that no apology is necessary for the appearance
of the present essay in a periodical devoted to this science.
Some knowledge of physics and meteorology is indis-
pensable to a proper medical education : the study of
optics, acoustics, dynamics, of atmospheric pressure, of
the laws governing the pressure of fluids and the expan-
sion of gases, of electricity, of the distribution of heat
and moisture, and of allied subjects, suggests their
importance and uses to the intelligent physician. An
important subdivision of climatology is topography, the
study of which, in its relation to climate, should embrace
the peculiar features of contiguous portions of the ocean,
as well as those pertaining to the land and soil. In con-
sidering the climatic characters of any continental section,
it is not sufficient merely to recognize its general con-
25

370 Doughty on the Physical Geography [Jan.

tiguity to the ocean ; the general effects of such relation
between land and water are often modified by existing
local peculiarities in the circulation of the latter. Uniform-
ity of effects can only result where the general causes are
the same, and similar relations maintained ; their absence
produces climatic diversities. Hence, the difference be-
tween the climate of our eastern and western coasts ; the
adjoining water-surfaces, although equally extensive, yet
differ in their topographical features, which, with the
incidental assistance of prevailing winds and the conti-
nental configuration, cause the difference of climate.

This circumstance brings medicine into profitable con-
nection with the new and beautiful science, the Physical
Geography of the Sea. The rivers of the ocean, and its
other geographical characters, must appear for study with
those of the continents, as well in the benignity of their
functions as in their commercial importance.

To the general reader, the sea is at present one of the
most interesting subjects. It is not a great while ago
since the philosopher and the herdsman alike viewed its
waters in the light of a great waste, void of aught but
dangerous breakers and striving elements, and destitute
of any feature, except its immensity, calculated to exact
admiration. For centuries its navigation has been suc-
cessfully followed by maratime countries, some of which
exist only in history, and yet, beyond its use as a medium
for commercial intercourse ; as a theatre for warlike ope-
rations, upon which to assert a fickle supremacy; and as a
commodious fishery for our support and comfort, very
little is known of it. Its harmonies with the balance of
creation were unrevealed. A great mass of saline water,
without order and treacherous in all of its attributes, was
the substance of the rude idea entertained of it. The
faithful mariner committed himself to its faithless waters,
feeling no security, except in the computed strength of

1867] of the North Pacific Ocean. 371

his vessel to withstand the furious assaults of the winds
and waves, and although often possessed of strength
sufficient for this defensive purpose, yet was as often
drifted -and borne hundreds of miles from his course for
the want of that tact and knowledge which the light of
recent science furnishes. Even of those portions of the
sea which are the constant thoroughfares of international
trade, until recently, little was known of their precise
circulation, and the developments now made, in their
fullest extent, are declared by him,* whose labors have
done more to harmonize its workings with the other
departments of nature than all others, and to offer, per-
haps, the only satisfactory explanation of certain of its recog-
nized actions, to be "only a table or two of contents from
the interesting volume which the Physical Geography of
the Sea is destined, some day, to open up to us." By the
light of his labors, which have secured for him the de-
served title of the " Philosopher of the Sea," science has
unfolded to our view some of its mysteries, and held up
to our admiring gaze its settled harmonies with the rest
of creation.

The saltness of the sea does not appear a simple chem-
ico-physical property, designed to make it a fit medium
for the countless multitudes that dwell in it, but as inti-
mately concerned in the production and preservation of
that system of currents and counter-currents which is so
beautifully displayed. The little animals (corals, etc.)
which cluster so abundantly upon its sides and in its bed
are no longer regarded as supernumeraries in creation,
but, in the excretory office that they perform in the
economy of the ocean, we observe a necessary, healthful
function j they, too, it is supposed, may contribute to its
motive power. The various currents surface and deep-
sea currents of differing temperatures in different parts

* Lieut M. F. Maury, formerly of the U. S. N.: Physical Geography of the Sea, page 271.

372 Doughty on the Physical Geography [Jan.

of the ocean-bed, are not now considered as the results of
accidental agencies, or of geographical or latitudinal
acquirements, but as the grand efforts of old ocean to
equilibrate its temperature and saltness, and thereby
extending its munificence to the land-climates. The Gulf-
stream that "river in the ocean," as it has been called
is no longer regarded as an accidental emergence of
heated and saline waW from the tropical sea and gulf,
its parent, but its original purposes are discovered as a
boon, although at times a terror also, to navigation,
a moulder of land-climates, a restorer of lost heat and
salinity to the arctic waters, as well as affording an
escape for corresponding surplus states from the tropics.
Looking at it in its entirety, in the infinity of its opera-
tions, we recognize it as the great necessary correlative of
the air and the land, without which neither could perform
its destined purposes.

There is a strict conformity in all its workings to the
known principles of physical and chemical science. We
find there life, energy, and ceaseless activity, and above
all, in its contemplation, we realize the wisdom and
goodness of that Being "who weigheth the waters in the
hollow of His hand and fixeth bounds for the sea that it
can not pass." In its simple product of hydrogen and
oxygen water aside from the substances held in solu-
tion, its sublime motions, its harmonizing efforts, and
their benificent results, we discover an element almost
unlimited in its adaptation to the wants of nature. Without
it, the world would be converted into a vast charnel-house ;
the air we breathe would dry up the very fountain of
life ; the fatness of the earth would be destroyed ; and,
in the language of another, "the fair face of nature, still
as fresh and blooming as in her infant days, would con-
tract in ghastly wrinkles, and the comeliest landscapes
grow cadaverous with premature age."

1867] of the North Pacific Ocean. 373

We do not propose, however, to treat of the ocean at
large, in any of its interesting characters, nor, indeed, to
consider even its general meteorological influences, but
simply wish to offer some considerations touching the
more prominent peculiarities of one of its subdivisions,
viz : the North Pacific ocean. These will relate to the
peculiarities of its circulation ; the reasons for and the
causes of those peculiarities, as we apprehend them ; and,
finally, their effects upon the climate of the countries to
which they are contiguous.

Variations of the form and modes of circulation of the
various divisions of the ocean necessarily result from the
interposition of continents and parts of continents. The
configuration of these masses determines, to a greater or
less extent, individual peculiarities of circulation in each
of the divisions created, when sufficiently large to vary it
at all. Thus, the North Atlantic oce,an has the course of
its currents determined and preserved, to a great extent,
by the relations of the two continents to it ; the course
and direction of the currents of the Indian ocean result
from the intrusion of the neighboring land areas ; and
the North Pacific ocean has similar characteristics. It
follows, therefore, that the circulation of each corresponds
with, or differs from, that of the others only as they
acknowledge a similarity, or difference, of land relation-
ships, and that their peculiarities are to be brought to
light by comparison. Those of the North Pacific must
be studied comparatively with what division shall we
compare it ? Its natural ally of the northern hemisphere
the North Atlantic is that most eligible and best
calculated, by our more thorough knowledge of it, to
guide us in our reasonings. And, first, let us inquire,
in what respects do they differ ?

The Atlantic ocean is longer and narrower than the
Pacific, and in its northward extension gradually merges

374 Doughty on the Physical Geography [Jan.

itself into the Arctic sea and Polar basin. Its waters
coursing northward are almost unimpeded, except by the
diurnal rotation of the earth ; its principal northern outlet
is found between Greenland and the continent of Europe,
and is large enough, and wide enough, and deep enough,
to allow an easy progress of surface and deep-sea currents.
Between Greenland and the American continent there is
another great channel, represented by Davis' strait and
Baffin's bay, which, although inferior to the other, affords ,
a free communication and interchange of its waters with
those of the Polar basin proper. Looking at it in its
main body, the relations of the adjoining continents are
such as to give it the appearance of a long narrow body of
water occupying a valley-depression between them, and
having at either end sufficient capacity to permit the
free ingress and egress of other currents of water. The
continuity of the mass upon its left is comparatively
unbroken from the point of Florida to the Island of
Newfoundland, near the fiftieth parallel of latitude, at
which point the southern extremity of the Arctic waters
enters the Atlantic almost at right angles to the advanc-
ing shore-line. This being crossed and the point of
Greenland reached, the direction and continuity of the
shore-line are maintained to the easternmost part of
Greenland, whence it turns almost due north, thus in-
creasing the width of the ocean-surface in this latitude.
On the right, however, near the thirty-fifth parallel, the
continuity of the coast-line is seriously interrupted by the
Mediterranean sea, which both receives from and dis-
charges into the Atlantic ocean large bodies of water.
From the Straits of Gibraltar northward, the coast-line
presents a succession of indentations, and, in some cases,
large parts of the continent are entirely separate, standing
out in the ocean-bed. In the intervening water-area, the
North sea, with its extension inwardly to the Baltic sea

1867] of the North Pacific Oceav. 375

and Gulf of Bothnia, we have " the attempted reproduc-
tion" of the Mediterranean sea.

The Pacific ocean (N), on the other hand, appears to
be a vast encroachment of water-area upon the eastward
and westward extension of the continents forming its
boundaries, possessing much greater width than length,
and having twice the breadth of the Atlantic. Its northern
limit is entirely within the embrace of the two continents,
except at the single point, Behring's straits, which, in
comparison with even the lesser outlet of the other ocean,
is narrow and shallow. The continental arrangement is
such that the two coast-lines, running respectively a north-
west and northeast direction, very nearly approach each
other ; and throughout their whole extent do not present
a single interruption that allows the descent of northern
waters or the escape of southern. The Asiatic boundary,
from its commencement to its end, is irregular, and
numerous islands stand off from it, thereby multiplying
small seas, as the China, Eastern, Japan, Okhotsk, and
Kamschatka. On the American coast, no encroachment
occurs worthy of mention. Its southwestern part is
studded with thick clusters of islands, which, in a general
view of it, materially encroach upon its superficies and
depth. Moreover, across the point of escape for its
waters are the Aleutian islands, extending from the
Peninsula of Alaska, on the American side, in a regular
continuous series, nearly to the Asiatic continent.

We perceive, then, that while the Atlantic ocean is so
related to its contiguous shores as to secure freedom of
ingress and egress for its waters at both ends, and has
frequent inlettings of its arms into them, the Pacific
has only a single outlet for the northern escape of its
waters, and through which to interchange with the
polar waters. This, moreover, is narrow and shallow,
and we find placed immediately in front of it a semi-

376 Doughty on the Physical Geography [Jan.

circle of islands, as if to submit the waters entering and
escaping to a sort of percolation. Freedom of entrance
to extraneous bodies of waters is only granted at its
southern part (the northern being closed, except at
Bearing' 3 straits), and even here other waters are
brought in chiefly as under-currents.

Bearing in mind these important differences, and
recalling the mode of circulation of the Atlantic ocean,
ought we not to expect such alterations in the circulation
of the Pacific as may be termed its 'peculiarities ? "We
think so, and now invite attention to their discussion.

Along the western borders of these two oceans, the
analogies of their circulation are preserved, a signal
correspondence in topographical features existing; the
important differences the distinctive peculiarities are
thrown along their eastern borders in consequence of
the closing up of the outlets for the escape northward of
the Pacific waters. The waters of the Atlantic under the
guidance of the Gulf-stream, coming full upon the western
shore of Europe, escape partly above and partly below it,
and, in some measure, course along its border, whilst those
of the Pacific, in their great bulk, are turned down along
the northwestern coast of America. At the place of
distribution of the latter, or near the points where this
doubling of the waters upon themselves occurs, those
peculiarities are observed, and so far as our information
extends, they have never been clearly elucidated.

In the origination of distinct currents, the Indian
ocean sustains to the Pacific a relation precisely similar
to that which the Caribbean sea and Gulf of Mexico bears
to the Atlantic. It is the great central focus to which,
we are taught, the moving masses of the entire Pacific
ocean ultimately tend, in obedience to that demand of
nature which requires the counterbalance and removal of
those concentrated saline and heated waters; and from

1867] of the North Pacific Ocean. 377

which are dispatched those benign currents whose special
object is the mitigation of the severities of climate in
far-off latitudes and countries, both northward and south-
ward. The Indian ocean differs, however, from the
Caribbean sea and Gulf of Mexico, in having a higher
temperature for its waters, and the force of evaporation
there is much greater. Thus it is said that the "tem-
perature of its waters is frequently as high as 90 Fahr.,"
and that "fifteen or twenty feet of water" are "yearly
carried off from this ocean by evaporation ;" and, again,
that "the evaporation in certain parts of the Indian ocean
is from three fourths of an inch to an inch daily."

The current* of most interest to us, issuing from this
tropical sea, "makes its escape through the Straits of
Malacca, and, being joined by other warm streams from
the Java and China seas, flows out into the Pacific, like
another gulf-stream, between the Phillipines and the
shores of Asia." The general character and course of
this stream are closely analogous to and, in some respects,
identical with the Gulf-stream ; the causes which deter-
mine them ; their indisposition to mix with the general
sea-water, produced by their peculiar chemico-physical
properties; their objects and their results are doubtless
the same. This current is designed to effect in the
Pacific ocean what the Gulf-stream accomplishes in the
Atlantic.

From the Phillippine islands, its precise direction has
been more accurately pointed out by Lieut. Bent, U. S.
JS\, of the Japan expedition, at a meeting of the 'New
York Geographical and Statistical society, in January,
1856.t He says: "This offshoot the Kuro-Siwo, or

*According to Lieut. Maury, U. S. N., there are at least two other currents that issue
from this ocean: "One of them is the well-known Mozambique current, called at the Cape
of Good Hope the Lagullas current." "There is, at times at least, another current of
warm water from the Indian ocean ; it finds its way south, midway between Africa and
Australia." Page 137 Physical Geography of the Sea.

f Blodget's Climatology of the United States, page 20.

26

378 Doughty on the Physical Geography [Jan.

Japan stream is separated from the parent current by
the Bashu islands and south end of Formosa, in lat.
22 north, long. 122 east, and is reflected along the east
coast of Formosa, where its strength and character are as
decidedly marked as those of the Gulf-stream on the
coast of Florida. This northerly course continues to the
parallel of 26 north, where it bears off to the northwest
and eastward, washing the whole southeast coast of
Japan as far as the Straits of Sangar, and increasing in
strength as it advances, until reaching the chain of islands
southward of the Gulf of Yeddo, where its maximum
velocity, as shown by our observations, is eighty miles
per day." From the Japan islands, which correspond in
their relation to it, to the grand banks of Newfoundland,
it acquires a northeastwardly direction, and "attempts
the great circle route to the Alentian islands." As it
advances farther and farther into the Pacific, it slowly
spreads itself out upon its common waters, and silently
dispenses its higher temperature to the air and water
around ; and, finally, having reached its ultimate destina-
tion the northwest coast of America there, after a
journey of seven thousand miles or more, exhausts its
fertility, and, having accomplished its destined purposes,
commences its circuitous return to the attracting centre.
By far the largest part of this current thus turns down
the American coa'st, the remainder finding an outlet as a
surface-current, through Behring's straits into the Polar
sea. The place of separation of the latter from this
great whirl of warm water is the projecting extremity of
the Peninsula of Alaska.*

* So far as the ultimate distribution of this current and of the Gulf-stream reflects their
original design, it seems that the latter was intended chiefly for distribution through the
Arctic waters, or, in other words, for its ameliorating influence upon the climates of the seas,
although also conferring benefits upon countries contiguous to its waters in their passage,
whilst the former, from its limited access to polar waters, would, on the contrary, appear to
be intended more particularly to recover the vast extent of land area, comprising the north-
west of America.

1867] of the North Pacific Ocean. 379

Considering now the starting point of this current
and its destination, the extreme difference of latitude
between them, and the great distance to be travelled over;
and knowing that the shortest distance between any two
points on a sphere is "the arc of a great circle," we per-
ceive that the course marked out and pursued by1 it is
perhaps the shortest possible way, and just such as any
other body would have pursued under the present physi-
cal requirements. Moreover, it will be observed that, at
the various points of higher or lower latitude at which it
strikes the American coast, a series of super-imposed, and
to some extent, concentric arcs will be described of vary-
ing length and dimensions, according to the part of the
coast taken. For instance, the arc described by those of
its waters which first reach the continent in the latitude
of San Francisco or Monterey would be less than that
described by such as at first touch the British American
coast ; or than the arc described by the Japanese junk that
was borne to the mouth of the Columbia river in 1831 :
just as, in like manner, the most southern portion of the
great whirl of the Gulf-stream necessarily describes a
smaller arc than that which first reaches the higher lati-
tudes of the continent of Europe. The principle of action
is this, that the shorter the distance between any two
points upon a sphere, the smaller the arc described by any
object in passing between them.

Furthermore, if this reasoning be correct, the lesser
arcs of the current, possessing at the commencement the
same temperature and travelling a shorter distance, would
indicate at their termination a higher temperature than
the greater ones; therefore, upon such parts as the waters
forming them would impinge, a higher absolute tempera-
ture would be expected. We cannot assert positively that
this observation has been actually verified by instrumental
observations, for the record of sea-temperatures in the

380 Doughty on the Physical Geography [Jan.

Pacific is at present too incomplete, but as far as known
they do tend to verify it the sea-temperatures in the lati-
tude of San Francisco being in the winter season somewhat
higher than for several degrees above it, and higher also
than the water temperature for several degrees below, it
in theK summer. It is highly probable that the part of this
coast just mentioned is that at or near which the lowest
circles, or the southernmost layers of this Japan current,
reach the American coast ; a supposition well calculated
to throw some light upon the phenomena of the ocean at
this point.

Just here, we would venture another remark in refer-
ence to this current. It is well known that, in certain
latitudes, the Gulf-stream does not preserve at all times a
uniform width or possess uniform dimensions, but, being
subjected to alternate pressure upon the right and upon
the left, its two edges are made to vary their position. In
the month of September, its northern limit is in close
proximity to the Newfoundland shores ; but in March, is
removed several degrees of latitude farther south. The
intervening space is successively travelled over " once
each way during the year." This, then, is the free edge
of the current, and has, therefore, a greater tendency to
alter its position. With the China stream, however, by
reason of its land-locked distribution and the want of a
free northern escape for its waters, its southern limit
becomes the variable one, and hence, the same causes
operating in both cases, in March and September, the
points of approach to the shore would also vary several
degrees of latitude. In this, we believe, is to be found
the true reason why the warm waters of the winter months
off the coast of California are supplanted in the summer by
those having a lower temperature. But we must reserve
such observations as we design making upon this point

1867] of the North Pacific Ocean. 381

until the discussion of the alternation of sea-temperatures
here indicated is directly in hand.

Westward of San Francisco, and bounded on the north
by this current, is the ocean-expanse of its common waters,
possessing the ordinary characters of oceanic-waters gen-
erally, a part of which forms also the centre of drift for
the Pacific, analogous to the Sargasso sea, midway of the
Atlantic. Between this mass and the smaller portions
flowing southward along the coast of California there
exists, at all seasons, a difference of temperature, to which
we wish now to direct attention.

"During the winter," says Mr. Blodget,* "at sea, on
the Pacific side, the absolute temperatures are at once
higher than those of the land, and higher than in summer
for two or three degrees of longitude next the coast. The
thermal lines bend abruptly to conform to this difference'
but it is probable that, after changing position four or five
degrees of latitude, they follow the parallels for an indefinite
distance toward the centred region of the Pacific ocean."
Here, then, the isothermals, after leaving the shore,
acquire a northward turn for several degrees of latitude?
and then assume the direction of the parallels toward the
heart of this great ocean. The general waters must then,
at this time, have a lower degree of temperature than
those next the coast. In the summer season, the order
of things is reversed the cold waters being nearest the
coast, whilst the warmer ones are out from it. The same
author remarks on this point as follows: "Taking the
observations of the Pacific, in means for areas of five
degrees of latitude and longitude, we find the areas west-
ward of San Francisco to give 56 5', 62 3', 64 4', and
68 successively. The areas next southward, or between
30 and 35 of latitude, increase in temperature west-
ward from longitude 120, by the successive numbers of

Blodget'8 Climatology of the United States, page 301. The italics are our own.

382 Doughty on the Physical Geography [Jan.

60 5', 63 3', 65 7', and 66 7', to the meridian of 140.
South of the parallel of 30 there are no summer observa-
tions on the coast. In the latitude of the Sandwich
islands (20 to 25), the temperatures increase from 72
at the meridian of 120 to 77 at that of 150 in the
vicinity of those islands." (Page 278). The isothermals,
upon reaching the water-surface, are at once depressed
southward several degrees, and having passed the narrow
belt of cold waters, rise again to the northward in
pursuing their course to the interior of the ocean. It
appears, therefore, that the waters which are subject to
this alternation of temperature do not compose a part of
the ordinary sea-water, properly so called, or as distin-
guished from the current under consideration, but that
they are distinct and separate. The latter experience
changes of temperature only as similar parts of other seas,
in obedience to the nearer or more distant approach
of the sun.

Again, we have already stated that a correspondence of
circulation of the two oceans, Atlantic and Pacific (N),
is more fully established on their western sides than else-
where. The existence of a stream or current of cold
water coursing along the Asiatic continent southward,
between it and the China stream, fixes this similarity :
this current is analogous to the returning cold waters
between the Gulf-stream and the American continent,
and has in view the accomplishment of the same objects.
This, we feel authorized in saying, is that visible part of
the polar waters which goes to supply the place of the
great equatorial current, of which we have spoken. It
is undoubtedly only a part of the masses dispatched for
this purpose, and finds its exit from the Polar basin
through Behring's straits as an under-current, or partly
as an under, and partly as a surface-current.

1867] of the North Pacific Ocean. 383

Lieut. Maury says that "the surface-current flows north
through Behring's straits into the Arctic sea," but Prof.
Henry relates it as an interesting fact, which he acquired
from Capt. Rodgers, "that an offshoot from the great
whirl in the Pacific, analogous to that which impinges on
the coast of Norway, enters along the eastern side of
Behring's straits, while a cold current passes out on the
western side, thus producing almost as marked a difference
in the character of the vegetation on the two shores of the
strait, as between Ireland and Labrador."* In either
case, the result would be the same to us ; if it enters tlje
Pacific through this strait, even as a surface-current, the
warm and lighter waters of the other would overlay it,
just as occurs in the case of the Gulf-stream and its cold
counter-current. Now, bearing in mind the fact that
the only access of the Arctic waters to the Pacific ocean
is by means of the limited capacity of this strait limited
in comparison with those performing a similar duty in the
Atlantic, we may assume that wherever, in its northern
area, cold currents are found, they obtain entrance through
it, and may be taken as divisions of the under-current
which there flows southward. An attempt to account for
them in any other way, as by deep-sea currents from the
south, would be contrary, in our judgment, to all the
other actions of the sea, and violative of its harmonies.

Allusion has already been made to one such body of
cold water in this ocean, not immediately traceable to,
although undoubtedly derived from, the waters let in at
this point. This is found oft' the coast of California
during certain parts of the year, but is not of clearly
definable limits. The mysterious character of this mass
of cold water lower in temperature, even in the summer
months, than the waters in its immediate vicinity, and
lower also than those by which it is supplanted in the

Patent Office Reports for 1855, page 363. The italics are our own.

384 Doughty on the Physical Geography [Jan.

winter season is at present a source of much perplexity to
climatologists and physical geographers. They recognize
in its low temperature its unnatural influence upon land-
climates ; rudely define it ; and refer it very properly to
its great supposed head, the polar waters, but are at a
loss how to account for its remarkable intrusion in the
dry season of the Pacific slope : the rationale of its ap-
pearance at this time and place is unexplained. We have
some reflections to oiler upon this subject, and hope to be
able to throw some light upon it.

We have already stated that its dimensions have never
been determined, but the results of our investigations, with
the aid of the published labors of others, lead to the con-
viction that its most northern point of contact with the
shore is near the 41 of north latitude, and the direction
of its northern or northwestern line of limit, if it can be
represented by a straight line, is toward the point of
Alaska. It probably extends southward on the coast-
line about from seven to ten degrees of latitude, and in
width, or extent from the coast, several degrees of longi-
tude. In the subjoined note,* which contains an extract

* This is a recapitulation of certain temperature data which had been given in the ascent
of the coast from San Francisco, lat. 37 48', to Fort Astoria, lat. 46 11', and contains also the
conclusion as to the highest point of latitude at which the cold masses reach the continent.

" Let us recapitulate : From San Francisco, lat. 37 48', northward 2 58' to Fort
Humbolt, we observe a continuation of the same reduced monthly mean temperature with
a strict parallelism throughout the dry season. To this point the refrigerating influence
appears to be about the same. Progressing 1 58' farther northward, to Fort Orford, we
observe a sudden and material increase of 2.70 per month over Fort Humbolt, for the
summer season, and from June to September an average monthly increase of 2.49; also a
higher summer mean temperature by 2.25. Then continuing 3 27' farther up to Astoria,
we have an elevation of 16.66 per month over Fort Orford for the summer, and a monthly
average of 1.05 from June to September. Hence, we see within a distance of two degrees of
latitude a sudden elevation of temperature, amounting to 2.70 per month for the summer,
and within five and a half degrees of latitude, a monthly elevation of 4.36 for the summer
over Fort Humbolt, and a difference in the summer .means of 3.88. To what may this
difference within so short a distance be attributed?

Now, perhaps we are better able to locate the northern edge of this cold current, and to
appreciate the point near which its direct effects cease and where those of simple proximity
begin. Fort Humbolt certainly falls within the range of its region of contact, for the slight
and mere nominal differences that exist between it and places five or six degrees of latitude
farther south afford positive proof of the fact. That it extends any distance above this point
is exceedingly problematical, for an advance of not quite two degrees of latitude gives a much
greater difference of temperature than has been noted for at least six degrees south of that
point, and advancing five degrees from this point, such differences are observed as point to
an almost entire absence of its influences, direct or indirect. It is likely that its proximity
to the coast off Fort Orford largely affects its temperature distribution and prevents the
more material and increased differences which would otherwise occur between it and Fort
Humbolt. Besides, if we take as strictly true the remarks of Mr. Blodget, that this cold
current passes "nearly due southeast" from the point of the Peninsula of Alaska, and esti-
mates its breadth at seven or eight degrees of longitude (the distance westward from San

1867] of the North Pacific Ocean.

oo

from an article presented by the author to the Medical
Association of Georgia, at its annual session m 1859,
entitled "An Essay on the Adaptation of Climate to the
Consumption," etc., and including an investigation of the
climate of the Pacific slope of the United States, may be
found the principal circumstances that have induced us
to assume the limits here assigned it, particularly its
northernmost point on the coast.

In regard to the origin and track of this current, we
believe the following explanation sufficient :

It will be remembered by those who are familiar with
the physical geography of the Atlantic ocean, that the
cold surface-current which enters it through Davis' strait,
after meeting in its southward flow the Gulf-stream,
becomes divided into two parts one of which runs as a
surface-current between the latter and the continent, and
the other, becoming an under-current, underlies it, form-
ing its bed, even to the Pass of Florida, it is thought.
Xow, in the Pacific, the cold waters enter principally as
an under-current through Behring's straits, a part of
which becomes the surface-flow along the Asiatic coast,
while the remainder must continue an under-current,
which will either lose itself gradually in its southward
course, or, if proper conditions arise sufficiently far north,
will rise to the surface. We can not say whether the
China stream is underlaid to its ultimate source by the
cold waters here obtaining entrance, as is the case with
the Gulf-stream, but we do believe that at least one of
the divisions of the latter is entirely overlaid by the

Francisco, which gives the reduced mean temperature), and establish its probable northern
line of "limit' by this assumed direction and width, it will appear to approach the United
States coast somewhere between Forts Humbolt and Orford, latitude 40 4b' to 42 44'. We
do not presume that this northern boundary is as distinct from the waters beyond it as some
may suppose, or even as distinguishable by the thermometer as the Gulf-stream is by the
eye from its cold banks. Yet, if it can be represented by a straight line, that would, we are
le"d to believe, extend from the point of Alaska to the western coast, at or about latitude
41 north. This, then, would bring within the scope or direct range of this current but an
extremely small portion of the coast of Oregon, and, as has been intimated, show the position
of this cold line to be "a little distance oil at sea.'; Southern Medical and Surgical Journal,
vol. xv, Nov. No., page 731.

27

386 Doughty on the Physical Geography [Jan.

former during certain parts of the year, and but partially
at others, having, during the latter, found those proper
circumstances to which we have alluded, admitting its
appearance upon the surface.

Incidentally, we would add, Lieut. Maury states that
this strait is too shallow to admit of "mighty under-
currents ;" and as the Pacific waters in their greatest
bulk do not escape through it, but return toward the
equator thus supplying a southward flow there is no
necessity for such "mighty under-currents " as might
otherwise be expected. If we assume the amount enter-
ing this ocean by means of this under-current to be equal to
that escaping from it, it must appear insignificant in com-
parison with the amount borne northward by the China
stream, and therefore can not be intended as a full supply
for that withdrawn from the Indian ocean.

As to the causes of a division of this under-current
from the Arctic sea, we may remark that, besides the
lighter properties of the warm southern current, which
preserves a part of it as a deep-current, the physical
obstacles the Alentian islands between which its waters
have to pass as through the meshes of a sieve, are them-
selves sufficient to divide it, and to promote a wider
separation of those divisions. This being effected, and
the subdivisions being now, as it were, unrestrained in
their southern tendency, would select such routes as are
most favorable to a direct passage. Thus we may sup-
pose that those upon the right would tend toward the
Asiatic coast, whilst those upon the extreme left would
be led to seek a more direct or shorter pathway to the
south, along the American coast. More than this^: do we
not see, in the presence of those numerous groups of
islands which are crowded together so thickly in the
southwestern part of the ocean-area, another obstacle
calculated to aid in determining the course of the latter

1867] of the North Pacific Ocean. 387

branches ? It may be that the capacity of the ocean, in
that portion of it, is so fully taken up by the remarkable
current that we have considered, and so far encroached
upon by these islands, that the great body of under-
moving cold water can not accompany the China stream,
with its channel as a guide, to the southern sea. In other
words, by reason of the shallowness of this part of the
ocean, as indicated by the island-areas, the great channel,
so to speak, for the southward flow of arctic waters, is
thrown partly along the American continent. These
several circumstances tend, in our opinion, to point out
the reasons for the adoption of the course pursued by
that branch which at times wells up to the surface on the
coast of California. The well-known fact that the Gulf-
stream and its underlying cold bed occupy the deepest
part of the Atlantic ocean is, to some extent, corrobo-
rative of the supposition that this left-hand branch is
seeking a deeper channel.

But why, it may be asked, should this current make its
appearance upon the surface on this coast during the summer
months alone, and why its disappearance in the winter ?
And in answer to this, we must be allowed to refer again
to the analogies of the Atlantic ocean. We have spoken
of the changing limits of the Gulf-stream : what were the
instrumentalities by which those changes were effected ?
We can not do better than to give the language of the
great expositor himself:* "Therefore, though the waters
of the Gulf-stream do not extend to the bottom, and
though they be not impenetrable to the waters on either
hand, yet, seeing that they have a waste of water on the right
and a ivaste of icater on the left, to which they offer a sort of
resisting permeability, we are enabkd to comprehend how the
waters on either hand, as their specific gravity is increased or
diminished, will impart to the trough of this stream a vibratory

* Lieut. Maury : Physical Geography of the Sea, page 44. The italics are our own.

388 Doughty on the Physical Geographg [Jan.

motion, pressing it now to the right, now to the left, according
to the season and the consequent changes of temperature in the
sea." Here is the manifest reason for the appearance of
these waters at this season at this place. As soon as the
sun crosses the equator and commences his course through
the northern hemisphere, in March, the vast ocean-mass
in the interior, and standing off a few degrees of longitude
from this coast, begins slowly to imbibe heat, which
rapidly increases to the summer months. In proportion
as it becomes elevated in temperature, its specific gravity
is altered and its expansion produced ; and by reason of
the consequent pressure upon the free southern edge of
the warm and resisting waters, the latter is forced several
degrees of latitude above its lowest winter position. As
this northward displacement of the warm waters is taking
place, the cold masses, which have heretofore been pur-
suing their silent course as an under-current, lift them-
selves to the surface at such points in their pathway as
have been relieved of the superincumbent warm waters,
by reason of a lower specific gravity than the common
sea- water. Their specific gravity, then, though greater
than that of the great western current of warm water, is
nevertheless less than that of the common sea-water, by
virtue of which they rise to the partial displacement of the
latter. It may be that these three different bodies or classes
of water are identical in character, though not superim-
posed one above the other, with the stratified layers of the
Arctic sea, as reported by Commodore Rogers :* "His
observations show uniformly this arrangement or stratifi-
cation in the fluid masses of the Arctic ocean warm and
light water on the top, cold water in the middle, and
warm and heavy water at the bottom." Just as long,
therefore, as the present relations are sustained and the

* Smithsonian Report for 1856, page 349.

1867] of the North Pacific Ocean. 389

pressure maintained, just so long will the cold masses
continue as surface-waters. And this is found to be the
case, for throughout the months embraced in the dry
season of California -the period of increasing heat they
are present in some degree, and are felt in some measure
in their chilling influence.

On the other hand, as the sun retreats to the southern
hemisphere, carrying with him his warming influences,
the sea-water slowly reduces its temperature, contracts
upon itself, and recovers its lost winter specific gravity ;
and with these changes gradually withdraws its pressure y
consequently the free edge of the warm current again
returns southward, overlying the cold ones, and causing
their disappearance. Hence, in the winter season, the
cold ones have been entirely supplanted by those warmer
and lighter. In these various modifying and forming
circumstances is also seen the reason of the indistinct and
indefinable limit of this body of cold water. It is simply
a remarkable intrusion of cold water in the summer,
irregular in outline and transient in duration. The limit
of the northern edge of the Gulf-stream at certain latitudes
varies, from March to September, from ^ve to six degrees
of latitude (from 40-41 to 45-46 at "the meridian of
Cape Race"), and this, we think, is about the extent of
variation of the southern edge of the warm waters in the
Pacific. The variation of the former, off* the grand banks
of Newfoundland, "is, as the temperature of the waters of
the ocean changes, first pressed down toward the south,
and then again up to the north, according to the season
of the year." The same is true of the other, and, except
as a result of scientific inquiry, would be as little thought
of, were it not for the unnatural impressions made upon
us by its occurrence in the summer season ; and this last,
we the more readily perceive, because its refrigerating
character is made more sensible to us in consequence of

390 Doughty on the Physical Geography [Jan.

the aid furnished by the general atmospherical circulation
which drives the air inland. On the Atlantic side, the
Gulf-stream's variations, or the nearer and more distant
approach of its warm waters to the Newfoundland shores,
and the subsequent substitution of cold waters for them,
are of little consequence, because the westerly atmospher-
ical movements bear its influences from us, and, as is the
case, we would seek no knowledge of it, as we have said,
except as a scientific fact, and as a curious feature in the
history of the Gulf-stream.

Passing now to the last clause of our subject, we would
remark that we propose simply to indicate the general in-
fluences of these peculiarities of the Pacific circulation
upon the climate of the American coast, and not to attempt
a minute examination of them. The latter, as far as the
present record will admit, we have already done in the
essay before referred to, to which we would respectfully
refer our readers.* Moreover, in our notice of the general
influences, we shall be very brief, and shall, at the same
time, draw from the writings of others.

These general influences are not difficult to trace, for
the warm waters of the China stream, coming full upon
the extreme northwestern part of the continent, confer
upon its immediate coast features similar to, and to some
extent identical with, those conferred upon the correspond-
ing latitudes of western Europe by the Gulf-stream. The
difference of the results of the two currents, or the loss of
a positive identity of effects, results from the greater loss
of temperature sustained by the former, by reason of the
greater width of the Pacific ocean : the difference, how-
ever, is one of degree only. Wherever these waters
strike the coast they exert a softening influence upon its
climate, by mitigating the severities of the winter season
and by elevating to some extent the summer heat, in the

* Southern Medical and Surgical Journal, Vol. XV, commencing with the May number.

1867] of the North Pacific Ocean. 391

higher latitudes; and withal, tend to the preservation
at all times of a comparatively uniform temperature
condition.

"North of the 45th parallel," says Mr. Blodget, "the
cool, humid summer of the west of the British islands
and Norway exists, with apparently no great measure of
difference in like latitudes. It is little known as yet,
except on the coast of Oregon and at Sitka, but where
not shut in by rugged mountains it is very favorable, at
least to the 55th parallel. Vancouver's island is pecu-
liarly favored, and its area is large enough for a flourishing
state. It is said that here the summer is warm and pro-
ductive, and that all branches of agriculture common to
the latitude, 48 to 52, in Europe flourish whenever
undertaken. It cannot be otherwise than that a large
area of valuable lands and favorable climates extend
between this point and Sitka, at lat. 57. At this last
point, the saturation becomes excessive in summer as well
as at other parts of the year, and there is almost constant
cloudiness and rain. Richardson says that 'the climate
of Sitka is much warmer than that of Europe at the same
parallel, but the atmosphere is charged with vapors,
whose condensation occasions almost constant rains. In
the month of July, the sun is seldom visible more than
three or four days, and then only for an instant. The
humidity gives astonishing vigor to the vegetation, yet
corn does not grow there ; and, in fact, the want of level
surface is an impediment to cultivation.'" Some idea
may be had of the excessive vegetation, when we con-
sider the size of the pine and spruce trees grown here, as
given by the same author: they attain "a diameter of
seven feet, and a height of one hundred and sixty feet."
The productive capacity of the region, however, is not so
extensive. It is said that " along all this immediate coast
Indian corn, the characteristic American staple, fails to

392 Doughty on the Physical Geography [Jan.

come to perfection, and at the greatest exposures will not
grow at all. In the valleys opening to the sea it will
often grow a slender stem of nearly full height, but with
no tendency toward formation of grain. The summer
at Vancouver's island is more favorable to it than at
Monterey, thirteen degrees of latitude southward, though
it is believed that it is scarcely cultivable at the first
locality at least its cultivation there does not appear in
notices of the islands."

In regard to the correspondence of the temperature
condition on this coast and along the wTest of Europe, the
same writer (Mr. Blodget, page 209) continues as follows:
4 'the identity of the two west coasts in regard to climate
may require the citation of some statistics in this connec-
tion, to establish it. In latitude there is little difference
between the southwest of England and Vancouver's
island, and the correspondence of climate is quite decided.
Though we have no instrumental observations at the last
point, we are informed by navigators that there is little
frost in winter, and that vegetation advances rapidly in
February and March. The wrhole climate, indeed, is
peculiarly soft, equable, and English. It is such on the
coast of Oregon and California as has been described, and
particularly at Sitka and the upper intervening islands.
In the statistics the same low curve of differences among
the months, and the same low range of variation for the
day, belong to both." "The average ascending differ-
ence being 4. 2 for each month at London, and 4. 4 at
Steilacoom, the most nearly corresponding American
position. At Faris this average is 5; at Sitka 8. 8, and
at Fort Iioss only 1.88"

This is, perhaps, sufficient to convey a general idea of
the character of the climate, at all seasons, north of the
latitudes which are the seat of the alternating warm and
cold masses of water. The latter comprise the coast of

1867] of the North Pacific Ocean. 393

California and a small part of Oregon. During the winter,
or wet season, of the Pacific slope, in which the warm
waters circulate off the entire coast, the same general
features are continued to the more southern part due
allowance being made for the difference of latitude. Thus
at this season the mean temperatures along the coast are
brought very nearly to the means of the water-tempera-
ture, and a degree of uniformity and regularity of tempe-
rature maintained, that, in some of its parts, is without a
parallel in the eastern United States. So great is the
consequent uniformity that, with the aid of the altitudi-
nous interior of the Pacific slope, " the decrease in the
mean is but ten degrees for fifteen degrees of latitude,
from San Diego to Astoria, or two thirds of a degree of
temperature to one of latitude. Continuing to Sitka,
there is a diminution of six degrees of temperature
for eleven of latitude, or nearly the same proportion ;"
and "of isothermals differing five degrees, but three can
be made to cut the Pacific coast from San Diego to the
49th parallel."*

But in the summer, or dry season, of the southern part
of the Pacific coast, the refrigerating influence of the cold
waters circulating off the coast is so great that the climate
is rendered exceptional, and its various mean temperatures
are reduced below those higher up on the coast of Oregon
and Washington territory. The effect of this mass of
cold waters upon the adjoining land-area is greatly en-
hanced by the configuration of the continental mass itself;
the close proximity of the San Joacquin and Sacramento
valleys to the sea, with their furnace-like temperatures,
is the chief element of the latter. As the tempera-
ture increases in these valleys with the approach and
progress of the dry season, and simultaneously with the

* On the Atlantic coast, the temperature diminishes " at the rate of two and seven tenths
degrees of the thermometer to one degree of latitude a ratio, in comparison with that of the
Tacific coast, of more than four to one." Army Meteorological Register, page 710.

28

394 Doughty on the North Pacific Ouan. [Jan.

rise and influence of the cold waters themselves, the im-
pressions of the latter are more perceptibly felt. So that
in the summer months the greatest intensity of action of
the latter is manifested, and so great is it that, at certain
points of the intervening coast structure, the mean tem-
peratures of the summer months indicate hut a slight
advance over the spring means, and the first fall month
affords the highest monthly mean for the year. *

The indraught of the cold atmosphere of the Pacific in
this latitude is the result of the combined agencies of the
heat of the interior valleys and the cold off the coast.
And where these conditions obtain, the remarkable fact
that we have alluded to is produced that the means of
the summer months at places from two to fifteen degrees
farther north are above them. The positive reduction of
temperature along the coast of California would be an
interesting fact, if it were possible to determine it ; but
an approximate calculation made by the writer in the
essay already quoted from, in which the most exposed
point of the coast, San Francisco, and the temperatures at
Fort Miller, in the interior valley, were taken, gave an

* Some idea may be formed of the degree of refrigeration experienced at such points by
the following extract from our former article: "At San Francisco, we find the mean tem-
perature of the month of June, so great is the influence of the sea, reduced virtually to the
temperature of the latter (the sea-temperature 56.5), there being a difference of only 0.36
in its favor. This influence of the sea-temperature is still farther exhibited in the trifling
increase of July over June, the advance being only 1.04, and over that of the sea itself only
1.40. August, again, while it recedes 0.68 from the mean of July, is yet 0.36 higher than
that of June, and only 0.72 higher than the mean water-temperature. September, instead of
manifesting a decline in its mean temperature, when compared with the last two summer
months, at San Francisco, as is also true of Monterey, shows the highest mean temperature
of the dry season along the coast of California." "Comparing it with the mean of the sea-
waters, it is 1.76 higher in its mean temperature." (Southern Medical and Surgical Journal,
vol. xv, July number : An Essay on the Adaptation of Climate, etc. By the author.) And
again, when comparing the Pacific coast with the State of Florida : At San Francisco, " the
whole amount of augmentation of temperature during the entire period from April to Sep-
tember, as evidenced by the difference of their means, is only 2. 89. May, instead of giving a
mean from 4.72 to 6.94 above that f April, declines slightly from it, and June only
increases over May so far as to exceed the mean of April by 1.49 ; from June to July, the
increase is only 1.04, whilst August retreats so far from July as to make its mean only
0.36 higher than that of June ; and, finally, September gives a mean of 1.04 above that of
August, but only 0.36 over that of July. The entire period of a declination of temperature
occupies here a single month, and amounts to only one third of a degree. By this nominal
decline, the month of October presents the same mean that July has. Hence, an unparal-
leled uniformity of temperature-condition exists here from April to October. At other places-
on the coast of California, similar, though not identical results are manifested, and for some
degrees of latitude, both northward ana southward of San Francisco, a corresponding uni-
formity is observed, so that the advance of temperature, during the summer, amounts to only
"one degree for one hundred and twenty miles northing." Southern Medical and Surgical
Journal, vol xvi, February number; same article.

1867] Dugas on Fracture of Os Femoris. 395

average reduction at the first of 28. 97 per month for the
summer season. Finally, it thus appears that the relation
which these peculiarities of the Pacific circulation sustains
to the climate of the contiguous shores is a controlling
one endowing each season of the climatic year with the
features common to the particular current then present
oft' the coast. Moreover, the climate of the immediate
coast in the dry season is subdivided in such a manner as
to create the lower mean temperatures in the southern
latitudes, and the higher in the northern, during the
summer months proper.

In conclusion, while making a free acknowledgment of
the liberal use of the labors of others, we would remark
that we have only been induced to record our reflections
on this subject by the remarks of Lieut. Maury, that
" ' stay-at-home travellers,' as well as those who 'go down
to the sea in ships,' are concerned in the successful prose-
cution of the labors" involved in a scientific study of the
sea. And the writer trusts to the shield thus generously
thrown by this encouraging call over the apparent pre-
sumption of one who is practically but little acquainted

with the sea.

* < .

Compound Fracture of the Os Femoris healed in four days.
By L. A. Dugas, M. D., Professor of Surgery in the
Medical College of Georgia.

Capt. A. D., about twenty-two years of age, wa^
wounded on the 21st of August, 1864, near Winchester,
Va., in the battle of Summit Point. The missile, supposed
to be a minnie ball, struck him on the left side of the scro-
tum, and, passing between the testicles, entered the right
thigh, fracturing the femur near the junction of the upper
and middle third, and remaining in the limb. The wound
being considered mortal, he was carried to a neighboring
house and left there with a cold-water dressing, but with-
out being splinted.

396 Dugas on Fracture of Os Femoris. [Jan.

On the fourth day the wound in the thigh was entirely
healed no suppuration having taken place. On the 19th
of September the fracture had united sufficiently for him
to undertake the journey to Augusta, Ga., without a
splint. Upon his arrival here (27th Sept.) I visited him,
and found that the fragments of the femur had united,
with some overlapping and a shortening of two and a half
inches, but no other deformity. The captain related to me
the history of his case as now written out.

The wound of the scrotum proved very painful ; one of
the testicles became much swollen, and he suffered severe
attacks of neuralgia along the spermatic cord, on his way
home ; but when he reached here all was well. He
subsequently suffered again several attacks of the neu-
ralgic pains.

May 20, 1866. Capt. D. informs me that, during a
recent visit to the seaboard, he had an abscess formed,
which opened at the orifice of entrance of the missile in
thigh, but that it soon healed without discharging any
foreign body nor fragment of bone. He states that it was
carefully probed by a skillful physician, who ascertained
that it did not communicate with the bone nor ball.

The captain is now (iSTov., 1866) in fine health, and
feels no inconvenience from the presence of the ball.

This case is remarkable as an illustration of union by
first intention in a gunshot wound of the thigh, and of the
successful treatment of an important fracture without the
use of splints nor of any other retentive appliances.
Every one must have observed with what facility fractures
become consolidated in the lower animals without the in-
terference of art. A fracture of the leg in a cow came
under my observation, which, although causing the limb
to dangle loosely for some time, ultimately united without
leaving the slightest deformity. Such facts teach us, at
least, that it is not absolutely necessary to prevent all

1867] Ford on Fracture of Femur. 897

motion between the fragments in order to secure their
union.

I may be permitted to relate another ease of

Gunshot wound which healed by first intention.

In 1862, Mr. J., a young man, twenty years of age,
was handling a small pistol, when he accidentally shot
himself through the palm of the hand. ISTo bone appeared
to be broken and there was but little hemorrhage; yet
the blood continued to flow, and seemed to be arterial.
I applied a thick compress, wet with cold water, to the
palm of the hand, and bound it down firmly with a roller
bandage, which closed the dorsal orifice of the wound also.
The dressing was ordered to be kept wet with cold water
and the hand placed in a sling. On the fourth day, I
removed the dressing and found both orifices healed
without the least evidence of suppuration. The dressing
was, however, reapplied and worn for eight or ten days
longer, merely as a measure of precaution. No deformity
resulted.

Report of a Compound Fracture of the Femur uniting with-
out suppuration. By DeSaussure Ford, M. D., Pro-
fessor of Anatomy in the Medical College of Georgia.

C. Rollins, of the army of Northern Virginia, nineteen
years of age, athletic, of sanguine temperament, weighing
160 lbs., a farmer, was wounded in the first battle of
Manassas, and removed from the battle-field to the
General hospital at Culpepper Court-house, Virginia.

The ball entered behind and below the left trocanter
major, fracturing the femur, and was found in the ab-
dominal walls, in the middle of the inguinal region of
the opposite side, from whence it was extracted. The
foot was extremely everted, and after being straightened,

398 Ford on Fracture of Femur. [Jan.

if released, would resume the unnatural position ; crepi-
tation was distinctly felt during these movements. The
shortening was half an inch. I saw him a week after the
injury, and so slight, almost imperceptible, was the
swelling; the wound of entrance healed, no discharge of
pus ever having been noticed, and only complaining of
pain when the limb was straightened. I hesitated to
interfere, as by this early union of the soft parts the
fracture was converted into a simple one. On the tenth
day, however, I straightened the limb, and applied ex-
tension by attaching a light brickbat to the foot, by means
of a bandage, which passed over a railing at the bottom
of the bunk, allowing the weight to hang near the floor,
and a long splint, extending from the foot to a point six
inches above the iliac crest, adjusted to the outside of the
thigh by interrupted bandages. The weight of the body
acted as a counter-extending force.

Six weeks after the injury he was furloughed the
fracture having united without any suppurative inflamma-
tion. There was slight eversion of the foot and shortening
a quarter of an inch after the treatment wras completed.

The extracted ball was rough and jagged, the symmetry
having been so destroyed with difficulty it was determined
to have been a round ball. The minnie ball striking a
long bone usually splinters it, causing fissures which
extend many inches above and below the point of con-
tact; whereas, a round ball, projected by a musket,
generally merely fractures the bone, the solution of con-
tinuity being comparatively limited. It wTas the experience
of many Confederate surgeons that compound fractures
of long bones, caused by round balls, resulted much more
favorably than those produced by the minnie ball.

1867] Fox on Action of Fungi 399

On the Action of Fungi in the Production of Disease. By
Dr. Tilbury Fox.

[There are many questions connected with the action
of fungi in the production of disease which are most
interesting as well as important. Thus it is questionable
whether these so-called parasites are vegetable or not in
nature, and whether they are distinct species, or only
varieties of one species. It is now admitted by all that
the fungi are really of a vegetable nature, and that their
germs are derived from the exterior.]

The mode of entry of the Fungus into the system. There
is no difficulty in accounting for the access of germs to
living bodies, for these germs are freely distributed and
disseminated in the air. The best illustration of this fact
may be noted in the experiments of M. Bazin (Gazette
Med. de Paris, July 30, 1864), which consisted in passing
currents of air over the head of a favus patient, and
thence over the open mouth of a jar containing ice. The
ice cooled the air, causing the deposition of moisture, in
the drops of which the achorion sporules were detected.
The same thing may be shown by holding a moistened
glass slip near the head of a patient, and just rubbing his
scalp freely. Of course, actual contact is much more
effectual in the implantation of germs. But, without
delay, let us suppose that the sporular elements find their
way to the human surface ; how get they deeply into the
tissues? In various ways, probably. Let us take a
general sketch. The greater the degree of moisture and
heat, the better is the chance of entree.

First of all, the fungus elements may enter by fissures
or natural orifices; for example, in ordinary ringworm
the sporules lodge themselves at the opening of the hair
follicles, and presently get beneath the epithelial scales.
We shall see, directly, how. A great many experi-
ments have been made at different times, upon this
point, in the case of plants. De Bavy (Die gegenwartig

400 Fox on Action of Fungi. [Jan.

heiTschende Kartoftelkrankheit, ihre ursache und ihre
Verhutung, Leipsic, 1861) found that, in terminal fila-
ments of potato mould, so-called zoospores were formed,
which bud, protrude filaments forming a mycelium which
has the power "of penetrating the cellular tissue in twelve
hours, and when established there it bursts through the
stomata of the leaves." This "boring" operation is quite
likely to occur, especially where the structures are dis-
eased; as, for example, the muscardine in silkworm, in
diseased mucous surfaces or epithelial changes ; here the
entrance by continuity is easily accomplished by the
growing filament. It lias been supposed that mycelium
may get within the shaft of the hair, in some part of its
course, in this way. I do not believe it. If a fungus
finds an entrance, it is either through a cut end, a distinct
fracture, or, what is usually the case, the soft, growing
root. A good deal of doubt has been expressed as to
whether the spores could find their way into the interior
of plants through the stomata. It seems pretty clear that
the latter are not sufliciently large for the occurrence.
There can be no question, however, that, in a large
number of instances, the spores send out little processes,
which get into the plant through the stomata. Here the
recent experiments of De Bary help us again. They are
noticed by Mr. Cooke, in his admirable popular work on
microscopic fungi. The observer took a large number
of common garden-cress plants, placed their roots in
water containing zoospores, and though the former
became covered with these latter bodies, yet not a jot
of evidence of penetration occurred. De Bary, however,
found that if the cotyledons, or seed-leaves, are watered
with fluid containing zoospores, that slender tubes put
out by the zoospores enter the stomata, the terminal
ends enlarge, branch out, and become the centres from
Avhich a ramifying mjxelium is produced, which presently

1867] Fox on Action of Fungi* 401

shows itself externally. De Bary tested 105 plants in like
manner and under similar circumstances, with water free
from zoospores, and without the production of any sign
of rust in these. De Bary concludes that plants are not
infected by spores entering through the roots or leaves,
or through the medium of the seed-leaves of cotyledons.
But it is probable that the fluid contents of the spore-
cells may be absorbed and give rise to disease. The
Rev. Mr. Berkeley, several years ago, found that the
germs of bunt placed in contact with seeds infected
them, without there being any evidence to show that any
spore or mycelial thread had effected an entrance. It
seemed as if the granular fluid contents were taken up
by the plant and caused mischief. It is possible that
minute threads might have penetrated the seeds never-
theless. There is, however, no difficulty in supposing
the granular contents of spores (sporules) capable of
reproducing the typical spore. But, in the next place,
there can not be a doubt but that in the human subject
the germs of the fungus find their way to the roots of the
hairs, and are carried bodily upward into the shaft in
the process of growth, developing as they go, till at last
they degenerate and break up the fibrous structure in
which they are. By analogy we should quite expect that
such a thing is possible, and, indeed, of frequent occur-
rence in the case of the tender roots of plants ; and this
is more likely to happen when the contents of the original
spore (which is as large as the spongiole cell) happen to
be discharged by bursting. Moreover, it is quite clear
that the germs of parasites enter at a much earlier period
than we are apt to imagine, and lie dormant, brooding
mischief till the favorable opportunity arrives. De Ban-
proved this in the case of the white rust (cystopus) which
hybernates, as it were, in the sub-epidermal structures
during the winter, till the spring arrives. In addition,
29

402 Fox on Action of Fungi. [Jan.

the fungi "make head," so to speak, into structures in
virtue of the chemical action which they set up. This is
best seen in the hard structures of animals. Carbonic
acid is given off at the terminal cells. This dissolves the
lime of the shell and allows the parasite to effect an
entrance most easily. The experiments of Wittich,
quoted by Robin, all tell in the same direction. Panceri
has come to the conclusion, however, that, in the case
of the eggy the minute germs effect an introduction
through minute microscopic holes which exist in the
shell. Lastly, traumatic lesions afford an easy channel
for the conveyance of fungi to deep structures. This is
what happens in the mycetoma or fungus foot of India.

We have then, as modes of entrance (1.) That through
natural orifices ; (2.) That in which the growing force
forces the mycelial thread beneath the layers of the-
superficial tissues; (3.) That in which processes shoot
out from the spore and enter by such openings as stomata;
(4.) That where the cell contents are absorbed ; (5.) That
in which the spores are carried bodily inward by grow-
ing parts ; or (6.) dissolve away the opposing structures
by chemical action; or (7.) enter by traumatic lesions.
In each and every instance the germs of parasites are
derived ab externo and not generated spontaneously.

There are some special circumstances that deserve-
comment. It has been asserted that microscopic ento-
phytes have been discovered in close cavities utterly cut
off from communication with the external air. But these
instances are open to grave objection; fungi have been
found in the fluid of the ventricles of the brain, which,
however, was allowed to stand all night exposed before it
was examined. Again, it is asserted that in the kidneys
the like has been found. This is open to exactly the same
objection. The case of the egg parasite has been ex-
plained away by Panceri ; and it has yet to be shown,

1867] Fox on Action of Fungi. 403

supposing the urine has ever during life contained fungus
elements, that air can not enter the bladder. The case of
germs of vegetable nature in the blood-current presents
some difficulty; but even here the most considerable
caution is needed. We know that fungi spring up with
enormous rapidity; and it must be proved that those
spores and mycelia are present at the moment of death,
nay, during life, before we can give credence to any
theory which asserts that they have been present and
introduced during life, and not by a communication with
the external air. It is still a question whether the endoe-
motic action of the villi may not be able to account for
the presence of cryptogams in the blood-current. As far
as the facts of vegetable parasitism go, we are bound to
deny any such occurrence. And, upon analogical grounds,
I venture to assert that the entozoa found in muscle,
which have lately caused no little sensation, are not vege-
table in nature. Should they be proved so, it will entirely
alter the whole subject of vegetable parasitism : for we
are justified at present in asserting that there is probably
no known instance of a growing plant in any situation
not in direct or possible cotnmunication with the air. I
am bound to say that Dr. Thudicum believes in the vege-
table nature (see Report of Medical Officer of Privy
Council for 1865) of the rinderpest entozoa (?).

I pass to the consideration of the part played by fungi
in diseased states. Two theories the most opposite in
intention have been held by writers and others, so opposed
that really the conclusion is forced upon one that both
must be wrong and a middle belief correct. Whilst one
batch of inquirers affirms that parasites are accidental,
another contends that they are the essential cause of those
diseased conditions found in " association " with their
growth. Ehrenberg, in speaking of organized parasites
at a time when the exact nature of many of them was

404 Fox on Action of Fungi. [Jan.

indistinctly recognized, said "that there is more cause
for wonder at the limitation of their effects by the actions
of living bodies they inhabit than at any morbid effects
they appear actually to produce." It must first of all be
noted that there are certain conditions which are pecu-
liarly favorable to the growth of vegetable parasites. The
latter are ubiquitous, capable of resisting the action of
heat, cold, and decomposition, have a tremendous and
rapid power of increase, and will remain for a very long
time in a state of inactivity; yet, notwithstanding all
this facility, there are certain states of organisms against
which they fail ; which will somehow resist their inroad
and attacks; and it is now clear that though parasites
may for the moment get a temporary hold, yet they will
not flourish upon a typically healthy surface. This is a
fundamental truism that must be observed in reference to
therapeutics. For rusts and mildews prevail in direct
ratio to the wetness of the season, or after drought, as in
the pea or hop ; damp itself is very favorable, and where
there is much drought the vigor and the circulation of
plants are diminished very considerably. When plants
are very ripe also, there is a less degree of vitality pres-
ent, in consequence of the cessation in great extent of
the circulation and vital connection between the fruit and
the stem. The same thing holds good in every instance
where animals, plants, or men are attacked. We may
instance the case of muscardine. The experiments of
Claude Bernard also showed that frogs kept in captivity
got out of order, and aphthous conditions arose. A
healthy frog brought near its diseased fellows " set con-
tagion at defiance/' but unhealthy frogs were at once
attacked by the vegetation flourishing on the aphthous
surfaces of others; and the case of favus in man, or scab
in sheep, of which an account may be seen in the Gar-
dener's Chronicle for April 24, 1864, is illustrative of the
fact under notice.

1867] Fox on Action of Fungi. 405

There is always a certain resistant power about all
healthy living beings; and a certain amount of fungus,
however it acts, may be present without giving rise to
what one can possibly call disease. In young life, of
course, one would expect that fungi would obtain a hold
more effectually than in old life ; and it is very remarkable
that the white rust before referred to, according to De
Bary's experiments, should effect an entrance into the
system of the garden cress, by attacking the young leaves
or cotyledons. The young and tender stage becomes an
easy prey; and this is exactly what we find in the human
subject, the young being most liable to ringworm.

Taking all things into consideration, it is clear that
parasitic disease or, as I have named it generically, tinea
can not be explained by either of the conflicting theo-
ries I have referred to, but consists of three distinct com-
ponents, which must be recognized, if the physician
would cure his patient well and quickly.

1. A certain state of soil : in speaking of polymorphism
of fungi, I noticed that each fungus appeared to require
each its special kind of pabulum.

2. The access of air, and the presence of heat and
moisture the conditions necessary to support the life
of fungus. And,

3. The introduction from without to and action upon
the body of the vegetable germs.

The first and second will be passed over without com-
ment : my remarks are specially intended to define the
action of the parasite in the production of diseased states.
Now, fungi are not " accidental " and unimportant, but
act in several distinct ways when once they take hold
and grow upon the surface. This is important; if we
insist upon some one modus operandi, we shall assuredly
find our position utterly untenable. They act then (often
in more than one way in the same instance be it remem-
bered) :

406 Fox on Action of Fungi. [Jan.

Firstly, mechanically. If you simply rub into the sur-
face some of the fungus elements, in many eases you get
what we know as irritation. This is seen in the ordinary
herpetic ringworm of the surface, where the mycelial
threads range over the skin beneath the epidermis and
lead to erythema, etc. A very remarkable case is re-
corded by Dr. Kennedy, of Dublin, in which a quantity
of flax powder was inhaled by a lad who became attacked
with measles and peculiarly severe local dyspnoenal symp-
toms, evidently dependent upon the direct mechanical
irritation exerted by the fungus elements. In the case of
mildew of plants, the same thing is seen the threads of
the mycelium grow, and force asunder the tender struc-
tures near it. Now, it is this mechanical action exerted
by the growing force which is at work, especially in ring-
worm. The fungus finds its way to the sub-epidermal
space, from thence to the hair follicle, irritating and
interfering mechanically with the growing parts, enters
into the hair, and by its increase and development simply
splits up the hair-shaft, appropriating also its juices, and
rendering it all the more brittle, and therefore the more
easily destructible. To declare in such a case that the
parasite is accidental in any sense of the word is to turn
a deaf ear to the plainest voice of facts ; but this very
action can be isolated. I have performed a good many
experiments at different times with diseased hairs out of
the body, and occasionally it is possible to get a hair
containing spores, which spores will germinate and
actually produce the splitting up of the hair, and the
other changes that are observed in ringworm in fact, to
produce the lesion of ringworm out of the body. In those
instances in which the mycelium abounds, the epithelium
seems to suffer particularly. On the mucous surfaces
there are no such structures as hairs which form a lodg-
ment, so to speak, for the fungi, and hence no marked

1867] Fox on Action of Fungi. 407

results are visible. The cells of the tissues are invaded
and destroyed, the mycelial phase abounds and ramifies
in the secretion, and not in the tissues themselves ; but
there is the same capability of damaging when parasites
attack only the internal surfaces. If we would wish for
examples of the enormity of the force exerted by a grow-
ing fungus, we have only to confine some of the more
ordinary varieties and see the result. Now, it so happens
that no other agent can produce in disease the same kind
of action as that exerted by a growing fungus such as
splits up the hairs in the way in which this is observed in
tinea; and it is this state of things which I regard as the
pathognomonic lesion of ringworm, viz. : the mechanical
action of the parasite upon the hair and epithelium in
connection with other minor changes.

One word as to definition. I use the word tinea as the
generic term, and particularize each variety by the terms
favosa, tonsurans, sycosis, vesicolor, circinata, etc., the
tinea signifying especially the diseased state of the hair
and epithelium. Now, take the case of sycosis, which
means inflammation of the follicles of the chin and lips.
It may not be caused by a parasite; but undoubtedly
cases are sometimes caused by a fungus, and these I called
tinea sycosis. Again, tinea circinata means the parasitic
herpes circinatus, and tinea decalvans the baldness pro-
duced by the fungus (microsporun Audouini), as dis-
tinguished from alopecia, non-parasitic baldness, the result
of many different causes. The term tinea is very dis-
tinctive.

Secondly, Fungi act by inducing local chemical change.
They absorb oxygen and give out carbonic acid ; and, as
has been before observed, they hereby secure to them-
selves the power of penetrating calcareous structures. In
addition, a large amount of gas is evolved as in cases of
sarcinal disease. Moreover, they lead to fatty degenera-

408 Fox on Action of Fungi. [Jan.

tion. If any one will take the trouble to examine care-
fully some of the old stubs in favus, he will notice a
certain amount of fatty changes going on in the cell
structures. Remove a hair of this kind loaded with
sporules, and get the latter to germinate, and the fatty
alteration goes on at a rapid rate, till after a time a large
quantity of crystalline fat is produced. Now, this will
not happen unless the fungus germinate ; but happening,
it is worked out in accordance with the views lately put
forth by Dr. Bence Jones, and was expressed in precise
terms in my book on parasitic diseases. It has been
remarked by many observers that fat is always present in
considerable amount in connection with the development
of fungi. M. Signol believed that fat very much favored
the development of bacteridia. Perhaps the very best
exemplification of the association of fatty change with
parasitism is that afforded by the case of the madura foot,
where the oily matter is so very abundant. The tissues
degenerate, and the crystalline fat is so varied and pecu-
liar as to have actually misled observers into the belief
that it was a form of fungus. Now, it becomes a question
whether fat assists the development of fungi, or whether
the latter attract fatty matter, the fungus forming a center
of attraction for crystallization, or the fatty change be
the result of cryptogamic growth. I adhere to my origi-
nal belief, and Dr. Carter is of the same opinion, that the
fatty change is coincident with, and a consequence of the
growth of fungi. Nitrogenized and other matter becomes
fatty in this way very readily. Of course, under such
circumstances, the fungi become a center of attraction
for the fat. It is a chemical action entirely, as far as the
degeneration is concerned ; a process of oxidation which
the fungus induces under favorable circumstances, in
connection with the performance of its own vital func-
tions.

1867] Fox on Action of Fiingi. 409

Thirdly, Fungi act as conveyers of poison. This is a mode
of influence which has been altogether disregarded by
observers. If the endogenous pus-cell can convey the
noxious poison of an acute disease, why may not the
elements of a fungus act in a similar capacity ? Recent
research has shown that all fungi exhibit great transporta-
bility. Now, what action have the cells afloat in the air
of hospitals during the time of epidemics, such, for in-
stance as cholera (see Dr. Thomson's Observations at St.
Thomas' in 1854); may they not take the virus of a
hospital gangrene from one patient to another, acting the
part of a fomes in the very same way, comparatively
speaking, that man himself does ? Suppose we inoculate
"with fungus elements, it is clear that in some instances
symptoms ensue (as in Dr. Kennedy's and Salisbury's
cases) before the onset of local symptoms. Again, the
fungus elements would appear to be most active in their
early stage, that is to say, when the poison produced
simultaneously with their development is in its freshest
and most active condition. Again, respirators in epi-
demics have been found to be efficacious. And, lastly,
direct experiments, upon plants especially, have shown
that disease may be produced by the contact of fungus
elements, when there is not a particle of evidence to
prove that sporules, spores, or mycelial threads have
entered the organism of such plants, but where there is
the greatest probability that the granular and fluid con-
tents may be the poisonous compound which, when
absorbed, gives rise to the subsequent malady. It is not
unlikely that in catarrh and influenza especially, such a
conveying property may be at work. We have the
strongest possible amount of analogical evidence in regard
to animal life, comprehended in all the details of the
" animalculae theory of disease " a doctrine that may be
pooh-poohed by some, but which must ere long be fairly
30

410 Fox on Action of Fungi [Jan.

discussed. One might give a great deal of very inter-
esting matter under this head. Those who are interested
in the subject should read Sir Henry Holland's article, in
his Medical Notes and Reflections, 4th edition, I think,
on the Animalcule Theory of Life, and to Dr. Daubeny's
essay in one of the volumes of the Edinburgh Philosophical
Journal, some few years back. The occurrence of epi-
demics, be it noted, moreover, is often associated with the
peculiar prevalence of various moulds and mildews a
source of terror and superstitious horror in bygone time,
which gave rise to the idea of a raining of blood. Plu-
tarch refers to such an occurrence in the plague of Rome.
Hecker, in his work on the Epidems of the Middle Ages,
also associates it with the disasters of 789 and 959. The
spots were actually observed on garments, and called lepra
vestium ; signacula was another term. In 1502 and 1503,
it again frightened everybody. Agricola was certainly
one of the first to give a rational explanation, he attribut-
ing it to the appearance of a lichen. The fungi attacked
walls, bread, cheese, meat even, and garments, in Venetia,
in 1819, and also articles of food, and garments, and all
fruits, during the years following to 1829. And is there
not something similar observable now-a-days ? Have we
not had some very remarkable and severe epidemics, and
have not fungi been remarkably abundant on vegetation ?
I will not theorise, but merely just draw attention to the
coincidence. The particular action of fungi now under
notice will perhaps be better appreciated in connection
with that now to be described.

Fourthly, which looks upon these organisms as developers of
poison, and comprehends Dr. Richardson's forsaken theory
of zymosis a doctrine that appears to me most satisfactory.
It has been suggested at different times by one and an-
other observer, that the fungi themselves induce change
actually in the circulating current, sufficient to account for

1867] Fox on Action of Fungi. 411

disease, either by setting up a kind of fermentative action
in the blood, giving rise to the production of a specific
compound a poison, in fact, just in like way to that
which happens in ordinary fermentation, or setting up
change by catalysis a wonderful enigma. Others affirm
that no poison is produced in the body itself, but that the
fungus helps out its increase when once introduced into
the system. For my own part, I can not believe that any
very important change could be induced by the growth of
fungi in the blood-current. The presence of air is so very
necessary; and not only mere presence, but such as is
implied by a direct communication between the growing
vegetation and the external air. Outside the body, or in
the cavities which communicate with the air, many very
important and frequent changes are induced without a
doubt.

Dr. Salisbury is a careful observer. lie declares, and
as far as I know holds to his opinion, that a form of dis-
ease, if not identical, at any rate very like measles, results
under certain circumstances from the inoculation of the
fungus of wheat straw. Dr. Kennedy has given con-
firmatory evidence. Does the fungus, per se, produce the
result, or is it a conveyer, or is it the producer of the
poison outside the body in the musty straw ?

Dr. Richardson, quoted by the late Dr. Barker, of
Bedford, records the onset of erysipelatous mischief from
a like cause. In France the most serious inflammatory
mischiefs of veins and lymphatics have followed wounds
inflicted with instruments used to cut oft' the diseased
vine-shoots. Dr. Collin, the medical inspector of the
waters of the St. Honore, Nievre, records even fatal
results. MM. Demartes and Bouche of Vitrany have
also investigated this subject, and conclude that the
oidium can produce such mischief, but they suggest some
sort of coincidence between the special development of

412 Fox on Action of Fungi. [Jan.

the oidiuni and the occurrence in greater frequency of
inflammatory disease. It is to be hoped that the French
Academy will, now it has taken note of the subject, enter
into a full investigation of it. It is true that ill effect
does not always follow experiments with the oidium.
MM. Speneax and Letellier failed to produce anything
beyond a little redness and irritation by inoculating
people with the rasping of leaves diseased by the oidium
(Pract. Jour, of Med. and Surgery, Nov., 1864); and
MM. Leplat and Taillard on the one, and M. Wertheim
on the other hand, came to opposite results by injecting
fungus elements into veins of dogs and other animals.
There can be no questioning that some fungi are more
hurtful than others, and much depends upon the con-
comitant conditions. The arunda donax, the large red
reed of the south of Europe, is attacked by a black rust,
and those who cut the reeds suffer from very violent
headaches; it is affirmed by M. Michel that the spores
produce a papular rash on the face, with much swelling,
and a good many serious general symptoms (Yearbook,
1861-2). It would seem that the fungus, per se, is not
sufficient, but that there is something in addition which
is intimately connected with the vitality of fungus. This
would seem to be taught by the case of bacteridia.
Whatever they be, no injurious results happen unless the
medium itself in which they exist contain some peculiar
virulence of its own, just as in the case of inflammatory
attacks caused by oidial inoculation. The power of vege-
table organisms to induce transformation, which must of
course be accompanied by distinct chemical change, has
been well exemplified by an experiment of M. Lemaire,
who took some beans, placed them on a moist sponge,
and found that bacteridia soon sprang up, before germi-
nation, being succeeded by monads and vibriones; and
the like happened after the soil used had been heated to

1867] Fox on Action of Fungi 413

a red heat. Now, if a small quantity of phenic acid
(which has the property of suspending infusorial devel-
opment) was added, the germination came to a standstill
until the phenic acid evaporated, when it recommenced.
M. Pasteur's experiments on acetic fermentation tend to
the like result ; and M. Trecul's observations lead to the
belief, that the change induced in solutions by fungi, as
in the case of alcoholic fermentation, depends upon the
performance of the nutritive act of the vegetable cell.
The fact is, the fungus, when growing, necessarily decom-
poses the medium, and induces chemical change, whilst
the result depends upon the composition of the material
acted upon. In like manner, it is conceivable that the
fungus of wheat straw acts upon the juices of the stem,
producing some subtile compound; bacteridia do the
same in sang de rate, and the oidium in the vine disease.

It has been supposed that the poisons of measles, influ-
enza, cholera, nay, asthma, and some other acute diseases,
may be produced in the way indicated ; but it must be
remembered that two or more of the modes of action
already noticed may be conjoined , that is to say, a fungus
may act mechanically as a conveyer and developer of
poison at the same time, and in one case. But not only
acute but chronic diseases are produced. I refer to the
large class of instances in which vegetable parasites
induce slow changes of deleterious nature in articles of
diet, giving rise to "ergotism." Bad grain, bad potatoes,
bad rice, bad maize, are illustrative. The late Russian
epidemic, the Irish fevers, pellagra in Lombardy, gan-
grene in sheep and beasts, ergotism in horses, have all
been regarded as taking origin especially from the play of
ergotized foods. In the group of chronic maladies the
material acted upon by the fungus is a solid. The access
of air is not so perfect nor so free ; the moisture is con-
siderably less ; all of which tends, in great measure, to

414 Fox on Action of Fungi. [Jan.

account for the difference of the quality of the resultant
morbid product. The productiveness of grain so infested
is considerably lowered. Sir H. Davy proved this long
ago. He found that diseased wheat yi elded from 21 to
65 per cent, of nutritious matter against the 95 per cent,
of the healthy grain. It has been suggested at various
times that the degeneration of rice by parasitic action
gives rise to the formation of products which occasion
very severe symptoms of intestinal irritation, resembling
dysentery, and that cedema of the leg often follows. And
it is not unlikely, that the many peculiar ulcerative con-
ditions of the lower extremities are favored by the quality
of food and induced in like manner. The diminution in
the productiveness of the silkworm affected by muscar-
dine affords a capital instance of analogical occurrence.
The statistics issued by the Chamber of Commerce of
Turin show that although formerly about some 650,000
myriagrammes of cocoons were produced in the country,
in 1864 there were 525,000, and last year 283,000 only.
I have been paying some little attention to the case of
mildewed cotton hunting after illustrative facts and I
find that the germs of mildew are really present in the
cotton in its rough state, as sold in the market before it
reaches the manufacturer. It of course is possible that
the processes through which it passes in the hands of the
latter may destroy all the vitality of the fungi, but this is
not certain ; but if it really does, still the fact of the
presence of mildewed germs in vigor would imply the
existence of a certain degree of deterioration in the actual
fibre itself, perhaps induced by the bad cultivation or
growing of the original plant a point of no mean inter-
est to the merchant. It would make the fibre less able to
resist the action of the size and other agents tased in the
manufacture into stuffs.

I have spoken of things going on outside the body, and

1867] Fox on Action of Fungi. 415

then introduced to it ; but within a recent time, certain
facts have come to hand showing that under special
conditions, though good food be taken into the stomach,
yet, in the digestive tract, changes of objectionable char-
acter may be induced by the agency of fungi. I have to
quote Dr. Salisbury again as rny authority. He believes
that chronic diarrhoea in the army is caused in this way
(see the report of the surgeon-general of Ohio, in the
Amer. Jour, of Med. Sciences, 1865). Wherever there is a
poor amylaceous diet, and there be retention of the food,
the torula, almost always present, grows, and in so doing
induces fermentative changes, with the evolution of gas
the production of intestinal irritation and diarrhoea the
torula vegetating into a myceliated " algoid" mass, which
may be observed in the faeces; and it appears that its
amount is in direct relation to the severity of the disease ;
the production of sugar being rapid and detectable in the
mucous tissues. The green stools of children are so pro-
duced, and Dr. Salisbury thinks also that semi-paralytic
symptoms ensue. The case of sarcinal disease is on a par
entirely; deranged digestion, detention of food, the pres-
ence of penicillium, and the evolution of gas with the
formation of sarcinse ; vomiting is the result of gastric, as
diarrhoea that of intestinal irritation. The stomach in
the former, and the intestines in the latter, getting semi-
paralysed, at least losing tone and getting relaxed. In
both cases there is the mechanical action of the fungus
and the induction of chemical changes within the body.
The case of diseased foods is one of surpassing conse-
quence, and deserves all the attention we can afford to it.
The quality and character of the poisons or products of
this fermentative act are matters of no little interest. Dr.
Richardson has lately deserted the zymotic, and given his
adhesion to a new theory, which regards the poisons as
of an alkaloid character basing this position upon the

416 Fox on Action of Fungi. [Jan.

supposed isolation of the pyaemic poison ; however, fur-
ther experiment is needed to establish the truth of the
new doctrine. If the poison of so-called zymotic diseases
be chemically inorganic, how comes it that nothing of the
kind can be obtained by chemical analysis ? The diffusion
and spread of disease is opposed also to such a view.
There is a power of increment about these viruses which
is very marvellous and peculiar. There is also a vital
principle or act which is very distinct. Another feature
worth notice is this, that the effect of the poison does not
seem to be, as is the case with mere chemical agents,
proportionate to the dose, so to speak, but to the peculiar
virulency, which varies as much as the state of the nutri-
tion of the organism acted upon. The viruses certainly,
as to their characters, vary considerably, and are not
definite in the way that we would expect if they were of
an alkaloid nature. Independently even of these kinds
of influence already noticed, fungi, in the fifth place,
would seem to possess inherent noxious qualities in some
cases. Just as insects have the power of producing
special poisons, so may fungi in a much less degree. The
anamita muscaria affords a resinous principle, which
chemists isolate. In other cases for example, the mush-
room there is evidently an alkaloid, as MM. Sicard and
Schoras have shown [Journal de Pharrnacie, 1865); but the
action of it is different from that of viruses altogether.

Now I have mentioned five different ways in which
fungi may act ; and these may be summed up as follows,
being divided into those which are direct and indirect :
Directly, they may act mechanically, or by inducing local
chemical change ; indirectly, by bringing about changes
in substances out of the body, which are brought to influ-
ence the latter; by setting up a kind of fermentative
action in part due to the oxidation consequent upon the
nutritive changes in the plant, or by giving rise to

1867] Fox on Action of Fungi 417

products having an acute or a chronic action, and whose
nature is at present a matter of doubt.

And now I am prepared to meet the hypothesis that
parasitic disease has nothing essential to do with the de-
velopment of parasites. Mr. Hunt takes the boldest view
in the ranks of the opposition, declaring that the causes
of parasitic disease are four, and four only uncleanli-
ness, atmospheric impurities, deficient exercise, and con-
tagion. I take my stand upon the mechanical action of
fungi and the induction of fatty changes, and defy any
one to shake me the least from my footing. Mr. Hunt
states that the above four conditions "poison the blood,
producing not only their immediate effects in the form of
parasitic skin diseases, but laying the foundation probably
of more serious disorders, manifested in after life by the
presence of lumbrici, ascarides, tape-worm, pediculi, fungi,
hydatids, tubercles, and perhaps cancerous germs, in the
various organisms." What does this mean ? That these
varied mischiefs have not each their proper cause, but
arise from one and the same influence. This is surely
either subversion of the logical definition of cause un-
conditional sequence which is so tenaciously upheld and
received as our only true belief. I grant that the four states
lower the nutrition of the system, and make it more fit
for parasitic growth ; this is only one item of the total.
The true state of the case I take to be this : That there is
a necessary nidus, which is exalted by some into the
position of the supreme disease, to the negation of any
and every effect produced by the fungus itself, which
finds the soil congenial a soil associated with bad living
and bad hygiene of all kinds ; the fungus growing acts in
the various ways already detailed ; in ordinary cutaneous
affections, the effect upon the hair and epithelium (me-
chanical and chemical) being ixtthognomordc. Parasitic
disease, then, is a composite affair, consisting of mal-
31

418 Fox on Action of Fungi [Jan.

nutrition, a growing parasite, and certain effects of such
growth.

There is yet one category of facts that needs a word or
two of comment, viz. : the comparative pathology or the
intertransmission of parasitic (vegetable) maladies. In
addition to what I have given in my work, a good deal
of information has been accumulating. It is now admit-
ted that the transmission of the common ringworm of the
surface from animals to man is very common. I am
informed upon good authority that this is of very frequent
occurrence in Australia, the milkers of cows especially
being largely affected. Professor Gerlach (abstract in
Ed. Yet. Rev., vol. ii.) has noticed it in dogs, horses, and
oxen, and in man, but the sheep and pig seem to offer
exception. Dr. Frazer (Dub. Quart. Jour, of Med. Science,
May, 1865) contributed a paper, "Remarks on a Common
Herpetic Epizootic Affection, and on its alleged frequent
Transmission to the Human Subject," containing cases.
This gentleman quotes Mr. Brady and Mr. Whitla, in
reference to other instances. Dr. Fehr has noticed in
Switzerland the transmission from cattle to man. I can
confirm by my own experience the truth of these state-
ments. I do not mention any old cases, such* as mice
affecting man, but my friend, Dr. Allchin, informs me
that he has seen the transmission of mange from a cat to
a child.

Now, I might argue just in like manner in regard to
the animal parasites. The two classes of cases are mutu-
ally illustrative of each other's modus operandi. I take the
case of scabies. The acarus demands a suitable soil. It
has been pretty well shown, in animals especially, that
acari will not grow on all surfaces, but only on those
whose hygienic condition we have reason to know, from
the circumstances that have been at play, is not that of
health. The limit of variation is by no means made out

1867] Jones on Fevers. 419

in the case of the animal parasites. The relations of
acari on bodies generally is being canvassed, especially by
German writers. The mode of entry has an analogy
also. There is the same difference of opinion as to
whether the acari are accidentals or verce coaiscb ; but there
is plenty of evidence to indicate the iraction as mechani-
cal irritants, and as the possible developers of irritant
products. But these points I can not now enter upon.

The matter of the action of fungi is a large and wide
one; already we see enough to show that the studious
inquirer will be amply repaid if he tread carefully the
somewhat now uncertain path before him, and the prom-
ising indications of success are many. Edinburgh Med.
Journal, April, 1866, p. 875.

On Fevers. By Dr. H. Bence Jones, F.R.S.

[Perhaps the term zymotic disease is as good as any to
designate the action of those poisons which get into the
system in such a mysterious way that we can not explain
them. The term implies some action by which different
vegetable or animal ferments, living or dead, can be intro-
duced into the body and produce different diseases, such
as small-pox, scarlet fever, measles, typhus fever, etc.]

Of all the modified peroxidations that can occur in the
body, small-pox is the most definite, because the poison
can be got apart, and the quantity necessary for producing
the action can be fixed, and through the most glorious
discovery of vaccination it can be set in action whenever
we please. We can almost see it passing from the cellu-
lar tissue into the blood, and from the blood into every
particle of every texture, rendering it incapable of under-
going the same action again.

Let us look a little closer at this action of small-pox
poison. If the minutest particle of substance, a little

420 Jones on Fevers. [Jan.

dried albuminoid substance, in a peculiar chemical state
of action, on a lancet, or in the dust of the air, is put into
the cellular tissue or is inhaled into the lungs, it passes on
to the blood, and through it into every texture. In a few
days the chemical actions of oxidation and nutrition
throughout the body are altered, and the particle of mat-
ter has reproduced itself immeasurably. The violently
increased chemical action, the peroxidation, is shown by
the increased heat of the body, the violent fever. The
altered nutrition is evident, not only in the eruption of
pustules in the cellular tissue under the skin, but in the
altered condition of the blood and in all the textures of
the body; each particle of substance being rendered
incapable of undergoing the same process again, and by
assimilation every future particle that takes the place of
every modified particle is also generally incapable of
being modified again.

Throughout the course of the general peroxidation,
and more especially at the end of the fermentation, local
peroxidations frequently come on in any part of the body.
Inflammations of the eyes, the ears, the mucous mem-
branes, the joints, the serous membranes, the parenchy-
matous tissues*, anywhere an unmodified peroxidation is
ready to begin, and this easily gives rise to suppuration
or causes obstructions which the feeble circulation can
not overcome.

The most striking facts concerning this small-pox fer-
ment are, first, the very small quantity of substance that
produces so much effect; secondly, the immeasurable
increase of the poison in the body, each pustule having
the same property as the original ferment ; thirdly, the
period of incubation during which the poison must at
first slowly increase in every texture, and there give rise
to the modified peroxidation and altered nutrition which
constitute the attack.

1867] Jones on Fevers. 421

The poison of scarlet fever, of measles, and of typhus,
though less tangible, are not less substantial than the
small-pox ferment. Like it, they can most probably be
dried and carried from place to place, and pass into the
mouth with the dust which we each moment inhale or
swallow. In chemical composition, scarlet fever, measles,
and typhus ferments most probably resemble albumen in
complexity, and, like albumen, they may be altered in
composition and action by heat, alcohol, arsenic, tar
acids, and many metallic salts. As soon as they reach
any spot where they can oxidise, they set up an oxidation
and reproduction in each contiguous particle of albumin-
ous substance. From the cellular tissue, the air passages,
or the stomach or bowels, the contact action spreads into
the blood, and there it multiplies, whilst it is carried into
all the capillaries, and through them into every texture
of the body; then the increased oxidation and formation
of ferment becomes most violent, and fever to a greater
or less degree is present. Long after the strongest action
is reached, a slower action continues, and at any time or
in any part or texture of the body, whilst the specific
chemistry is going on, an ordinary local peroxidation may
be lit up, and a more or less acute inflammation may be
added to or follow the fever which the ferment has pro-
duced.

During the height of the fermentation in typhus fever,
the heat may rise to 5, 6, or even 10 Fah. above the
ordinary temperature; and when the fermentation is
ended, the albuminous textures of the body are so
changed that they are incapable of going through the
same process again. Between these two results there are
innumerable other products of chemical change, varying
with the kind and degree of fermentation. In typhus
fever it is said that urea is increased and carbonic acid
diminished. To these and a multitude of other chemical

422 Jones on Fecers. [Jan.

questions regarding fermentation chemistry will give
definite answers; but above all questions, one of the
most difficult to answer and yet one of the most impor-
tant, is the amount of oxygen that is consumed in the
different kinds and degrees of peroxidation which can
take place within us.

In each organ, according to the intensity of the action
set up by the ferment, altered functions may arise, and
these may be still more altered when an ordinary peroxi-
dation at the same time takes place. Thus the brain,
heart, lungs, kidneys, liver, or any texture composing
these organs may show by more or less wrong mechanical
results the effect of the ordinary or modified peroxidation;
and the effects of the fever and of the inflammation may
be so mixed that neither during life nor after death may
any accurate separation be possible.

Closely related in chemical composition to these violent

jferments are the less active ferments of ague and typhoid
fever. There is so little difference in the chemical com-
position of animal and vegetable substances that the dis-
tinction between animal and vegetable poisons is no
longer possible. Vegetable albuminous matter under-
going change may produce almost, if not quite, exactly
the same poison as animal albuminous matter. Hence,
probably, the resemblance between ague poison and the
typhoid fever poison, and the possibility that sometimes
one and sometimes the other of these poisons may be
formed from the same changing matter under different

I circumstances.

Ague ferment is probably a highly complex nitrogenous
substance, capable of being dried and carried by the wind
far from the place where it was produced. It enters by
the mouth with the dust, and, like animal or vegetable
alkaloids, it passes from the blood into every texture of
the body, and acts on each much or little, according to

1867] Jones on Fevers. 423

its chemical properties, Probably it acts most strongly
on the nerves that regulate oxidation, causing for a time
contraction of the arterial vessels, and consequent sub-
oxidation everywhere. The increased obstruction of the
small arteries reacts on the tension of the blood, and this
produces increased contraction of the heart, which con-
tinues to increase until the obstruction yields and a state
of peroxidation is set up, by which the poison is partially
destroyed. During the remission, probably, the poison is
reproduced until sufficient, in from one day to three days,
is formed to go through the same action again.

This theory of ague admits of a reasonable explanation
of the action of quinine and arsenic in stopping the
paroxysms of the complaint. On the ague poison itself
quinine and arsenic may have no action, but they pass
into every texture from the blood, and, combining with
the nervous substance on which the ague poison acts,
they form a compound on which the ague poison is inca-
pable of producing an effect before it is oxidised and
destroyed.

The ague poison, unlike the small-pox or. typhus fever
ferment, instead of protecting the body by making it in-
capable of undergoing the same action again, makes the
nerves more ready on the slightest renewal of the poison
to undergo the same action again; so that it has been
said that the ague poison may lie dormant for years. It
is far more probable that a much smaller quantity of the
poison can produce the return of the symptoms than that
the original ferment should retain its properties for
months, or even for years, after its first action had passed
by. In this respect, and, in some others, the action of
ague poison proves that it is a very peculiar ferment, and
hence, though I have placed it near to the typhoid fer-
ment because of its origin, I must shortly point out to

424 Jones on Fevers. [Jan.

you the different effect which the true typhoid ferment
produces.

The typhoid ferment is probably formed out of vegeta-
ble or animal albuminous substance. In sewers, in drains,
in ditches, possibly even in the drains of the human body,
a substance may be formed which is not volatile in itself,
but by foul gases or currents of air can be carried into
the mouth, and in some period between a few hours and
fourteen days it sets up a modified peroxidation. More
slowly absorbed and less rapidly reproduced and changed
than typhus ferment, it passes into the blood, and from it
into each texture ; whilst some of the poison has a local
action on the glands of the small intestine, and produces
increased action, effusion, obstruction, and retrograde
action, causing ulceration, sloughing, and even perfora-
tion, by which mechanically the contents of the bowel
may escape, and an uncontrollable simple peroxidation
may be set up. The poison that has passed into the
tissues acts on each organ more slowly than the typhus
poison ; still, like it everywhere, it gives rise to altered
functions, and everywhere local peroxidations are ready
to occur; bronchitis, pneumonia, peritonitis, tubular
nephritis, cystitis any of these and many other inflam-
mations may be set up at any time during the course of
the fever. Probably the substances produced by the
increased chemical action in typhus and typhoid fever
will be found to be very similar. There may be the same
amount of heat, the same excess of urea, the same excess
of antecedent substances from which the urea is formed ;
possibly the same consumption of oxygen when the same
temperature in each fever occurs ; but in the properties
of the ferment formed in the body a distinct difference
of diffusibility must exist, the typhus poison passing with
greater ease into neighboring bodies ; whilst the typhoid
poison rarely, if ever, is communicated by infection.

1867] Jones on Fevers. 425

On the Mechanical Disorders that arise out of the Chemical
JEiTors in Fevers. In all fevers the loss of mechanical
power is quite as remarkable as the increase of chemical
action. The chief amount of energy liberated by the
action of oxygen in the body seems expended in the
production of heat, so that far less than the ordinary
amount of power remains to be employed in the produc-
tion of mechanical motion. The muscles may be con-
sidered as machines made for the conversion of chemical
force into mechanical motion. How this is done can not
be explained in the present state of our knowledge of the
mechanical, chemical, or electrical actions in the muscle ;
but that the muscular force arises from some equivalent
force, and sooner or later must come from the chemical
force in oxygen, hydrogen, and carbon, opens an immense
field for investigation, and is easier of belief than that
force should be each moment created and destroyed. The
amount of sugar and fat present in any muscle would
soon be used up if in the working of the muscle itself
fresh fuel was not produced. The action of oxygen on
the syntonin in the muscle may be direct, and may give
rise to the force required ; but it is more probable that
the syntonin splits into substances of two classes one
ending in urea, which is incapable almost of combustion,
the other in inosit, which would immediately give water
and carbonic acid.

In fever the poisonous ferment in the muscle probably
determines a different chemical action from that which
takes place in the muscle in health. The increased heat
and the increased urea mark the increased action, but
loss of motor-power in the muscles shows that the con-
version of chemical into mechanical force does not take
place.

This mechanical disorder becomes, by its action on the
muscles of respiration or circulation, the source of com-
32

426 Jones on Fevers. [Jan,

plications and dangers in fever, to which I must shortly
allude. Gradually in the course of fevers the sounds of
the heart may be found to become more and more feeble,
and the respiration, without any wrong in the lung, be-
comes shallow and weak from the diminished power in
the muscular tissue. The diminished tension in the
arteries has a direct effect upon the circulation through
the capillaries, and the motion in the veins is more or less
stopped ; hence congestion of blood in the venous system
occurs hemorrhages, effusions, and coagulations in the
veins may take place anywhere. The imperfect action of
the muscles of respiration produces the same mechanical
effects in the circulation through the lungs; imperfect
oxygenation takes place in the lungs from the stoppage
of blood in the pulmonary veins ; without any inflamma-
tion, oedema of the lungs, hypostatic consolidation may
occur. The circulation through the lung is so feeble that
even the force of gravity acting on the blood in the lungs
can not be counteracted, and accumulation takes place in
the most dependent parts.

The muscles of the bladder are also so weakened that
the urine accumulates, and frequently external muscular
pressure is required, after the catheter has been passed,
to cause the urine to flow.

In another large class of zymotic diseases the qualita-
tive and quantitative errors of oxidation are scarcely
detectable, whilst the qualitative and quantitative errors
of nutrition chiefly mark the action of the poison.

Of these diseases true syphilis may be taken as the
type.

It can scarcely now be doubted that the actions of two
poisons have been included under the term syphilis. The
first, like impetigo, is capable of being communicated,,
and often repeated, because it exists only locally, or passes
up to the nearest lymphatic glands; whilst in the true

1867] Jones on Fevers. 427

syphilis the poison from the local sore enters the blood
and passes from it into each texture, where it multiplies
and produces changes of nutrition, and, partly unchanged
and partly changed in composition, passes out perhaps in
each secretion.

This true syphilitic ferment resembles very closely the
small-pox ferment in the universal diffusion of the poison,
and in the consequent protection it gives from another
attack by rendering a second similar change in each tex-
ture impossible. The protective power of the alteration
is to a slighter degree extended to the progeny through
the germ and spermatozoon ; so that a race partly pro-
tected by inheritance may suffer less from these diseases
than a purer race, whose textures are free to undergo the
full change which constitutes the disease. Both poisons
give rise to increased cell-growths, effusions, oxidations,
congestions, and ulcerations ; and these may take place
in any part of the body, for the poison exists everywhere.

True syphilis differs, however, altogether from small-
pox in its definiteness of course as to time. Syphilis
produces no fever to terminate the fermentation in a
definite period, and it may consequently remain active or
dormant in the textures for years.

It is vain now to ask what circumstances at the end of
the fifteenth century produced the first modified albumi-
noid matter which gave rise to the first true syphilitic
poison. In cancer, which bears a distant resemblance to
syphilis, although the spontaneous generation of the first
cancer-cell is daily occurring in some predisposed texture,
yet we are as yet quite unable to say what produces the
first modified particle of matter which multiplies and
communicates its composition to adjacent predisposed
textures by contact, and is carried by lymphatics and
blood-vessels to every part of the body, and affects the
nutrition of each part with which it comes in contact,

428 Editorial and Miscellaneous. [Jan.

provided the textures are in a condition to propagate the
cancer-cells.

Another instance of spontaneous generation of a poi-
sonous ferment is presented to us in rabies ; and with this
poison also, unless a peculiar condition of system exists,
the ferment when inserted has no action ; and here also
our knowledge is at present unable to say what circum-
stances determine the formation of the first particle of
poisonous saliva ; except by its effects, the peculiar change
in the albuminoid matter of the saliva in the present
state of chemical knowledge could not be recognized.
Med. Times and Gazette, March 17, 1866, p. 275.

CONSERVATIVE MEDICINE.

Among the improvements in medicine which character-
ize our epoch, none is more gratifying than the gradual
abandonment of excessive medication, and especially of
deteriorating agents, and the increasing reliance upon the
resources of the economy supported by improvers of the
stamina. Under the influence of the phlogistic and an-
tiphlogistic doctrines which have so long swayed the
profession, nearly all diseases were regarded as more or
less indicative of exalted or excessive action and increased
vitality, requiring at the hands of the physician the use
of such means as might seem best adapted to the reduc-
tion of the morbid orgasm, and to the impairment of
the vital forces supposed to be in excess. Hence the very
general resort to the abstraction of blood and to depletion
by means of emetics, cathartics, abstinence from food>
and the disintegrating influence of mercurialization. The
sole object of the medical adviser seemed to be to impair
the energies of the system. While he was dealing her-

1867] . Editorial and Miscellaneous. 429

culean blows at the disease, he seemed to forget that he
was doing so at the- expense of an organism already con-
tending with an enefrny which was sapping the very foun-
dations of its existence. And yet results show that all
who were thus treated did not die ; for while with some
the thread of life is snapped by the most trivial causes, it
is in others so strong as to resist the most extraordinary
combinations of violence.

But the Broussaisian ultraism wrought its own cure;
and Andral, Chomel, Louis, and others of the Parisian
school, boldly took their stand in the breach, and suc-
cessfully inaugurated the researches and observations
which are now culminating in conservative medicine.
Ilahneman, disgusted with destructivism, but not pos-
sessing genius enough to suggest anything else, resorted
to the miserable subterfuge unfolded in his " Organon,"
instead of manfully acknowledging that he preferred no
treatment to that then in vogue. The French had already
ascertained that many affections were more successfully
treated by " expectation," but this did not lead them to
the abandonment of professional interference where this
could be manifestly advantageous. The era of observa-
tion had commenced, and we are now reaping the benefits
of a more thorough acquaintance with disease as well as
with physiology and therapeutics. We now look upon
morbid action as an impairment instead of an exaggera-
tion of vitality, which may be arrested by antidotes when
the cause is appreciable, and by sustain ers or improvers of
the energies of the system in other cases. We are now
satisfied, in managing cases for which we know no
specific, to strive to enable the patient to live through the
disease, instead of striking in the dark at the expense of
the vital energies.

Our malarial fevers, so called, furnish us with one of
the most striking illustrations of the improvement to

430 Editorial and Miscellaneous. [Jan.

which we refer. In these the antidotal has superceded
the empirical and the antiphlogistic treatment, ft matters
little whether we regard quinine as #, neutraliser of the
poison which induces these fevers, or as acting in any
other way. No one questions its specific effect, through
the instrumentality of which we have acquired the mas-
tery over this class of affections, and thus learnt at least
that antiphlogistics are not necessary to subdue the in-
tense excitement (I use this term for want of a better) so
often apparently attending these affections, and that it
may be abated simply by fortifying the system against the
poison which induced it.

Again, look at the history of the treatment of typhoid
fever, and see what variety of means have been invoked
to subdue the fever and the local ulceration so generally
accompanying it. All the deteriorating agencies have
been tried in vain ; expectation was somewhat more suc-
cessful ; but when we compare these results with those
recorded by Chambers under the conservative plan of
treatment so ably set forth in his Clinical Lectures, we
have every reason for congratulation.

<: Since the opening of the hospital in the summer of 1851, to the time
of my leaving London for the vacation last August (1863), there have
been registered as under my care 230 examples of continued fever.
Of these, 109 have been treated on what may be termed "general
principles ;" that is to say, they took neutral salines three or four
times a day, with small doses once or twice a day of hydrargyrum cum
creta at first, and later in the disease bark, ammonia, ether, and wine,
when these remedies seemed required by the symptoms. Leeches and
cupping were employed to the exterior of inflamed viscera as occasion
called, and food was administered at the ordinary four daily meal-
times. The other 121 have been treated on an uniform plan of con-
tinuous nutrition ; animal food, in a liquid form, has been given every
two hours, day and night, while the patients were awake, and between
every dose of nutriment a dose of hydrochloric acid. They have been
sponged two or three times daily with tepid water, when the skin was
hot and dry; and, in a few instances, leeches or cupping have been
used to the exterior of inflamed localities in the abdomen or chest.

1867] Editorial and Miscellaneous. 431

Of the first series (viz., those treated on general principles),

9 are entered as Typhus, and of these there died 4
44 are entered as Typhoid, and of these there died 16
56 are entered as of doubtful or unrecorded type 3

Total 109 Total 23

Of the second series,

25 are entered as Typhus, and of these there died 0
52 are entered as Typhoid, and of these there died 2
44 are entered as of doubtful or unrecorded type 2

Total 121 4

For purposes of comparison in a therapeutical inquiry, it will proba-
bly be considered right to exclude from the first table two deaths, and
from the second table one death, which occurred within two days of
admission: for the exhaustion caused by the journey to the hospital
in severe fevers allows but little scope for judging of the action of
treatment during that period. This leaves the average mortality under
general treatment 21 in 107= 19 per cent., or nearly 1 in 5 ;* under
the second method of treatment, by continuous nutriment and hydro-
chloric acid, 3 in 121=2J per cent., or only 1 in 40.

The continuous liquid nutriment given every two hours consisted of
strong beef tea and milk, of which together about six pints were ad-
ministered in the twenty-four hours. The hydrochloric acid was given
every two hours in doses of twenty minims of the Pharmacopceal dilute
acid in water or eau sucree. Both food and drugs were seen by the
nurses to be swallowed, and not left to the discretion of patients, who
from nausea and occasional delirium can not be trusted to help them-
selves." Chambers' Lectures on the Renewal of Life, pp. 118-120.

One of the first and most important steps in conserva-
tive practice was taken in the management of persons
affected with phthisis pulmonalis. Who does not recollect
the repeated blood-lettings for the arrest of hemoptysis,
the low diet for the reduction of febrile action, the anti-
monials to promote expectoration, the blisters to excite
revulsive action, and the confinement in a heated apart-
ment to obviate the baneful influence of cold in winter ?

* This mortality is higher than is usual at special fever hospitals, being about the same
at the other general hospitals in London.

432 Editorial and Miscellaneous. [Jan.

All this was done under the impression that action or
vitality was in excess, and should be lessened. But now
that we look upon phthisis as characterized by defective
stamina or impaired nutrition, how different the treat-
ment. We do all in our power to improve, to strengthen,
and to brace up the powers of the system in order that
they may combat the tendency to death. We promote
digestion by every possible means, administer nutritious
oils, and order free exercise in the open air, and thus save
many who would have otherwise perished.

Since then many other diseases have been successively
subjected to the test of conservative medication, and
always with most beneficial results. May we not hope
that the profession wall calmly review the grounds of their
old faith in deteriorating medication, and ascertain
whether they may not be more successful by the adoption
of a more conservative practice ? They will find much
valuable aid in so doing by perusing the lectures of Dr.
Chambers, already cited. L. A. D.

OUR MOTTO.

It will be perceived that we have replaced the old
motto of this Journal upon its title-page, in lieu of the
one adopted by our predecessor in the first number of
this volume. This is done in no captious spirit; but
simply because we prefer that under which this Journal
has earned its reputation for practical and impartial
literature. It is concise, to the point, and a correct
exponent of the principles by which we intend to be
governed in filling these pages. We shall adopt what is
good wherever we find it.

1867] Editorial and Miscellaneous. 433

Pereira's Materia Medica and 'Therapeutics ; being an
abridgment of the late Dr. Pereira's Elements of Ma-
teria Medica, arranged in conformity with the British
Pharmacopoeia, and adapted to the use of Medical
Practitioners, Chemists and Druggists, Medical and
Pharmaceutical Students. By F. J. Farre, M.D.,
Senior Physician to St. Bartholomew's Hospital, and
London Editor of the British Pharmacopoeia; assisted
by Robert Bentley, M.R.C.S., Professor of Materia
Medica and Botany to the Pharmaceutical Society of
Great Britain; and by Robert Warington, F.R.S.,
Chemical Operator to the Society of Apothecaries.
With numerous additions and references to the U. S.
Pharmacopoeia, by Horatio C. Wood, M.D., Professor
of Botany in the University of Pennsylvania. Illus-
trated with wood engravings. First edition. Phila-
delphia: Henry C. Lea, 1866. 8vo., pp. 1,030.

This book supplies a deficiency long and seriously felt.
The parent work of which it is an abridgment is a stand-
ard one both in this country and in Europe, and yet its
elaborate, recondite character has made it more or less
unsuited to strictly practical readers ; in other words, it is
better adapted to the purposes of men of research than
the medical student and practitioner. This objection no
longer exists : it has been abridged, condensed, simplified
in short, converted into a manual of easy reference for
those who need it most.

The English authors state that they have retained the
original classification, but have excluded all remedial
agents, except those termed "pharmacological/' and, of
the latter, such as are not contained in the British Phar-
macopoeia. To this selected material, the American
editor has contributed numerous references to the XT'. S.
Pharmacopoeia, thus adapting it to our home readers
also. While, perhaps, it cannot be expected to supercede
the admirable American works upon materia medica and
therapeutics of recent publication, it will, nevertheless,
33

434 Editorial and Miscellaneous, [Jan.

become a welcome addition to every physician's library
and a valuable text-book for students. To such as need
additional books for consultation on this branch of medi-
cine, we would respectfully commend it. W. H. D.

The Science and Practice of Medicine. By Wm. Aitken,.
M.D., Ed. Professor of Pathology in the Army Medi-
cal School, etc., etc.; in 2 vols. From the 4th London
edition, with additions by Meredith Clymer, M.D., late
Professor of the Institutes and Practice of Medicine in
the University of New York. Philadelphia : Lindsay
& Blakiston, 1866. Vol. 1; 8vo., pp. 955.

This is one of the most extensive works upon the
practice of medicine in our language, and comes to us
with the prestige acquired by the rapid sale of four
editions in England. We have as yet received only the
first volume of the American edition, but learn that the
second is nearly ready. Intended for the use of the
Medical officers of the British army, the influence of
climate upon disease has been kept in view, and the
author has largely availed himself of the practical con-
tributions of the medical staff of the British army and
navy, and of the resident physicians of the East Indies.
The Department of Medical Geography received atten-
tion for the first time in a treatise on the practice of
medicine. The practical importance of the thermometry
of disease is set forth, and diagrams illustrative of the
typical ranges of temperature, particularly in febrile dis-
eases, are given for the first time in a work of this scope.

The additions by Dr. Clymer will add considerably to
its favor in this country ; but the American editor has
not done himself justice in having omitted much that he
might have added in relation to our diseases and our mode
of treating them.

1867] Editorial and Miscellaneous. 435

A Practical Treatise on the Physical Exploration of tlte Chest
and the Diagnosis of Diseases Affecting the Respiratory
Organs. By Austin Flint, M.D., Professor of the
Principles and Practice of Medicine in the Bellevue
Hospital College, etc. Second edition, revised. Phila-
delphia: Henry C. Lea, 1866. 8vo., pp. 590.

This invaluable book has reached its second edition,
and, contrary to the prevailing custom of authors, it is
reduced in size not from the want of materials, but
because the author, appreciating its practical worth, sought
to increase it by divesting the subject of "complexity and
needless refinements."

We would not hesitate to commend it in even extrava-
gant terms, if by so doing we could arrest the attention of
those who need it most. If possible, we would place it
in the hands of every student, preceptor, and professor,
with the assurance that, under its careful study, more
knowledge of the subjects discussed would be obtained
than from any other publication extant. Ordinarily, phy-
sical exploration by the various methods now practiced
is an exaggerated "bug-bear," and exactness in its results
is considered so difficult as to be beyond the attainment
of ordinary persons. We venture to assert that this
delusion will be quickly dispelled, if any thoughtful
student will follow the order of this work ; it would be
better for him if he had never heard of, or experienced
confusion of mind from, the old, arbitrary terms applied
to respiratory sounds, as "rude" respiration, a "short,
whiffing" sound, ending abruptly in a "click" etc.; for,
adopting the nomenclature of the author, he would have
a simplified form, the types of the different sounds (ex-
cept the adventitious) being found in the normal respira-
tion. He is led first to examine the sounds of the healthy
chest in its various topographical regions in percussion
and auscultation. The normal vesicular resonance, and
the laryngeal, tracheal, bronchial, and vesicular respira-
tion are taken as types of sounds in their intensity, pitch,

436 Editorial and Miscellaneous. [Jan.

and quality, with which are to be compared the variations
or modifications produced by disease. When, therefore,
in the second stage of pneumonia, the inquirer meets,
perhaps for the first time, the "tubal" respiration (of old
writers), he instinctively applies the word bronchial, be-
cause it is similar to the normal bronchial sounds, although
heard over the vesicular structure ; and so also with the
"rude" respiration present in the early stage of phthisis,
which is called broncho-vesicular, because it presents modi-
fications of the normal vesicular and bronchial respiration
combined. The nomenclature is descriptive, and con-
veys in itself the distinctive characters of the most im-
portant signs. The author devotes little attention to their
mechanism, but labors to establish and define their
pathological significance by means of extensive " clinical
facts in connection with morbid anatomy."

The chapter upon the " Correlation of Physical Signs"
is an admirable production, convenient for consultation.
Taking any single sign, you can thereby easily trace its
correlative associate signs in all the methods of physical
exploration, percussion, auscultation, mensuration, inspec-
tion, palpation, and succession. In the new edition this is
presented in a tabular form, which, we think, is not so
advantageous as the chapter in the first edition.

Physical exploration ensures the exact diagnosis of
pulmonary diseases its revelations are purely objective,
and, therefore, more reliable, and, when properly associ-
ated with rational symptoms, they establish the diagnosis.
Every physician can attain (indeed, is inexcusable if
he does not) such a degree of proficiency in the art as
to approach with confidence a majority of the pulmonary
affections encountered in practice. For the better quali-
fication of all, we press upon the attention of the reader
this work. We have drank freely from the fountain
with intense satisfaction, and are entitled to a voice in
its praise. W. H. D.

1867] Editorial and Miscellaneous. 437

Orthopedics : A Systematic Treatise upon the Prevention and
Correction of Deformities. By David Prince, M.D.
Philadelphia: Lindsay & Blakiston, 1866. *8vo., pp.
240.

The study of orthopedics has been too much neglected

by the generality of medical practitioners, and many cases

are therefore left without treatment, or are unsuccessfully

managed. All endeavors to facilitate the acquisition of a

knowledge of the principles and mechanical appliances

by which deformities are treated should be encouraged.

The work before us will be found eminently practical and

useful. It is an American book, and quite creditable to

the author.

The Essenticds of Materia Medica and Therapeutics. By
Alfred Baring Garrod, M.D., F.R.S. Second edition,
1865. New York : William Wood & Co.

As its name imports, this is a concise, comprehensive
digest of medicines; their nature and value in the treat-
ment of disease. Its conception was a happy one, how-
ever difficult its execution may prove. It is no easy task
so to epitomize a diversified subject of this character as
to retain only the essential materials ; few writers possess
the happy faculty of saying neither too much nor too
little on a given subject. The author designed presenting
the profession with a work which, while it omitted nothing
essential, yet excluded "such details as are often embar-
rassing to the student and seldom necessary to the prac-
titioner." In this he has succeeded admirably, although
the therapeutical division of the subject is scarcely as
complete as might be desired. We are informed, how-
ever, that this is to be followed by a "companion work,"
devoted exclusively to the therapeutical value of medi-
cines. We have no doubt that its forerunner will meet
with a favorable reception from the profession at large,
and we take pleasure in directing attention to it.

W. II. P.

438 Editorial and Miscellaneous. [Jan.

A Hand-book of Ophthalmic Surgery y for the use of Prac-
titioners. By John Z. Laurence, F.R. C.S. M.B. (Univ.
Lond.), Surgeon to the Ophthalmic Hospital, South-
wark, etc., etc. ; and Robert C. Moon, House Surgeon
to the Ophthalmic Hospital, Southwark. With numerous
illustrations. Philadelphia : Henry C. Lea, 1866. 8vo.,
pp. 190.

This little work, gotten up in Mr. Lea's best style, is a

most excellent manual of ophthalmology. It contains all

the modern improvements in diagnosis and treatment,

and condenses in a small space what is too often made to

fill a ponderous volume. The illustrations are graphic,

and will aid the student very much in understanding the

use of several modern instruments for examining the eye.

D.

Practical Therapeutics considered chiefly with reference to
Articles of the Materia Medica. By Edward John
Waring, F.R.C.S., F.L.S., Surgeon in Her Majesty's
Indian Army. Second London edition, 1866. Phila-
delphia : Lindsay & Blakiston.

Works upon therapeutical science multiply rapidly ; it
is questionable, however, whether all of them add to its
perfection or material development. In this instance we
confess our inability to appreciate the necessity for its
appearance, possibly because we can not be classed in the
author's category of "floating practitioners" (surgeons in
the army, the navy, the East India Company's service,
those engaged in "emigrant or merchant ships," and resi-
dent in "isolated spots" in distant colonies), for whom he
thinks it most useful. He asks for the book no higher
"distinction" than that of a meritorious compilation; but,
while cheerfully according its proper value in this regard,
we are constrained to subordinate it to the level of all
works of a similar character when compared with the
great representative works of the science. A signal
degree of diligence and industry has been displayed in

1867] Editorial and Miscellaneous. 439

completing it, and if any of our readers of cosmopolitan
habits require such a volume, we think it a valuable one
for their purposes. W. II. D.

A Practical Treatise on Diseases of the Shin. By J. Moore
Neligan, M.D., M.R.J.A., etc. Fifth American, from
the second revised and enlarged Dublin edition. By
M. Belcher, M.A., M.D., Dublin, etc., Fellow, Censor,
Examiner, etc., King and Queen's College in Ireland,
etc., etc. Philadelphia: Henry C. Lea, 1866.

Already has the distinguished author's volume gone
through five editions a favorable comment upon its
value and acceptance. Skin diseases have so many re-
semblances that the observations of careful men can not
fail to place dermatology in a favorable relation to the
other branches of medicine. Xo class of diseases is so
obscure to the mass of the profession, and the editor has
made it "the chief aim throughout to make this book
thoroughly fit for the practical man."

The subject has been elaborated with great care, and
brought up to date. The chapters treating of "Exanthe-
mata," the "Appendages of the Skin," and the "Thera-
peutics of Diseases of the Skin" will be perused with
interest and profit. F.

An Introduction to Practical Chemistry, including Analysis.
By John E. Bowman, F.C.S., late Professor of Practi-
cal Chemistry in King's College, London. Edited by
Charles L. Bloxam, F.C.S., Professor in King's College,
London ; Professor of Chemistry, etc., Woolwich. With
107 illustrations. Fourth American, from fifth revised
London edition. Philadelphia: Henry C. Lea, 1866.

We recommend this volume very strongly, not only to

the student of the science, but to the educated physician.

It will be found particularly useful in simplifying many

analyses which become necessary among critical medical

observers. F.

440 Editorial awl Miscellaneous. [Jan.

A Manual of Auscultation and Percussion. By M. Barth
and M. Henri Roger. Translated from the 6th French
edition. Philadelphia : Lindsay & Blakiston, 1866.

This manual is very full and complete for the use of
those already familiar with the foundation principles of
auscultation and percussion. It will be found of less use
for the medical student. We think that very few "who
are entirely novices in auscultation" will adopt the
recommendation of the preface, to "hold fast to this
treatise." But for this recommendation, we should have
concluded that this abstract from the large and valuable
work of the distinguished authors was intended only as a
manual for the expert.

To those using these methods of physical exploration
intelligently, and ambitious of becoming experts in the
arts, we commend it as a very full condensation of the
large work to which they may not have access.

We are particularly gratified at the fair acknowledge-
ment of the credit due to Drs. Camman and Clark, of
New York, as the authors of auscultatory percussion;
and surprised at the author's low estimate of what we
regard its high value in determining, with exact precision,
the limits of the solid organs of the thorax and abdomen,
and of accidental tumors and their connections. F.

Asiatic Cholera; A Treatise on its Origin, Pathology, Treat-
ment, and Cure. By E. Whitney, M.D., and A. B.
Whitney, A.M., M.D., late Physician and Surgeon to
Diseases of Women in the Northwestern Dispensary ;
Visiting Physician, etc. New York : M. W. Dodd,
Publisher, No. 506 Broadway, 1866.

The recent prevalence of cholera in different portions
of this country has invited a careful examination into its
origin, development, and treatment. The volume before
us contains many valuable suggestions of rational prac-
tice, and some practical ideas on "prophylaxis." F.

1867] Editorial and Miscellaneous. 441

On Wakefulness, with Introductory Chapter on the Physiology
of Sleep. By William A. Hammond, M. D., Fellow of
the College of Physicians of Philadelphia ; Honorary
Corresponding member of the British Medical Associ-
ation ; late Professor of Anatomy and Physiology in
the University of Maryland, etc., etc. Philadelphia:
J. B. Lippincott & Co., 1866.

This small volume is replete with original and philo-
sophical views. It treats of the " physiology of sleep/'
the "pathology of wakefulness," the exciting causes of
wakefulness," and, lastly, the treatment of wakefulness.
Coming from such a valuable observer, whose physiologi-
cal researches have elicited so much applause from the
scientific world, it can not fail to be interesting and in-
structive, exposing as it does the erroneous teachings of
the physiology of these states still taught by prominent
authors. We cheerfully recommend it. F.

Creosote in Diphtheria.

Dr. J. J. Knott, of Griffin, Ga., recommends very
highly the local use of creosote in diphtheria. His
formula is as follows :

Creosote ij.

Aqua font ^ij.

Pulv. acacia q. s. to make an emulsion. To be applied
to the affected surface with a sponge or mop, twice a day,
until the exudations disappear.

Bleeding at the Navel.

Dr. Zober, in the Monat f. Schr. Gcburtsch, xxvi., as
quoted by the Southern Journal of the Medical Sciences, who
distinguishes bleeding of the navel proper from bleeding
due to an improper tying of the chord, or to the existence
of a fungous exuberant growth, bases an opinion upon
the fact that, as icterus is usually present, nutrition is
partly deficient, and that the bile itself plays a part in the
34

442 Miscellaneous. [Jan.

destruction of the coagulability of the blood. Autopsies
develop the existence of coagula in the umbilical vessels,
or an aneurismatic condition of them. Martin found
once an unusually large umbilical artery, with an origin
from the arteria sacralis media. The blood, which flows
uniformly, never in a ray, and is perfectly clear, may ooze
out of a swelling or without a visible opening out of the
navel. The duration of the haemorrhage is various.
Besides the symptoms of anaemia we may have concur-
rent with them, or at a later period, eczema, and petechias
on the skin ; or bleeding from the intestines, which may
produce death just as purpura after the bleeding has
ceased. Treatment in these cases is very uncertain.
Compression, styptics, and the actual cautery are alike
unreliable. Th. Hill once succeeded by pouring a layer
of plaster of Paris over the navel. Dr. J. Ii. Pooley, of
Yonkers, N. Y. (the American Journal of Medical Sciences),
failed with the ligature en masse. He passed two stout
steel pins at nearly right angles to each other through the
integument and under the navel, and then applied a waxed
silk figure-eight ligature, with no other result than an
apparent checking of the bleeding for a couple of hours.
This child was also very much jaundiced with urine
highly charged with bile elements. No post-mortem ex-
amination allowed. N. Y. Med. Record.

Treatment of Fractured Patella by the Padded Ring Method.
Dr. W. A. Gibson, of St. Louis, Mo., in a contribution
to the Medical and Surgical Journal of that city, relates his
successful treatment of a transverse fracture of the left
patella, in which there was a separation of the fragments
to the distance of about an inch. He measured the sound
patella and had a ring made of iron (allowing for pad-
ding), which was well guarded with cotton wadding cut
in strips and wrapped round the ring, over which a band-
age was applied. To each side of the ring he sewed

1867] ^Miscellaneous. 443

strips of bandage. He then placed a well padded splint
twenty-four inches long to the posterior aspect of the leg
and thigh, which he secured by a few turns of bandage
at the lower and upper ends, the bandage being loose so
as not to interfere with the circulation. He kept the
fragments in apposition and the ring in place by strips of
bandage over the splint. At the end of thirty days, when
the ring was removed, the union was bony and complete.
The appliance gave no pain, and six weeks after the
injury the patient was having a very good use of the
limb. Ibid.

Action of the Bromide of Potassium upon the Nervous
System.

The actions of the bromide of potassium, according to
Dr. J. Crichton Browne, in the Am.' Journal of the Medi-
cal Sciences, are : 1. It mitigates those convulsive move-
ments or spasmodic twitchings which are the result of the
rapid conversion of sensory impressions into motor im-
pulses, or of morbid reflex action through the medulla
oblongata, and it exercises a peculiar influence over the
phenomena which are characteristic of epilepsy. Whether
the increased excitability of the medulla oblongata is
so great as to be productive of epilepsy, or so slight
as to extend itself in minor spasmodic complaints, the
bromide seems to exert an excellent effect on it. 2.
It has a sedative effect upon the action of the heart in
certain cases. 3. It lessens and mitigates that rapid and
preternatural excitement of spasm, tremor, and other
outward manifestations which, in some forms of nervous
disease, follow upon any emotional or moral disturbance.
4. It acts as an anodyne, under certain circumstances
relieving hypersesthetical sensations. 5. It promotes
sleep. 6. It exercises a sedative influence over the sexual
functions. 7. It exercises a beneficial influence over
certain mental diseases. Ibid.

444 Miscellaneous. [Jan.

A New and Simple Bullet Probe.
Dr. Vincent Geilisch, of Los Angeles, CaL, in the Pa-
cific Medical and Surgical Journal, calls the attention of the
profession to the effectiveness of white pine wood as a
substitute for the famous Nelaton probe. A pine probe-
shaped splinter, when introduced into a wound, and
rubbed against the suspected object and quickly with-
drawn, will present traces of lead equally as well as
unglazed porcelain. Ibid.

Sulphate of Zinc vs. Iodine in Injections for Hydrocele.

Mr. Haynes Winslow, of St. Mary's Hospital, Dublin,

clings to the rather old-fashioned remedy of sulphate of

zinc, of the strength of three grains to the ounce, as an

injection for the radical cure of hydrocele. The zinc

injection excites more vascular action than the iodine

and gives more pain, but the greater assurance of suecess

is more than a set-off in favor of the zinc. He directs

that "after the hydrocele fluid is withdrawn the injection

should be thrown in with a syringe through a trocar, and

kept in the tunica vaginalis till there is pain in the loins

and groins, which usually comes on in four or five min-
utes. Then the fluid ought to be let out."' Ibid.

Hyposulphite of Soda in Malarial Fevers.
Dr. W. H. Baxter, of Moscow, Iowa, writes to Prof. N.
S. Davis, that he was induced by Dr. Leavitt's statement,
in No. 1 of this journal, for April last, as to the efficacy
of the hyposulphite of soda in malarial fever, to employ
that article. In the last month, Dr. B. says he has treated
" over one hundred cases of intermittent and remittent
fever with this remedy alone, and in no case has there
been an exacerbation after taking the remedy a reasonable
length of time." He gave it in fifteen grain doses in
solution in water. He has not trusted to this remedy
alone in pernicious or malignant types. Am. Journal of
Med. Sciences.

1867] Miscellaneous. 445

A New Caustic.

Dr. Pinckney W. Ellsworth, of Hartford, Conn. ( Medi-
cal and Surgical Reporter), alludes to the discovery by a
Mr. Augustus Barnes of the fact that the solar focus is a
most efficient and admirable caustic.

Dr. E. states that he " saw one gentleman who had a
naevus on his face, extending from the eye to below the
mouth and involving the lower eyelid to the very edge,
and covering four or five square inches of surface; it was
of a deep cherry-red color, approaching purple, and cov-
ered with knobs of condensed tissue, an eighth of an
inch high. This mevus could be seen as far off as the
color of the face. After two applications the spot has
nearly disappeared, the skin generally having the hue of
a surface blistered some days previously, and it is now
nearly well. Some portions were absolutely like normal
skin, and entirely colorless. Every knob was gone, and
where stood one of the largest, and where the rays were
longest condensed, was a perfectly healthy looking cutis.
* * * * This man can be considered practically
cured, although there is at present the appearance stated,
but which does not especially draw attention. * * * *
The rays were condensed with excellent success, even on
the very edge of the lid. * * * * Xor is the pain
as severe as we might apprehend, as it is confined at each
instant to a very minute point. * * * * Patients at
any rate submit very readily and without the* use of anaes-
thetics." Mr. Barnes uses a lens of two and three inches
diameter, condensing the rays upon the object to be re-
moved, and goes over the whole, if not more than three
inches in surface, at one sitting. Lupus, Ichthyosis, and
small tumors involving the surface of the skin, have been
subjected to this experimentation with promising results,
at least as far as we may infer from Dr. Ellsworth's com-
munication to the journal above quoted. N. Y. Med.
Record.

44(> Works Receive,!. [Jan.

WORKS RECEIVED.

A Practical Treatise on Fractures and Dislocations. By Frank Hastings
Hamilton, M.D., Professor of the Principles of Surgery, Military
Surgery and Hygiene, and of Fractures and Dislocations, in Bellevue
Hospital Medical College; Surgeon to Bellevue Hospital and to the
Charity Hospital, New York ; Professor of Military Surgery, etc, in
the Long Island College Hospital ; author of a Treatise on Military
Surgery. Third edition, revised and improved. Illustrated with 294
wood cuts. Philadelphia: Henry C. Lea, 1866; 8vo., pp. 775.

The Science and Practice of Medicine. By Wm. Aitken, M.D., Edin.
Professor of Pathology in the Army Medical School, etc., etc. ; in
two vols. ; from the fourth London edition, with additions by Mere-
dith Clymer, M.D., late Professor of the Institutes and Practice of
Medicine in the University of New York. Philadelphia: Lindsay
& Blakiston, 1866.

A Hand-book of Opthalmic Surgery, for the use of Practitioners. By
John Z. Laurence, F.R.C.S., M. B., University of London, etc., etc. ;
and Robert C. Moon, house surgeon to the Ophthalmic Hospital,
Southwark ; with numerous illustrations. Philadelphia : Henry C.
Lea, 1866.

Pe re ira's Materia Med ica and Therapeutics ; being an abridgment of
the late Dr. Pereira's Elements of Materia Medica, arranged in
conformity with the British Pharmacopoeia, and adapted to the use
of Medical Practitioners, Chemists and Druggists, Medical and
Pharmaceutical Students. By F. J. Farre, M.D., etc., etc.; assisted
by Robert Bcntley, M.R.C.S., etc., etc ; and by R. Warrington, F.
U.S., etc., etc. ; with numerous additions and reference to the U. S.
Pharmacopoeia, by H. C. Wood, M.D., etc., etc. ; illustrated with
wood engravings. Philadelphia : H. C. Lea, 1866.

The Essentials of Materia Medica and Therapeutics. By A. B. Garrod,
M.D., F.R.S. Second edition. New Yrork: William Wood & Co.,
1866.

Practical Therapeutics, considered chiefly with reference to articles of the
Materia Medica. By E. J. Warring, F.R.C.S., F.L.S., etc. Phila-
delphia : Lindsay & Blakiston, 1866.

A Practical Treatise on Diseases of the Skin. By A. M. Neligan, M.D.,
etc. Fifth American, from the second revised and enlarged Dublin
edition. By M. Belcher, A.M., M.D., etc., etc. Philadelphia : H.
C. Lea, 1866.

An Introduction to Practical Chemistry, including Analysis. By J. E.
Bowman, F.C.S., etc, etc. Edited by C. L. Bloxam, F.C.S., etc., etc.
Fourth American, from the fifth revised London edition. Philadel-
phia: 11. C. Lea, 1866.

A Manual of Auscultation and Percussion. By M. Barth and M. II.
Roger. Translated from the sixth French edition. Philadelphia:
Lindsay & Blakiston, 1866.

Orthopedics ; A systematic Treatise upon the Prevention and Correc-
tion of Deformities. By David Prince, M.D. Philadelphia : Lindsay
& Blakiston, 1866.

1867] Works Mectieed. 447

Asiatic Cholera; A Treatise on its Origin, Pathology, Treatment, and
Care. By E. Whitney, M.D., and A. B. Whitney, A.M., M.D., late
Physician and Surgeon to Diseases of Women in the Northwestern
Dispensatory ; Visiting Physician, etc. New York : M. W. Dodd,
publisher, No. 50C Broadway, 1860 ; I0mo., pp. 214.

On Wakefulness, with an Introductory Chapter on the Nature of Sleep.
By Win, A. Hammond, M.D., Fellow of the College of Physicians of
Philadelphia, etc., etc. Philadelphia: J. B. Lippincott & Co., 1866 ;
12mo., pp. 93.

Why Not? A book for every Woman. The Prize Essay to which the
American Medical Association awarded the gold medal for 1865. By
Horatio Pt. Storer, M.D., of Boston ; Assistant in Obstetrics and
Medical Jurisprudence in Harvard University ; Surgeon to the New
England Hospital for Women ; and Professor of Obstetrics and Dis-
eases of Women in Berkshire Medical College. Issued for general
circulation, by order of the American Medical Association. Boston :
Lee & Shepard, 1866 ; 18mo., pp. 91.

Successful Removal of the Uterus and both Ovaries, by Abdominal Sec-
tion; the tumor, fbro-cystic, weighing thirty-seven pounds. By Horatio
R. Storer, M.D., of Boston. Reprinted from the Amer. Jour, of the
Med. Sciences, for January 7, 18G6. Boston : David Clapp & Son ;
1866.

A Treatise on Vesico- Vaginal Fistida. By M. Schuppert, M.D., Surgeon
of the Orthopedic Institute, at New Orleans, La. New Orleans
Daily Commercial Bulletin print, 1866 ; 8vo., pp. 46.

On Excision of the Superior Maxilla. Report of a case, with remarks
on certain tumors of this bone. By Wm. R. Whitehead, M.D.,
University of Paris, etc., etc. New York : John Medole, 1866 ; 8vo.,
pp. 28.

Prize Essay ; Illustrations of Disease with the Microscope. By Francis
Peyre Porcher, M.D., Lecturer on Materia Medica and Therapeutics.
Charleston, S. C. : Evans & Cogswell, 1861.

Report of the Committee of the Georgia Medical Society, on the Hygienic
Condition of the City of Savannah and Surrounding Country. Made
to the Society and adopted May 16, 1866.

Essay on the Phosphate of Iron. By E. N. Chapman, M.D., Professor,
etc., etc- ; with notices of its combinations and forms of prepara-
tions, etc., etc. By Caswell, Mack & Co., Family and Dispensing
Chemists. New YTork : John A. Gray & Green, 1865.

Chemistry Victorious over Cholera. By J. P. Gilbert, M.D. New York :
Gilbert & Co., 1865.

The Hunterian Ligation of Arteries to relieve and to prevent Inflamma-
tion. By Henry F. Campbell, M.D., Professor of Anatomy in the
New Orleans School of Medicine, etc., etc. Augusta, 1866 ; 8vo.,
pp. 18.

Valedictory Address to the Graduating Class of the New Orleans School
of Medicine, Session 1865-6. By J. L. Crawcour, M.D. ; 1866.

Traite Nonographique des Maladies Chirurgicales. Par Benjamin
Anger, Prosecteur des Hopitaux de Paris. Precede d'une introduc-
tion par M. Velpeau, membre de Tlnstitut, etc., etc. Paris : G.
Bailliere, 1865.

4^8 Works Received: [Jan., 1867]

The Richmond Medical and Surgical Journal. Edited by Dr. E. S.

Gaiilard and W. S. McChesney.
The Memphis Medical and Surgical Monthly. Edited by Drs. F. A.

Ramsay, D. D. Saunders, E. M. Willet, and W. H. White.

The Savannah Journal of Medicine. Edited by Drs. I. Harriss, J. B.
Read, and J. G. Thomas: Savannah, Ga.

The Atlanta Medical and Surgical Journal. Edited by Drs. J. G. and
W. F. Westmoreland: Atlanta.

The New Orleans Medical and Surgical Journal. Edited by Drs. W.
Stone, J. Jones, S. E. Chaille, and W. 0. Nichols : New Orleans.

Southern Journal of the Medical Sciences. Edited by Drs. E D. Fenner,
D. W. Brickell, and C. Beard: New Orleans.

The American fcurnal of the Medical Sciences. Edited by J. Hays,
M.D.: Philadelphia.

The Medical News and Library. Philadelphia.

The Dental Cosmos. Edited by Drs. J. H. McQuillen and G. J. Ziegler:
Philadelphia.

The Chicago Medical Examiner. Edited by N. S. Davis, M.D.

Buffalo Medical and Surgical Journal. Edited by J. F. Miner, M.D.

Revue de Therapeutique Medico- Chirurgicale. Par A. Martin Lauzer.

The New York Eclectic Medical Review. Edited by Drs. R. S. Newton
and E. Freeman.

The Medical Record. New York.

The American Artizan. New York.

The Signet and Journal. Edited by J. E. Blackshear, M.D., and S.
Lawrence : Macon.

Illustrated Catalogue of Medical, Surgical, and Scientific Publications.
By II. C. Lea : Philadelphia, 1866.

The Medical Reporter. Edited by Dr. J. S. B. Alleyne and 0. F. Potter :
St. Louis.

The Druggists' Circular. New York.

The Southern Cultivator.

The Medical and Surgical Reporter. Edited by S. W. Butler, M.D. :
Philadelphia.

MEDICAL COLLEGE OF GEORGIA.

The Medical College in this city is rapidly recuperating
from the disasters of the war. The class in attendance
this session is double that of the last year.

SOUTHERN

efeal^ ^Digital loKnial

AUGUSTA, GA,

Vol. XXL] MARCH, 18G7. [No- 4

ORIGINAL COMMUNICATIONS.

The Medical Statistics of the Confederate Slates Military
Hospitals. By m. H. Doughty, M.D., Augusta, Ga.,
Professor of Materia Medica in the Medical College of
Georgia.

The October number of this journal contains an inter-
esting and instructive article from Professor Jones upon
the "Relations of Pneumonia and Malarial Fevers,"
which incorporated also a "table illustrating the rate of
mortality in pneumonia under different modes of treat-
ment, prepared from the hospital and field reports of the
Confederate army of America, and also from the pub-
lished statistics of various European hospitals and
armies."

The destruction of the voluminous records of the
Medical department at the fall of Richmond has devolved
upon individual officers the duty ot publishing such
portions as may yet remain in their possession, in order
to supply the loss as far as possible. In the table ad-
verted to above, Professor Jones has given to the pro-
fession a mass of statistics, the value of which will be
35

450 Doughty on the Medical Statistics of the [March

duly appreciated by generalizes and statisticians at large.
The particular use which he has made of them we can
not altogether approve, since so much of the compilation
as embraces the Confederate reports can not possibly reflect
the "rate of mortality under different modes of treatment"
The modes of treatment are not given (as in the case of
the civil hospitals), simply because it could not be done.

One would infer, from reading this article, that sur-
geons in charge of hospitals had it in their power to
" test the value of the different modes of treatment be-
fore the profession," when, alas! the poverty of their
resources was painfully prominent. Some of the records
which he cites had been completed long before he was in
a position to " urge" this important measure " upon each
medical officer." His tour of investigation was made
long after every vestige of the unfavorable circumstances
(not the mode of treatment) which determined the high
mortality had disappeared, and at a time when not even
gleanings of previous disadvantages could be obtained
from officers then on duty. Their comparison with the
longest-established, best-organized, and best-conducted
hospitals of the old world, with the view of indicating
the relative value of the treatment, can scarcely be con-
sidered a happy one : in the latter, the most favorable con-
ditions for treatment under every method obtain, while in the
former the most unfavorable conditions are coupled with an
unselected mode of treatment

The fact, therefore, "that the mortality from pneumo-
nia in a large number of Confederate hospitals was greater
than the mortality in this disease under the different modes
of treatment in European hospitals" loses its importance,
since it can not be taken as a test (as was designed) of the
methods of treating the disease in the South. The results
were worse than the worst there employed, because the
conditions, not the manner, of treatment were so also.

1867] Confederate States Military Hospitals. 45 1

We venture to assert that our medical officers, as a gene-
ral rule, had no choice in the matter : in many cases they
had to improvise the means of treating disease, and, dis-
regarding for the moment mere medicines, could not so
much as command suitable dietetic measures. If their
facilities had equalled, we shall not presume to say those
of the European hospitals, but those of their implacable
enemy, who condemned as contraband of war even medi-
cines and instruments, they would now have no reason to
shun the comparison.

While mournfully admitting that their hospital records
are "bad enough," indeed "no better, and even worse
than the heavy mortality characteristic of the rigid anti-
phlogistic method with bleeding, blistering, calomel, and
opium, and tartar emetic," they can yet proudly challenge
the charity of the profession by an exhibition of the des-
perate circumstances under which they contended with
disease. Destitute of the means and conditions necessary
to success, their records only prove that soldiers, like others,
will die in great numbers when adversely situated.

We are not attempting a criticism of this article, nor a
mere defense of Confederate surgeons : simply wish to
place in proper connection with the disastrous record
those unfavorable conditions which had more to do in
producing it than the worst system of therapeutical man-
agement possible. Surgeon Jones was too generous and
courteous an officer to cast censure even inadvertently
upon his colleagues-in-arms. Although familiar with their
embarrassments, he will doubtless be gratified with the
publication of all the conditions which determined or in-
fluenced the gross results which he has manipulated.

Having organized and had charge of one of the hos-
pitals* which he cites for eleven months (April, 1862, to

* Floyd House Hospital, then known as General Hospital, Macon, Ga.

452 Doughty on the Medical Statistics of the [March

March, 1863), when its highest mortality occurred, we
have better knowledge of the circumstances connected
with its mortality, and have the pleasure of giving to the
profession the first sanitary report of that institution, as
evidence of the facts stated. Surely, they will agree with
us in the exclamation that " under such circumstances it
is not astonishing that many died nay, it is rather more
so that more had not died."

SANITARY REPORT,

Accompanying the Report for the quarter ending June 30, 1862.

Reports of this kind are expected to reflect all the circumstances
that may have influenced the mortality at this post, or modified the
type of its prevailing diseases. In the present instance, a brief notice
of the circumstances that led to the establishment of the General
hospital at Macon, Ga., should be given, since it will bring to view the
first of a series of influences highly prejudicial to those who were to
be benefitted by it, viz. : the improper transportation of the sick.

After the fall of Fort Pulaski (April 11th) the military authorities,
apprehending an attack upon the city of which it was a defensive out-
post, ordered the immediate removal of the sick at and in its vicinity
to the interior. Unfortunately, this removal was attempted and exe-
cuted without discrimination as to the condition of the sick or their
ability to stand it ; the necessity of the case outweighed the question
of propriety, and all alike, the convalescent and the critically ill, were
hurried off to a place of safety.

The greater part, perhaps 220, of those sent here were from Camp
Davis, on the Central railroad, where they had rendezvoused about
the middle of March. The remainder (60) were from the Savannah
hospitals. The former, particularly, were raw and undisciplined; were
chiefly from rural districts, and characteristically careless of all those
important hygienic rules which, whenever and wherever violated, are
sure to inflict misery and suffering. While at the camp of instruction
the weather was exceedingly inclement, being both damp and chilly
from the heavy rains that fell during the early spring and its change-
able winds.

Rubeola, parotitis, pneumonia, etc., the scourges of our camps, soon
appeared and spread rapidly among the troops, laying the foundation
for those diseases commonly recognized as their sequelae- At this
juncture it was attempted to transport them to this city, a distance of
160 miles, in box cars, without a single comfort other than a scanty
supply of straw. During their transit it continued raining and damp,

1867] Confederate States Military Hospitals. 453

and after their arrival at this place they were conveyed upon open
vehicles, through a drizzling mist, to a place provided for their re-
ception.

The latter, like most provisional hospitals established in a period like
the present, being intended only to meet the emergency that gave rise
to them, afforded but a feeble respite from the disagreeableness of
their situation for the previous 36 hours. But two days' notice had
been given the city authorities in which to provide for so large a num-
ber (280), and it was found impossible to obtain clothing or hospital
furniture of any kind sufficient to meet the exigency. The building
was at that time occupied as a low-class hotel, and was exceedingly
filthy and unclean. It consists of two wings at right angles to each
other, and located in the southeastern part of the city, at the intersec-
tion of two streets running northeast and southeast. It is very old and
the interior much decayed in parts and is subdivided into 75 small
rooms, the largest of which can only accommodate ten beds. The halls
are narrow, running through the centre of each wing, with frequent
interruptions by ascending and descending staircases. The second
and third stories are used for hospital purposes, the stores on the first
being let out to Jews and Irish of a low class.

Moreover, the exigency required the retention of the hotel bedding
and other articles of furniture, and upon these the wearied sick of
every disease were indiscriminately thrown ; in some instances two
and even three occupied the same bed. The floors were still covered
with carpets that had not been removed for years ; and to all this was
superadded an insufficiency of nurses, food, and clothing.

At the time of our assignment to duty, 24th April, and even to the
early part of May, many of the sick wore the same clothing that had
been used in camp, and upon exposing their skins the accumulations
were very nearly as thick as the cuticle itself. Volunteer physicians
and nurses did their utmost, but what could they accomplish? Ochlesis
had done and was still doing its work, and nothing but a return to the
innovated laws of hygiene could save those wrho apparently only
awaited their turn for sacrifice.

A few of the sick died shortly after reaching their quarters ; fre-
quent relapses occurred among those convalescent ; and the most dan-
gerous sequelae of their respective diseases manifested themselves.
Very soon the evil effects of crowding, want of ventilation, and un-
cleanliness began to be manifest in the aggravated type of disease and
its fearfully increasing mortality. For several weeks the above condi-
tions obtained, and the result was an assemblage of disease of most
appalling and malignant character, as pneumonia typhoides, febris
typhoides, erysipelas, and one case of phagadaena.* The mildest

* These occurred principally as secondary diseases or relapses, and therefore do not
appear so fully in the return, the diagnosis of the primary disease having previously been
entered.

454 Doughty on the Medical Statistics of the [March

cases were manifestly assuming a low nervous (or typhus) condition.
Parotitis, usually the simplest of the diseases of childhood, was fol-
lowed by acute meningitis and pneumonia typhoides, rubeola by febris
typhoides, pneumonia, and bronchitis capillaris ; and the few cases of
febris intermittens that were then present readily assumed a typhoidal
aspect. Under such circumstances, it is not astonishing that many
died nay. it is rather more so that more had not died. As an evi-
dence of the disastrous effects of these influences, there occurred be-
tween the 13th of April the period at which the hospital was opened
and the close of the month, nineteen deaths, three of which were
from febris typhoides, seven from rubeola, the sequel of which was
pneumonia, and nine from acute pneumonia. Moreover, fourteen-
fifteenths ( 14-15) of the mortality for May occurred among the subjects
thus exposed, and twelve-fifteenths (12-15) of the number by the 15th
of the month (as will appear by the register of the hospital) and
during the continuance of the above injurious circumstances. One of
the deaths from febris typhoides was a relapse about that period.

It thus appears that thirty-four (34) of the forty-one (41) deaths re-
ported Jor the quarter are ascribable in a great measure to the 'prejudicial
circumstances surrounding the sick during and after removal from camp.

It was not until the middle of May that good nursing, well-prepared
food, cleanliness, and other proper hospital accommodations were pro-
vided for the sick, since which time the type of the prevailing diseases
has changed and the mortality become greatly diminished, as will
appear by the mortality for June less than half that for May
although at one time during the former there were 170 cases on hand.

Respectfully submitted.

WM. H. DOUGHTY, Surgeon in Charge.

Iii connection with the above report, we would beg
leave to remind our readers that, under the military forms
employed for the registration of diseases, neither the
hospital register nor the reports of sick and wounded
based upon it present a record correct and complete in
every particular; the medical statistics, as contradistin-
guished from the surgical, are rendered incomplete, from
the fact that "Form II" of the Eegulations, which is the
one prescribed for the register, makes no provision for
the registration of secondary or supervening cases, which,
under some circumstances (as under those depicted in the

1867] Confederate States Military HospitaU. 455

above report), become very prominent in hospital experi-
ence. The form requires the entry of the original or pri-
mary " complaint," but the secondary are unprovided for,
unless the surgeons feel interest enough to prompt its
notation among the incidental facts pertaining to the case,
under the general head of "remarks." This places it
upon so insecure a basis as to cause its oversight in many
instances, and to restrict this method of recording them
to the most striking cases. The reports are mere trans-
cripts of the register for the time embraced, and must
inherit its imperfections. Our attention was drawn to
this defect at an early period, and we took the liberty of
suggesting an alteration in the form, in order to secure
greater accuracy. Toward the close of the war a new
form was adopted which served the purpose, but the
value of the antecedent reports was already impaired.
This is no inconsiderable circumstance. We are satisfied
that many cases escape record in this way, except in the
event of the death of the patient. Many, perhaps the
majority of cases of pneumonia and all other affections of
an intercurrent or secondary nature, that occurred at
General hospital, Macon, Ga., were noted incidentally,
and some probably omitted, but unless the reviewer was
careful to examine the incidental remarks, there would
be great danger of mistaking the actual number treated.
It is very possible, then, for the results of treatment to appear
less favorable, or the proportion of deaths to appear much
greater, where the 'primary diseases are alone made prominent.
Since the close of the war we have been informed from
the Surgeon-General's office that, in regard to secondary
diseases, "it was deemed impracticable in time of war
to use a form of return so complicated as would be neces-
sary for their full registration."

456 Legal Status of the Profession in Georgia. [March

The Legal Status of the Profession in Georgia.

[The following article is from a legal gentleman of this
city of acknowledged ability, also a graduate of medi-
cine, and will be read with interest by the profession.
Ed.]

It will be new to many in the profession to know that
physicians who have commenced the practice of medicine
in this State since the, 6th of March last, and have charged
fee or reward, are liable to indictment under the penal
law, and, upon conviction, to be fined $500, and for the
second offence to imprisonment in the common jail of the
county ; and farther, that all physicians not in practice
on the 1st day of January, 1863, are not legally author-
ized to pursue their profession, at least can not enforce
compensation therefor. Stranger, however, is the fact
that hydropathists and homceopathists are not obnoxious
to these strange and harsh provisions. These gentlemen,
and all other outsiders, except followers of the "reformed
practice of medicine," so called, are favored by our law
to the extent of being authorized to practice and charge
for the same under diploma alone.

A brief review of the history of our State legislation
relative to physicians and their license to practice,
will show how these absurdities have been evolved
from the hands of our law-givers, and may, we trust, by
drawing attention thereto, effect tin organic change in the
law as it now stands upon the statute-book.

The law should be, to a learned, liberal, and benevolent
profession, a stay and prop: it has become a snare and
pitfall.

In order tp insure her people against the effects of ig-
norance, imposture, and empiricism from the wiles of
the quack, charlatan, and mountebank the Legislature
of our State, so early as in 1825, established a board of

1867] Legal Status of the Profession in Georgia. 457

physicians who were annually to assemble, to examine
applicants in all the branches of medicine, and thereupon
to grant or refuse licenses to practice medicine and sur-
gery. No one (excepting such physicians and surgeons
as were at that time in the practice) was allowed to
prescribe or perform an operation and charge therefor
without a license had been first had of this board. In
order to make this provision effective, no debt, no matter
what shape of bond or note the obligation had assumed,
or into whose innocent hands for value such note or bond
might have come, could be collected, the consideration of
which was the medical services of one who had not been
duly licensed. And to add a still stronger sanction, it
was enacted that, should any person thereafter presume,
without such license, to practice physic, surgery, or in
any manner prescribe for the cure of disease for fee or
reward, he should be liable to indictment, and on convic-
tion should be fined a sum not exceeding $500 for the
first offence, and for the second to be imprisoned not
exceeding the term of two months. If any applicant had
received a diploma from any Medical college, the board
were to license without examination ; but this was modi-
fied a few years later (1831) by an act which made it
incumbent on the board to examine in all cases, notwith-
standing the exhibition of a diploma, when a doubt arose
:as to the qualifications of the candidate, and by the same
act it was declared unlawful for the board to license any
person whatsoever who should not have produced before
it satisfactory testimonials of good moral character.

The board itself was invested with all the rights and
powers of a corporation to hold property, real and per-
I sonal, to keep a common seal, sue and be sued, to make
by-laws for its government, and to maintain its perpetuity
by filling vacancies occasioned by death, absence, resigna-
tion, or otherwise. The book in which the names of the
36

458 Legal Status of the Profession in Georgia. [March

licentiates and the dates of granting the licenses were
entered was raised to the dignity of a record, and a certi-
fied transcript from the same was declared competent as
evidence in every court of justice in the State.

The whole spirit of these acts (1825-1831) and every
letter of them, manifested an intention on the part of the
Legislature to render this board one of the fixed and
permanent institutions of the land.

Had the scheme been fully carried out, according to
the design of its contrivers, it is not difficult to conceive
the good it had accomplished. Not only would the citizen
have been protected against the blunders of the illiterate
and the vices of the sharper, but much reproach would
have been arrested which has fallen on the followers of
our calling. A license would have afforded presumption
at least of fair acquirement and of good character on the
part of its possessor.

The board of physicians, with its corporate powers and
ample discretion, had hardly commenced its sessions, and
entered upon the performance of its high trusts, before
its action was rendered ineffectual, and barren of good
results. So soon as an applicant had been refused a
license for want of character or lack of attainment, he
applied to the Legislature for relief, and this body never
failed to pass a private act in his behalf, and to grant him
those privileges which the board had, under the obligations
of their office been forced to deny him. The discovery
was made in a short time, that it was less expensive, as
well as more convenient and certain, for the candidate to
apply to the Legislature for license than to repair at some
appointed time and place and stand an examination by
the board. The latter cost time and money and was of
doubtful issue, while the former was certain in result,
required only the promise of his county member, and
cost nothing but a vote.

1867] Legal Status of tJie Profession in Georgia. 459

The functions of the board become idle as the wind,
and that body soon closed its sessions. The act was re-
pealed in 1836, revived in 1839, and re-enacted in 1847,
when a new board was nominated. At the same session
a Botanico-Medical board was instituted by the Legisla-
ture with the same powers and duties in reference to
candidates for practice in this persuasion. This fact of
itself was sufficient to render nugatory any and all action
of the regular board, but the same old causes continued
to operate and defeat the good which was intended to
be accomplished. At every session of the Legislature
acts were passed with muster-rolls of names who were
authorized to practice medicine and surgery, and charge
for the same without farther license. As a sample of
these we may instance one, in which this authority was
given to "practice medicine on the Dutch and Indian
plan." The board met but once or twice, if at all, and
had discontinued its functions, when in 1854 an act was
passed authorizing any graduate of a Medical college of
the United States to practice medicine and surgery, and
to charge for the same.

Thus stood the law of Georgia when the Code was
adopted (1862). The Code substantially re-enacted the
act of 1825, declared there was in this State a board of
physicians of the allopathic school of medicine, and also a
board of physicians of the reformed practice of medicine,
conferred on each the like powers and duties, declared
debts not collectable without a license from the one or the
other, and made the practice for fee or reward without a
license penal by ~&ne and imprisonment. Thus these pro-
visions only repeated what had been on the statute-book,
but the anomaly was produced by adding what was not
before known to the laws of Georgia. Section 1,348
provided : " Neither board can license persons to practice
in a school different from their own. Plu/sieians belonging

460 Bailey on Knee-joint Resection. [March

to a school of medicine not represented by a board of physi-
cians may practice wider their diplomas alone." The Legis-
lature of 1866 made a few alterations, such as that of the
act of March 6th, which declared that the penalties for
practicing without a license were not to be enforced
against physicians practicing since the adoption of the
Code and before the passing of that act. And the act of
March 9th, which exempted from the provisions of the
Code all who were in practice under legal diploma on the
1st day of January, 1863.

So that at this day the law upon our statute-book reads :
If the graduate be of the regular school of medicine, he
must first obtain a license before he shall attempt to gain
a livelihood in the pursuit of his profession, from a board
of physicians, which the law says exists, but which in fact
does no such thing. He is, therefore, required to do work
gratuitously, or subject himself to criminal punishment.
But if the graduate be Hydropath, Homoeopath, or Dutch
and Indian doctor he has full authority to practice and
charge by virtue of his diploma, which throws around
him a mantle of protection from those penalties to which
the learned, scientific, regular practitioner is made liable.

Ita lex scripta est. It seems it should only be named to
be speedily abrogated.

A Case of Knee-joint Resection. By A. W. Bailey, Sur-
geon 1st Eeg't S. C. V. Infantry.
Lieut. J. W. Harlee, Co. I, 1st Reg't S. C. V. Infantry,
Bratton's brigade, age about twenty-seven years, and of
robust constitution, was wounded in the battle of the
Wilderness, May 6th, 1864. A minnie ball passed late-
rally through the right knee-joint, fracturing the head of
the tibia. A curved incision was made, extending from
one condyle to the other, reaching just below the inferior

1867] Dugas on Surgical Pocket Case. 461

border of the patella. All the ligaments with the synovial
sac were divided, and the semi-limar cartilages removed.
A transverse section of the head of the tibia, embracing
the fractured portion, was made above the articulation
with the fibula. The patella was not ablated. The wound
was closed with sutures and adhesive straps, and the limb
secured to a long outside splint. The next day he was
transported about twenty-five miles over a rough road to
the rear, and two of the sutures cut out, thereby exposing
the internal condyle. In a short time the exposed sur-
face was covered with healthy granulations, and the space
soon filled up. In the course of six or eight weeks true
anchylosis had taken place, and the wound healed, except
a small place where the condyle was exposed, leaving a
small fistula, which healed in a short time afterward.
This officer, who returned to his command to be retired
on the invalid corps, gives the following account of the
treatment carried out after being sent to the General hos-
pital : He was furnished with a quart of good whiskey
daily, and requested to drink as much as he could, and
use the balance on his leg. He says he drank the quarter
portion each day, and dressed his wound twice daily with
one part of whiskey to three of water. His leg is about
three inches shorter than the other, wears a high heel
and thick sole to his boot, by which means he is enabled
to walk without crutches, and even dance with ease.
Barnwell Dist, S. G, Dec. 13, 1866.

Surgical Pocket Case. By L. A. Dugas, M.D.
In the construction of pocket cases of instruments for
the use of general practitioners of medicine and surgery,
the makers have heretofore seemed to be governed by
neither fixed principles nor definite purpose. The conse-
quence is, that these cases differ exceedingly in the kind

462 Dua as on Surgical Pocket Case. [March

and n amber of instruments they contain, and are rarely
found to answer the purpose for which they are obviously
intended.

A pocket case should contain not only such instruments
as are of daily use in practice, but also such as may be
needed in cases of emergency, which require immediate
action. This is especially necessary with country practi-
tioners who may be at considerable distances from home
when called upon for professional services requiring the
use of instruments. A pocket case should, therefore, not
be a mere dressing case, but one adapted to the relief of
all affections which demand prompt attention.

The instruments, moreover, should be made by the
most approved patterns, in order to be useful : for there
is nothing more disagreeable than to have to depend upon
ill-shaped or otherwise badly-constructed instruments.
They should be made light, and placed in a morocco case
provided with a good clasp.

With these views, I had a case made many years ago
for my own use, by Charriere, of Paris, and have en-
deavored to have similar ones manufactured in our coun-
try. The greatest difficulty encountered by our dealers
has been in securing instruments made from good models.
Few, if any, of our manufacturers seem to understand
the importance of working with approved models, and
the consequence is that very many of their instruments
are comparatively worthless. Charriere, by devoting his
life to the business, has succeeded in adapting his instru-
ments to the wants of the surgeon more effectually than
any one else; and his patterns should, therefore, be
adopted in this country.

My case is constructed as follows:

1. Jointed silver caustic-bearer (porte-caustique), divi-
ded into three parts: one for nitrate of silver; one for
sulphate of copper; and one containing a cataract needle>

1867] Dugas on Surgical Pocket Case. 463

for the removal of motes from the cornea, etc. The
closed instrument is four inches long, but may be length-
ened to live and a half inches by inverting the joints.
This is one of Charriere's most ingenious contrivances.

2. Female silver catheter, with jointed extremity, which
may be removed to give place to an adult or an infant
male catheter of the same metal, also contained in the
case.

3. Dissecting forceps with slide, so as to be used as
artery forceps, the extremity being so rounded as to allow
the ligature to slip over jt and lodge upon the artery. The
inner surface of the jaws serrated and grooved, to serve as
a needle or pin bearer.

4. A thumb lancet.

5. Delicate dissecting forceps for extracting bodies in
the nostrils and ears, eye-lashes, etc.

6. Spatula of soft iron, which may be bent for use as a
curved spatula; the other end being of hard steel, termi-
nating in a serrated point, for use as an elevator of frac-
tured cranium.

7. Belloc's instrument, for arresting nasal hemorrhage.

8. Scissors strong, straight, and blunt pointed.

9. Ear scoop with tumor hook at the other end, which
may be made double by drawing down a slide.

10. Silver grooved director, with the handle split so as
to serve for cutting the fraenum linguae.

11. Two silver probes with eye ; different sizes.

12. Two silver probes with grooved director ; different
sizes.

13. A tent-bearer (porte-meche).

14. Polypus and shot forceps, as long as the case will
admit ; will do also for dressing wounds, removing bodies
from the pharynx, etc.

15. Dupuyten's oesophageal hook and probang; with
three joints, so as to be admitted into the case.

464 Dugas on Surgical Pocket Case. [March

16. Large and small convex bistonris in one handle, with
slides or spring backs.

17. Large and small straight bistonris in one handle,
etc., etc.

18. A straight, probe-pointed bistouri of usual size, and
a very small and sharp-pointed straight one, for opening
whitlows, abscesses, etc., in one handle, etc., etc.

19. Gum lancet and grooved exploring needle, in one
handle, etc., etc.

20. Tenaculum and artery needle for ligations, in one
handle, etc., etc.

21. Six semi-lunar suture ueedles, and six straight ones,
of assorted sizes.

22. Silver wire and saddler's silk, for sutures.

The handles of the double instruments should be made
of tortoise shell, and should be long enough for the
blades at each end to work easily, with slides or spring
backs.

The cost of such cases may be lessened by substituting
German silver for the pure metal, and some other material
for the tortoise shell. But when we consider that a good
pocket case will last one's lifetime, it will be found
cheaper in the end to get the best at first.

The case which contains these instruments is, when
closed, six and a half inches long and three inches wide.
When open its greatest length is eight and a half inches,
including the flap for clasping. It folds in the middle.
With contents complete, it weighs only twelve and a half
ounces. Thus constituted, the case actually contains
thirty-two instruments, besides the needles, wire, etc., in
such a small compass as to make it portable as a pocket
companion without inconvenience.

1867] Evans on Bromide of Potassium. 465

ECLECTIC.

Bromide of Potassium in Epilejwj. By Horace Y. Evans,
M.D.

It is a matter of surprise that the bromides of potassium
and ammonium have not come into more general use in
the profession.

Dr. Hammond's little book awakened some of us to a
realization of the fact that insomnia could be successfully
treated without the use of opium ; and further, that in
many cases of wakefulness it was positively contraindi-
cated ; yet how very few think of using the bromide of
potassium in this affection.

Sir Charles Locock made public, years ago, his success-
ful use of this remedy in hysteria ; yet the old and offen-
sive drugs are to this day used nine times where the more
agreeable and effectual bromides are used once.

Delirium tremens can be throttled at its very outstart
by this medicine, yet how rarely does a case in private
practice escape the routine of opium, alcohol, blisters,
digitalis, lupulin, and capsicum. In no disease have their
beneficent effects been more marked than in epilepsy.

I propose, therefore, relating the three following cases
of this disease out of eight within my knowledge, treated
with the bromides.

Case 1. Farmer, aged thirty, living in a miasmatic re-
gion. Enjoyed perfect health until attacked with ague ;
was treated with quinia, and the chills checked. Then
followed convulsions, which at first resembled, as far as
the pulse was concerned, apoplexy, but soon became
clearly epileptic. The attacks returned at irregular inter-
vals of from seven to ten days. He had been carefully
treated with remedies such as the symptoms from time to
time indicated. When he came under my care he was
using tonics and alteratives, and ice-bag to the spine.
87

466 Evans on Bromide of Potassium. [March

His pulse was 98, full and strong, tongue furred, bowels
sluggish, disgust lor food, very restless, severe headache,
and marked mental confusion. I continued the ice-bag
to his spine half hour daily, ordered saline purge every
day, and farinaceous diet. He was very soon visited by
another convulsion, which left him in a dull melancholy
condition, severe headache and insomnia, but no paralysis;:
commenced next day with the bromide of potassium, gr.
xv, three times a day ; continued the saline mixture, ice.
bag, and restricted diet. An improvement in all the
symptoms commenced within twelve hours, and at the
expiration of four weeks the patient was apparently well ;
there was no return or tendency to return of the convul-
sion. All treatment was then omitted, and at the expira-
tion of seven weeks from the commencement of the
treatment, considering himself well, he returned to the-
use of animal food, which was followed within ten hours
by the most severe epileptic fit of any that he had had
and two days later by another. He then returned to the
city and was again put upon the use of the bromide and
the ice-bag. As at first, the improvement was rapid, and
at the expiration of a fortnight, without my consent*
omitted all treatment. He returned to the country, used
promiscuous diet, and has now passed through the fever
season of the locality without ague or convulsions. Says
he was never in better health than at present.

Case 2. G. M , a young man twenty-one years of ager
apparently in a good physical condition, has had epileptic
convulsions for the past fifteen years, and at the time of
commencing his treatment (March, 1866) he was having,
on an average, three attacks a day. He was ordered a,
saline purge twice a week, ice-bag to spine one hour
daily; bromide of potassium, gr. xx, three times a day,,
and total abstinence from animal food. The interruption
in the attacks was immediate; he continued without even

1867] Evans on Bromide of Potassium. 467

an Maura," or any other evidence of the presence of the
disease, for nine consecutive weeks.

The peculiar effects of the bromide, named by Bazire
bromism, having now become developed, the drug wftfi
omitted for two days, Huxham's tincture of bark, and a
more liberal diet substituted. Before the end of the
second day, a severe convulsion returned, and was fol-
lowed by numerous aura epileptica or minor "spells."
The bromide was immediately resumed, and its use con-
tinued for three weeks without a return of the disease.
The increased flow of saliva, sore throat, and restlessness,
again gave premonitions of the return of bromism. The
dose was now reduced to gr. x, ter die. Again the lurk-
ing foe took advantage of the truce and made several
sorties, which were repulsed by the bromide of ammonium,
with the iodide of potassium as an ally. Another month
now elapsed without an attack, but the combination last
used became so offensive to him that it had to be omitted,
and the bromide of potassium resumed in gr. xx doses,
which is now (November) being used with results beyond
the most sanguine anticipations.

Case 3. Mrs. B. B , aged twenty- eight, the mother of
two children. Insanity and epilepsy in her family. After
a serious family trouble, was attacked with convulsions at
intervals of a fortnight. The disease was diagnosticated
hysterical epilepsy, chiefly on account of the long duration
of the convulsion. The usual treatment for hysteria
scarcely palliated the insomnia and almost delirium
during the intervals. Having seen an account of Lo-
eoek's treatment of this disease with the bromide of
potassium, I was induced to give it a trial. She com-
menced with gr. xx doses three times a day, and an addi-
tional dose at night if necessary to produce sleep. Within
a week every vestige of the disease had vanished. The
medicine was contiuued in reduced dose3 for a month.

468 Evans on Bromide of Potassium. [March

after which it was entirely omitted. Four months have
since passed without a symptom of hysteria or epilepsy,
notwithstanding the continuance and actual increase of
her family troubles.

I have in my possession notes of other and aggravated
cases of this disease, which have been so far interrupted
and modified by this treatment, that the patients have
been enabled to commence life almost anew. The three
just given are the forms with which we most frequently
meet, and therefore cover the whole ground; namely,
first, those having an apparent or known cause ; secondly,
congenital ; and lastly, hysterical. The first and third, we
have reason to believe, are cured. The second is so far
palliated as to give periods of entire exemption ranging
from three to four months. The modus operandi of this
drug has never been satisfactorily explained. The author-
ities tell us that it has alterative, resolvent, and sedative
effects upon the nervous system.

Looking as we do upon the convulsion as a symptom
of the disease, and that the disease consists of an irritated
and congested condition of the brain, medulla oblongata,
or spine, then the ice-bag comes in as an important aux-
iliary in producing sedation though in numerous cases
the drug has performed the whole work single handed.
It seems to me that the field of usefulness for this medi-
cine is very extensive. It dispels a large proportion of
the aches and pains met with in women. Neuralgia,
refusing subservience to all other treatment, has yielded
to this. So also with chorea, headache, and the forming
stage of delirium tremens. It palliates the patoxysms of
pertussis. Dr. M. A. Withers, of Pottstown, related to
me a case under his care, of melancholy, culminating at
times in insanity, which has been so far improved by the
use of large doses of this medicine as to give strong hopes
of eventual recovery. Am. Jour, of Med. Sciences.

1867] Use of Thermometer in Diagnosis, etc. 469

Use of the Thermometer in Diagnosis and Prognosis.

The number of the Neio York Medical Journal for No-
vember last contains some interesting remarks by Prof.
Austin Flint on the thermometric phenomena of disease,
a subject which has latterly engaged the attention of
clinical observers in Germany and Great Britain. The
following propositions contain the substance of his re-
marks :

1. The thermometer is indispensable for obtaining ac-
curate information of the temperature of the body, the
perceptions of patients and the sense of heat or coldness
communicated to the hand of the physician being alike
fallacious.

2. In the essential fevers and all acute affections, the
heat of the body is more or less above the maximum of
health ; and the increase of heat, as a rule, persists during
the career of the disease. Fevers and acute affections
may, therefore, be excluded by the fact of the heat of the
body remaining within the limits of health ; and the ex-
istence of an essential fever or an acute affection of some
kind may be predicated on a persistent increase of heat.

3. A fever is purely malarial, that is, it is not a con-
tinued fever, nor is it associated with a continued fever,
if, between the exacerbations, the temperature fall nearly
or quite to the range of health.

4. The diagnosis of neuropathic affections which simu-
late inflammations may be based on the fact of the tem-
perature not being raised.

5. Coma from uraemia may be discriminated from the
coma occurring in fevers or dependent on meningitis, by
finding the temperature not raised; and in cases of
uraemia, coma, and convulsions, intercurrent inflamma-
tory affections may be excluded if the temperature remain
normal.

470 Use of Thermometer in Diagnosis, etc. [March

6. In tuberculous affections, when tuberculization is
going on, there is more or less increase of heat. In cases
of suspected tuberculosis, a normal temperature shows
either that tuberculosis does not exist, or, if existing, that
it is not progressive.

7. In cases in which the history and symptoms excite
fears of the existence of meningitis, the existence of this
disease is not probable if the temperature be not in-
creased ; and, on the other hand, increase of temperature
sustains these fears, provided the patient have not an
essential fever.

8. The amount of increase of heat, as shown by the
thermometer, provided the increase be not transient, is
proportionate to the gravity of the disease, and. is a crite-
rion of the immediate danger. A persistent temperature
of 105 alwaj^s denotes great severity of disease, and a
still higher increase renders it almost certain that the
disease will speedily prove fatal.

9. The temperature in the different essential fevers and
inflammations is governed by certain laws as regards
progressive increase, daily fluctuations, and the rapidity
or slowness with which it returns to the normal standard
(defervescence) of the time of convalescence. Each essen-
tial fever or inflammatory affection has its own laws in
respect of the points of difference just named; and any
notable deviation from these laws, in individual cases, is
an unfavorable prognostic. Thus, a decrease of heat
below the normal range may indicate an internal hemorr-
hage, and a sudden increase may point to an important
complication or the occurrence of an intercurrent affec-
tion. Mildness of the disease, and the absence of com-
plications or intercurrent affections may, on the other
hand, be predicated on the disease pursuing its regular
course as regards temperature.

10. The surest evidence of convalescence from an es-

1867] Hicks on Nffii-Blmdmesk. 471

sential fever, or an acute inflammation, is a return of
temperature to the normal standard. If an increase of
temperature persist, after apparent convalescence, or, in
self-limited affections, after they have reached the end of
their career, either morbid conditions pertaining to the
disease continue, or some affection has heen developed as
a sequel to the disease. Hid.

Niqht-Blmdness in the Confederate Army. Bv Robert J.
Hicks, M.D., Williamsburg, X. C.

This is a curious and obscure disease, called, according
to Lawrence, nyctalopia, as often as hemeralopia, and as,
according to the same high authority, these learned terms
have been the cause of great confusion, I have preferred
the simple English term, because it is free from all ambi-
guity. "While the highest authority is on the side of
hemeralopia, philology would rather support the latter
nyctalopia being derived from the Greek, meaning inca-
pacity on the part of the eye to transmit the impression
of light at night. While in the army I, with others, were
in the habit of calling this disease hemeralopia. Medical
writers seem to differ as widely, with regard to its cause
and pathology, as they do in reference to its appropriate
name. And the accounts hitherto published have been
so meagre and contradictory, that I thought a more ex-
tended notice might not be unacceptable to the medical
profession, especially as it was a source of such very great
inconvenience in our army, although not a serious affec-
tion in the great majority of cases.

For a disease so common in armies, it seems to have
attracted but little attention. It is casually noticed by
Baron Young, in Xapoleon's Egyptian campaign; called
forth a short report in the Crimean war, and has a short
notice from Lawrence, and about half a page from Littelh

472 Hicks on Night-Blindness. [March

It is said to occur occasionally at sea ; is very rare in
private practice ; but prevailed in the Army of Northern
Virginia so extensively as to resemble an epidemic.
Soldiers attributed it to the effect of the moonlight falling
upon their eyes while sleeping upon the ground. Among
medical writers it is considered by one " a species of
amaurosis;" by another "a species of impaired sensi-
bility of the optic nerve," and by others a " sort of par-
alysis of the retina," generally concurring, however, in
the belief that the disease has its seat in the nervous
apparatus of the eye, and that its cause is to be found in
the effect of excessive light. While differing from their
opinion, I shall not discuss them; but on the contrary
give the simple result of my own observations.

This disease prevailed most extensively in the Army of
Northern Virginia, when encamped in the vicinity of
Fredericksburg. The affection is gradual in its' approach
and development. The soldier, who had marched all day
without inconvenience, would complain of blindness upon
the approach of early twilight, and make immediate
application for transportation in an ambulance. At such
times he would be found blundering along just as a blind
man, holding on to the arm of his companion. There was
an entire absence of all constitutional symptoms, and the
eyes appeared, upon inspection, perfectly natural. Some-
times both eyes were affected, but frequently only one.
In the latter case little complaint was generally made.
It was not, therefore, surprising that medical officers
should have been sceptical regarding the very existence
of the disease, and should have frequently accused the
patient of malingering. I confess I shared in this feeling
until accident placed in my way what I consider a certain
means of deciding the existence of the complaint. It is
the use of simple candle-light in the examination of the
eye, after the sun lias disappeared. To such light the

1867] Hicks on Night-Blindness. 473

pupils refuse to respond ; and such was the uniform result
in all my examinations. It was a curious circumstance,
that the pupil should remain dilated, and the patient fail
to see that the ciliary nerves and the retina should lay
aside their functions as soon as the sun disappeared, to
resume them again upon his rising. Observing this fact,
and justly attributing it to the more stimulating quality
of sunlight, I concluded that the affection consisted in a
want of tone in the nervous apparatus of the eye a
condition of enfeebled local innervation, reaching no
farther than the retina, and a branch of the ophthalmic
nerves. The remedy successfully used confirms this
view. Cupping, leeching, blistering, mercury, and iodide
potassium, were used extensively, but in my hands did
harm rather than good.

Cases frequently recovered spontaneously, after all
treatment had been abandoned. But a great many of
them were very obstinate yielding to nothing within the
hands of medical officers, except a furlough, and this was
the grand remedy, failing in no instance that came under
my observation. The disease resulted from the meagre
diet, the absence of vegetables and vegetable acids, and
other depressing influences of a soldier's life. The proof
of this is found in the fact that the removal of these in-
fluences and the substitution of those of home its clean-
liness, improved diet, and relief from mental anxiety and
physical exhaustion, never failed of effecting a speedy
cure. It is furthermore well known that poverty and
want and filth are the fruitful sources of those affections
of the eye which are most similar to this, and which are
of most frequent occurrence in the degraded portions of
the populations of large cities.

As before remarked, in the great majority of cases this
disease is little more than an inconvenience a simple

38

474 Hicks on Night- Blindness. [March

inability to see at night, with no other unpleasant symp-
toms. Littell, however, remarks that, although the prog-
nosis is generally favorable, if not treated properly
incurable amaurosis is apt to follow. Among the very
large number of cases that came under my observation,
there never was any such result. There was, however,
of this number, amounting probably to more than a hun-
dred, one of great interest, because it seemed that this
debility of the nerves of the eye extended to the brain,
and produced a fatal result. Our records were all lost at
the surrender of General Lee, and I can, therefore, give
the history of the case from memory only.

It was in the person of a private of the twenty-third
North Carolina regiment, and occurred at Williamsport,
Maryland, after a long and fatiguing march down the
Valley of Virginia. When first brought to me, this
soldier was found to have been suffering for several days
from inability to see at night. Being examined at night
by candlelight, the pupil was found dilated, and refusing
to respond to the stimulus of this inferior light. On the
next day he complained of considerable debility. In the
course of the day, this debility had increased, and was
attended with some obtuseness of intellect. The pulse
became weaker, and there was a disposition to coolness of
skin. When night again came on, the night-blindness
was still farther aggravated. The stimulating plan of
treatment being clearly indicated, was used, but failed
utterly to retard the progress of the disease. On the
next morning all the above symptoms of depression had
become greatly aggravated, and within seven or eight
hours he died without a struggle. Being interested in
this disease, I watched the progress of this case with
great interest, and it seemed to me to be essentially one
of debility or depression. The enfeebled or atonic condi-

1867] Hicks on Night- Blindness. 475

tion of the nerves of the eye seemed to quietly but rapidly
extend to the great nervous centres, depressing them
beyond the point at which vitality was possible.

It may be possible, but I think it hardly probable, that
these two affections the one of the eye and the other of
the brain should have been coincident only; for the one
seemed quietly to deepen into the other, in a similar and
most connected manner. There was a gradual exhaustion
of all the sources of life death steadily proceeding from
circumference to centre. There was an entire absence of
delirium trismus and spasmodic action of the muscles of
the back, attendant upon cerebro-spinal meningitis, under
which head, no doubt, some would have reported it.

Should this complaint be met with in private practice,
which, though very rare, occasionally happens, the proper
plan of treatment, as deduced from the above facts, would
be the use of those articles calculated to give tone to the
system. Iron might be used with advantage, as protracted
cases are apt to become ansemic ; and as the disease is
most prevalent when symptoms of scurvy manifest them-
selves, vegetable acids, in all probability, would be of
service. These are not only great anti-scorbutics, but
may be considered tonic, inasmuch as they perform a very
important part in the digestion and assimilation of food.
It is also highly probable that some local stimulating ap-
plication, as advised by some, might be of advantage.

But to comprehend the whole plan of treatment in a
few words, I would recommend, in the first place, to
remove all known or supposed causes a recommendation
that applies as well to all other diseases ; and in the second
place, to follow that plan of treatment which approxi-
mates most closely in its effect to that of a furlough upon
a soldier. Richmond Med, Jour.

476 LeConte on the Law of the Sexes. [March

" On the Law of the Sexes ;" or the Production of the Sexes
at Will By Joseph LeConte, M.D., Professor of
Chemistry and Geology in the University of South
Carolina, Columbia, S. C.

The following is a very brief extract, condensed from
the American Journal of Science and Arts, for July, 1864,
and January, 1865, of an important memoir of M. Thuny,
of Geneva, and of an account of some experiments of M.
M. Coste and Gerlee on the law of the sexes. The origi-
nal memoir of M. Thuny was published in the Bibliotheque
Universelle in 1863, but, as we have seen no notice of it
in the agricultural or physiological journals of the South,
we think the intelligent public, as well as the medical
profession, will be interested in this abstract.

M. Thuny was first led to his conclusion by the follow-
ing well-known facts :

1. The fundamental or morphological identity of the
sexes. From this he concludes that the difference of
sexes is due to slight differences in the process of devel-
opment of the ovum in its earliest stages.

2. That in plants (those which are unisexual), the
character of the sex may be controlled by the manage-
ment of external agents.

3. 'That, according to Huber, ova of the bees, if fecun-
dated early, produce workers (females), whilst, if fecun-
dation be retarded until the twenty-second day, all the
eggs deposited produce males.

For these reasons M. Thuny concludes that the sex is
determined previous to fecundation, or rather by the
maturity of the ovum at the moment of fecundation.

It is well known to physiologists that there is a devel-
opment, and therefore a history to the ovum previous to
fecundation. If no fecundation takes place, the develop-
ment is arrested at a certain stage, and the ovum perishes;

1867] LeConte on the Law of the Sexes. 477

but if fecundation occurs there is a new accession to life's
force, which suffices to carry it through all stages of
embryonic and extra-uterine life.

Now, according to M. Thuny, during the earlier stages
of the anti-fecundation history of the ovum, the sex is
female ; but if the development continues without fecun-
dation it becomes male. By impregnation the sex is fixed
for ever. If, therefore, impregnation takes place while
the ovum is immature, and its sex therefore female, the
embryo will be female; but if fecundation is delayed
until a late period, when the sex of the ovum has become
male, then the embryo will become male.

It is easy to see the important practical applications of
the law. In uniparous mammalia the ovum leaves the
ovary at the beginning of each rutting period in a very
immature condition, and passes slowly through the fallo-
pian tubes, the uterus, and finally, if unfecundated, is
discharged.

Now, during the whole of this slow passage, the ovum
is maturing. If, therefore, fecundation takes place early
in the period of heat, the sex of the embryo will be
female. If later it will be male.

The period of heat, or generative period (as Thuny
calls it), here spoken of, must not be confounded with the
season of heat, or rutting season. All farmers are aware
that during the season of heat there are regular periods of
exacerbation, which in the case of the cow, occur about
every two weeks. These are the generative periods
spoken of by M. Thuny. They are really menstrual
periods, and, if attentively observed, are found to be
always attended with slight menstrual discharges. Now,
if M. Thuny is right, fecundation at the commencement
of the menstrual period will produce females, and later,
will produce males. He does not indicate the exact turn-
ing point.

478 LeCoxte on the Law of the Sexes. [March

Anxious to subject his theory to the test of disinterested
experiments, M. Thuny gave minute directions to M.
Cornaz, an intelligent Swiss stock-raiser, and son of the
President of the Swiss Agricultural Society. These
directions were followed in twenty-nine cases, and in
every case, without exception, the desired sex was pro-
duced. First, in order to propagate the breed of a very
fine Durham bull, M. Cornaz wished to get heifers; he
made twenty-two experiments and got heifers every time.
He then wished to get a few bulls of half breeds to sell
to his neighbors ; he made seven experiments and got
bulls every time.

In the case of multiparous mammalia and birds, the
test is much more difficult, and the results contradictory.
M. Thuny's observations lead him to think that in the
domestic hen " the last eggs laid are the cocks of the
clutch." He accounts for this by supposing that in each
generative period several ova commence to operate to-
gether, but are separated from the ovary successively, and
therefore at the moment of fecundation (which takes
place in the oviduct), the last separated are the most
mature. M. M. Coste and Gebre on the contrary, find
that when several ova are fecundated by one copulative
act, the first laid eggs produce cocks and the last hens.
These results are in accordance with certain observations
which are as old as Aristotle. This great naturalist ob-
served that pigeons laid but two eggs, one of which pro-
duced a male, and the other a female. The celebrated
physiologist, Flourens, confirmed these results of Aris-
totle, and in addition proved that the egg first produced
the male, and the other the female. These observations
of Coste and Gerbc, and of Flourens and Aristotle, cer-
tainly seem to contradict the theory of M. Thuny on
hens ; but that may be accounted for on his theory, by
supposing that during a single generative period, several

1867] LeCoxte on the Law of the iSexes. 479

ova commence to develope successively, and separate
successively at the same stage of development, and con-
tinue their development in the oviduct previous to fecun-
dation. Being thus regularly arranged in the oviduct in
the order of their ages, and therefore of their maturity.
If all are fecundated by one copulative act, the most ma-
ture, or the males would be laid first. Embryologists
must settle the important questions we have started. If
definitely settled, then it would seem that experiments on
hens were best adapted to test M. Thuny's theory ; but
until definitely settled, experiments on multiparous ani-
mals will avail little. In the meantime the experiments
of M. Cornaz on cattle have never been controverted.

Such is a brief extract of the memoir of M. Thuny,
and of the experiments of M. M. Coste and Gerbre, inter-
mingled, however, with some explanations of our own, in
order to make the whole more intelligible. We would
like to see the subject taken up by some of our intelligent
stock-raisers.

The great importance of the theory, if true, both in a
scientific and practical point of view both to the physi-
ologist and farmer, can not be doubted. But the history
of the theory can only be accomplised by intelligent and
very careful observers. The physical signs of the gene-
rative period differ in the different species, and in different
individuals of the same species, particularly in domestic
animals. It is always well marked in wild animals, but
in domestic animals it is often obscure. Close and patient
observations will, however, overcome all these difficulties.
Nashville Journal Med. and Surg.

480 Hamilton on Dislocation. [March

On Dislocation at the Shoulder-joint. By Dr. G. Hamilton,
Falkirk.

[The difficulty in reducing a dislocated shoulder is fre-
quently that it is impossible to fix the scapula whilst
extension is made. Many plans have been recommended
and tried, such as putting the arm through a common
ladder, putting a transverse bar in the axilla, and placing
the patient in a high-backed chair, with his arm extended
over the back.]

About two years since, I met with rather a difficult
case, in the person of a large-bodied and very muscular
man, in which I took advantage of a huge arm-chair, with
a strong high back, which I found in the house. On this
I placed a pillow, for the axilla to rest upon, and with the
assistance of two strong men I reduced the dislocation
very satisfactorily. Another followed, shortly afterward,
where I had no suitable arm-chair, but where I found a
common screen for drying clothes, and this, with the
pillow, also did very well. In a third case, neither of
these being at hand, I mounted the patient on a table,
placed the axilla on a pillow on the top of a door, and
succeeded equally well. About six months since I had,
unfortunately, to make personal acquaintance with this
accident. In passing over a railway bridge, my horse
took fright at a passing train, and came down with me.
In stretching out my right arm to save myself, dislocation
at the shoulder took place, of which I was immediately
made aware by the ugly tearing sensation that occurred.
Fortunately, a house was near at hand, in which I received
shelter. Without losing a moment, I looked about for
some suitable apparatus with which to effect reduction.
Finding nothing better, I got a narrow table, on which I
placed, on its side, a long narrow stool, such as is found
in cottars' houses. On the top of this I had a pillow
placed, on which I rested my axilla, my body being

1867] Hamilton on Dislocation. 481

placed between the two feet of the stool. Two strong
men, who were at hand, kindly lending their assistance,
reduction was effected after a few minutes' traction. I
was so much pleased with the results in these instances,
that I was thinking of having constructed a suitable appa-
ratus which I could keep by me for use in such disloca-
tions, when I cast my eyes upon a set of painter's steps,
which immediately struck me as precisely the article I
wanted. I have used this now in three cases, and its use
seems to me to give very considerable advantages over
the modes of reduction generally employed.

The "steps" I use are four feet ten inches high, and
the moveable support should be fixed with an iron rod,
and not with a rope, as is often the case, as the former
secures a greater amount of steadiness. A pillow is laid
across the top step, and the patient ascends as high as
may be convenient, of course placing the axilla on the
top of the pillow. One or two assistants now lay hold of
the arm, drawing, at first, steadily outward and slightly
downward, traction in the latter direction being gradually
and cautiously increased by approximating the arm to the
steps. Reduction in all the cases I have had has been
effected easily, and even, if I may use the expression,
elegantly, but none of the dislocations had remained un-
reduced for more than twenty-four hours. The great
power that we here possess, however, seems to me to
render it highly probable that, in cases of longer stand-
ing, this simple apparatus will also be found very effica-
cious.

The three agencies mainly to be relied on in ordinary
cases of shoulder-joint dislocation are evidently extension,
counter-extension, and leverage, and especially the com-
bination of these. When the dislocation has remained
long enough unreduced for adhesions to form, perhaps,
also, the putting in practice preliminarily some such
39

482 Hamilton on Dislocation. [March

manoeuvre as Sir Astley Cooper saw the Lancashire bone-
setters use, where they rapidly whirled around the arm
before attempting reduction, may be of importance to the
operator.

In using the " steps/' their height is very convenient
for exercising extension, while the counter-extension
required is made to a great extent by the weight of the
patient's body, the rest being easily supplied by the foot
of an assistant. The height, again, is very important in
exercising leverage power, and its amount at command is
enormous, and of course requires caution in its use. In
laying hold of the arm of a person placed in a position
for experiment, I have the feeling that I could with ease,
if I wished, produce either dislocation or fracture of the
humerus. Here, also, the combination of these powers
is easy and natural, simply by causing the assistants to
approximate the arm to the steps. Almost all our best
surgeons have dwelt upon the importance of employing
leverage in these cases, and yet the usual modes of reduc-
tion supply this very inefficiently. The heel in the axilla,,
or the knee of an assistant, gives us but little; while,
when the pulley is employed, leverage power, from the
points of extension and counter-extension being fixed, is
lost altogether. To remedy this, I recollect seeing Mr.
Liston, as he recommends in his " Operative Surgery,"
endeavor, with a towel under the patient's arm, to lift up
the head of the humerus ; but the power given by this
means is evidently very slight compared with such lever-
age as can be got in using the " steps." With these, even
should the pulley be used, leverage could easily be com-
bined with extension, by gently moving the steps forward;
or, perhaps, this might be done more effectually and con-
tinuously by having wheels attached to the steps.

In brief, this modification of the usual modes of reduc-
tion of these dislocations, which I have proposed, seems
to possess the advantages

1867] Broadbent on Matyncmi Tumors. 483

1st. Of enabling the surgeon to dispense with his per-
sonal exertions.

2d. It gives an amount of power in extension and lever-
age limited only by a considerable of the resistance pos-
sessed by the tissues; and it also enables the operator
easily and naturally to combine these powers.

3d. The position of the patient gives perfect freedom
for the administration of anaesthetics, if such should be
wished or required. Edinburgh Medical Journal, Sept.,
1866, p. 248.

On a New Method by which Malignant Tumors may be Re-
moved, with little Pain or Constitutional Disturbance. By
Dr. W. H. Broadbext, London.

The attention of the author was directed to the treat-
ment of cancer under the following circumstances : In
1864 he was consulted by a lady suffering from cancer of
the breast. By his advice the breast was removed by Mr.
Walter Coulson. The disease returned, and was again
removed in August, 1865. In May of the present year,
a tumor was growing more rapidly than ever near the
cicatrices of the former operations. It was decided that
no further removal wras advisable ; and, unless something
could be done, a miserable fate was before the patient.
The hypodermic syringe is now in the hands of every
physician ; and it seemed to the author that by it some
fluid might be injected into the tumor which might so far
alter its structure and modify its nutrition that its growth
might be retarded or arrested. After considering the
various substances which presented themselves to his
notice, he selected acetic acid, for the following reasons :
1. This acid does not coagulate albumen, and might,
therefore, be expected to diffuse itself through the tumor;
and the effects would not be localized at the point injected.

484 Broadbent on Malignant Tumors. [March

2. If it entered the circulation it could do no harm in any
way. 3. Acetic acid rapidly dissolves the walls and
modifies the nuclei of cells on the microscopic slide, and
might be expected to do this when the cells were in situ.
4. It had been applied with advantage to common ulcer-
ations.

On May 18 the first injection was practised. The tumor
was of about the size of a small egg, and a patch of skin
of about the size of a shilling had become adherent to it.
The needle was introduced through sound skin an inch
or more from the part involved in the disease, and passed
to the centre of the mass. About thirty minims of dilute
acid (one part of acid to one and a half or two of water)
were injected. It gave little or no pain. Next morning
a bulla containing dark bloody fluid was found to occupy
the patch of adherent skin.

May 23. This portion of the skin dry, hard, and horny;
the adjacent part of the tumor not so hard. Again in-
jected.

The patient, residing in the country, was not again seen
till June 7, when the piece of skin mentioned was found
detached from the surrounding sound skin ; and a probe
could be passed in all directions to a distance of three-
quarters of an inch or more between the tumor and the
healthy structures. A little discharge issued from the
fissure mentioned. Injected on this date, and again on
the 9th, the acid used being little stronger. It gave a
little pain, and swelling and tension of the parts around
followed.

On June 13, a few days afterward, there was a free
discharge of fluid and solid portions, with relief of the
swelling, etc. No fcetor whatever attended this discharge,
which afterward diminished greatly.

Seen again on June 26, when, on external examination,
the tumor was found to be much smaller; and, on passing

1867] Broadbext on Malignant Tumors. 485

a probe into the opening, it entered a large cavity extend-
ing on all sides. Part of the walls seemed free from
malignant structure, but at several points a crust of can-
cerous deposit remained. On attempting to inject, it was
found too thin to retain the fluid, which either entered
the tissues and gave great pain, or made its way into the
cavity. The cavity was stuffed with lint saturated with
dilute acid, and the case left in the care of the family
medical attendant, who was to inject as he saw oppor-
tunity.

July 13. No impression made on the remaining disease,
which had, in the opinion of the medical man, extended
somewhat. Carbolic acid was tried for a few days as an
application, but discontinued, and the cavity dressed
daily with strong acetic acid by the medical attendant,
and injections practised daily. This energetic treatment
gave much pain, and excited inflammation all around.

When again seen by the author on August 4, there
had been considerable hemorrhage, which had been ar-
rested by free application of tincture of sesquichloride of
iron. The result, however, was apparently the entire
removal of the remains of malignant disease ; and when
last seen, a healthy granulating surface was left at every
point.

Three other cases were related by the author. The
author further formulated certain conclusions from the
experiments detailed, and stated the cases to which, in
his opinion, the treatment was not applicable. Guided
by his experience, he considered large quantities of dilute
acid preferable to stronger acid ; and he would not, with-
out great hesitation, attempt the destruction of any tumor
which had not involved the skin. His aim had originally
been, as stated in the early part of the paper, not necrosis
of malignant tumors, but a modification in their nutri-
tion. The theoretical grounds for this hope were, that

486 Guillon on Croup. [March

cancer owed its malignancy to its cellular (to use a nomen-
clature now almost antiquated) or foetal structure; and
that in acetic acid we had an agent which might be ex-
pected to diffuse itself through ' the tumor and reach the
cells, and, having reached them, to effect changes in their
structure, and affect them vitally, while it could scarcely
do harm. The results he had brought before the profes-
sion at the earliest possible moment. The ultimate value
of the treatment he left to be decided by a more extended
experience. It was important to use large quantities of
dilute acid, and not to have the acid too strong. Medical
Times and Gazette, Sept. 1, 1866, p. 229.

Rapid Care of Cynanche Trachealis and Membranous Croup,
b]f means of insufflation of pulverised Nitrate of Silver. By
Dr. Guillon.

Cynanche trachealis and membranous croup carrying
off new victims every day, I think it my duty to call
attention to a treatment by means of which that disease
is very promptly cured, even when the false membranes
have extended to the larynx. This treatment, the ad-
vantage of which has been demonstrated to me by long
experience, consists in the insufflation of a very fine
powder of nitrate of silver on the diphtheritic membranes
and the surrounding parts. Were this treatment more
generally known, it would in many cases have done away
with the operation of tracheotomy, which is performed
with success only when the disease does not extend
beyond the larynx.

For the first time, in 1828, I had recourse to insuffla-
tions of nitrate of silver with two patients suffering from
cynanche trachealis ; after having ascertained that alum
was powerless to prevent the spread of the disease, and
that cauterization with a sponge dipped in hydrochloric

1867] Guillon on Croup. 487

acid could not reach the false membranes behind the
pillars of the palate, above it and in the larynx.

Experience having taught me, at a later period, that
nitrate of silver in solid pieces left in the mouth a taste
more disagreeable than when it was pulverized, I adopted
the powder, and have used it pure, well pulverized, and
perfectly dry. Should it be in any way damp, it can be
easily dried by holding it- in a silver spoon over a candle
or hot coals. The only point of importance with regard
to the instrument, is to observe that the powder on leav-
ing the tube is spread all round, and not projected in a
lump covering only one place.

The advantages which I have invariably obtained from
that treatment, make it a duty on my part to call to it the
attention of my confreres : 1st. Because the use of nitrate
of silver, finely pulverized and carried by insufflation on
the diphtheretic membranes and surrounding parts, cures
the disease very quickly, when it begins by the mouth
and larynx. 2d. Because I am convinced that a good
many persons who have died of cynanche trachealis
(angine pseudo-membraneuse), the march of which has been
impeded neither by cauterizations with liquid caustics
nor other known remedies, would have been very
promptly cured, had the insufflations of pulverized nitrate
of silver been used. 3d. Because the projection of that
substance on the false membranes behind the pillars of
the palate, on the palate itself, and in the larynx, causes
their quick expulsion. 4th. Because the styptic action
of that salt on the mucous membrane prevents the disease
from spreading to the nasal fossae and larynx, and from
bringing on membranous croup and membranous coryza.
5th. Because the astriction produced by the expulsion of
the false membranes, spares the patient the intoxication,
the diphtheritic poisoning, resulting from absorption,
when the disease is not checked in its course. 6th.

488 Guillon on Croup. [March

Because, cynanche trachealis being a local disease when
it begins, this local medication, with a suitable regimen,
ought to be preferred to emetics, purgatives, etc., pre-
scribed by some physicians to destroy what they call the
specific morbid element.

It must also be used in preference to the substitutive
medication, recommended by Dr. Trideau, which does
not prevent diphtheritis from extending from the pharynx
to the trachea, and from constituting a croup which soon
becomes fatal. Hear what he says (page 11 of his book) :
" The croup which follows cynanche trachealis, we must
admit, will almost invariably resist all sorts of treatment."

I must here observe that, had this treatment been more
general, we should not have seen so often those cases of
paralysis brought on by diphtheritic poisoning, which
happen in the course of that disease paralysis of the
oesophagus, which compels the use of stomach tubes for
the introduction of food, as also those cases of sudden
death resulting from paralysis of the respiratory organs.

As the insufflations are performed in two or three sec-
onds, and the pain produced by the nitrate of silver is
only felt later, if the patient presented any symptoms of
incipient croup, the first insufflations should be made
when he takes a deep inspiration, so that the powder may
reach the larynx and stop the croup in its beginning,
before the pain is developed.

As the diphtheritic membranes are sometimes formed
again, I use astringent gargles, and should these fail, I
have recourse to a new insufflation of nitrate of silver.

In 1858, Mr. B. and his son were both attacked with
cynanche trachealis. The insufflation in Mr. B.'s mouth
was performed in presence of Mr. Bretonneau ; that on
the son, in presence of Mr. Blache. Two insufflations in
each case were sufficient to insure complete success.
Another cure was obtained on a patient of Dr. Delpech,

1867] Guillon on Croup. 489

a young Belgian princess, suffering from cynanehe tra-
<mealis covering the whole palate and pharynx, with
violent fever and engorgement of the submaxillary glands
and cervical ganglions. Several cauterizations with hy-
drochloric acid having obtained no result, two insuf-
flations of nitrate of silver were performed at two days'
interval, and were perfectly successful. The first insuffla-
tion was done at four o'clock in the afternoon ; and at our
visit the next day, the mouth and pharynx were found
entirely free of diphtheritic exudations, and fever had
ceased. Two days afterward, and notwithstanding the
use of alum gargles, new membranes were formed ; when
a third and very light insufflation was performed, and this
time the cure was complete. Several other examples
might be cited, but these we consider as sufficient.

Wishing to know how far the nitrate of silver pene-
trated into the aerial tubes, we made (Mr. Trousseau and
myself) two insufflations to an average-3ized dog. On
examination, we found the powder had reached the end
of the second divisions of the bronchi.

Since, by insufflation, the powder can be carried as far
as the second divisions of the bronchial tubes, it can be
practiced with advantage to blow powder into the larynx
and trachea, in cases of incipient membranous croup ;
that is to say, in circumstances where tracheotomy is tried
with some chance of success, but often with an unfavo-
rable result. Since this local treatment, used early in
diphtheritis when it begins with the mouth, has obtained
results which can not be reached by applications of liquid
caustics, insufflations of alum or tannin, the use of chlo-
rate of potassa, of bromide or iodide of potassium, mer-
curials, emetics, purgatives, balsams, etc., it seems to us
that this local treatment ought to receive the preference
over all others. Revue de Therapeutique.

40

490 Fletcher on Dressing New Born Infants. [March

Dressing of New Born Infants. By W. B. Fletcher, M.
D., Indianapolis.

If there be one custom of time-honored follv, which
we have continued to this day in the "lying-in-chamber,"
it is that absurd and cruel system of the first dressing.
There is no reason for quoting from the most ancient
authors to find absurdity upon this point, when our most
recent text-books and lecturers give almost the same
directions. But even if they did not, how many phy-
sicians ever personally attend to this important point,
whereby the comfort of the child and mother are all at
stake. In most cases, as soon as the child is born and
the cord divided, it is tied and the baby given to an
employed nurse, some wise neighbor or friend. The
question of " What will she do with it " may best be
solved by watching her. First she huddles it up in an
old shawl or other garment. She is careful to cover its
head, as though it were a young puppy she would
smother; or rid the world of an infant cat. In a few
moments, some one brings water, soap, and towels, and
also a heap of old linen, and a trunk full of new. The
good woman now turns to the blazing fire, or the hot
stove, that the baby may not take cold, and while the
youngster implores with yells and cries, she bakes its
tender skin on one side while she dabbles its head, eyes,
mouth, and body wnth a vile solution of frequently very
bad soap. After this ceremony has been past (it matters
not whether the child be cleaner than before) she turns
her attention to the cord, upon which she frequently
deposits, slyly, some pestiferous saliva, "Its healin'," she
says, and now she follows authority. 1st, She cuts or
bums a hole in the centre of a bit of cloth, through
which she draws the cord ; 2d. She places a rag upon

1867] Fletcher on Dressing New Born Infants. 491

this; 3d. A rag upon that; and 4th. She puts on a
" binder." Now it is upon this operation she prides her-
self, if she be a hireling, that is the closeness and com-
pactness with which she can pin the binder round the
expanding body of the infant; 5th. She puts on a little
garment, called a shirt, which is in fact without body,
neck, or sleeves, as far as protection goes; 6th. She puts
on the "square" with more pins; 7th. She pins on a
" waist " with a long skirt ; 8th. Another waist with a
long skirt ; 9th. A dress. And now the baby is present-
able. The doctor sees it's all right, and goes home. He
hears not within an hour the stifled screams of compressed
lungs, that with every breath are expanding the chest,
and the nurse wisely says it appears " colicky," for which
it must be drenched with some damned decoction of
catnip, sling, brandy, laudanum, water, and molasses, etc.

The next visit the nurse swears it's a good child, only a
little " colicky," but she can cure that, and away the
doctor goes, where he can not hear the little one cry, and
see it dosed for screaming on account of the "cord" hav-
ing become a half putrid, half drying mass, glued and
ulcerating to the tender belly.

This picture may be overdrawn for some cases, or for
some countries (if there be any), where professional
nurses are selected for their intelligence, and not from
the most "vulgar ignorant." One thing I am sure of, and
that is, upon carefully examining, you will find some of
the above named outrages, if not all of them, in force at
once.

In my experience, adopted in some sixty cases, I have
found the following method of procedure give the most
comfort to all hands, by giving the baby no excuse for
those cries, which are hardly ever heard if an infant is
not uncomfortable.

My baby is first quickly washed by oiling the hand and

492 Mitchell on Hypodermic Injections. [March

rubbing the parts to which the secretions have adjiered^
and then with a soft cloth, soft water, and trace of castile
soap, and frequently with warm water alone, the infant
may be cleaned. Then I begin dressing. 1st. A bit of
lint or linen, two inches square, is tied closely upon the.
end of the cord like a cap ; 2d. The square, or diaper, of
soft and old material, is put on loosely with a diaper pin \
3d. A fine warm flannel gown (like a woman's night
dress), with long sleeves, and coming below the feet, is
put on, and thus the baby is quickly and comfortably
dressed, and placed in its mother's arms, where the tem-
perature of her own body is food and strength for her
new-born babe, until the milk is secreted.

Let any physician try this plan, and he will meet with
opposition from every old lady in the land. " Why, doc-
tor, its bowels will burst out when it cries, if you don't
pin a binder on !" and a number of similar excuses, for
not being directed by the physician. But the physician
will be rewarded by finding the infants more clean, sleep-
ing more, and eating more than when uncomfortably
dressed, and I believe less liable to umbilical hernia and
ulceration about the cord. I have known children res-
cued from apparent suffocation by simply unpinning a
close binder. Cincinnati Lancet and Observer, July, 1866.

Ulceration from Hypodermic Injections.

Dr. W. S. Mitchell reports the following case in the
Southern Journal of Medical Sciences :

A male Swiss, aged twenty-three years, was admitted
to the Charity Hospital, New Orleans, suffering from
partial emprosthotonos, all the anterior muscles of the
trunk being rigid in a semi-contracted condition, muscles
of the arms and legs rigid, arms extended from the body,
but flexed at the radio-humeral articulation ; muscles of
face slightly rigid, inability to articulate understanding^,.

1867] Bruce on Searching for Ballets. 493

mind clear, tongue much furred, bowels very torpid ; little
if any acceleration of pulse or increase of heat of the
body. In seeking for an exciting cause, a large irritable
ulcer, the size of a Mexican silver dollar, was found to be
located just above the insertion of the left deltoid muscle;
the border of the ulcer almost a circle, clean cut; the
areolar and adipose tissues beneath entirely destroyed,
presenting to view the uncovered muscle, which had the
appearance of a piece of partially roasted beef, cut across
the fibres, conveying to the mind the idea of some corro-
sive action.

The symptoms gradually but rapidly increased in inten-
sity, and the patient died. On inquiry, it was found that
the patient had been treated two months previously in the
same hospital for intermittent fever, by hypodermic injec-
tions of quinia, the injections having been practiced over
the lower deltoid region of the left arm. Recovering
from the fever, the patient was discharged, but in a few
weeks again presented himself with the deep ulcer occu-
pying the arm injected. Dr. Mitchell inclines to the
belief that quinine is of itself a positive and powerful
irritant, when introduced into the tissues by the hypo-,
dermic method ; he has seen in several instances much,
pain, and considerable redness result from injections of
small quantities of quinia, 6imply suspended in water,
without any of the dissolving acids, and he is satisfied
from hearsay, that this is not the only case of ulcer which
has followed the hypodermic use of quinine in the city of
New Orleans.

Searching for Bullets.

The Lancet contains an interesting record of observa-
tions in the military hospitals of Dresden, by Dr. Bruce,
of University College, London. There was ample oppor-
tunity for observing the effects of the different bullets

494 Bruce on Searching for Bullets. [March

employed by the three armies, and after a careful exami-
nation, Dr. Bruce says he can not agree with the gene-
rally-entertained opinion that the bullet of the Prussian
needle-gun produces a less serious wound than that of the
Austrian Minnie rifle. The Prussian soldiers fired at
short ranges ; the Austrians and Saxons at long ones.
The doctor continues : The search after bullets and their
extraction was a source of the greatest interest, both to
surgeons and patients. It often proved a matter of the
greatest difficulty to determine whether a bullet was
lodged in the body or not; frequently the men would
positively assert that the ball had been extracted on the
field, when it subsequently proved not to have been the
case. The excitement produced in some men by the sight
of the bullet was most astonishing. An Italian seized his
bullet, bit it violently, and cursed it so furiously that it
had to be taken from him, to prevent him injuring him-
self. A Prussian soldier, apparently by no means an
excitable fellow, on seeing the ball which had been re-
moved from his thigh, burst into tears, and shaking hands
with us all round, divided his attention between blessing
us and cursing his bullet. The men always kept them
as valuable relics, and would not have parted with them
at any price. The " Garibaldi sonde," as it is called after
the illustrious hero for whose sake M. Nekton invented
it, proved of the greatest service. I have known a bullet,
buried at the depth of four inches in the fleshy part of
the thigh, recognized by the faint streak of lead left on
the unglazed porcelain at the end of the probe. By this
aid it was easy to determine between a fracture-bone and
a bullet. Of the instruments used ,for extraction, the
ordinary bullet-screw and long forceps were perhaps the
two most commonly employed ; but the new American
bullet-forceps was very highly spoken of. With regard
to the apertures of entry and exit, there was, as a rule,

1867] Dunn on Syphilid. 495

very little difference to be observed between them ; they
were often of the same size, and presented very much the
same character. I frequently observed that the supposed
aperture of exit healed more rapidly than the other. The
account of the patient could rarely be trusted, and I found
the holes in the clothing to be the best guides, as here the
aperture of exit was invariably the larger and more
regular of the two. In one case, where a bullet had pene-
trated both thighs, it was only by examining the trousers
that we could determine the direction it had taken, the
patient's account proving incorrect. Medical and Surgical
Reporter.

Non-Mercurial Treatment of Syphilis.

Mr. R. W. Dunn, in a pamphlet on the mercurial and
non-mercurial treatment of syphilis, gives the results of
experience ot many authorities, as well as of his own ;
and from these draws the following deductions. 1. The
primary sore can be healed without mercury. 2. Mercury
does not prevent secondary symptoms. 3. The secondary
symptoms that follow the non-mercurial are slighter tham
those that follow the mercurial treatment. 4. Seconda-
ries are more frequent after the mercurial than after the
non-mercurial treatment. 5. If the patient be of a stru-
mous diathesis, mercury ought to be avoided. 6. Rupia
and bone-disease seldom follow the non-mercurial treat-
ment. 7. Perhaps the disease disappears more rapidly
under the mercurial treatment, but the result is not effect-
ive or lasting; and by avoiding the use of the drug alto-
gether, we do not damage the constitution, and nature,
with a little help, will cure the disease. 8. In hereditary
syphilis, the rate of mortality is lower, and the duration
of treatment is shorter, when treated without mercury.
Brit. Med. Journal.

49(3 Bernard on Medical Statistics. [March

Medical Statistics.

Claude Bernard, in his Introduction a U JEtiide de la Mede-
cine HJxperimentale, just published, gives us his views as to
the value of statistics in medicine. The opinions of such
a man on such a subject will interest most of us.

There are (he says) political, social, and medical theo-
rists, among whom statistics have a sort of mysterious
veneration. Everything can be proved by statistics. It
is a convenient way of getting rid of troublesome facts
and of presenting hypotheses in an imposing form. Thus,
when the number of pulsations are measured by an in-
strument throughout the day, and an average is taken of
the varying numbers, " on aura precisement des nombres
faux." The figures are exact, the average is an error, for
it represents no actual condition. The pulse diminishes
during the intervals of fasting, accelerates during diges-
tion, and varies continually according to other influences,
such as movement and repose ; all these biological pecu-
liarities disappear in the average. In like manner, when
averages are struck from calculations respecting secre-
tions, there is a mingling together of the most varying
conditions ; a secretion which is alkaline at one moment
is acid at another ; in the average it appears a compound
of the two. When a physician collects a number of cases,
and from them draws up a description which represents
the symptoms on an average, he describes that which
never existed in nature.

This error of averages is strikingly exhibited in the
various theories of food propounded by physiologists.
The amount of oxygen, or any other substance, consumed
by an animal in one day is estimated and compared with
the weight of the animal ; but the weight represents a
total of various substances with which the oxygen has very
various relations, some of them being totally unaltered

1867] Bernard on Medical Statistics. 497

"by the oxygen, others profoundly affected by it. In like
manner, a poison is estimated according to the amount
required to kill an animal of a certain weight. " II fau-
<irait pour etre plus exact calculer non par kilo du sang
et de l'element sur lequel agit le poison." But even then
the mere weight tells us little. Other conditions inter-
fere, and these, which vary with the age, size, sex, state
of digestion, etc., of the animal, determine the effect of
the poison.

Obviously, the first condition of statistical comparison
must be that the facts compared are exactly observed
and are capable of being reduced to unities comparable
with each other. How often is this condition present in
medical statistics? Every one familiar with hospitals
knows what numerous causes of error have vitiated the
reported " cases." Very often the diseases have been
named at hazard after a superficial diagnosis ; and even
when the cases have been carefully examined, no two
precisely resemble each other; age, sex, temperament,
the complication of other diseases, and a crowd of cir-
cumstances interfere ; and if this is so with two cases,
how much more will it be with a hundred ? The average
is supposed to eliminate all these differences; but when-
ever the physician has a case before him, that case is indi-
vidual, not an average; its peculiarities are not elimi-
nated, yet on its peculiarities must depend the effect of
his treatment.

M. Bernard reminds us that it is only when the cause
is quite undetermined that any one thinks of applying
statistics. No one enumerates cases in which oxygen and
hydrogen compose water; no one counts the number of
times in which division of a nerve paralyzes its muscles.
It is only when the cause is unknown that cases are
counted, and then the enumeration throws no light on
the conditions. For example: some experiments showed
41

498 Bernard on Medical Statistics. [March

that the anterior roots of the spinal nerves were insensi-
ble ; other experiments showed that they were sensible ;
would it have thrown any light on this difficulty to say
that the law of sensibility in the spinal roots is that of
twenty-five per one hundred? Or ought we to invoke
u la loi des grands nombres," and say that the roots are
as often sensible as insensible? It would be absurd.
There is obviously a reason why they are sensible, a
reason why they are not, and it is these reasons we are to
discover.

A great surgeon performs an operation many times ;
he then gives a tabular statement of the cases which
have been fatal and the cases which have been successful,
and statistically concludes that the mortality of this ope-
ration is two in five. What will this tell us respecting
the certainty of the next case? "We can not know
whether it will be one of the two or one of the three.
We ought to know what are the conditions which will
range it infallibly under one or the other head. Instead
of an idle enumeration, we should make a fruitful study
of each special case, and discover, if possible, the cause
which renders the operation fatal. The same reasoning
applies to curative remedies. A certain remedy has in
twenty instances been followed by a cure ; in seven in-
stances no cure has been effected. You will say, perhaps,
that there is twenty to seven in favor of success. ~Not in
the least. You do not know how many of those twenty
patients would have recovered had there been another
remedy tried, or no remedy at all; you do not know
what was the precise action of the remedy, what changes-
it effected in the organism, what its effects will be on the
organism now about to be submitted to it. As a great
mathematician observed: "La loi des grands nombres
est toujours vraie en general et fausse en parti culier."
And as to the " compensations which bring about the

1867] Paste which will Adhere to any Substance. 499

law," they are useless in medicine. Mathematicians
admit that if a red ball has come up fifty times in suc-
cession, that is no reason why the white should come up
on the fifty-first ; the white ball is certain to come up
some time or other; but its appearance depends on spe-
cific conditions which have nothing to do with what has
gone before.

Is there, then, no utility in statistics ? M. Bernard is
far from saying so. He admits that statistical results
lead to probabilities and suggest research; but he protests
against the idea that medicine must be only conjectural.
He insists on the necessity for a scientific basis, and de-
clares that every method of treatment which is not
grounded on a clear recognition of the casual connections
between agents and the organism is mere empiricism, not
much removed from charlatanism. American Journal

White Paste which will Adhere to any Substance.

Make the following mixture : Sugar of lead, 720 grains ;
and alum, 720 grains; both are dissolved in water. Take
two and a half ounces of gum arabic, and dissolve in two
quarts of warm water. Mix in a dish one pound of wheat
flour with the gum water cold, till pasty in consistence.
Put the dish on the fire, and pour into it the mixture of
alum and sugar of lead. Shake well, and take it off
the fire when it shows signs of ebullition. Let the whole
cool, and the paste is made. If the paste is too thick, add
to it some gum water, till in proper consistence. Journal
of Applied Chemistry.

500 Editorial [March.

EDITORIAL AND MISCELLANEOUS

THE MEDICAL ASSOCIATION OF GEORGIA.

The approaching session of this body will be held at
Griffin, on "Wednesday, 12th April, and its importance
suggests the appropriation of our editorial space to its
consideration. The members of this association, in re-
ferring to its past meetings, instinctively recall the paucity
of members in attendance, and, notwithstanding its high
functions, the little interest manifested by physicians at
large. A few who were ardently devoted to the advance-
ment of science, and ambitious to place the society above
a mere nominal, formal gathering of physicians, sought
to make it a true exponent of the scientific labors of the
profession of the State. Through their agency many
valuable papers have emanated from it from time to time
contributions of intrinsic value to the scientific, and
of practical avail to practitioners. The pages of this
journal (its official organ) for the last twenty years are
rich in practical articles and essays upon the different
branches of medicine, which, in the aggregate, constitute
a volume of great value one, indeed, worthy of addition
to any medical library. In this is exemplified a fact that
we have seen elsewhere stated, namely, that medical
journals can no longer be regarded as mere "finger-posts"
but as true exponents and representatives of the science
in its progress to perfection and exactness. The an-
nouncement of a discovery or the new interpretation of an
old accepted idea is made and diffused through this me-
dium, and long in advance of the more stable works upon
the subject, the verdict of the profession is returned. So
that a diffusion of knowledge is obtained which could not

1867] Editorial 501

be so speedily and thoroughly done by any other means.
A practical familiarity with the literature of the medical
press is, therefore, one of the most profitable resources of
the physician, and, indeed, may be taken as a test of his
acquaintance with the present state of the science. Jour-
nalism instils its information silently and satisfactorily, a
fact which will receive its due weight from those of our
readers who have complacently watched and now recog-
nize the great change which at present constitutes medi-
cine a temple of conservatism instead of a school of " exces-
sive medication."

But, not to digress further, the next session of the State
Society we believe to be the most important since its
organization. Its re-organization finds the profession in
a far different condition from that of the past, and it
should not be left to the direction of a few. The modest
practitioner must not consign his interest to ambitious
scientific aspirants, but all must move in concert for a
common interest. At the time of its foundation we were
in an independent .position, one, indeed, which warranted
the absorption by the purely scientific of all other inter-
ests; but the business interests, at least for the time-being,
must receive equal attention. Emancipation has robbed us
of the basis of that independence; and, unfil the latter is,
by some means restored, the profession must remain crippled
in resources, and shorn of their strength. Heretofore it
has been regarded as mercenary to intimate pecuniary
matters in connection with medicine, these, by common
consent, being generously absorbed in the benevolence
and nobler aspects of the calling, but the time has come
when the instinct of self-preservation compels their con-
sideration. Spoliation has deprived us of our resources,
and however modest or delicate, physicians must no
longer disregard their long-neglected business affairs. One
way to foster them is through the State Association,

502 Editorial [March

where, after conference and discussion, a concerted move-
ment may be inaugurated to relieve the present depen-
dence aud restore lost influence. It is to further this
object that, at our solicitation, the article upon the "Legal
Status of the Profession" has been prepared. Many,
doubtless, will be astonished at the exposition, and re-
ceive the first intimation of the fact that they not only
have no legal rights, but by practicing for "fee or
reward," without a license, are openly violating one
of the statutes of the State, thereby incurring the
double risk of a loss of their earnings and of a criminal
prosecution, the penalty of which is fine and imprison-
ment. As stated in the article referred to, all physicians
of the rational school of medicine not in practice on 1st
January, 1863, under a legal diploma, are debarred by law
from the collection of claims, and while those who have
been thus engaged between the adoption of the Code
(1862) and March 6th, 1866, are relieved from the penal-
ties of the offence against the law, yet they are equally
powerless to enforce payment. The possession of a di-
ploma confers no right to practice for fee or reward within
the limits of this State, unless the possessor be a graduate
of a Medical College having the right in its charter to
invest its graduates with all the rights and privileges
of a licentiate under the law. All of the Colleges are not
clothed with this authority, and, as a public journalist, it
is our duty to apprise the profession of the fact. Of the
graduates of last year, only those of the Medical College
of Georgia, now or since practicing in the State, without a
license from the Medical Board legally established, are
authorized so to do. Where the charter does not give
the vested right, a license from an Examining Board,
which does not really exist, is, in the terms of the law,
necessary to prevent prosecution, and indispensable to the
collection of debts. Physicians coming into the State are

1867] Editorial 503

not protected by their piiplomas an intermediate step is
required, namely, a license which must be secured and
duly recorded.

It may be objected that such a law is a " dead letter:"
it may be so far as a prosecution is concerned, but, in the
case of a suit, it is all-sufficient. It can not be set aside
or rendered inoperative by judge or jury.

In this respect the quack has the advantage over the
regular practitioner; the Legislature has placed a pre-
mium upon Homoeopathy, Hydropathy, Dutch and Indian
Doctors, "Dr. Durham's Urine or Water System,"* et id
omne genus, by waiving the necessity for additional license,
not, we flatter ourselves, because they thought the rational
school less honorable, but upon the principle that the
greater license these pretensions had the sooner they
would explode.

It is useless to pursue the subject further. Suffice it to
say, that all physicians not in practice on the 1st of Jan-
uary, 1863, who may have come into the State or grad-
uated at any College not possessing the vested right
adverted to, and now practicing, require a license as an
indispensable pre-requisite to their lawful action. The
licensing Board of Physicians exists in law, but not in
fact. This state of affairs should no longer exist : either
abolish the law or vitalize the board.

Apothecaries are even more seriously affected than
physicians, and as many of the latter are also engaged in
this capacity, we give the law upon the subject. A di-
ploma does not clothe the graduate with the right to sell
drugs (beyond the dispensing of them in the pursuit of
his practice) without a license from the Examining Board.

* In 1854 a special act was passed amendatory of an enactment in 1852, authorizing one
Wm. C. Dabbs, of Floyd County, to practice "l>r. Durham's Urine or Water System," in
lieu of the "Homoeopathic System," a fit substitute, doubtless, each for the other, in the
minds of the legislators.

504 Editorial. [March

When he becomes an apothecary he must comply with
the law as determined for that class of merchants.

The act of 1825 required apothecaries to obtain a
license from the Medical Board, and section 1,351 of the
Code (adopted 1862) as amended by the act of 1866,
reads :

" No person in this State shall open or keep an apoth-
ecary store without first obtaining a license therefor from
the Medical Board of his own school."

Section 1352. " Any person violating the preceding
section is liable to indictment, and, on conviction, to be
fined not less than one thousand and not more than five
thousand dollars, and for continuing after conviction to
the like fine and imprisonment not exceeding six months.
The onus of proof is upon the defendant to show his
authority."

Section 1353. " Druggists are exempt from obtaining
said license, who were engaged in said business prior to
24th December, 1847, and who continue so at the adop-
tion of this Code ; and merchants and shop-keepers may
deal in medicines already prepared, if patented, or if not
patented are legally warranted by a licensed druggist."

Prominent among the business interests to be canvassed
is that of the relation of physicians to plantation practice.
Formerly it was an individual matter of the planter, or
owner of slaves, but now it is a collective interest, in
which at least three parties are concerned the freedman,
contractor, and physician. It is plain that the contract
system is the only one now practicable for general pur-
poses, and it behooves the profession to adopt some uni-
form scale of charges which will secure general support.
If the physicians of each neighborhood are left to such
desultory plans as each may see proper to adopt, the re-
sult will be continued dissatisfaction to all parties. If a
uniform system prevails, each county will soon be mapped
out into practicing districts included in a radius of five or
eight miles, thereby securing a fair distribution of the

1867] Editorial. 505

labor and gain, and equalizing incomes. We have been
in communication with physicians in different parts of
the State, and find a general testimony borne to the value
and practicability of the contract system, the terms being
fixed by the distance and number of laborers. We would
suggest to our country brethren, who are most interested,
the propriety of holding meetings for the discussion of
the matter, and the appointment of delegates to the Asso-
ciation, who may come prepared to represent their views
and mature a plan of operation. Not being members of
the Society already, need not deter them, for all of good
repute will be welcomed to an immediate and full con-
nection, and to a participation in its deliberations.

At the last session the following resolution was adopted:

" Resolved, That the permanent location of the Association at some
suitable place, in the opinion of this meeting, is called for by the highest
interests ; and that, in view of said interests, we do invite and call upon
its members, in every portion of the State, to meet with us at our next
annual meeting, and settle definitely this question.''

We recall it only to condemn it. We can not perceive
how its highest interests require its location. If this is
done its organization must likewise become permanent
a condition which will soon place it under the control of
local influences. Its members are diffused over the
whole area of the State, and each section in turn should
be favored with its sessions. In imitation of the practice
of other State associations, let it continue to alternate the
places of its meeting; this will do more to increase its
members and bring them into pleasant association, than
any other course. Commending the subject to the earnest
consideration of the profession, we dismiss it, with the
hope that the approaching session may prove fruitful of
good to all their interests. W. H. D.

42

506 Editorial. [March

IS A CRYING BABE NECESSARILY COLICKY?

Nothing is more common than the belief that when an
infant cries it must have the colic, and that it should be
treated accordingly. Now, can it be true that infants
never cry unless they suffer pain, and that colic is the
most common cause of this pain ? Have we not, on the
contrary, every reason to believe that the cry of the infant
is merely a substitute for language, and is therefore used
to make known to the mother or nurse such simple wants
as may be experienced by one so young ? While it would
seem probable that an infant who suffers no pain, and
who is sufficiently supplied with its natural food, can
have no cause to cry, such is not always strictly the case.
There is a great difference in the temper and disposition
of infants ; some being naturally irritable, cross or peev-
ish, and others good-natured and cheerful. All nurses
understand the difference between a good and a bad
child ; and it would be interesting to take note of these
early indices, for the purpose of ascertaining whether or
no they may be relied upon as the premonitions of subse-
quent developments in the adult. Some infants will
remain quiet until a sense of hunger or thirst impels
them to cry out ; while others will cry to be turned over,
or to be taken in the arms, or even to be walked about ;
and if these caprices are indulged, the child soon becomes
so " spoiled" that its nurse will have no rest. It is sur-
prising how soon the infant learns by experience what he
may exact by his cries ; and, although born good-tem-
pered, he may become extremely troublesome if too
much indulged. Some of them only a week old will
keep the nurse all the time busy, merely because they
were not at first allowed to cry at all, without being
handled.

It can not be denied that peevishness is, alike in infants

1867] Editorial 507

aud adults, very often consequent upon the discomfort of
bad health ; and it is important that the cries occasioned
by this state of things be distinguished from those induced
by actual pain. A judicious mother or nurse can not
fail to discover the difference by a little careful observa-
tion, and it should be the duty of the medical adviser to
assist in this diagnosis ; for until the real cause of the
cries be ascertained, there can be no rational medication.
The cries of an infant are in reality only symptoms of
the mental or physical condition of the child. It is our
business to give to them their proper interpretation. The
child cries ! Is it caprice ; is it hunger ; is it discomfort ;
or is it positive pain? These are the questions to be
solved before we should resort to medication, if we wish
to be consistent with philosophy, or even with ordinary
common sense. And yet, how often do we not find
infants dosed with "colic drops" whenever they cry!

Most of the nostrums vended as "colic drops" contain
opium in some form or other, and some aromatic or car-
minative. These "drops" are therefore primarily narcotic
and stimulant, and secondarily constipating ; so that
although they may compose or put the child to sleep,
whether the cries proceed from colic or not, their use, or
rather their abuse, is objectionable. Again, how are we
to determine that the child has colic ? Pain in the bowels
may depend upon spasmodic contractions of their muscles
induced by indigestion, or irritation of some kind; or it
may be occasioned by mere flatulency. While the spas-
modic pains usually precede or attend looseness of the
bowels, such need not be the case with the presence of
flatulency. The former pains come on in paroxysms more
or less severe, which subside very soon, and leave the
patient entirely relieved until they return again. Flatulent
colic is more persistent, never so intense, and may be
usually recognized by the hollow sound produced by

508 Editorial [March

percussion of the abdomen, especially if this circum-
stance be taken in connection with the other points in the
history of the case.

The diagnosis of infantile diseases is by no means so
difficult as is generally imagined. In the affection before
us, it is just as easily made out for a child as for an adult.
If the physician knows his business, and will use with
due diligence the resources of art, he will rarely fail to
establish the diagnosis satisfactorily.

If the bowels are regular and the evacuations in a
natural state, while the abdomen yields a natural sound
upon percussion, has a natural feel to the hand, is not
distended nor knotted by spasmodic contractions, is not
painful when pressed upon, we may very safely conclude
that the child can not have colic.

Have we any good grounds to believe that colic is often
almost habitual in infants too young to speak and who
can only cry, whereas it is only an accidental or occasional
disease in those who can speak and in adults ? Such a
violation of analogy ought not to be admitted to exist
without much more evidence than can be adduced in
favor of it.

Ear-ache is very common with children, and may either
make them peevish or cause them to cry violently and
protractedly. This affection can always be detected by
pressing a finger just below or in front of the ear, by
which the pain will be much increased and the child will
renew his cries. As there is usually but one ear affected
at the time, the experiment must be tried on both sides.
If the pain be purely neuralgic or nervous, it may be re-
lieved by almost any warm application ; but if it be oc-
casioned by the formation of an abscess about to break
in the ear (in which case we may usually detect a little
fulness or hardness in the angle just below the ear, or in
the slight depression just in front of the orifice of the

1867] Editorial 509

ear), these remedies are very apt to fail, and we have to
resort to a little Laudanum taken internally, or dropped
into the ear in combination with a few drops of oil.

Closely connected with the treatment of the so-called
colic is the common practice of

Jolting Infants.

If the child be really suffering with colic, it would be
as absurd to expect to relieve it by such violent shaking
and jolting, as it is to suppose that there is any efficacy
in the veterinary practice of making a colicky horse trot
up and down the road, until almost exhausted. But if
the poor child happens to have pain in the ear or head-
ache, both of which are very common, the cruelty of
violent rocking, shaking in the arms, and jostling upon
the knees, with the loud singing and jargon of the nurse,
must be apparent. The treatment of Sancho Panza by
the maid of the enchanted castle was trifling in compari-
son with this.

The affectionate and tender-hearted mother can not
bear to remain quiet while her babe is screaming, and
she freely exerts her lungs and limbs to the uttermost in
the hope of giving relief. It is a natural and a laudable
feeling which prompts her, and the exertion relieves her
nervous system by working off1 the nerve force which
would have been otherwise concentrated in the brain. It
therefore requires some philosophy, that which emanates
from enlightened reason, to examine quietly for the true
cause of the child's cries, and to administer the proper
remedy. If no medicine be necessary, the child will, if
laid comfortably on his bed or held quietly in the mother's
lap, very generally go to sleep after crying a little while.
It can certainly not go to sleep so long as it is not allowed
to be at rest.

510 Editorial. [March

Do Children bear Disease better than Adults f

To suppose that children can bear disease better than
adults, is to admit that the weak have more powers of
resistance than the strong ; that an unfinished fortification
is better adapted to resist attacks than one already com-
pleted. And yet, we continually hear persons manifesting
a desire that their children might take the measles,
hooping-cough, etc., while young, so as to be rid of sub-
sequent danger ! This is a radical error. Children should
be kept from sickness as long as possible, for no one can
predict the result of what might at first seem to be the
most trivial affection. '

Common sense should lead us to avoid sickness at all
times, and at any age. If we carefully keep our children
from visiting houses in which there is any sickness, and
remove them from districts affected with epidemics ; if,
in short, we use clue diligence in avoiding all known
causes of sickness, we shall have nothing to reproach
ourselves, when, notwithstanding such precautionary
measures, they are overtaken by disease. The very fact
that children are more prone to sickness than others,
should incite parents to great watchfulness in regard to
their hygienic condition, their cleanliness, their clothing,
their food, their exercise, their supply of fresh air, inso-
lation, etc., etc.

The best evidence that children do not bear sickness as
well as adults, is to be found in our mortuary statistics,
which reveal a frightful loss of ljfe among infants and
children. This is equally true with regard to the lower
animals and plants. The more tender the plant the more
feeble are its powers of resistance, and the more liable it
is to disease. L. A. D.

1867] Editorial 511

Clinical Observations on Functional Nervous Disorders. By
C. Handfield Jones, F.E.S. Philadelphia: Henrv C.
Lea, 1867.

The American public has already been made familiar
with this work through the Medical News and Library, but
many of the profession will see with pleasure its re-
appearance, in its present neat and convenient form.

A work which would represent, in a practical manner,
the influence which the recent important and highly in-
teresting researches into the physiology and pathology of
the nervous system have exercised, in that most obscure
of all the chapters of medical science, the functional
neuroses, is just now much needed, and would fill a sen-
sible gap in our medical literature. We can not say that
this has been done in the work before us, but the busy
practitioner will, we think, glean more practical points
from the perusal of this little volume than from more
compendious treatises. It is an advantage of the form of
clinical notes, which our author has given to this book,
that it enables him to dispense with systematic descrip-
tions and details familiar to every one, while it allows
him to dwell with greater stress upon new and important
facts.

Xo systematic arrangement is attempted. The different
parts of the mechanism are taken up in their natural
anatomical order. The work opens with a chapter on
General Pathology, in which the author develops the
basis of his peculiar views on neuro-pathology. It is to
be regretted that this particular part is not more full and
explicit, as many readers will be unfamiliar with the
recent extraordinary advances in neuro-physiology. In
this chapter much attention is justly paid to the interest-
ing and highly important discoveries relating to inhibitory
and vaso-motor action. We can not coincide with the

512 Editorial. [March

views of the author on either of these subjects. His idea
that inhibitory action is purely pathological, and produced
by defect, or excess of power in any nerve, seems to us
directly refuted, by its undoubted existence as an auto-
matic regulator of cardiac action. Section of the vagi
could only accelerate the movements of the heart by the
removal of a normal inhibitory influence on the centre of
its rhythmical action. On the whole subject of animal
heat, and the beautiful part taken by the nerves of the
heart, and blood-vessels in its regulation, his notions seem
to be exceedingly crude. Had he understood this subject
better, he would have spared himself and his readers the
curious theory of an alternation in the action of the ordi-
nary motor, and the vaso-motor nerves. This is one of
those awful explanatory hypotheses that used to impress
us so wonderfully in the old days, when expounded " ex
cathedra," but which we And somewhat indigestible now.
In spite of all this, the numerous instances scattered
through the book, in which the influence of vaso-motor
action in the production of the most varied forms of dis-
ease is demonstrated, constitute, we think, the greatest
merit of the work.

The Southern practitioner will find here and there
through the work, and especially in the chapters on
Malarioid Diseases, much valuable information in relation
to the singular influence of malaria in producing the
most varied neuroses, which he will be able to make
practically useful when practicing in our malarious
country. Among the special chapters, we would espe-
cially commend those on Cerebral Paresis and Cutaneous
Neuroses, which will be found to contain some novel
views and practical hints.

The work is illustrated throughout by copious records
of cases, which greatly assist us in making out the
author's meaning, where his style is somewhat obscure.

1867] Miscellaneous. 513

The diagnosis in many of these cases is what would have
been designated in our student days as "tali guessing,"
and some are not above a worse suspicion; but the gene-
ral practitioner, little accustomed to thread the mazes of
the complicated mechanism of the nervous system, where
the lesion is frequently at one point while its only mani-
festation is at others often widely distant, will find in these
records of cases, analyzed by a practiced hand, an inval-
uable guide in practice. G.

Use and Abuse of Poultices.

In his lecture recently delivered at the College of Phy-
sicians, Dr. Richardson made the following remarks on
the subject of poultices :

The application of moist heat in the form of poultice to
suppurating parts requires, I think, remodelling, in order
that it may be placed on a true scientific basis. I am
afraid that the common recommendation, " You must
put on a poultice," is too often among us all an easy way
of doing something about which we are not quite sure,
and concerning which it were too much trouble to think
long. From what I have recently observed, I fear that
mischief is often done by a poultice, which might well be
avoided. The people have always a view that a poultice
is applied to " draw," as they say a term in truth which,
though very unsophisticated, is in a sense, a good term,
for it means what it says. The question for us is, whether
it be sound practice to carry out, as a general rule, the
" drawing " process, either by fomentation or by poultice.

When a part is disposed to suppurate, the first step in
the series of changes is an increased flow of blood through
the capillary surface, followed by obstruction, and there-
upon by an excess of sensible heat derived from the fric-
tion that is set up. Then follows transudation of liquor
43

514 Miscellaneous. [March

sanguinis into the connective tissue, and its transforma-
tion, under the influence of heat, into what is called
purulent fluid. When to the part in this state we apply
moist heat, we quicken suppuration, mainly by upholding
the temperature : at the same time, we secure the trans-
ference of water from the moist surface into the fluids of
the inflamed part, by which tension of tissues is produced,
and in the end yielding of tissue at the weakest point.

When the suppurating surface is circumscribed, the
rapid induction of the process may be attended with little
injury ; but when the surface is large and when the exuded
fluid is thrown into loose structures where it can burrow
readily, the practice, I think, can not be good to extend
the mischief. Hence, in the treatment of carbuncle and
phlegmonous erysipelas, it can not, I opine, be sound
practice in the early stage to apply moist heat. Experi-
ence also, not less than principle, warrants this conclusion.
In cases of carbuncle especially, I have of late altogether
avoided the application of moist heat in the early stages ;
and, I feel assured, with good results.

But when, in the course of local disease, suppuration is
actively established, and is naturally circumscribed ; when
the increased temperature of the part has fallen to or
below the natural temperature then the value of moist
heat comes on with full force ; then the tension which is
exerted determines the escape of fluid at the weakest
point of the surrounding tissue, and, when the fluid es-
capes or is liberated by the knife, the escape for a long
period is aided by the application of moist heat.

The continued application of moist heat for a long time
after the escape of purulent fluid is again, I conceive, in-
different practice. It sustains discharge; it sets up un-
healthy decomposition of fluids ; it produces a thickened
soddened condition of skin, most favorable to the produc-
tion of sinus ; and it retards recovery. When a surface

1867] Miscellaneous. 515

is freely open and suppurating, dry and not moist heat is
the remedy. We are in want in these cases of a simple
invention ; we require something which we can apply as
readily as a poultice which shall keep up the temperature
of the part, and at the same time take up moisture, and
gently dessiccate, without injuring the tissues. Brit. Med.
Journal, May 12, 1866. Am. Journal Med. Sciences.

A Monster.

The following short account of a singular case of labor,
and the birth of an extraordinary monster, was sent us
by Dr. J. K. Hamilton, of Stone Mountain, Ga.

We very much regret not being able to obtain the much
desired examination of the body, in order to ascertain the
direction of the cord from the point of attachment, and
the exact nature of the other peculiarities connected with
the formation of this child. Atlanta Med. and Surg. Jour.,
Dec, 1866.

Editors Medical Journal: I was called, on the third of
April last, to see Mrs. K"., who was in labor with her first
child, eight months enceinte.

I made a vaginal examination, and discovered a case of
placenta prsevia. The pains were regular and persistent,
with slight protrusion of placenta during paroxysms.
Considerable hemorrhage ensued, which was partially
controlled by the tampon, cold applications and rest. The
labor lasted about two hours : the afterbirth emerged
first, and was followed almost immediately by the expul-
sion of the child.

The most remarkable feature of the case was : The
umbilical cord was attached to the crown of the head,
leading directly from the placenta, seeming to permeate

516 Miscellaneous. [March

the brain, or more probably the inner surface of the
scalp. The neck was unusually large, caused probably
by an undue supply of vascularity and nervous influence,
with a consequent developement of tissues surrounding
them.

There was a cleft in the upper lip, constituting simple
hare-lip. The abdomen contained a fissure extending
from the epigastrium to near the symphesis pubis ; hence
the child was nearly disemboweled, with apparent oblite-
ration of the umbilicus. The liver and intestines were
well developed, and although it exhibited evidences of
recent vitality, it came still-born, owing, doubtless, to the
anomalous attachment of the placenta and cord. The
father of the child, during the late war, lost his left fore-
arm in Virginia, it being amputated about six inches
below the elbow : the child, also, on same side, had its
forearm off the stump bearing a great similarity to the
arm of the father.

The assimilation process in this instance, as respects
growth and development, was normal, the trunk and
limbs being properly proportioned.

I do not propose, in this short report, to attempt to
explain the causes which may give rise to these preter-
natural perversions of the laws of th? animal economy.
In one respect it may have ensued from some accidental
change of position experienced by the foetus at some
period of its uterine existence ; and, in another, it may
have originated from the influence of the maternal imagi-
nation on the foetus in utero, or attributable to a primitive
defect in the germ. Whilst we know and appreciate the
opinions of learned physiologists, in regard to the causes
of monstrosity, further deponent saith not.

J. K. Hamilton, M.D.

1867] Miscellaneous. , 517

Death from Chloroform.

A death from chloroform occurred at Birkenhead on
Thursday week last. The patient was a boy named
Hughes, and the operation that was to be performed was
lithotomy. The death took place previously to the per-
formance of the operation, the boy ceasing simply to
breathe, and the action of the heart ceasing almost at the
same moment. The chloroform was administered with
every care, and there was nothing in the condition of the
patient to indicate special danger. The jury returned a
verdict of death from chloroform, with an intimation that
the anaesthetic "had been properly administered."

This case is very remarkable, owing to the youthful age
of the deceased. It has been almost accepted as proven,
that if moderate care be employed persons under fourteen
years can hardly be exposed even to risk by chloroform
inhalation. The fallacy of this view is now proved by a
sad experience, and that which was thought to be a
sequence is shown to be a coincidence. If the truth be
told, neither in this fatal case, nor in the fatal case at
"Bristol, where the radial artery was about to be tied, need
chloroform have been administered at all ; unless it be-
proved that local anaesthesia would not have afforded!
every requirement for a painless procedure. Med. Times
and Gaz., Nov. 24, 1866.

Absorption of Wounds.
M. Demarquay read to the French Academy of Medi-
cine a paper on this subject, of which the following are
the chief conclusions : 1. A substance which is soluble in
water, like iodide of potassium, when applied to a large
denuded surface is rapidly eliminated by the saliva. 2.
Applied to a recent wound, the presence of iodine is

518 Miscellaneous. [March

recognized in the saliva in a period of time which varies
between sixty, thirty, nineteen, and fifteen minutes. 3.
When wounds are completely organized they possess
great absorbing power, so that at the end of ten, eight,
six:, or four minutes, and even less, very evident traces of
iodine are found in the saliva. We may, therefore, ask
whether the septic element which gives rise to puerperal
fever or erysipelas may not be absorbed by the wound
itself. 4. In that dangerous complication of wounds
known as purulent infection, may we not suppose that
this absorbing power, which has hitherto been so little
investigated, plays a considerable part, and will it not
explain some of the phenomena generally attributed to
phlebitis? 5. Iodine injections thrown into the cavities
of abscesses or cysts are rapidly absorbed, elimination
having been proved to have commenced in a period vary-
ing 'from forty-five to three minutes. 6. When these
injections are employed in too great quantities, or too
often repeated, harm may result from the incessant intro-
duction of iodine into the system. 7. Iodine introduced
by these various means is generally eliminated by the
saliva and urine in from four to five days. Ibid.

Inoculability of Tubercle.

In the Gazette Hebdomadaire we have a continuation of
M. Yillemin's researches as to the inoculability of tuber-
cle. In rabbits he has again and again succeeded in re-
producing it in this manner, not only when taken from
the human subject, but still more rapidly when derived
from the cow ; further, the tubercular matter thus pro-
duced in one rabbit could be in like manner transmitted
to another, in the same way as syphilis. Ibid.

1867] Miscellaneous. 519

Sudden Death in a Dentist's Office.

Last week, Edmund Kerosin, a young man, twenty-
three years old, entered the office of Dr. Ralph Lee, a
dentist of this city, to have a tooth extracted. Anaes-
thesia was produced by nitrous oxyd gas, a cork having
been placed between the teeth to keep the mouth open.
As the tooth was extracted, we understand, it slipped
from the forceps, and with the cork was drawn into the
mouth. The tooth was subsequently thrown up from the
stomach, but the cork which does not seem to have
been missed entered the larynx, and by its presence
there caused suffocation and death in an hour. A post
mortem revealed the presence of the cork in the larynx
and the cause of death. This case and its lamentable
result should serve as a caution to those who employ such
adjuncts in the dental laboratory, and the physician who
may be suddenly summoned to patients in a dentist's
office, should bear in mind the possibility of an accident
like this, and be prepared to open the larynx, if need be,
which in this instance would, in all probability, have
given instant relief, and saved the life of the young man..
Med. and Surg. Reporter.

Poisoning by Strychnia ; Cannabis Jruiica,
In a recent number, we reported in our periscopic de-
partment, a case of recovery from strychnia poisoning,
by means of chloroform. We now add another, which
recovered under the use of cannabis indica, and tr. of
camphor. The case occurred in the practice of Dr. S. A.
McWilliams, of Chicago, by whom it is reported in the
Med. Examiner. Patient, thirty-one years of age, took,
suicidally, five grains of strychnia. Was seen by Dr.
McW. three hours and forty-five minutes afterward, when

520 Miscellaneous. [March

he had extensive, frequent, and severe spasms, and with
each a blowing of froth from the mouth! He lay upon
his back, arms extending obliquely from his body ; face
flushed ; perspiration rolling off him ; pupils dilated
widely ; pulse one hundred and thirty per minute ; color
of lips natural ; stiffness of muscles and inability to move
limbs ; mind perfectly clear. A drachm of the tincture
of cannabis indica was immediately given, and another
in five minutes ; then two similar doses at intervals of ten
minutes; afterward two such doses at fifteen minutes
interval, with a rapid amelioration of symptoms; the
next drachm was given in an hour and a half. The
remedy, which afterward was alternated with camphor,
was continued as the urgency of the symptoms demanded,
and the patient recovered, with uninterrupted convales-
cence, after forty-eight hours. Ibid.

Gun-shot Wound of Heart.

Professor Hamilton presented the specimen of a case,
which had already been described several years ago in
the American Journal of Medical Science, but the specimen
had never been presented before to this Society.

It was a heart containing a bullet, of a boy who, when
fourteen years of age, received a musket ball into the
right side and shoulder, at Chatham Four Corners, New
York. This was in 1840. The ball could not be dis-
covered at the time. Six weeks after the injury he re-
turned to work, and lived until 1860 twenty years
having been married in 1845.

Five years after the receipt of the injury he was at-
tacked with violent palpitation of the heart, the result, as
far as could be ascertained, of violent exertion, from
which he never entirely recovered.

1867] Miscellaneous. 521

When he died in 1860, the autopsy revealed the pres-
ence of a ball in the right ventricle, near its apex, sur-
rounded by atheromatous deposit. The heart was some-
what dilated, but not hypertrophied. His last illness was
ascribed to cold, the result of exposure from washing
sheep in a brook. Med. and Surg. Reporter, Dec. 15, 1866.

Minute Injection and Preservation of Anatomical Subjects.

During the past two months, Dr. Joseph Jones, Pro-
fessor of Physiology and Pathology in the Medical De-
partment of the University of Nashville, has conducted a
series of experiments upon the preservation of entire
bodies for purposes of dissection, and anatomical and
physiological demonstration.

Dr. Jones has succeeded in preserving the entire bodies
of animals, which have remained for four weeks, in a
close warm room, heated with a stove, without the small-
est disagreeable odor, and without any marks of decom-
position.

The antiseptic agent used by Dr. Jones in his experi-
ments, is carbolic acid : the liquid carbolic acid, as com-
monly sold in the shops, is mixed with the usual injecting
matters, and is thrown into the blood-vessels by the ordi-
nary process.

For the human subject, used in dissection by students,
and for class demonstration, Dr. Jones employs the fol-
lowing method : Two mixtures are required ; one to fill
the capillaries and smaller vessels, and the other to distend
the larger vessels. The former, which will be called

No. 1, Preservative Fluid for 3Iinute Injection,

consists of the following ingredients ; the amounts given
being sufficient to inject a single human body.

Three fluid ounces of carbolic acid; one pint of linseed
44

522 Miscellaneous. [March

oil (oleum lini.) ; one pint of oil of turpentine (oleum
terebinthinae) ; one ounce of best Chinese vermillion (red
sulphuret of mercury, hydrargyri sulphuretum rubrum).
Mix the turpentine and linseed oil, and add the carbolic
acid, and stir well together ; then mix in thoroughly the
coloring matter. Inject this fluid mixture slowly and
steadily into the arteries.

No. 2, Preservative Fluid for the Injection and Distension of
the Large Arteries and Veins.

Carbolic acid, four fluid ounces ; oil of turpentine, one
quart; linseed oil, one quart; tallow, one pound; bees-
wax, one pound. Mix the turpentine and linseed oil, heat
carefully, and then add the tallow and wax; and after the
complete melting and mixture of the wax and tallowy
remove the vessel from the fire, and add the carbolic acid
and coloring matter; stir this mixture well, and inject
whilst hot, into the large blood-vessels.

This last injection forces the first fluid injection into
the most delicate capillaries, and thus brings all parts of
the body under the influence of the carbolic acid.

The proportion of wax and tallow in the Injection
Mixture No. 2, may be increased or diminished, as the
object may be to produce a harder or softer material,
upon cooling ; and it is best to immerse the subject in hot
water, during the injection of this mixture.

The first injection should not be allowed to flow out of
the arterial system.

This method is best applied to subjects designed for
anatomical dissection and demonstration.

For minute anatomical injections, designed to make
dried preparations, the mixture of turpentine and linseed
oil is not suitable as a vehicle for the carbolic acid and
coloring matters. Turpentine does not dry readily.

For dry preparations, Dr. Jones is in the habit of em-
ploying Canada balsam (Canada turpentine, balsam of fir,

1867] Miscellaneous. 523

terebinthina Canadensis) as a vehicle, and sulphuric ether
as a solvent. The carbolic acid mixes readily with the
ether and Canada balsam; and the coloring matter is
well suspended. Tallow and wax may also be dissolved
in the Canada turpentine by the aid of heat.

When an organ thus injected is exposed to the air, the
ether evaporates rapidly, and the Canada balsam gradu-
ally dries to a hard material, enclosing the coloring mat-
ter, and filling up the blood-vessels.

The method employed by Dr. Joseph Jones, is also of
great value in the preservation or embalming of bodies
for transportation to a great distance, or for any other
purpose. "\Yhen the colored fluid is properly injected, it
tends to impart a life-like appearance to the skin.

It is well known that carbolic acid arrests fermentation
and putrefaction, and destroys the lower forms of vege-
table and animal life.

As far as the experiments in the University of Nash-
ville have extended, carbolic acid appears to be the best
of all antiseptics for the injection of bodies designed for
dissection, and must supercede, in the dissecting room,
the chloride of zinc, which discolors the structures, and
injures the knives; and the poisonous arsenious, and
arsenic acids, which endanger the health, if not the life,
of those who dissect habitually.

Dr. T. B. Buchanan, Curator of the Museum and Pro-
sector to the Chairs of Anatomy and Surgery in the
University of Nashville, is also conducting a series of
experiments upon the preservation of organs and tissues,
in water impregnated with carbolic acid. Such a mixture
would be infinitely cheaper than alcohol, and such experi-
ments have a high practical value. Up to the present
time, the results obtained by Dr. Buchanan have been
most satisfactory. Nashville Jour, of Med. and Surg.

524 Miscellaneous. [March

Redaction of the Subcoracoid Dislocation of Humerus.

Dr. Alexander Gordon states (Brit, and For. Med. Chir.
Bev., October, 1866) that he has successfully emplo}<ed, in
nine consecutive cases, the following mode of reducing
this dislocation :

" If the right shoulder be dislocated, I place the patient
on his back, with the shoulders raised, in bed, or on a
mattress laid on the floor, or on a sofa. Standing on the
same side, and raising the elbow, I grasp the lower end
of the right humerus ; the thumb on the inner, with the
fore and other fingers on the outer side, the forearm lying
flexed at an acute angle, resting on the web between the
thumb and fingers. I raise the arm upward and forward,
so as to place it at right angles with the surface upon
which the patient is lying. Besides, to have complete
muscular quiescence, I tell the patient to permit the ex-
tremity to rest upon and be supported entirely by my left
hand. "With the right hand I feel for the head of the
dislocated humerus, and press it downward and outward,
either through the anterior wall of the axilla or in the
axilla, moving at the same time, with the left hand, the
lower end of the humerus upward and backward, with
rotation chiefly inward.

" Whilst thus engaged, I have felt on several occasions
a snap or jerk, so marked as to lead me to suppose, for
the moment, that the dislocation was reduced. This snap
or jerk is due to the head of the humerus having changed
its position ; for when we depress it we free it from the
coracoid process, and the supra and infrarspinati muscles,
being on the stretch, jerk it outward to the anterior bor-
der of the glenoid fossa. When in this position, with the
fingers in the axilla, I can feel almost the whole of the
upper articular surface of the humerus, which I press
outward and forward; or, in other words, I lift the head

1867] Miscellaneous. 525

of the humerus over the inner margin of the glenoid
cavity, assisting with the left by rotation and very slight
extension, if necessary, when the head enters the glenoid
fossa with a distinct snap."

Dr. Gordon is convinced that this mode of reduction is
equally applicable to other forms of dislocation of the
humerus. Am. Jour. Med. Sciences.

4 Remarkable Solvent.
It is now discovered, it appears, that if a piece of cop-
per be dissolved in ammonia, a solvent will be obtained,
not only for lignine, the most important principle of all
woody fibre, such as cotton, flax, paper, etc., but also for
substances derived from the animal kingdom, such as
wool and silk. By the solution of any of these an excel-
lent cement and water-proofer is said to be formed ; and,
what is equally important, if cotton fabrics be saturated
with the solution of wool, they will be enabled to take
the dyes such as the lac dye and cochineal hitherto
suited to woollen goods only. Hydriodide of ammonia,
we may also observe, was long since discovered to be an
equally remarkable solvent of the most refractory, or, at
least, insoluble mineral substances. Now it is an inter-
esting circumstance that ammonia, according to Van
Helmont, and other old chemists and alchemists, was one
of the requisite materials in the " formation of the alka-
hest," or " universal solvent," of the ancient sages.
Detroit Review,

Surgeon Ebon Swift, U. S. A., is suing the Hannibal
and St. Joseph Railroad for loss of his baggage. He
claims $5,958 50 damages, one half of the amount being
estimated to be the value of an unpublished work of his
on "Veterinary Surgery," the manuscript of which was
in his trunk.

526 Miscellaneous. [March

A New Remedy in Erysipelas Iodide of Potassium.

Dr. II. B. Withers, of Rantoul, Illinois, writes to the
Chicago Med. Journal that he has used iodide of potassium
in about thirty cases of erysipelas with perfect success.
It arrested the disease in from twelve to thirty-six hours.
He gives usually ten grains every two hours, observing
closely the effect. As soon as the disease begins to sub-
side, the medicine is discontinued. No external applica-
tion is used, but the parts are simply kept covered and
moist. The author doe3 not recommend it as a specific,
but considers it a very valuable remedy in the disease.

Organic He-mains.

Among the passengers recently at St. Louis, by steamer
from the Upper Missouri river, was an agent of the
Smithsonian Institution at Washington, D. C, in charge
of a large number of petrified organic remains for the
Smithsonian Institute and the Philadelphia Academy of
Natural Science.

The collection, which comprises over three hundred
different kinds of small animals, extinct and living,
together with bears, etc., of mammoth size, was made in
Dakotah Territory, near the head of White river, by
Professor Hayden.

A New Diagnostic Sign in Disease of the Kidneys.

According to M. Corlien, the odor of cubebs, aspara-
gus, etc., can be detected only in the urine secreted by
healthy kidneys ; and reasoning by exclusion he maintains,
that where this sign is absent, the kidneys must necessa-
rily be diseased. Med. Record, Feb. 15, 1867.

1867] Medical College Commencement. 527

MEDICAL COLLEGE COMMENCEMENT,
AUGUSTA, MARCH 1, 1867.

The ceremony of conferring the Doctorate took place at the Masonie
Hall, in presence of a large and appreciative audience. The Trustees
and Faculty, accompanied by the Students, arrived at twelve o'clock,
when the Vice President, C. F. McCay, L.L.D., took the Chair, and the
meeting was opened with prayer by the Rev. Mr. Lamar. The Report
of the Dean, Dr. L. A. Dugas, was then read, and, on motion, ac-
cepted ; after which the Vice President felicitously extemporized words
of wisdom to the Graduates, and proceeded to confer upon them the
degree of Doctor of Medicine. The Rev. Dr. H. H. Tucker followed
with an address of rare excellence and fine taste, fully sustaining the
Reverend gentleman's high reputation as an accomplished orator.
Finally, a chaste and manly valedictory address was delivered by Dr.
Wm. H. Foster, of this city. The whole ceremony was effective and
highly creditable to all the parties concerned.

The Class in attendance on the session just closed numbered seventy,
three, of whom forty-five were from Georgia, eleven from South Caro-
lina, eleven from Alabama, two from Texas, two from Pennsylvania,
one from Virginia, and one from Florida.

The following is a list of the Graduates :

Francis L. Brooks, of Columbus, Ga.
James A. Dozier, of Columbia County, Ga.
William R. Eve, of Richmond County, Ga.
William II. Foster, of Augusta, Ga.
William R. Gates, of Kingston, Pa.
Thomas C. Gower, of Gainesville, Ga.
Samuel S. H. Gray, of Gainesville, Ga.
Ludy M. Henderson, of Mt. Pleasant, S. C.
Charles N. Howard, of Cusbeta, Ga.
Robert T. Jennings, of Galveston, Texas.
Thomas L. Lallerstedt, of Augusta, Ga.
Thomas J. Lumpkin, of Lafayette, Ga.
Frank H. Matlack, of Downington, Pa.
James K. McWhorter, of Pickens District, S. C.
James M. Milton, of Greenville, Ala.
Thomas M. Murdock, of Burke County, Ga.
Redden J. Reid, of Bartow County, Ga.
Cornelius 0. 0. Roberts, of Lake City, Fla.
Richard P. Spencer, of Hicksford, Va.
Henry T. Templeton, of Laurensville, S. C.
Losson J. Turner, of Sterling. Texas.
William F. Wilson, of Hannahatchfe, Ga.

528 Faculty of the Medical College. [March, 1867

PROFESSORIAL CHANGE.

Dr. I. P. Garvin having resigned the Chair of Materia
Meclica, Therapeutics, and Medical Jurisprudence, in the
Medical College of Georgia, Dr. Wm. H.. Doughty, of
this city, was elected to till the vacancy.

FACULTY OF THE MEDICAL COLLEGE OF
GEORGIA, AT AUGUSTA.

I. P. GARVIN, M.D.,

Emeritus Professor of Materia Medica, etc.

L. D. FORD, M.D.,

Professor of the Theory and Practice of Medicine.

JOSEPH A. EVE, M.D.,

Professor of Obstetrics and the Diseases of "Women
and Infants.

L. A. DUGAS, M.D.,

Professor of the Principles and Practice of Surgery.

G. W. RAINS, M.D.,

Professor of Chemistry and Pharmacy.

EDWARD GEDDINGS, M.D.,

Professor of Physiology and Pathological Anatomy.

DeSAUSSURE FORD, M.D.,

Professor of Anatomy, general and descriptive.

WM. II. DOUGHTY, M.D.,

Professor of Materia Medica, Therapeutics, and
Medical Jurisprudence.

JOHN L. COLEMAN, M.D.,

Demonstrator of Anatomy.

1ML Dean.

Notice of works received will appear in our next.

SOUTHERN

tbkM Surgical four ml

AUGUSTA^ GA

Vol. XXL] MAY, 1867. [No. 5

ORIGINAL AND ECLECTIC.

On the true Homologies of some Structures, usually accounted
Epithelial. By Edward Geddings, M.D., Professor of
Physiology and Pathological Anatomy in the Medical
College of Georgia.

The rapid advance of cellular-physiological and patho-
logical doctrines in recent times, which bids fair to bring
about a total reform in medical science, lends a peculiar
interest and value to any attempt to trace out the natural
affinities of the cellular elements, and the laws which
govern their protean transformations. We Iiave learned
to refer everything essentially vital, the prime movement
in every living act, not so much to the adjustment of the
living mechanism as a whole, but to the individual cellular
elements themselves, to regard the organism as a society
of living Monads, each of which contains wdthin itself all
that gives peculiarity to its acts, while it is dependent on
its association with the rest only for a supply of the
physical conditions necessary to every manifestation of
vitality, food, warmth, moisture, and oxygen. There is
45

530 Geddings on Epithelial Structures. [May

little doubt in the mind of any real physiologist of the
present day, that could we, without injury, transplant a
single organic cell from one organism to another, in
which it would be furnished with the necessary physical
conditions, it would continue to grow, produce its kind,
and perform all other characteristic acts exactly as in its
original site. ,f} i >j //"/-

Under such circumstances it is of the last importance,
to the just appreciation of any physiological or patho-
logical action, that we should comprehend, as far as pos-
sible, the actions of the individual cellular elements into
which it might be analysed. We must not only endeavor
to understand those characters which distinguish all kinds
of cell life, but those peculiarities in which they differ
one from another. We must compare them, trace their
similarities and differences, assemble them in groups,
according to the degree of their affinities ; in a word,
classify them.

In a series which, like the constituent cells of the living
organism, start from a single typical form, and reach
their ultimate characteristic qualities by a successive
transformation and repeated divergence, it were natural
to expect to find a number of sharply-defined groups,
such as have been so beautifully established in the great
series of animate beings, class, order, and species, in
which the later divisions would contain the qualities of
that which preceded them, while differing from each
other in other respects. Very little has been done in
this direction. We have numerous classifications of tis-
sues, from Bichat down, all bearing more or less the im-
press of the peculiar tendencies of the school from which
they emanated, but a real natural classification of cells
has never been attempted.

Nevertheless, the researches of the great micrographists
of our day, Reichert, Ilenle, Remak, Robin, Virchow,

11

1867] Geddings on Epithelial Structures. 531

Kolliker, and others, clearly indicate the limits of the
first great division, the classes. We have gradually be-
come familiar with three great divisions of animal cells,
to which most of the existing forms could, without much
difficulty, be referred, viz. : the Epithelial, the Connective,
and the Nervo-muscular.

It is not the object of this paper to pursue this classifi-
cation farther, nor to show how far such a division of
cellular elements into the three great classes mentioned,
is justified by known facts. But assuming it to be cor-
rect, it is intended to exhibit that certain structures,
which have been usually reckoned among the epithelial,
ought in reality to be referred to the connective series.
Such are the serous membranes, the lymphatic ganglia,
and the blood-cells.

In the classification of cells, as of other series of natu-
ral objects, we must not rely too much on one or more
prominent characters, but should, as much as possible,
compare all their known qualities. The failure to follow
this rule has been a fruitful source of error in the history
of zoological classification. I need only allude to the
marsupials, the cirrhipeds, and others. So, in the classi-
fication of cells, the general observations that most free
surfaces were covered with epithelium, and that epithelial
structures consisted of closely-packed cells without inter-
stitial substance were alone deemed sufficient to place the
serous membranes among the epithelial structures. So,
likewise, the general resemblance of the lymphatic gan-
glia to glands, and a supposititious function, led to a clas-
sification of the lymphatic ganglia, among epithelial
structures. Neither of these generalizations will bear
the test of closer scrutiny, and a comparison of all the
known characters of such structures.

In the present state of our knowledge of cell-life, I
think that characters for comparison can be drawn from

532 Geddings on Epithelial Structures. [May

the development of cells, from their anatomical form and
connections, their physiological and pathological trans-
formations, one into the other, and their living acts under
normal and abnormal conditions.

One of the earliest acts of the embryo, after the fissure
of the yelk, is to divide itself into three parts, from
which very different structures arise a lower or visceral
germinal membrane or layer, an upper or animal layer,
and a medullary tube, the foundation of the nervous
centres. Now, it was shown by Remak, long ago, that
nearly all glandular and epithelial structures were derived
from the lower or visceral layer. This membrane, in
conjunction with the animal layer, curves downward and
inward, and gradually encloses a tube or cavity, which
eventually becomes the intestinal canal. Conjunctiva
nares and pharynx are originally parts of this great
cavity, and remain connected with it throughout life.
From it are developed many homologous structures, all
undoubtedly epithelial, viz. : the lachrymal glands, the
salivary glands, the lungs, the thyroid gland, the thymus,
the liver, the pancreas, and the genito-urinary cavity
(allantois, corpora wolftiana, ductus Mullen). All these
structures are developed in exactly the same way, by a
process of gemmation. One exception is usually admitted
to this law of liemak, the epidermis, with its appenda-
ges, nails, hair, and horns. But there is just a possibility
of error here. It is well known that, at a very early
period of embryonic life, two buds or protrusions, one
before and one behind, are shot off from the margin of
the umbilicus, which, curving over the ends of the em-
bryo, gradually envelop it in a double membrane, or bag.
As usually described, these vesicles are developed from
the animal layer alone, and the outer bag coalesces with
the chorion, while the inner becomes the amnion. But

1867] Geddings on Epithelial Structures. 533

it is possible, in view of the great difficulty of investiga-
tion at this period, that the visceral layer may likewise
follow the animal, in the protrusions, and that the outer
bag should become the amnion, while the inner would
become the epidermis. This would give the embryo a
covering of epithelium, and the amnion the epithelial
lining it undoubtedly possesses at a later period.

As is known, the majority of connective structures,
such as the bones, cartilages, ligaments, tendons fasciae
as well as the loose areolar tissue, is developed from the
upper or animal layer. It may be considered an open
question, whether the same distinction can be shown be-
tween these and the third group, the nervo-muscular. It
would seem like a heresy to say that nerves and muscles
are developed from the medullary tube, and not from the
animal layer, where we usually find their first traces. But
such will eventually be, I believe, the established fact. It
has been well made out, that the nervous portion of the
organs of special sense are developed by protrusion from
the anterior extremity of the medullary tube, and it would
be but a fair analogy to suppose that other nerves were
evolved in the same way. In point of fact, we see about
this time a series of dark lines shoot out from the medul-
lary tube, one for each vertebra, and extending even
beyond the limits of the embryo. It is impossible to say
that these are the foundation of the future nerves and
muscles, but it is not impossible. Again, when any part
of the medullary tube, from which the organs of sense
arise, is defective, the corresponding organ of sense is
wanting also. Xow we find the same law in regard to
other nerves and muscles. When any portion of the
nervous centres is defective, not only are the nerves which
should spring from it wanting, but the muscles also, even
the heart. This well-known law of pathological embry-
ology does not hold the other way, for the muscle may be

Geddixgs on Epithelial Structures. [May

wanting, while the nerve is intact, or the nerve be defec-
tive, while the centre exists. These facts furnish strong
presumptive evidence that nerves and muscles are origi-
nally developed from the medullary tube, but at so early
a period that it has escaped attention.

Tha three great types of cells are thus distinctly laid
out at the earliest period of embryonal life. Subsequently
they extensively interpenetrate each other, but at first
they are distinct. It will not be difficult to show that the
serous membranes are developed from the second or con-
nective series.

When the division takes place between the visceral and
animal layer and the medullary tube, there remain two
cavities, which mark the separation. These are the great
serous cavities, the pleura and peritonaeum (at first one),
and the arachnoid and their walls are the serous mem-
branes. Now if we examine the evolution of the embryo
more attentively, we find that it is only the lining of the
visceral and medullary tubes, which become respectively
the epithelial and nervo-muscular structures. Outside of
each of these remains a layer of cells, which, in one case,
becomes the fibrous connective stroma of the intestine
and glands, and in the other the fibrous portion of the
arachnoid and neuroglia. So that the great serous tissues
are developed from and among cells of undoubted con-
nective type. The synovial capsules, sheaths, bursae,
etc., are of course developed from the same source, but
what is more to the purpose, they may, at any time,
develop adventitiously. "Wherever two parts slide over
each other, there we will find a bursa make its appear-
ance, and we can distinctly trace its formation, from the
loose connective tissue, by the gradual proliferation of the
stellate cells, and the secretion of mucine instead of fibro-
genic material, by a partial reversion, therefore, to the
embryonic type.

1867] Geddings on Epithelial Structures. 535

All this applies equally well to the blood-vessels, and
their serous lining, the endangium. They make their
appearance in the upper or animal layer. Some embry-
ologists admit a special or vascular layer, where the ves-
sels are developed, but this is incorrect. It is never truly
separated from the upper or animal layer. As is well
known, the first blood-cells are developed from the same
cells as the walls of the vessels, and in situ. Precisely
the same thing may occur at any period of life. "Wherever
we have a new growth, from connective tissue, there will
we find a new formation of blood-vessels, and according
to 6ome of blood-cells, perfectly distinct from already
existing vessels. But this is only from connective struc-
tures, never from epithelium. We may have the most
massive development of epithelial cells, as the cholesteat-
oma, or pearl tumor of Miiller, where they form large
rounded masses of closely packed cells, or in horns, but
never do we see such structures penetrated by vessels,
unless they are, at the same time, permeated by a stroma
of connective tissue. Very instructive, in this respect,
is the comparison of true horns and antlers. Both are
intended for the same purpose, but one is epithelial, the
other connective structure. The first are never perme-
ated by vessels, the other always during the period of
their growth.

From the anatomical form we can glean but little in
support of our argument. The serous cells exhibit indeed
a tendency, but a tendency only, to assume the character-
istic fusiform and stellate shapes of connective cells,
especially in the blood-vessels, but as similar indications
of a tendency to assume the fusiform shape at least are
to be found among cells, undoubtedly epithelial, in the
urinary passages, the sign is of little value. Even the
most characteristic peculiarity of connective tissue, the
presence of the intercellular cement, is wanting in the

536 Geddlnuis on Epithelial Structures. [May

serous membranes. The cells are as closely packed as the
pieces of a mosaic. This may be the reason why they do
not send out their characteristic prolongations. Both
characters, however, make their appearance when the
structure hypertrophies. Something like this is normally
observed in the synovial structures where the cells never
form a continuous covering, but the interstitial substance
is here and there uncovered. Here we not only find fusi-
form, but even star-cells.

Very important, on the contrary, are the anatomical
transitions. If we compare vertical sections of serous
and mucous membranes, as we can easily do in the intes-
tine of small animals, where the two are in close apposi-
tion, we will find the margin of the mucous epithelium,
where it strikes the connective stroma, sharply defined.
Not so the serous. It is impossible to tell where the
serous tissue ends, and the connective commences. As
we pass outward we find the star-cells at first perfectly
discreet, gradually becoming more crowded, and shorten-
ing their processes until they pass, by insensible grada-
tions, into the cells of the serous covering. This is
especially the case with the vessels, particularly those of
small size. To see this distinctly, we should examine the
vessels of the living animal, and I can recommend for
this purpose the mesentery of the lizard. Not only are
the structures more transparent during life, but when the
vessel is contracted, as after death the condensed portion
is drawn away from the rest, which gives an apparent
distinctness to the vascular tubes, which they do not
really possess. So, also, when the vessel is injected, the
walls are compressed, and again appear more distinct.
But in the living animal the vessels appear in their true
character, as mere channels in the connective tissue. As
we approach the cavity, the cells become more numerous
and more crowded, and finally pass into the characters of

1867] Geddings on Epithelial Structures. 537

the endangium. I am here speaking only of the smallest
vessels. In the larger the interposition of the elastic and
muscular elements gives them the character of indepen-
dent tubes, as well as their stratified appearance. But, if
we imagine these taken away, even the larger arteries
would appear as channels in the connective tissue.

The transition from connective cells to serous struc-
tures seems to have struck all observers. Thus Henle,
starting from the idea that the serous covering was real
epithelium, speaks of the connective cells beneath as
"metamorphosed epithelium ;" and Kolliker, comment-
ing on the subject, says: " The similarity of these layers,
which I will call the striated layers, with the fibre (con-
nective) cells beneath, and the epithelium does not justify
us in considering them as derived from the latter, since
nothing proves that the two are genetically connected.
* * * But, it seems to me, allowed to consider
them as originally of equal value, originally the same,
but developed in different directions." (Kolliker Gewebe-
lehre, p. 544.) Eemak proposed to call the serous layer
the cell layer, " because it, differing in this respect from
other epithelium, passed into the connective structures
without defined limits, so that we frequently can not tell
where one commences and the other stops." (Ibid.)

It may as well be mentioned here, that our ideas of the
structure of the capillaries have recently undergone a
considerable modification. We no longer consider them
as a network of star-cells, in the interior of which the
blood circulated ; nor do we regard them as formerly, as
structureless tubes. They consist, like the endangium
everywhere, of a mosaic of flattened fusiform, or even
stellate cells closely fitted together. So delicate are they,
so perfectly adjusted, that we fail to discover the limit
between them ; but the silvering method, as now prac-
46

538 Geddings on Epithelial Structures. [May

ticed, plainly exhibits the outline of a cell around each
nucleus.

The transition of serous structure to fibrous, is not the
only one we can demonstrate. In every joint we can
show the transition from cartilage to synovial structure.
The latter, as is known, does not cover the head of the
bone, the cartilage is quite bare, but where the capsule
joins the cartilage^we can see every stage of transition,
from one to the other. In the spleen and the lymphatic
glands, we can distinctly trace the splitting up of the
ends of the vessel, intima and all, into ordinary con-
nective tissue. We will return to this presently.

In comparing the physiological characters of serous
tissue with the epithelial and connective structures, it
must be remembered that the two last represent classes,
the physiological characters of which may be variously
specialized in the different species that compose them,
and it is not always easy to seize the general characters
amidst the mass of detail. In general it may be said that
it is the office of epithelial structures, to secrete some
material, differing, more or less, from the general nutri-
tive material from which it is made. The connective, on
the other hand, performs mechanical functions, builds up
the solid framework of the organism and of the indi-
vidual organs, binds parts together and facilitates their
movements upon one another. The distinction is marked
enough if it could be carried out, but there are various
difficulties. Thus, the epidermis, with its appendages,
performs a mechanical part in protecting the subjacent
structures, but it does so by a true secretion, the elabora-
tion of a substance widely differing from the nutritive
plasma, keratine. Again, all cells secrete, and so do the
connective, but their secretion is the same everywhere ;
when young, mucine; when old, iibrogenic material.
This would be characteristic enough if the epithelial

1867] Geddings on Epithelial Structures.

structures did not sometimes secrete the same materials.
Mucine is secreted by laminated epithelium, but there
remains the distinction that in general mucine is the se-
cretion of ripe epithelium, but of young connective cells.
More characteristic is the iibrogen material. True epi-
thelium sometimes secretes fibrine, or at least a coaffu-
lated proteine substance, closely resembling fibrine in its
physical character, as we see in diptheritic and croupous
inflammations, and even in the ordinary inflammation of
single-layered epithelium, such as lines the ultimate
ramifications of many glandular structures, as the lungs,
kidneys, salivary glands, etc. But too much weight must
not be laid on the physical characters of the proteine
bodies, for their protean transformations, under varying
conditions, are but little known. Physiologically, fibro-
gen material and croupous exudation are two very distinct
things. Never do we see the latter, like the former,
undergo the transformation into fibrillated cement, never
form those adhesions and indurations, so characteristic of
connective structures. We may, therefore, say in general
terms, that a structure which, when young, produces
mucine, and when old, fibrogen material, belongs to the
connective series.

Tested by these physiological characters, the serous
structures clearly coincide with connective tissue. Their
function is purely mechanical, to allow different parts to
move freely on each other, and in this respect they assim-
ilate to the loose areolar tissue. "When under morbid
conditions, two parts begin to move freely on each other
which did not move before, there we will usually find an
adventitious development of serous structure, and always
from connective cells. When serous membranes secrete
anything beyond the ordinary nutritive plasma, it is
always mucine or fibrogen material, never more special
secretions.

540 Geddings on Epithelial Structures. [May

A striking peculiarity of epithelial structures is, that
they are deciduous. They are being constantly cast off,
and replaced by others. Not only do we find them in all
secretions, but when these are retained, as in the first
formation of all true cysts, they accumulate, and render
the fluid opalescent or opaque. Nothing of the kind
occurs with serous structure. The fluid is either trans-
parent, or, if troubled, it is from coagulated fibrine or
pus. The serous cells are not transient, but permanent
structures, the duration of whose existence, like other
connective cells, equals that of the organism.

As a physiological peculiarity of epithelial structures,
may be mentioned their tendency to throw out protru-
sions, or crypts, which frequently branch, as in true
glands. This we never see in serous membranes ; they
are always perfectly smooth, and never form glandular
structures of any kind.

The above characters derived from their development
their anatomical form and relations, and their physiologi-
cal attributes would, I think, be sufficient to remove the
serous structures from the epithelial series, and establish
their homology with the connective, but the induction is
still more strikingly borne out by the phenomena they
exhibit under pathological processes. Herein lies the
great importance of placing them in their proper classr
since this at once gives us the key to the transformations
they are likely to undergo.

When epithelial structures hypertrophy, either the cells,,
as they multiply, are cast off, or they remain attached,
forming thick laminated masses, without interstitial sub-
stance. When the hypertrophy starts from the connec-
tive layers beneath, forming warty excresences, the epi-
thelium is never broken unless by ulceration, but forms a
continuous, more or less, thickened investment. With
the serous membranes it is very different. Let any one

1867] Geddings on Epithelial Structures, 541

examine the vegetations so frequently found upon the
valves of the heart or the pericardium, and he will find
that they consist of connective tissue in various stages of
development with well-defined interstitial tissue, without
a trace of investing epithelium. Yet the latter has by-
no means been cast off, for such vegetations may cover
the whole face of a serous membrane without our finding
any cells in the serous exudation.

Very characteristic are the differences of the inflamma-
tory process in the two classes of structures. In epithe-
lium the active congestion is followed by a copious secre-
tion of thin albuminous fluid, which soon passes into the
ordinary thick glairy mucous. Simultaneously, there is
a rapid proliferation of the epithelium, the cells of which
are rapidly cast off from the outer layers, rendering the
fluid at first opalescent, then opaque. At first the cells
have all the characters of ripe epithelium, but as the pro-
cess progresses, younger forms make their appearance ;
at first large rounded granular cells, gradually followed
by smaller and smaller, until they reach the form of small
round granulated cells, with tripartite or multiple nuclei,
usually regarded as characteristic of pus. When the pro-
cess runs off, the secretion diminishes by degrees, riper
forms make their appearance, and complete "restitutio ad
integrum" results, provided the process has been con-
fined to the epithelium, and the connective structures
beneath have not been laid bare. Such is the well known
picture of ordinary catarrhal inflammation.

Nothing of the kind occurs in serous membranes.
These structures inflame like a wound, i. e., like connec-
.tive tissue, with a secretion of fibrogenic material and
the formation of vascular granulations, and the result is
invariably, unless the process has been confined to its
earliest stages, not a complete " restitutio ad integrum,"
but a new growth of modular tissue with the well known

542 Geddings on Epithelial Strictures. [May

indurations and contractions, characteristic of the inflam-
mation of connective structures. The inflammatory vege-
tations of serous membranes, which are here put forward
as the homologa of granulations, are larger and less vas-
cular than these, but scanty vascularization is character-
istic of serous membranes generally, and their large size
is probably owing to the fact -that generally all the cells
ripen, whereas, in ordinary granulations, a large part are
cast oft' as pus. It might be objected to the distinction,
just tried to be established, between the inflammatory
process in epithelial and connective structures, that the
former may, and often do, secrete fibrine, and that the
highest development of the process is identical in both,
the production of pus ; but, as already pointed out, the
tibrine of epithelial structures (diptheria, croup, pneumo-
nia, morbus Brightii), is not identical with the fibrogenic
material of connective and serous tissue, for it never
organizes, never forms modular tissue. In the next place,
it may be doubted if the pus in these two cases is identi-
cal. The morphological characters are, it is true, the
same in both. But what are they '{ The characters of
young cells everywhere, of the young blood-cells in blood,
and lymph of the embryonal cells in the egg. But do
they secrete the same thing? We possess no reliable
chemical analyses on this point. But if the nose might
be allowed to take the place of such, I should say de-
cidedly not. The odor of pus is so characteristic that it
reveals to the practiced olfactories of the surgeon the
presence of the smallest wound in any part of the body.
But does any one recognize anything like this in a puru-
lent ophthalmia, a violent coryza, a bronchitis, or a gon-
norrhoea ? As a chemical character, every one must have
observed that epithelial pus does not blacken silver instru-
ments, or at least not to the same extent as ordinary pus.
This would indicate the absence of unoxydized sulphur,

1867] Geddings on Epithelial Structures. 54S

so characteristic of the pyine of Gueterbock. Catarrhal
pus frequently undergoes putrid fermentation, and devel-
ops intolerably foetid odors, but they are, as every one
knows, different from those of ordinary pus.

In every respect the inflammation of serous membranes
is identical with that of connective tissue. They secrete
fibrogen material* a part of which forms ordinary fibrine,
a part true fibrillated cement, and any cells that are de-
veloped, assume the characters of connective cells or true
pus. Never do we find a thickening of the so-called
epithelium, or a casting off of cells in mass, except as
pus. The surface of the pseudo-membrane, or when
formed, of the vegetations, is always bare, and we never
find, as in croup and diptheria, the epithelium underlying
the false membrane.

In general, the serous structure shows little tendency
toward the production of pus, unless it is exposed to the
air, or has been infected by a purulent deposit elsewhere,
as in puerperal peritonitis, metastatic pleuritis, etc. Here-
in we have a most direct analogy with the connective
tissues, for it is a fact familiar to every one, that the most
severe contusions and lacerations of the connective tissue
do not lead to suppuration, provided they are subcuta-
neous.

The formation of vascularized psendo membranes,
granulations, and adhesions, so common in serous mem-
branes, are equally characteristic of connective tissue,
for nothing of the kind is ever known to occur in epi-
thelial structures. These never exhibit either vessels,
granulations, adhesions, or contractions, unless the epi-
thelium is broken, and the connective structures laid bare.

It might be objected that in all these cases the epithe-
lium, as a single layered epithelium, is cast off, or degene-
rates (Buhl). But why does not the same thing occur in
the inflammation of single layered epithelium, else

544 Geddings on Epithelial Structures. [May

where ? Why does not every pneumonia end in indura-
tion and organization of the exudation ?

All this applies equally well to the endangium, for
nothing is easier than to excite adhesive inflammation in
the blood-vessels, and when a thrombus organizes, its
newly-formed vessels communicate directly with the vasa
vasorum, while the endangium remains* intact, a circum-
stance that never occurs in any epithelial canal.

Most of the degenerative processes occur in both classes
of structures. Thus the fatty and the amyloid degenera-
tion, as well as the formation of pigment, occur as fre-
quently in connective structures as in epithelium. All
are found in serous membranes. To this the calcareous
degeneration forms an exception. There is but one case
where a deposit of lime salts takes place in epithelial cells
under physiological conditions, and that is in the enamel
of the teeth. The exceedingly rare calcareous degenera-
tion of cataract is, perhaps, the only well-authenticated
instance in pathology. On the contrary, nothing is more
common than to find a deposit of lime salts, or even the
formation of true bone in connective tissue. Both are
common in serous membranes, and although such degene-
rations usually develop in the depths of the membrane,
and subsequently extend to the surface, yet we can often
distinctly trace at the margin of the deposit, the calcare-
ous degeneration of the serous cells, especially in athe-
roma, and the osteophytes of the synovial membranes of
joints.

Nine-tenths of morbid growths develop from connec-
tive structure, and all of these occur in serous mem-
branes, but it is impossible to say, in any particular
instance, whether from the serous cells or the connective
stroma beneath. The tubercular process, however, offers
us a case in point. A tubercle, according to the best and
most recent authorities, consists of a small mass of cells,

1867] Geddinos on Epithelial Structures. 545

formed by a rapid proliferation, and destined to undergo
an equally rapid degeneration. Hence they never attain
any considerable size, the process being carried on by a
similar proliferation, and degeneration from other centres
in the neighborhood. These may coalesce and form larger
masses, but each tubercle must be regarded as a distinct
development. Now, although nothing is more common
than to find tubercles in mucous membranes and in the
skin, they never take their origin from the epithelium,
which may be traced in the early stages, passing over
them perfectly intact. Nowhere is this more distinct
than in lupus. Here the insulated tubercles extend for a
considerable distance beyond the externally apparent
margin of the disease ; but we do not see them, because
they are covered by sound epidermis. If however, we,
with a probe, press somewhat rudely upon different points
of this apparently sound skin, the instrument will pene-
trate every now and. then into the tubercular mass be-
neath. In the tubercles so frequent upon serous mem-
branes, it is different. The individual tubercles are upon
the very surface, and we would look in vain for the serous
covering. It is from the serous cells themselves that the
morbid development has taken place.

Characteristic of epithelial structures are the various
forms of epithelioma, of which we have several varieties,
some benignant and others sufficiently malignant in their
nature. These tumors, easily recognized by the epithelial
nature of their elements, may penetrate any kind of
structure, but they are never primarily developed, except
from epithelium. This is not conceded by all, but the
facts which seemed to indicate a transformation of con-
nective cells into epithelium, under certain circumstances,

i such, for example, as the development of epithelial masses
in the neighborhood of epitheliomata, but in the midst of

1 connective tissue, observed by Schroeder van dcr Kolk,
47

546 Geddings on Epithelial Structures. [May

have recently received a readier explanation in the dis-
covery of the spontaneous movements and wandering
propensities of many young cells. The fact remains that
the first development of such tumors is always from epi-
thelium. In accordance with this, we never see a devel-
opment of epithelioma from serous membranes. When
it occurs there, it is by extension from other parts.

Cysts are so much more frequent in connection with
epithelial structures than anywhere else, that they may
be almost said to be peculiar to them. If we except a
few rare cysts, the origin of which is unknown, but which
probably reaches back to an early period of embryonic
life, and the pseudo-cysts, formed by degenerative pro-
cesses in other tumors, perhaps all cysts occurring in
connective tissue, and unconnected with epithelial struc-
tures at any period of their development, may be referred
to hypertrophied or otherwise altered synovial bursae,
normal and adventitious. This difference between the
two classes of structures is also reflected in the serous-
membranes, for apart from the serous bursae, the rarity
of cysts in serous membranes is well known. The only
point in these where cysts are at all frequent, is at the
broad ligaments of the uterus. But the real origin of
these is to be sought in the corpora wolfliana of the
embryo. They are analogous to cysts at the head of the
epididymis in the male, and must be regarded as epi-
thelial.

Thus, wherever we are able to establish a characteristic
difference, anatomical, physiological, or pathological, be-
tween the two great classes of cells, the connective and
the epithelial, we find the serous membranes everywhere
corresponding with the former, and differing from the-
latter in every essential particular. In many respects,
doubtless, the qualities of the serous structures seem to-
fade into those of epithelium ; but when we review the

1867] Geddings on Epithelial Structures. 547

whole chain of phenomena, and assemble in one picture
all the known qualities they present under the various
circumstances, we can not escape the conviction that their
true homologies are to he sought in the connective struc-
tures, bone, cartilage, and fibrous tissue, and not, as now
universally assumed, in epithelium.

The value of such an attempt to establish the true re-
lations of an extensive and important system of cells, will
be very differently estimated by those who are, and those
are not impressed with the great value of the discovery
of the organic cell to the science of life. The first will
regard it as idle speculation, while those who look upon
cell-life as the future stand-point of far more general
views in physiology and pathology than we now possess,
will see in it an attempt to begin a labor which the science
will have to accomplish, by more extended observation,
and the superior resources which the future will certainly
bring. The viewTs above put forth, even though errone-
ous, have the advantage of connecting together and ex-
hibiting in a clearer light many points long since empiri-
cally established in practice. We see, for example, why
we can not treat an epithelial cyst like an hydrocele or a
synovial bursa, by iodine injections ; why it will not do to
admit air into a serous cavity; why the inflammatory
process leads to such widely different results in a serous
and a mucous membrane; wThy the rheumatic process
attacks and makes metastasis to every serous membrane
in the body, while the numerous epithelial structures
remain constantly exempt ; why the erysipelatous pyemic
and septic inflammations are so apt to extend to the
serosae, while the catarrhal, croupous, and diphtheritic
processes, peculiar to epithelial structures, never attack
the serous membranes in their original form, and show
little tendency to extend to them, even when in immediate
proximity.

548 Geddings on Epithelial Structures. [May

Whatever applies to the serosae generally, and especi-
ally to the endangiuni, will of course apply equally well
to the lining of the lymphatics, which exhibits precisely
the same structure. From the recent anatomical re-
searches into the structure and termination of these
vessels, we can gather some new facts in support of the
views advanced. The smallest lymphatics, like the ca-
pillary blood-vessels, consist only of the lining membrane,
which here also consists of closely-packed fusiform cellsr
the outlines of which can be easily demonstrated by the
silvering process. According to Ludwig and Reckling-
hausen, each one of these vessels communicates with an
irregular star-shaped vacuole of the connective tissue.
Ludwig was able to inject these vacuoles, which farther
communicate with one another from the lymphatics. R.
found the lymphatics beginning with open mouths upon
the serous membranes, and was able to follow, with the
microscope, the direct absorption through them, not only
of fluids and emulsions, such as milk, but also of solid
powders, such as cinnabar. The absorption was frequently
so rapid as to create a distinct whirl around the orifice.
Chrzonzewski demonstrated, by an ingenious physiologi-
cal experiment, the identity of the vacuoles, in which the
lymphatics commence with the ordinary star-cells of con-
nective tissue.

The experiment consists in tying the ureters of birds,
which do not, like mammals, excrete their nitrogen, as
urea, but as uric acid. The urates are then retained, and
as sparingly soluble salts are soon precipitated in every
part of the body. If the animal is killed a certain time
afterward, every star-cell is found filled with an opaque
granular mass, which may be shown by the murexide
test to be uric acid. But what particularly interests us,
the same granular mass may be traced through the rays
of the cells into the minute lymphatics. Here, therefore,.

1867] Geddings on EpitheUal Sirueluve*. 549

we have the most direct transition of the endangium into
connective cells. At the other extremity of the vessel a
similar transition has long been known. Nearly all anato-
mists now agree that a lymphatic vessel on entering a
follicle of a ganglion, immediately splits up lining, mem-
brane, and all, into the connective stroma of the follicle,
and that it is impossible to say at what point one begins
and the other ends.

In the meshes of the sponge-like stroma thus formed,
the so-called glandular elements lie closely packed, the
whole mass constituting the follicle, being penetrated by
a fine network of capillary vessels. The cells represent,
for the most part, young, rounded, granular forms, of
various sizes, and not to be distinguished from the white
cells of the lymph, or from young cells generally. Be-
sides these we almost invariably find fusiform cells, and
other transition forms between the last, and the charac-
teristic elements of connective tissue. This is particularly
true of the spleen, which we must now regard as an
enormous lymphatic gland. From the ultimate blending
of these different kind of elements, we might at once infer
that they were genetically connected, were it not for the
impossibility of distinguishing the young forms of the va-
rious tissues. It is possible that we may have here con-
nective and epithelial structures developing side by side.
The permeation of the cellular elements, by a connective
stroma and blood-vessels, is more characteristic of con-
nective tissue, since it is very different from the habit of
epithelial structure generally. But as this actually occurs,
in at least one structure of undoubted epithelial nature,
the liver, the character can not be relied on.

The generation of the lymph cells from the stellate
cells of the stroma is assumed by many microscopists,
and the true homology of the entire structure seems to
have been more than once suspected by observers of the

550 Gbddinos on Epithelial Stru/'tvres. [May-

first class; among others by Yirchow. I translate the
following passage from the most celebrated work of the
great master : " I must once more call attention to the
fact that the lymphatic glands differ from real glands in
the ordinary sense of the term, not only in having no
excretory duct, but in respect to their development. They
stand by no means on the level of glands. On the con-
trary, their whole history assimilates them to the connec-
tive tissues, and we might be tempted to count them
among those structures which arise from the metamor-
phosis of the connective series. But this would be at
present a very bold undertaking." (Cellular Pathologic,
p. 45.) To prove the homology thus hypothetically ad-
vanced, we must inquire farther into the history of the
lymphatic elements. Although always regarded as se-
creting structures, no one has yet been able to demonstrate
what they secrete. No new substance has been discovered
in the lymphatics after passing through the ganglia. The
constituents of the lymph are those of the serum, or
rather of the nutritive plasma everywhere, and none of
these constituents exhibits a marked relative increase,
except fibrine, and even of this it has always been consid-
ered an open question whether it is a secretion of the
structure, or whether it has passed into the lymph by dif-
fusion from the blood. The point must however be now
decided in favor of the first hypothesis. Fibrine does not
pass, or passes With great difficulty, across the walls of
the capillaries. We may have the most extensive dropsi-
cal effusions, we may have the blood-vessels subjected for
weeks to a pressure sufficient to burst them, yet the exu-
dation does not contain usually a trace of perfect fibrine.
Wherever we find fibrine, such has not been derived from
the blood, but has either been produced in situ or reached
its position by open channels.

Fibrine must, therefore, be regarded as a secretion of

1867] Geddikgs on Epithelial Structures. 551

the lymphatic ganglia. Which of the two substances of
which fibrine is now known to consist, the fibroplastic or
the fibrogenic, is here secreted, or both, can not now be
determined. The secretion of fibrogenic material is, how-
ever, highly characteristic of connective tissue, while it
is not known to be produced by any epithelial structure.
Fibroplastic material is almost equally so, but is found
also in the crystalline lense, which belongs to the epithe-
lial class.

The chief function of the lymph cells is that of serving
as a matrix of the white blood-cells. Of this there can
be no reasonable doubt. Indeed, if we reject the now
exploded doctrine of a generatio equivoca of cells, we
must either suppose these to be generated from the cells
of the endangium, by direct division from the lymph
cells, or in the ganglia. For the first of these methods
there is no reason. The second is untenable, on account
of the movement of the lymph in mass. The only fact
which could militate against the third, the appearance of
white cells in peripheric lymph vessels, has received an
amply sufficient explanation in the recent discovery of
peripheric lymph follicles in almost every part of the
body. On the other hand it is confirmed by many patho-
logical observations. Every nutritive excitement of the
lymphatic ganglia causes an immediate increase of the
white corpuscles of the blood, and usually a simultaneous
increase of fibrine. This is notably the case in erysipelas,
both the true and the phlegmonous in lymphangoitis py-
aemia, etc. It is by no means as was once supposed, a
general character of the inflammatory process, for there
are many inflammations in which it does not occur. The
most obvious connection, however, between white blood-
cells and the lymphatic ganglia, is in the fatal disease
leukaemia, in which the most enormous increase of white
cells is found, but never unconnected with marked hyper-
trophy of the spleen, or lymphatic ganglia, or of both.

552 G ed dings 071 Epithelial Structures. [)&%$

The lymph cells of the ganglia, and the white cells of
the blood, are one and the same thing, in different situa-
tions. To prove that the white cells of the blood are
connective in their nature, is to prove the same thing of
the cellular elements of ganglia. This proof is given in
the most striking manner in the study of thrombus. We
owe very valuable observations on this point to the labors
of Blandin, Lobstein, Stilling, and more recently of Bill-
roth and 0. Weber.

Very soon after the formation of a thrombus, a yellow
spot appears in the centre, consisting of a cheesy mass of
broken down fibrine, in which a few white cells are em-
bedded, while the red have completely disappeared. The
superficial resemblance of this mass to pus, led to the
famous phlebitis theor}' of Cruveilhier. A little later, the
detritus has in a great measure disappeared, and become
replaced by numerous white cells, which might easily be
taken for pus, even under the microscope. But they are
not pus, as their subsequent metamorphosis proves. Vir-
chow was at one time inclined to consider these cells as
only the white cells remaining after the absorption or
disintegration of the red, and to suppose that they were
undergoing degeneration. But they are far too numerous,
and frequently till up nearly the whole space originally
occupied by the thrombus. Their origin, by direct mul-
tiplication of the original white ceils, has moreover been
now distinctly observed. The next stage is the trans-
formation of these same cells into connective tissue. The
individual cells elongate, become fusiform, and ultimately
send out anastomosing rays, while an indistinctly fibril-
lated cement makes its appearance. During the whole
of these transformations, the mass is completely separated
from any organized structure by a la\'er of coagulum,
which gets thinner and thinner, and ultimately disap-
pears. True to the law of connective tissue, blood-vessels

;

1867] Geddings on Epithelial Structures. 553

soon make their appearance, and are at first perfectly dis-
tinct from the vasa vasorum, with which they subsequently
freely communicate. Whether the first red cells which
these vessels contain are formed in situ, or are derived
from the general circulation, has not been definitely made
out, but the first is, for several reasons, more than proba-
ble. When the process is complete, the walls of the
vessel, the endangium, and the thrombus form one mass
of connective tissue, and the vessel is completely and
permanently obliterated.

These observations, if correct, render the homology of
the cells of the lymphatic ganglia, and the white blood-
cells with the connective series unassailable. They are
moreover interesting as exhibiting what slight causes may
cause one and the same cell to assume two very distinct
anatomical forms. For the development of lymph cells
into fibrous structure is not the only transformation they
can undergo, nor indeed the normal one. Physiologically
the lymph cells are the young forms of the red blood cells.
This idea, although even now not universally admitted,
has been steadily gaining ground for the last ten years,
And for the following very good reasons : The red cells,
being devoid of nuclei, are incapable of multiplication.
This is borne out by direct observation, for no one has
ever seen a red blood cell in process of division, which,
if it occurred, could not have escaped attention in the
innumerable microscopic examinations of blood, made in
almost every part of the world, more especially, as it is
easily demonstrated, in the blood of the embryo, previous
to the appearance of the liver and spleen, when the red
-cells are still nucleated. Either, therefore, the red cells
are permanent structures, or they are produced from other
cells. It can, however, be easily demonstrated that there
must be a constant production of blood cells during the
whole period of existence. In the first place, the mass of
48

554 Geddixgs on Epithelial Structures. [May

blood, and consequently the number of blood cells, in-
creases directly with the weight of the body. Farther,
the most excessive losses of blood cells from hemorrhage
and other causes, are repaired within a few days. Leh-
mann has demonstrated a very considerable decrease in
the number of red cells in the blood of the hepatic vein,
and the complete identity of the bile pigment and hemat-
oidine, the well known substance into which the coloring
matter of the blood is transformed, whenever it is any-
where in the body removed from the cells, is strong evi-
dence of the truth of his assertion. Brown Sequard
injected the eliptical blood cells of birds into the vessels
of rabbits, and observed that they could be found for
several days performing the same functions as other blood
cells, but then disappeared.

For these and other reasons, we must admit that there
is a constant destruction and reproduction of red blood
cells going on during the whole period of existence, and
since they can not produce their kind, like other cells,
and an autochthonous production of cells is no longer
admissible in physiology, they must owe their origin to
other cells. There is no reason why these should not be
the white cells, which are poured into the circulation in
6uch numbers and from so many sources. The splenic
blood alone contains ten times as many white cells as
ordinary venous blood, namely, one white for every tifty
red. If, therefore, an amount of blood, equal to that of
the entire circulation, should pass fifty times through the
spleen, a number of white cells would be added to it
sufficient to reproduce the entire number of red cells.
From all we know of the velocity of the circulation, very
few days would suffice for this. What then becomes of
this immense number of young cells thus continuously
poured into the circulation ? That they are immediately
destroyed without undergoing any transformation into

1867] Geddings on Epithelial Structures. 555

riper forms is contrary to all physiological analogy, yet no
transformation of these structures, other than into red
cells, has ever been observed under normal Conditions.
On the other hand, the direct evolution of red cells out
of white, may be directly observed in almost every speci-
men of splenic blood, and frequently in the thoracic duct.
The cell contracts, becomes clearer, while the nucleus
becomes granular, and ultimately disappears. The cell
then gradually fills with coloring matter, and becoming
flattened and biconcave, exhibits all the characters of the
perfect blood cell.

The origin of the red blood cells, therefore, clearly
connects them with the connective series, but it must be
confessed that the genetic connection is almost the only
fact which points unequivocally in this direction. Their
deciduous nature, and their secreting so highly specialized
a product as haemato-crystalline, would indicate epithelial
characters. Perhaps the valuable discovery of Alexander
Schmidt, that the contents of the blood cells are fibro-
plastic, that is, contain one of the proteine bodies which
are now known to form fibrin e when made to react on
one another, might be considered as additional evidence,
were it not that the same substance occurs in the crystal-
line lense, a structure of undoubted epithelial character.

The physiological and pathological transformations
which, next to their origin, furnish, as we have seen, the
most valuable clue for determining the homologies of the
cellular elements, are entirely wanting in the red blood
cells. Never, under any circumstances, has a transforma-
tion into any other kind of structure been observed. A
red blood cell, whether in or out of the circulation, is
doomed to inevitable destruction. This peculiarity is
probably due to the absence of the nucleus, for only
young forms can undergo organic metamorphosis, and
cells lose the power of generating their species with their
nuclei.

556 Geddings on epithelial Structures. [May

The homology of the red blood cells, therefore, with
the connective series, although from their origin, more
than probable, can not be demonstrated with the same
degree of certainty as for the other structures we have
examined ; but it would be far more difficult to exhibit
as close a connection with any other structure in the
body.

The views above advanced in regard to the lymphatic
cells, are fully borne out by pathological observation.
Hypertrophy of the lymph ganglia leads, not to a massive
accumulation of cells, but to induration with the produc-
tion of inodular tissue or a cheesy degeneration unknown
in epithelial structures. All the morbid growths, peculiar
to connective structures, are found arising from lymphatic
ganglia, which might indeed be owing to the fibrous
stroma, but on the other hand, those which are especially
characteristic of epithelium are wanting. None of the
forms of epithelium are primarily formed in lymphatic
ganglia, and although possessing a distinct follicular
structure, these never produce true cysts.

No transformation of the white cells after leaving their
matrix has been observed, except those already mentioned
into red blood cells and areolar tissue ; but attention has
been already called by Uhle and Wagner (Handbuch d.
allgemeinen Pathologie, p. 203) to the probability of their
giving rise to many varieties of morbid growth, when
arrested in a thrombus or extravasation. This, if ever
demonstrated, would throw much light on the now inex-
plicable metastases of many morbid growths.

Although the evidence adduced in favor of the ho-
mology of the serous-lymph and blood cells with the
great series of connective cells, does not possess that
degree of accuracy at present necessary to establish a
scientific fact, or to raise the doctrine put forward above
the rank of a mere hypothesis to be sustained or refuted

1867] Brown on Protoxide of Nitrogen. 557

by more extended observation than the science now pos-
sesses, yet it is claimed, that it renders ripe for discussion
the following important theses :

The distinction traced at an early period of the embryo
between the connective and epithelial series of cells by
the division of its germinal layers, is maintained through-
out the whole of its subsequent evolution and through
the whole range of pathology.

Epithelium is derived only from epithelium, and con-
nective structure only from connective. The members of
either group may be transformed one into the other, but
never can one of the connective series be converted into
epithelium, or connective cells be evolved from epithelial.

Protoxide of Nitrogen, NO. Nfia, NO5 = 3 ITO + 2 NO.
By J. P. H. Brown, Dentist, Augusta,

Protoxide of nitrogen, nitrous oxide, or laughing gas,
was discovered in 1776, by Dr. Priestley; but its anaes-
thetic properties were not known until after the researches
of Sir Humphrey Davy, in 1800, who then made use of
the following language : " As nitrous oxide in its exten-
sive operations seems capable of destroying physical pain,,
it may probably be used with advantage during surgical,
operations in which no great effusion of blood takes
place."

This prediction of Davy, it seems, was not fulfilled
until 1844, when Dr. Horace Wells, a dentist of Hartford,
Conn., conceived the idea of using this agent to relieve
the pain in extracting teeth. To test the matter, he in-
haled the gas himself and had one of his own teeth ex-
tracted. He was so impressed writh the success of the gas
as an anaesthetic, that he endeavored to introduce it into
surgical practice. In 1847 he succeeded in getting Dr. E.
E. Marcy, of Hartford, to allow him to administer the
during an operation of removing a scirrhous testicle;

558 Brown on Protoxide of Nitrogen. [May

and in 1848 Dr. P. W. Ellsworth, of the same place, per-
formed an amputation of a thigh on a boy. In this case
Dr. Ellsworth remarks, that the gas was administered
" with a success fully equal to that attained since, either
by ether or chloroform." Shortly after this operation,
Dr. S. B. Beresford removed an adipose tumor, six ounces
in weight, from the shoulder of an adult.

After these operations, nitrous oxide was abandoned in
surgical practice, until Professor Carnochan introduced it
again in 1855. This eminent surgeon, in the Medical and.
Surgical Reporter for February 10, 1866, says: "Since my
letter in December, I have performed four more capital
operations on adults, viz. : one amputation of the thigh,
one of the leg, the removal of a tumor from the side, and
the extraction of a cataract, making in all, since last July,
seven successful capital operations under the influence of
anaesthesia produced by the nitrous oxide. I have also
during this time used chloroform and ether in many ope-
rations, and my opinion in regard to the superiority of
the nitrous oxide as an anaesthetic is still unchanged."

Since last September the writer has administered the
gas some eighty odd times during operations of extracting
teeth, with perfectly satisfactory results. As the effects
from one administration seldom last longer than two or
three minutes, it requires rapid operating when there is
much work to be done. This briefness of its effects
makes it not so desirable for operations in the mouth
where there is much hemorrhage, particularly in the ex-
traction of roots on the lower maxillary. In the practice
of the general surgeon these difficulties can more easily
be overcome. By alternating the inhalations of the gas
with those of atmospheric air, patients have been kept
under its influence for sixteen minutes. In one case for
thirty-two minutes, with no bad effects.

*

I .8

Report of Society of Dental Surgeons of the City of New York, in Dental Cosmos for

March, 1867

1867] Brown on Protoxide of Nitrogen. 559

The modus operandi of nitrous oxide in the production
of anaesthesia, is not well understood. It is supposed to
produce insensibility by its rapid stimulating properties,
which overcome systemic excitability and cause the
partial interruption of vital activity. " This power of
nitrous oxide/' remarks Dr. Ziegler in his Researches on
Nitrous Oxide, "to produce anaesthesia by superoxida-
tion, overstimulation, etc., is quite distinct from that of
all other agents, more especially of the hydro-carbona-
ceous variety ; for they induce the anaesthetic condition
by non-oxidation and deoxidation of the system, and by di-
rectly checking chemico-organic reaction and annihilating
sensibility and consciousness. The former, therefore,
increases while the latter diminishes life action, with, in
both instances, the same general result of insensibility of
body and unconsciousness of mind, though relatively as
different in character from each other as sleep is from
stupor, or satiety from starvation."

When the effects of nitrous oxide pass off the system,
there is none of that feeling of nausea and lassitude which
usually attends the administration of chloroform and
ether. This may be accounted for by the fact that the
former agent increases the amount of oxygen in the
blood, wThile the latter agents diminish it.

While I am not aware of a well-authenticated case of
death from its use (though several reputed ones have been
reported), I am free to admit that injury may be occa-
sioned by its injudicious or excessive administration.

It can not be supposed that an agent capable of pro-
ducing by its inhalation, in a few minutes, an anaesthetic
condition of the system, can be so harmless as to be in-
trusted to the ignorant, and administered indiscriminately.
In the first place, the gas must be pure. In order to have
it so, it is not only necessary to have pure chemicals and
a complete apparatus for its generation, but chemical

560 Baxley on Ligation of the Axillary Artery. [May

knowledge and the utmost care are required in its prepa-
ration, otherwise noxious gases may pass over with the
nitrous oxide, rendering it impure and injurious to inhale.
The use of nitrous oxide is improper in certain condi-
tions of the system, as, for instance, where the lungs are
seriously diseased ; where there is organic disease of the
heart ; where there is a predisposition to cerebral conges-
tion ; and where the brain is diseased or any way un-
healthy.

Ligation of the Axillary Artery. By J. B. Baxley, M.D.,
of Richmond County, Ga., late Surgeon P. A. C. S.

Private J. W. Gomer, company B, twenty-fourth S. C.
volunteers, received a gun-shot wound of the left arm on
the 20th July, 1864, and was admitted into third Georgia
Hospital, Augusta, Ga., on the same day. It was a flesh
wound, a minnie ball having traversed the soft parts near
the junction of the middle and upper thirds of the arm,
internally to the humerus.

On the 29th of July, hospital gangrene, which had been
prevalent in the hospital, invaded this wound, producing
extensive sloughing in its vicinity, with great tumefaction
of the entire limb, and a rapidly exhausting constitutional
irritation.

On August 4th, the brachial artery sloughed, causing
profuse secondary hemorrhage, whereupon the axillary
artery was tied where it is embraced by the two heads of
the median nerve. It was deemed impracticable to ligate
.at the point of injury on account of the local disorgani-
zation of the tissues, hence the selection of the nearest
practicable point above it the axillary region.

It is interesting to observe the result : on the third day
afterward .the large slough separated, leaving a healthy
granulating surface, and in five or six days the swelling

1867] Prince on the Employment of Mercury. 561

of the limb had entirely subsided. The wound healed
rapidly, and in due time the ligature came away. The
patient was furloughed August 24th.

To hasten the separation of the dead tissues, a caustic
solution of sulphate of copper was used; the general
treatment was mur. tr. iron, thirty drops, three times
daily, with brandy and a generous diet.

Olft v

A Paper on the Employment of Mercury in Cholera, Dysen-
tery, and Diarrhoea, and upon the Question of its Action
upon the Liver * Head before the Morgan County Med-
ical Society, by David Prince, M.D., of Jacksonville,
Illinois, and communicated for the St. Louis Mediccd
Reporter.

RESULTS OF EXPERIENCE.

1. Mercury is found by experience to produce changes
in the function of the alimentary canal in health, increas-
ing the amount of liquids expelled, and changing the
color, apparently in consequence of the combination of
mercury with sulphur, producing a sulphide or sulphuret
of mercury of a green color.

2. Mercury is found by experience to change the action
of the alimentary canal in watery diarrhoea, so as to di-
minish or suspend the watery flow, and to suspend the
symptoms which attend the inordinate effusion of fluid.

3. The conditions which most indicate the employment
of mercury are those of acute and exhausting fluxes, most
frequently occurring in hot weather, as cholera infantum
in children, and cholera morbus in adults.

4. The power of mercury to correct other forms of in-
testinal derangements, especially those supposed to be i
attendant upon sluggish or obstructed portal circulation,
is certainly established by experience, irrespective of any
theory of its mode operating.

5. Experience establishes that, for the purpose of cor-
recting intestinal derangements, mercury has more effi-
cacy in acute attacks than in chronic states, in which

* This paper attempts to present a resume of the correct literature upon the question of
the action of mercury upon the liver, more than to produce anything original.

49

562 Prince on the Employment of Mercury [May

inflammation has become established in some portion of
the mucous membrane.

THEORY.

If these propositions as to the employment of mercury
in diarrhceal affections are correct, it follows that the-
effects are to be explained by supposing an influence
produced upon the mucous membrane and the various
glands connected with the alimentary apparatus, and not
by a change effected in the composition of the blood.

This does not imply that the medicine may not, in
whole or in part, be absorbed, and be carried into the
circulation; but that if so, the action determines upon
the organs where experience shows that the medicine
directs its agency.

The local irritation indicated by pain, tormina, and
inverted action of the duodenum, with entrance of bile
into the stomach and its ejection by the mouth, is best
explained by supposing a local action independent of ab-
sorption into the general circulation ; and this supposition
may help to explain the different effects of small and fre-
quent doses, from those which follow the administration
of large doses. In the one case a milder influence, more
widely spread, might be expected ; in the other, a stronger
local impression, confined chiefly to the portion of the
tube in which it is travelling along. This theory helps
to explain why, in cholera infantum, a fourth of a grain
of calomel, frequently repeated, may be more efficacious
in correcting the condition of the mucous membrane than
five grains given at once.

The passage of the medicine through the portal circu-
lation necessarily carries it through the liver in its course
to the general circulation ; but this constitutes no more
reason why mercury should be a special stimulant of the
liver than holds for the salts of magnesia.

The detection of a larger amount of mercury in the
liver in experiments upon animals than can be found else-
where in the body would not prove that mercury is a
special stimulant of the secretion of bile, but only that it
lodged there for the time in greater quantity than could
be found elsewhere. The probability of a portion of
mercury being carried in the bile back to the duodenum,
to be again absorbed and returned to the liver, might
stand as a theoretic reason for a greater proportion of

1867] in Cholera, Dysentery, and Diarrhoea. 563

mercury being found in the liver for a considerable time
^fter the administration of it.

The question of the power of mercury to increase the
flow of the bile rests entirely on the results of experi- ff
ments, and not upon the observed effects of mercury in
intestinal derangements.

If it could be proved that mercury is not at all a chola-
gogue, except as to emptying the gall bladder by the ;
perturbed movements that are connected with vomiting, I
the place which mercury holds in therapeutics, as built /
upon observation, would not be disturbed.

Those uses of mercury which are inferred from the
theory that mercury increases the flow of bile, should be
abandoned, however, unless it can be established that the
secretion of bile is increased under the administration of
this agent.

In this connection it may be stated that the vomiting of
bile in connection with the action of a full dose of calo-
mel or blue mass is no evidence whatever of an increase
of the secretion of bile, but only of the expulsion through
an unnatural channel of that already secreted and accu-
mulated in the bile ducts, or lodged in the gall bladder.
~No clinical observations can possibly settle the question ;
for several pints of bile are supposed to be produced
every day, to be again reabsorbed, after having performed
its part in rendering food and medicine capable of ab-
sorption. The loss by vomiting, or by brisk purging, of
a pint or more of this profuse production, would be no
evidence of its more rapid formation.

Experiments upon animals prove that the amount of
bile produced varies with the amount and kind of food,
very much as the salivary glands obey the stimulants
applied to the mucous membrane of the mouth.

Not many conclusive experiments have been performed
to determine the quantity of bile which flows, and the
influence of various agents in increasing or diminish-
ing it.

Much attention has been attracted by a series of ex-
periments performed in 1858, by Dr. George Scott, in the
laboratory of Dr. Lionel Beale, in London.

A fistula was made between the skin and the fundus of
the gall bladder of a dog, after having tied the common

564 Prince on the Employment of Mercury [May

duct so as to shut off all flow of bile iuto the duodenum.*
The dog maintained an appetite, but grew lean.

Four experiments were made with calomel, with dimi-
nution each time of the fluid bile, and of the solids se-
creted.

Three grains of calomel were given on the 13th of
June. The daily average of bile for two days previous
had been one thousand nine hundred and sixty grains of
fluid bile, one hundred and four of bile solids, and thirty-
two of bile acids. The daily average for two days after
the medicine, one thousand three hundred and fifty-eight
grains of fluid bile, seventy of solids, and twenty-six of
bile acids. The calomel in this case reduced the fluid
bile and the bile solids one third, and the bile acids one
fifth.

A second dose of six grains of calomel was given on
the 16th of June, with a diminution of fluid bile two
thirds, the solids one third, and the bile acids one sixth.

The third dose, of ten grains, was given on the 3d of
July, with diminution of fluids and solids, but with in-
crease of bile acids.

The fourth dose, of twelve grains, was given on the 7th
of July, with reduction of fluid bile from two thousand
six hundred and fifty-eight to one thousand seven hundred
and twenty-four grains, the bile solids from one hundred
and seventeen to eighty-five grains, and the bile acids
from fifty-four to forty-five grains.

These experiments tend to overthrow the commonly
received theory that mercury increases the amount of bile
secreted, carrying with it those therapeutic indications
based upon this theory, without, however, disturbing
those uses of mercury based simply upon observation.

Dr. Brown, in the article from which the account of
these experiments have been taken, quotes Dr. Scott as
referring to three experiments of Koliker, in which calo-
mel was given to a dog, and in two of which there was a
diminution of the amount of bile secreted ; and to Dr.
Thadicum, who in some remarks upon this subject, before
the Medical Society of London, states that in Vol. XIII
of Virchow's Archives, are some experiments by Masler,.
proving that mercury does not make its appearance in the
*s bile, nor increase the quantity secreted, even when given

* Trans. New York State Medical Society, 1864, p. 267; article by James L. Brown, M.D.
quoting from No. 3 Archives of Medicine, by Dr. Lionel Beale.

1867] in Cholera, Dysentery, and Diarrhoea. 565

in very large doses, from twenty-two to fifty-two grains.
Dr. Thadicum also alludes to some experiments by H.
Nosse, and by H. Miiller, in which it was found that the
addition of calomel to food, which under ordinary circum-
stances produced a certain normal quantity of bile in
dogs, diminished the amount secreted.

It may be claimed tj^at the action of mercury upon
healthy dogs can not settle its action upon diseased men ;
that while the amount of bile produced in a healthy dog
may be diminished, the amount may be increased in a
sick man. Xo direct experiment can be made to meet
this point, but the analogy of cathartics, diuretics, and
diaphoretics leads us to conclude that the action of me-
dicinal agents upon healthy organs afford a strong pre-
sumption of their action in morbid states, and with some
exceptional medicinal agents, that they are found to have
similar effects upon man and the lower animals.

There is a surprising want of reference to the liver in
the descriptions given of the results of mercurial action.
The salivary glands and adjacent parts, and the intestinal
canal, give signs of irritation, but the liver not.

In this connection it is proper to quote, on the other
hand, the explanation suggested by Headland, in "Action
of Medicine," p. 322, fourth American edition. Referring
to the influence of over-stimulation of a gland to produce
congestion, and a suspension of its proper function, he
says: " Cantharides and turpentine increase the urine
when taken in moderate doses, but when in over doses
they diminish it, and may cause painful strangury, with1
an almost total suspension of the secretion. The explana-
tion of such an action is obvious. Congestion is caused
by the excessive action. In the same way we find that a
large dose of mercury, naturally a cholagogue, may pro-
duce jaundice, by causing congestion of the liver. This
fact has been observed by Dr. Graves, of Dublin. But it
does not follow from this, as argued by Dr. II. Jones, that
mercury rightly administered does not increase the secre-
tion of bile, and stimulate the hepatic function."

It is hardly necessary to quote the experiment of Dr.
Beaumont, who gave his man twelve grains of calomel,
causing "commotion," " slight nausea," and " the secre-
tion of a white, frothy fluid, running from the aperture
like fermenting beer from a bottle."

The generally received opinion of medical men with
regard to the action of mercury, is expressed in the United

566 Prince on the Employment of Mercury [May

States Dispensatory : " In functional derangement of the
digestive organs, mercurials in minute doses often exert a
salutary operation, subverting the morbid action, and
that, too, by their slow alterative effect, without affecting
the mouth. In these cases no decided disturbance of the
vital functions takes place, but the alvine discharges, if
clay colored, are generally restored to their natural hue,
a certain proof that the remedy is stimulating the liver,
and promoting the secretion of bile. Indeed, there is no
fact better established in medicine than the influence of
the mercurial preparations over the hepatic system, and
whether the liver be torpid and obstructed, as in jaundice,
or pouring out a redundancy of morbid bile, as in me-
lcena, its judicious use seems equally efficacious in un-
loading the viscus, or restoring its secretion to a healthv
state."
/ The question involved is, whether mercurial prepara-
tions may not aid in the production of stools having the
color attributed to bile, but whether the effect comes
through any influence upon the liver, or through the
presence of bile.

A case in point is one which occurred under the obser-
vation of Dr. J. Hughes Bennett, of Edinburg, of impac-
tion of a gall stone in the common biliary duct. A deep
jaundice existed, with dark urine, and the patient gradu-
ally declined, though brown stools were secured. Four
days before death the stools were described as being green
and dark. On the post mortem the common duct was
found completely obstructed, and the biliary ducts greatly
dilated.*

Dr. Inman states that he has seen many cases of sup-
pression of bile, in which the feces maintained their natu-
ral color ; and, on the other hand, cases in which the
stools acquired a clay color without any hepatic derange-
ment.

Dr. Ward (British Medical Journal, 1860) had himself a
diarrhoea lasting six months, with clay colored stools,
without any other evidence of bilious derangement.

Dr. Inman states that the green color of calomel stools
is owing to to the sub-sulphide of mercury, as the black
color of the stools incident to taking preparations of iron
is owing to sub-sulphide of iron, and that there is no evi-
dence derived from chemical tests that calomel stools

Clinical Lectures on the Principles of Medicine," by J. Hughes Bennett.

1867] in Cholera, Dysentery, and Diarrhora. 567

contain any bile whatever, not even any of its coloring
matter. *

Dr. Inman maintains that fecification begins in the
colon, and that it is in the colon that the brown color
begins, and that the inference is that the color is the re-
sult of a secretion from the colon. A clayey diarrhoea in
this light demonstrates that the colon and not the liver is
sluggish.

Dr. Russell, of Birmingham, confirms the same theory
of the color of the feces.

The fact is referred to, that a diet continuously of bread
and milk produces a clayey color of the stools.

The inference from all this is, that the agency of the
bile (if it has any) in the production of the color of the
feces, is through some stimulation it produces upon the??
intestinal secretion, rather than through any material
which it directly furnishes.

It has been ascertained in further elucidation of this
subject, that the tests relied upon for detecting the color-
ing matter of the bile, secure the same reaction with the
coloring matter of the blood, where this is in a state of
disintegration, as in ecchymoses, presenting all shades of
color successively from deep brown, through green and
yellow, to the natural hue of the tissues.*

The inference from this is, that the coloring matter of
bile is hematoidine, the disintegrating hematine which
gives color to the blood. According to this theory, jaun-
dice is the retention in the blood of effete coloring mat-
ter, which ought to be chiefly eliminated by the liver, to
be finally decomposed in the intestine, so as no longer to.
be recognized by chemical tests.

If now it is found that calomel fails to secure a more
abundant secretion of bile, it will no longer be given for
the cure of jaundice, which, according to this theory, is
for the most part a result of the failure of the liver to
separate from the blood its coloring matter. It may be
mentioned in passing, however, that the jaundice of
yellow fever, and the icteric hue, resulting from bruises,
and the general sallow color after great losses of blood,
can hardly have any relation whatever to the function of
the liver.

* See Prize Essay by Dr. S. Fleet Spier, in transactions of American Medical Association,
for 1864.

568 Prince on the Employment of Mercury [May

With regard to the color of the feces, Mr. Inman pro-
pounds this question : " Did ever any one see the contents
of the small intestine brown, deep yellow, or of a bilious

r color ? Did ever any one see, in cases of hernia, a brown
fecal matter flow from the bowel, if the small intestine
only was implicated ? It is not a fact that the intestinal
fluid is always whitish prior to its reaching the ileo-caecai
valve, and that it obtains its fecal character and color in
the colon."

In view of these considerations, what must be the mode
in which mercury favors a restoration of the brown color
of the feces ?

1st. It may produce a green color by its own combina-
tion with sulphur, which can be washed out and detected
by chemical tests.

2d. It increases the amount and changes the character
of the secretion of the intestinal glands, thus tending to
correct the perverted functions of the passage.

It is now easy to see how careful observers may have
been misled, to think that they procured a flow of bile by
the administration of mercury. Thus, at the last meeting,
Dr. Cassell stated that in the treatment of cholera in 1833,
he was sure of the safety of the patients when, by the
administration of calomel, he procured bilious stools. In
this connection, Dr. Reed stated that a case occurred
about the same time under his observation in which no
mercury was given, but opium, capsicum, and camphor,
without cathartics of any kind, and the patient recovered
with this phenomenon. The first fecal evacuation, which
was a consistent one, was clay colored in its lower half
and brown in its upper half.

The inference from this fact is that the contents of the
intestine remaining at the cessation of the cholera-flux
retained its color, and that the material secreted from the
intestinal glands afterward had the characteristic brown
color, communicating the hue to whatever there might be
of insoluble ingesta.

The fact, then, of the safety of the patient on the oc-
currence of hiUoas stools has a reversed explanation. The
color comes in the stools, because the patient is beginning
to get well. The stools thus contribute a most valuable
aid in prognosis, and they will continue to be examined
with as much interest as though the action of the liver
were supposed to be the turning point in the progress of
the case.

4

1867] in Cholera, Dysentery, and Diarrhoea. 569

The changes which take place in the insoluble forms of
mercury, as the metallic mercury rubbed into tine parti-
cles as in blue mass ; oxide of mercury in ointment and
calomel ; to enable them to enter into the circulation, are
not well understood ; but the fact that they become dis-
solved is certain, if we admit the doctrine that only sub-
stances in solution can enter the circulation, for the pres-
ence of mercury is discovered in distant parts, to which
it can only be carried by the blood.

Miahle maintained that mercury became soluble by
being invariably converted into bichloride, so that this
substance might, by proper management, be substituted
for the other forms with the same results.

Headland claims that though this may be one of the
ways that mercury gets into the system, it is probably not
the usual mode.

According to this authority the bile acids form direct
combinations with oxide of mercury, and the saliva and
the mucous secretions of the intestinal canal take it up
with promptness.

We are now prepared to appreciate the different results
which may be obtained by varying the size of the dose of
mercury, and the frequency of repetition.

Where corrosive sublimate is given the immediate local
irritation which attends the contact of the agent, except
in a very dilute form, renders the importance of minute-
ness of dose obvious enough.

Calomel, however, is dissolved slowly, so that a large
dose may fail to secure any great degree of irritation, and
the medicine may be in part expelled unaltered in the
feces. There is always a risk, however, that a large dose
may be retained until its complete solution and absorption
may produce unwelcome results, either upon the mucous
membrane or upon the general system, through its aplas-
tic influence upon the blood or its determination to the
salivary glands.

Headland remarks that " Very much smaller doses of
calomel and blue pill than are usually given, will produce
very much the same effects, because sufficient to exhaust
the solvent power of the system. Thus, Dr. Law has
shown that one twelfth of a grain of blue pill, given every
hour for twenty-four hours, will produce salivation."

The efficacy of small and frequently repeated doses of
calomel in cholera gets its most plausible explanation in
this way : whether the medicine may be supposed to act
50

570 Stoker on Incision and Dilatation [May

first locally, or by being first absorbed and again deter-
mined upon the intestinal surfaces, as its way of getting
out of the system.

I am myself indebted to Dr. Henry Jones, of this place,
for a knowledge of the efficacy of small doses of calomel,
from one fourth to half a grain, every ten, twenty, thirty,,
or sixty minutes in cholera infantum.

The grinding of calomel with crystallized sugar may
be regarded as a preparation of some importance, as the
medicine must be more readily dissolved by the chemical
agents it meet with in fine powder than in coarse. The
sugar also gives the medicine a taste agreeable to a child.

The purpose of this paper has been to stimulate inquiry
and discussion rather *than to settle any questions. For
this purpose I have stated the grounds of the new doc-
trine with more fullness than those of the old, with which
all are supposed to be familiar.

The new idea is not intended to revolutionize the em-
ployment of mercury, but to limit its employment to the
uses established by observation, and to abolish the admin-
istration of the powerful agent in the cases in which it is
inferred that the liver is too sluggish or too active, need-
ing this regulator.

That an immense amount of harm has resulted from
this theory of the control of the function of the liver by
mercury is plain to every man of observation.

Comparative Merits of Incision and Dilatation of the Mouth of
the Womb in cases of Dysmenorrhoea, etc. By D. Hum-
phreys Storer, M.D. Read before the Boston Society
for Medical Improvement, August 27th, 1866.

Every member of this Society must have often been
impressed with the tendency which exists in the profes-
sion to be unduly influenced, I might, perhaps, with pro-
priety, say overawed, by the opinion of those who have
attained a commanding position in our ranks. This ten-
dency I consider an exceedingly unfortunate one it
destroys self-reliance, individuality ; it prevents the physi-
cian from faithfully performing his duty, inasmuch as he
yields his dearly-bought and invaluable experience to the
decided, oracular dicta of others. However much we
should value and endeavor to profit by the instructions of

1867] in cases of Dysmenorrhea, etc. 571

our fellow-laborers, we should never be willing to relin-
quish our own convictions, unless satisfied we are in error;
until it is clearly shown that the course we have pursued,
and are still pursuing, is erroneous. These*thoughts have
oeen suggested by the following circumstance. Since our
last meeting a gentleman called upon me with his wife,
who desired my professional advice. She had been an
invalid for some length of time, complaining more par-
ticularly of dysmenorrhea. I carefully examined her
condition, and found she had a retroflexion of the uterus,
the body of the organ being so completely bent upon the
commencement of the neck as to cause almost a complete
obstruction of the cervical canal admitting the passage
only of a very small metallic dilator. I told the husband
what derangement existed, and the course which should
be pursued to remove it; that I should advise the intro-
duction of sponge-tents to produce dilatation, and, when
this should be accomplished, the wearing of a stem pes-
sory until the distortion should be permanently overcome,
lie at once told me that Dr. , who had seen his wife,
stated that the plan I now suggested would formerly have
been pursued that it was not now, however, practiced
by the profession, but that incision of the neck was the only
approved method.

As the physician referred to has been a practitioner for
quite a number of years, and consequently must have
seen a greater or less number of cases similar to the one
now spoken of, he evidently, in this instance, tacitly
yielded his opinion to the weight of authority.

I think he must have read an article on " Dysmenorr-
hea, Metrorrhagia, Ovaritis, and Sterility, depending
upon a peculiar formation of the Cervix Uteri, and the
Treatment by Dilatation or Division," which was pub-
lished in the last volume of the Transactions of the Obstet-
rical Society of London, by Robert Barnes, M.D., President
of the Society, and also that he must have coincided with
the remark of Dr. Marion Simms, made at the meeting
at which that communication was presented, " that that
Society must be taken as the representative of professional
opinion on any subject falling within its domain." Now,
however willing we may be to admit the value of the
transactions referred to, we are unwilling to allow the
infallibility of any, even of the most distinguished of that
Society. And even at the meeting referred to, it was
evident that no little diversity of opinion existed between

572 Storer on Incision and Dilatation [May

Drs. Barnes, Baker, Brown, Greenhalgh, Routh, Savage,
Hewit, Wyner, Williams, and Sims, as to the location of
the obstruction in dysmenorrhea, and the local treatment,
whether by dilatation or division.

Thus Dr. Barnes considers the " seat of the obstruc-
tion," to use his own words, " almost invariably at the os
externum. The obstruction is due chiefly to the small,
round os itself; partly to the pointed, elongated form of
the lower part of the vaginal portion, and" partly to an
unusual rigidity of structure of this part, which impedes
the expanding action natural to the healthy formed os
uteri."

Mr. Baker Brown, on the contrary, differed from Dr.
Barnes as to the seat of the stricture ; he believed it to
be in the cervix itself, generally accompanied by narrow-
ing, contortions, and reflexion of this canal the results
of inflammation.

Dr. Greenhalgh 'considered, from a long experience,
that in a great majority of cases the stricture exists at the
internal os uteri.

Dr. Routh coincided with Dr. Greenhalgh.

How utterly absurd to allow our judgments upon this
point to be swayed by the opinions of either of the gen-
tlemen above quoted, when the experience of every week
assures us that the obstruction referred to may, and does
exist at any point from the outer to the inner os uteri.

But especial reference I would make as to the manner
of overcoming this obstruction, wherever it may exist.

Drs. Barnes, Baker Brown, Greenhalgh, and Simms
strongly advocated the employment of the metrotome, or
hysterotome; that a free incision be made; and Dr.
Greenhalgh urged that the internal os should be dilated
as well as the external os.

In other words, after the profession have for a series of
years considered that, in the vast majority of cases, a con-
tracted, an almost impervious os and cervix uteri may be
dilated, and in many instances the suffering produced by
this impediment removed by the employment of metallic
dilators or sponge-tents, we are told by the President of
the Society referred to, that " incision is now considered
as not only justifiable, but as the only efficient and per-
manent remedy for dysmenorrhcea." Mr. Baker Brown,
Drs. Greenhalgh, Routh, and Simms appear to have coin-
cided with this view of the subject.

1867] in cases of Dysmenorrhea, etc. 573

And why is this plan so strongly advocated? Dr.
Barnes says : " Hemorrhage, pyaemia, cellulitis, periton-
itis, have undoubtedly followed dilatation ; and it is cer-
tain that in many cases, however good the dilatation
effected by bougies or tents may appear at first, it is not
of long duration. I suppose there is no dilatation by
instruments more powerful than that effected by preg-
nancy and labor, yet after giving passage to a full-grown
child, the peculiar cervix will sometimes completely re-
sume its old vicious form."

Mr. Baker Brown agreed with Dr. Barnes, that " dila-
tation was an inefficient and only temporary remedy for
dysmenorrhea arising from the stricture of the canal."

Dr. Routh u had seen cellular abscess and death follow
the use of sponge-tents."

We remember having seen, in some New York journal,,
a year or two since, similar remarks to have been made
by Dr. Fordyce Barker and others respecting the employ-
ment of sponge-tents; that they had seen injurious results
produced by their employment. It would be presump-
tuous in the extreme for me to doubt tjie statements of
these gentlemen ; I believe they stated the truth ; I allow
all they utter may occur.- But is any known remedy
always reliable ? Is any known operation always success-
ful ? Is not an invalid sometimes made the sicker by the
dose administered? the suffering one made 'permanently a
sufferer by the surgeon's knife ? May not some of the
evils thus produced by sponge-tents be unnecessary ? May
not the time at which they are introduced, the size of the
tent, the manner of its introduction, influence the effects
produced? Not unfrequently, particularly in hospitals,
this operation would be advised by the attending physi-
cian, but be performed by a less skillful hand, even by a
nurse. Should there be an unusual excitement cf the
parts, such as frequently exists just preceding or following
a menstrual period, it would of course be contra-indicated.
The size of the tent is of great importance. We can
readily conceive that a large tent, which is capable of
being dilated to a great extent, should cause much dis-
tress at the moment of introduction, and produce long
continued and serious constitutional derangement. The
operation itself may be improperly performed. If, instead
of being carefully introduced, and the effects produced
being watched, the dilator is carelessly, roughly, unfeel-
ingly forced into the sensitive parts, suffering to a greater

574 Stoker on Incision and Dilatation [May

or less extent must inevitably be produced. This is self-
evident. From a somewhat extensive employment of
sponge-tents during the past ten years for the treatment of
dysmenorrhcea and sterility, I have formed conclusions dif-
ferent from those of the gentlemen of whom I have spoken.
I have not unfrequently been disappointed in the result
hoped for. The local obstruction has almost always been
overcome by the long-continued, persevering employment
of the dilator; but the opened canal does not always
remove the condition thought to depend upon its closure
dysmenorrhcea and sterility still remain. I have, how-
ever, never seen the ill effects spoken of from the em-
ployment of tents. I can not recall a single instance
where more than a few hours inconvenience have been
produced ; and in such cases the expanded sponge, when
removed, has proved to have been originally much larger
than was supposed to be showing that he who employs
these tents should be acquainted with their uncompressed
dimensions. My experience has taught me, then, that
these contractions, however firm they may be, may almost
invariably be overcome. The physician need not feel
that the part is undilatable because the application of
three, or five, or half a dozen tents does not overcome it ;
in a case occurring in my practice about a year since,
eighteen sponge-tents were introduced at intervals of two
and three days before the canal was opened. My perse-
verance was rewarded by the perfect relief of the patient.
I could point, were it necessary, to several cases where,
after years of sterility, the sufferer has been relieved and
borne children, and in the intervals in childbearing have
suffered no dysmenorrhcea. I have repeatedly seen cases
of dysmenorrhcea relieved for years, and known no re-
turn. In a word, I have relied upon dilatation to relieve
these affections, and whatever opinions may be advanced
by others, so long as I feel we have a remedy from which
we can confidently expect relief, and very rarely observe
any injurious effects, I shall feel it my duty to employ it.

That cases do occur where the difficulty can not be
removed by dilatation, there can be no question; but
" that incision is the only efficient and permanent remedy
(in most cases) for dysmenorrhcea," I unhesitatingly deny.

Let us for a moment look at the method proposed.
Those who advocate it should of course be satisfied that
it has superior claims over the means now employed. I

1867] in cases of Dysmevorrhora, etc. 575

have thought the ill effects produced by distension might
be occasioned by want of care ; but those arising from
incision may follow the operation of the most skillful
surgeon who advises it, when the metrotome cuts through
the walls of the inner os; and Dr. Barnes states, to em-
ploy his own language, " th^re is no doubt that the sur-
geon has actually cut through the substance of the uterus,
and wounded the plexus of vessels outside ; hence, severe
and dangerous hemorrhage has ensued, and the inflam-
mation of the periuterine tissues." And even supposing
the operation should be successfully performed, it is ac-
knowledged by Dr. Routh, one of its advocates, " that
such an amount of contraction frequently exists as to
render it necessary to have a dilating substance worn for
a considerable length of time to prevent its perfect occlu-
sion ;" and Dr. Williams observes that " oftentimes no
relief is afforded. He had seen a patient whose cervix
uteri had been slit up on both sides, forming two large
protruding lips, without affording any relief to the suf-
ferer." Where the external os has been almost cartila-
ginous to the feel, I have overcome the obstruction with
the hysterotome ; but I have never attempted to divide
the internal os. I can not, however, recall the instance
where it was required.

Fortunately for those who object to unnecessarily ex-
perimenting upon the os and cervix uteri, there were
those at the meeting when Dr. Barnes read his paper,
whose opinions coincide with ours upon this subject.
Thus, Dr. Savage, physician to the Samaritan Hospital
for Women, who was in the habit of treating the severest
cases of the character I have spoken of every week,
assures us he never failed to remove the obstruction with
the sponge-tent; and Dr. Graily Hewitt observed that
where the cervix uteri was not hard and tense, he pre-
ferred to employ the tents as dilators. With these opin-
ions Dr. Williams also coincided.

Enough has been said, I trust, to prove that the profes-
sion generally do not advocate the indiscriminate incision
of the cervix uteri in cases of dysmenorrhcea ; that the
physician should yield his scientific opinion only when
convinced of its error; that carefully attested facts are of
infinitely more value than the dogmatic teachings of the-
highest authority. Boston Medical and Surgical Journal.

576 Monthly Period of Infecundity. [May

Monthly Period of Infecundity.

We have received from Dr. Avrard, a physician at
Rochelle, an interesting little work, printed at Bordeaux,
by Gounouilhou, entitled " Generation and Duration of
Pregnancy in the Human Race." The object of this
work is to determine with almost mathematical precision,
" when fecundation is possible in woman, and to assign a
limit of time in the menstrual cycle to the generative
faculty."

The determination of this law forms the subject of the
first part of the pamphlet before us ; in a second part the
author treats of pregnancy, and inquires into the possi-
bility of recognizing its commencement, of determining
its duration, and of assigning to its termination a physi-
ological period.

The theory of M. Avrard, concerning the moment
when fecundation takes place, is no other than that of M.
Pouchet, verified, completed, and determined in its modes and
phases. "Fecundation," says M. Pouchet, " presents a
constant relation with menstruation ; also, with the human
race, it is easy to determine exactly the intermenstrual
period when fecundation is physically impossible, and
that when it can ofter some probability." By observation
he endeavors to gain a confirmation of this assertion ; to
establish upon a solid and scrupulously exact basis the
duration of the intermenstrual period, during which fec-
undation can alone take place ; and to fix, as well as pos-
sible, the limits of this period.

M. Avrard, after having learnedly related and discussed
the facts which seem to him calculated to throw light on
the question, arrived at the following conclusions :

1. The cycle of generative functions lasts twenty-eight
days. It is divided into three periods of unequal length,
which the author calls menorrhagic, generative, and hypnotic.

2. Menstruation returns normally every twenty-eight
days, starting from the accession of the courses. Its du-
ration is indefinite.

3. A certain time elapses, most frequently, and perhaps
always, between the end of the courses and the beginning
of the generative period ; this time the author calls the
interperiodic phase.

4. The generative period ends always the fourteenth
day after trie beginning of the courses.

1867] Monthly Period of Infecundity. 577

5. It has been shown, by an observation of fifteen
years, and resting to-day upon thousands of facts, with
proof and counter-proof, that woman is physiologically
barren during fourteen days in twenty-eight, that is to
say, after the fourteenth day, commencing with the ap-
pearance of the courses, till the end of the following
period.

M. Avrard does not admit, as does the Professor of
Obstetrical Clinic, at Paris, the possibility of impregna-
tion during the period of the courses.

In the second portion of his work the author maintains,
contrary to the opinion of M. Mattei, that parturition, at
natural term, coincides neither with the ninth or tenth
catamenial period ; but is effected always two hundred
and seventy days after impregnation, whatever be the
moment (often difficult to determine) of the generative
period when the woman was impregnated. This normal
limit can be exceeded, which is rare, or not be attained,
which is common enough.

We regret our inability to analyse more at length this
very attractive work of a distinguished observer, where
are treated with so much taste and talent questions of the
highest interest as regards midwifery, legal medicine, and
hygiene, and also in a still more important respect. In
short, far from considering the popularization of the phy-
siological fact of which he treats as necessarily involving
immoral results, a very learned theologian, to whom the
author had submitted the question of temporary infecun-
dity, has thought, on the contrary, that, man being free
to use marriage, if not as he pleases, at least when he
pleases, many men being prevented on prudential grounds
from cohabitation, through fear of a too numerous pro-
geny, will hereafter be able, thanks to the doctrine of
temporary infecundity, to allow themselves, in all secu-
rity, complete normal, and consequently lawful intercourse;
without which, in the opinion of the moralists, econo-
mists, and physicians, domestic happiness can not exist.
Jour, de Med. et de Chir., and New Orleans Med, and Surg,
Journal.
51

578 Treatment of Insanity. [May

A New Remedial Agent in the Treatment of Insanity and
other Diseases.

The following is an account of a remedy which after
several experiments Dr. S. Newington asserts he has found
most useful in the treatment of insanity. It is a remedy
which appears to him to afford a powerful and valuable
means of withdrawing the blood from any diseased organ
to which there is an abnormal determination ; and, at any
rate, it is often most efficient in subduing the excitement
of mania and in inducing sleep.

"It is not known," he says, "that during sleep the
quantity of blood in the brain is less than during wake-
fulness, and that the active circulation of much blood
through the brain is incompatible with healthy sleep.
"When the cerebral functions are disordered from excess
of activity, mental anxiety, or other cause, there is a de-
termination of blood to the brain, sleeplessness ensues,
and the effect in its turn becomes the cause of further
mischief. Maniacal patients have been frequently brought
to me who have been for six or seven days without sleep,
and when repeated doses of morphia and antimony have
proved worse than useless. Indeed, the frequent disap-
pointments from the administration of narcotic drugs
during an experience of twenty-two years in the treat-
ment of insanity, have led me to try various experiments
for the purpose of obtaining some simpler and more
certain method of calming excitement and producing
sleep.

!* While staying at Matlock Bath, I was induced to try
the effects of being wrapped up in cloths steeped in mus-
tard and water, and applied to the whole legs and to the
lower part of the abdomen. After the removal of a wet
towel which had been applied round the head and was
very uncomfortable, I began to experience the most sooth-
ing effects, and gradually passed into a dreamy semi-
conscious state, which lasted during the half hour I was
under treatment. On getting up, I felt very lively and
joyous, the liveliness lasting the whole day; and for
nearly twenty-four hours there remained a pleasant ting-
ling sensation in the legs, which were affected in no other
way than by redness. It occurred to me at once that this
kind of application might be very serviceable in certain
cases of insanity, and immediately on my return home I

1867] Treatment of Insanity. 579

set about making experiments for the purpose of testing
its value. The first experiment was upon myself.

" On retiring to rest I ordered a large basin of linseed
meal and mustard (ten parts of the former to one of the
latter) to be made into a paste, and spread upon a sheet
of brown paper sufficiently large to cover the whole
abdomen, a piece of muslin being interposed to keep the
skin clean. In a short time I fell asleep, and was con-
scious of nothing till eight in the morning, when I was
partially roused by persons about me ; but I was unable
to speak or move. One of my medical assistants was
thereupon sent for, and he pronounced me in a state of
stupor from some narcotic. Though I was unable to
speak, I heard the whole of the conversation, and was in
a dreamy semi-conscious state. On the administration of
some stimulant I presently recovered.

" Another form in which I use the mustard is this : two
handsful of crude mustard are tied in a cloth and placed
in hot water, then squeezed in the hand until the strength
of the mustard has been extracted. A thick towel, long
enough to reach round the loins, is then wrung out of
this infusion, wrapped round the body, and covered with
a large piece of macintosh. In one case a patient suffer-
ing from acute mania, who was restless, sleepless, and
refused food, was thus treated with the greatest benefit.
Before the application the pulse was one hundred and
eight, but after two hours of this treatment it had fallen
to sixty in the minute, and the patient was in a quiet,
semi-conscious state. Afterward he took his food regu-
larly, and in a short time left, perfectly recovered.

" A third form in which this derivative treatment may
be applied is as a mustard bath ; in other words, an ordi-
nary warm bath, into which have been thrown five or six
handfuls of crude mustard. In some cases the deep hip
bath only may be used ; but in severe cases of mania the
whole body of the patient, with the exception of the
head, should be placed in the bath. A lady so treated,
who had during the last year four attacks of violent
mania, each lasting for five or six weeks, has now for
twenty- two weeks had no further attack, although the
symptoms usually forerunning the seizure have on several
occasions occurred ; the mustard bath appears to have
warded oft* the recurrence of the excitement. In this
case the bath was used once every twelve hours, for half
an hour at a time, during a period of ten weeks ; so that

580 Treatment of Insanity. [May

the skin was kept in a constant state of redness. It may
be hoped that the habit of diseased action has now been
broken, and that this patient, after due probation, may be
discharged as recovered.

" Mr. W was brought to me in a strait-waistcoat, and
as many as six people had been, it was said, necessary to-
control him before his arrival at Ticehurst. Notwithstand-
ing repeated doses of opium, he had not slept for six daya
and nights ; and through the night after his admission he
was excited, restless, and talkative. On the following
night he was placed in a mustard bath for half an hour,
so that he was perfectly red on being taken out. During
the next eight days he had six of these baths, and at the
end of a fortnight after admission, he returned home on
trial.

" A lady who, notwithstanding repeated doses of mor-
phia, had not slept for seven days and nights, was admit-
ted in a state of mania, extremely incoherent and excited.
After being in the mustard bath for half an hour, she-
became calm and comparatively rational, and expressed
herself as feeling much more comfortable. She was then
wrapped up in a blanket and put to bed, where she soon
fell into a sleep that lasted for seven hours ; and in the
morning she awoke free from excitement. The treatment
was continued for six nights, and no further excitement
occurred, although, as she had been insane for two years,.
her mind remained unsound.

" These instances, with others that I might quote, suf-
fice to prove that in the proper use of these derivative
measures, we have a valuable remedial agency in the
treatment of insanity. As nature, aiming to restore the
nervous element of the brain wasted by the day's labor,,
diminishes the activity of the circulation through it, and
allows the process of repair to go quietly on, so we,
imitating nature, strive in this treatment of insanity
to withdraw the excess of blood from the disordered
brain, and thus to favor the restoration of the natural
equilibrium and the return of healthy function. And
as when a morbid action continues for some time,
a habit of it is apt to be formed, and the habit to
become a * second nature,' so, on the other hand, when-
ever the morbid activity is interrupted, the tendency
to revert to its sound type, which exists in all organic
elements, fails not to assert itself, and, if sufficient time
be allowed, to restore the normal function. We perceive

1867] Amputation at the Knee. 581

then, how exceedingly important it is to produce natural
sleep in the early stages of insanity.

" In using the mustard bath, it is necessary to protect
the privates with a folded dry towel ; and it is, of course,
desirable to have the bath placed near the bed, so that
the patient may pass directly from it into his bed. If a
little constraint is required on the first occasion of its use,
it will rarely be found necessary on any subsequent occa-
sion." Half-Yearly Abst., vol. xlii., from Lancet, June
10, 1865.

Amputation at the Knee.

Professor Syrue bears strong testimony {Edinburgh 31ed.
Jour., April, 1866) in favor of the advantages of Mr.
Carden's method of performing amputation at the knee,
which the Professor regards as one of the greatest im-
provements in modern surgical practice.

" When I began," says Professor S., " to amputate at
the ankle, and found the great advantage of dividing the
bone through its cancellated texture, it naturally occurred
that the same consideration was applicable to the knee,
and that, when circumstances permitted, amputation
should be performed here rather than through the thigh,
with. its dense shaft and medullary texture. But, unfor-
tunately, not being then aware of Mr. Carden's plan, I
formed a covering for the bone by cutting it from the calf
of the leg, which proved very inconvenient, and so coun-
terbalanced the benefit anticipated, that this operation
soon fell into disuse. Mr. Carden, pursuing quite an
opposite course, made a semi-lunar incision in front, from
side to side, with its convexity nearly over the tuberosity
of the tibia, and reflected the flap of skin thus formed,
so as to expose the muscles above the patella, where what
remained of the limb was divided transversely. The
popliteal artery, and any of the small branches that re-
quired ligature having been tied, the ample covering of
integument was brought down to its place, where, being
secured by sutures, it lay without any tendency to retrac-
tion, or requiring the restraint of bandages, while the de-
pendent opening afforded a free vent for the discharge of
matter. No trouble was experienced in the after-treat-
ment, and the stump proved entirely serviceable, since

582 Amputation at the Knee. [May

the skin over the bone, instead of becoming thinner, ac-
quired additional thickness, so that the patients could rest
upon it just 8 they do after amputation at the ankle.

" But the advantages of this operation are not limited
to its facility and satisfactory results in the event of re-
covery, since its great claim to respect and confidence is
the safety that attends its performance."

On the 19th of September last Professor S. saw, with
Mr. Annandale, a patient in the hospital " who had been
admitted with both of his legs completely shattered by a
large mass of iron falling upon them. It was obvious
that he must die if the limbs were retained, and no less
so that amputation of both thighs would in all probability
prove fatal. I therefore suggested that Mr. Carden's
operation might be performed, which was accordingly
done by Mr. Annandale with the most satisfactory result."

Soon after this (October 23) Professor S. saw, with Dr.
Mackensie, of Kelso, * a young farmer whose life was in
great danger. It appeared that while on horseback,
during the race week, he had been struck by the shaft of
a cart in the crowded street, with such violence as to
cause a fracture of his leg. There was no wround, but
the limb suddenly swelled and became cold, with dark
discoloration. Inflammatory symptoms succeeded, with
corresponding constitutional disturbance, and on the
fourth day it was generally supposed that the case must
prove fatal from spreading gangrene. But Dr. Mackenzie
thought that amputation might still afford a chance of
escape; and although the prostration was extreme, with
a pulse hardly to be felt, so that cutting through the thigh
must have been almost fatal, I proposed to operate at the
knee, and did so without delay, when it appeared that
the posterior tibial artery had been ruptured at the seat
of injury. The patient was no sooner relieved from the
mortified limb than he began to improve, and, through
careful nursing, made a good recovery with an excellent
stump.

" On the 4th of November, Dr. Ilislop, of North Ber-
wick, requested me to see a clergyman who had been
confined to bed for more than twelve months, by disease
of the knee-joint, with no prospect of improvement, and
constantly increasing weakness. It seemed that skin and
bone naturally predominated in the constitution of his
frame, and that from long-continued exhaustion little else
of it remained. I should, therefore, have regarded am-

1867] Amputation at the Knee. 583

putation of the thigh as a most unpromising procedure,
but with my recently acquired faith in the knee opera-
ration, felt no hesitation in performing it. Everything
went on favorably afterward, and the reverend gentleman
speedily regained his health, with a comfortable stump."

" On the 1st of January, W. M., aged thirty-two, was
admitted into the hospital on account of a compound
fracture which his leg had sustained on the railway. An
attempt was made to save the limb, apparently for a time
with some prospect of success; but on the 9th, from the
amount of discharge and the extent of shattering which
was revealed by the ulceration and sloughing that had
taken place, it became obvious that amputation afforded
the only chance of escape. I therefore operated at the
knee; and although the circumstances were most un-
favorable for recovery, I had the pleasure of seeing the
patient gradually improve in health, with the prospect of
a good stump.

" A boy, aged six, was admitted into hospital on the
20th of January, with mortification of the foot, from a
railway injury, and threatening of gangrene extending up
the leg. I amputated at the ankle, in the hope of arrest-
ing the mischief in progress, but with only partial suc-
cess, since inflammation affected the periosteum, so as to
cause necrosis of the whole tibia, and establish profusely
discharging sinuses above as well as below the knee. The
patient then became so extremely weak that his case
appeared to be hopeless, and would, I believe, have proved
to be so, had we not possessed a milder alternative than
amputation of the thigh. I removed the limb at the knee
on the 14th of this month, and the operation was followed,
instead of sinking, by such an improvement of condition
as encourages us to look for the most satisfactory result.

" Soon after his double amputation at the knee, Mr.
Annandale had a patient, in private, suffering from dis-
ease of the knee-joint, who was so exhausted by hectic,
bed sores, and profuse discharge, that amputation of the
thigh seemed to afford no prospect of recovery. He,
therefore, amputated at the knee on the 25th of October,
with the almost unlooked for result of complete recovery.

"Dr. Joseph Bell, who takes charge of the surgical
clinical wards in my absence, admitted a patient on the
26th of January, who had suffered a compound fracture
of both legs on the railway then in progress of construc-
tion at Queensferry, whence he had been brought all the

on Trichina and Trichinosis. "May

ten miles in a cart. One limb was shattered beyond the
ptMtbility of recovery, the other being less seriously in-
jured. The forr. ed at the knee, and" the
latter so successfully treated that the man is now able to
walk on it with the assistance of crutch

** From what has been said. I trust it will appear
' 1st. That Mr. Garden's operation is less dangerous to

i amputation of the thigh.
_ That the execution, ligature of vessels, and aver-
ment, are simp. .-.sy.
i. That the resulting stump is comfortable and
vice;

These considerations will. I trust, meet with due at-
tention, and tend to promote the adoption of a procedure
:;ed. I feel assured, to supercede amputation of the
:ich, notwithstanding all the attempts to prove
1 1 _ . mained an opprobrium of surgery."

C the Trick 1 By M. Delpech.

jut, Julliet. 1 -

In an elaborate report on various papers on trichinosis,
communicated to the Academy of Medicine, Paris, and
from a review of the whole subject, M. Delpech arrives
t the following conclusions :

Although the symptoms and gravr . ichinosis

had been fully known only since the year I860, still the
disease was by no means a recent one, and its existence
in Germany at a remote period, in an epidemic form,
could be readily demonstrated.

4* It was then confounded with various other affee:;
and was more especially looked upon as a peculiar and
nal variety of typhoid.

Tbe disease has since given rise to much arduous
research, and can scarcely in future escape detection,
when it has been attentively watched in every stage of
its development.

k* Disturbance of the digestive organs followed by
edema of the tace, and subsequently by severe muscular
pain, and by a degree of dyspnoea which may even end in
: of the impossibility of the move-
ments of respiration, is an aggregate of symptoms not to
be met with in any other affection. These morbid mani-
festations correspond with the successive birth in the

;7] Dklpbch on Tcfchin* and Trichma$U.

digestive tribe, and of the passage into the muscular

"ures of trichinae in numbers sometimes enormous,

but in g'erreral proportionate to the quantity of parasites

which Have : allowed. Their presence can be dem-

d'lring life by the microscopic inspection
minute part: muscle removed from the patient's

person with peculiar instrument*, and by an innocuous
and almost painless operation. In doubtful cases, the

at a certain sta/e of the disease,

>n.

<;Ir 2vneral, one tainted animal will infect many pr-

r less v. read and severe epi-

dem: ndition of the animals, the

quantity of the flesh consumed, and the mode of

cooking adopted.

ertain animal-* are, a~ well as man, liable to trichi-

In carnivora and omnivora the complaint occurs

spontaneously, and herb: vora may also artificially become

affected, but only by the intervention of the human

subject.

" In man the disease arises from the consumption of
raw or insufficiently cooked pork flesh, tainted by the
presence of trichina?.

44 In pigs the propagation of the parasites is referable to
several ea They eat trichinized animals, especially

lead or alive, or abandoned on dunghills or in fields.
They feed on human excrement, or on the dejecta of pig3
i have recently consumed trichinized flesh, and
which excrete, with the contents of their intestines, fec-
undated female trichina?. Moles, earth-worms, the larva?
of flesh-flies, the beetroot worm, have nothing to do with
the transmission of trichina?.

WTien the disease occurs spontaneously in pigs, it
seldom gives rise to characteristic symptoms, and micro-
scopic inspection alone leads to the knowledge of the
parasites. In the human subject, the cyst, when encrusted
with calcareous salts, can easily be "discerned with the
nak~l eye, in the shape of white patches, and the na
scope affords further con adence. Inthecou:

where trichinosis prevails, this mode of examination has
become a general precaution, whether carried o^t by indi-
viduals or by order of the Government.

' M rational microscopic examination, although

:less usefiil, can give no absolute security. i mi account

of the necessary absence of regularity and supervisiop.

586 Compton on Acuje Diseases. k(] [May

Compulsory examination alone can yield any seriously
beneficial results. Two objections are urged against it,
viz. : the difficulty of carrying it out, and the uncertainty
of the information supplied in cases in which the animals
are but slightly affected. These are, it is true, serious
considerations, but nevertheless the advantages derivable
from compulsory microscopic inspection are such that the
measure should unhesitatingly be, adopted in all countries
contaminated by trichinosis. /

" France appears hitherto to have escaped the conta-
gion, and no cases have yet been adduced of acute or
encysted trichinosis, nor have any records been brought
forward of former epidemics, as in Germany. The rats
of the slaughter-houses do not seem to have been infected ;
at least, not habitually. The immunity is to be traced to
the different customs of both countries, and to the more
complete boiling to which the meat is submitted in France,
which checks the development and propagation of the
parasites.

" A temperature of 75 Cent. (167 Fahr.) alone can
secure the destruction of the trichinae. The same result
may be attained by thorough and protracted salting, or
by a hot fumigation of twenty-four hours' duration. Cold
smoking does not destroy the worms."

- Mfr

On the Practical Value of Accurate Daily Observations of
the Temperature of the Body in Acute Diseases. By Dr.
Thomas Armetirding Compton.

The general conclusions which Dr. Compton has come
to have been arrived at after a careful study of some one
hundred and twenty-live cases taken by himself during
the last two years, at St. Bartholomew's Hospital, and also
of some seventy-five other cases taken in the same hos-
pital, during the same period, by Dr. Warter.

The total number of cases in which the temperature
and general symptoms have been watched and recorded
daily throughout their course, amounts to two hundred,
of which sixty are typhus, thirty typhoid, twenty pneu-
monia, fifteen scarlet fever, and the remaining seventy-five
comprise cases of febricula, acute rheumatism, erysipelas,
cholera, acute tuberculosis, etc. The total number of
observations in these cases, and in others in which only

1867] Compton on Acute Diseases. 587

one temperature has been recorded by Dr. Warter or Dr.
Compton, probably exceeds five thousand. Dr. Compton
states what he considers to be approximately the average
normal temperature of an axilla in a healthy adult. A
temperature of 98 -4 Fah. is the point generally settled
upon by the majority of authorities on the subject; but
this Dr. Compton believes to be too high, as although he
has not at present taken a sufficiently large number to
decide the question to his own satisfaction, yet he can
state that he has very rarely found such a temperature
present in a healthy adult under normal conditions. "I
have," he says, " every reason to think such a tempera-
ture to be nearly up to the maximum, consistent with
health, and to be only met with occasionally, just as one
comes across, now and then, a healthy adult with a tem-
perature below 96 Fah. I consider the healthy range to
be somewhere between 95*5 and 98#5 Fah., the most
common temperature met with, being probably 96 *4
Fah., i. e., one degree less than the temperature hitherto
most generally received as the normal one."

Dr. Compton seeks to establish the following proposi-
tions from his observations :

1st. That a continued daily temperature of 99 Fah.,
and upward, indicates an unhealthy condition, and occurs
in every case of acute disease.

2d. That any one observation of a very high tempera-
ture (such as 105 Fah.), in any case in which the general
symptoms do not appear of any particular severity, should
lead to a very attentive reexamination, send suggest a very
careful watching, especially if occurring in anon-diagnosed
case ; such a temperature being present only in severe
forms of any disease.

3d. That the thermometer is of great use, as a means
of diagnosis in those cases which frequently present
themselves, of general malaise, often accompanied by a
history of rigors, loss of sleep, etc. ; such symptoms being
due either to the commencement of one of the specific
fevers, or merely to some gastric or uterine disturbance
of a temporary character.

4th. That the temperature in every disease has a ten-
dency to run a peculiar course, and has a certain range of
altitude, a knowledge of which course and range is of
great value as an assistance to us in diagnosis and prog-
nosis.

5th. From the last proposition it follows, that the same

588 Compton on Acute Diseases. [May

altitude of the thermometer attained at one period of any
disease is not of the same importance as the same height
reached at another time in the same disease.

Thus, in typhoid fever, a temperature which has been
rising for two or three days, reaches perhaps 104 Fah.
between the seventh and fourteenth days, without causing
any anxiety ; whereas, should the same phenomenon occur
about the twenty-eighth day, a fatal termination may
probably be expected.

And again, the actual altitude attained on a certain day
in one disease is not of the same importance to our prog-
nosis as the same height reached on the same day in
another disease. Thus, a temperature of 104 Fah. in
erysipelas is very common during the first week, and
need not give rise to any alarm; but should such occur
at the same date in acute rheumatism, Dr. Compton would
consider it of much more importance.

6th. That although, in all diseases, a high range of
temperature generally indicates a severe case, with a slow
convalescence, and a low range usually occurs in a mild
case, and is followed by a rapid convalescence ; yet there
is no actual temperature in any disease which necessarily
foretells a fatal termination.

7th. That in the majority of cases a rise of temperature
is contemporary with a rise of pulse, although such is
often not a proportional one, and may not take place at
all unless the alteration in temperature by as much as 1JC
or 2 Fah.

8th. That where the temperature and pulse together do
not coincide with the general symptoms, the two former
may be generally relied on as to the actual state.

9th. That where the temperature and general symptoms
agree together, but do not coincide with the state of the
pulse, the two former may generally be relied on as to
the actual state.

10th. That in those cases in which the pulse and gene-
ral symptoms remain the same, a moderate fall of tempe-
rature on one occasion is not to be relied on ; but should
such a fall continue in a moderate and gradual maimer,
for some days, and at such a period when a fall was to
have been expected, the temperature may then be de-
pended upon. Severe cases of typhus, toward their close,,
often give examples of this sort.

11th. That in those cases in which the pulse and gene-
ral symptoms continue the same, being the one frequent

1867] Decaisne on the Treatment of Scabies. 589

and the other severe, a continuous rise of temperature for
some days, occurring at a period of disease at which some
improvement might generally be expected, is usually the
precursor of a fatal termination.

12th. That although it is possible that the state of the
temperature alone in acute disease may, perhaps, here-
after prove to be the one safest symptom to rely upon if
taken by itself (and I believe it is at present, at least,
equal to the state of the pulse, and of greater value than
this certainly, if only its frequency be taken into account"),
yet the temperature must be considered merely as an aid,
and all other symptoms must be carefully examined into,
as it is on comparison with these that its greatest value is
always to be found. Dublin Quarterly Journal of Medi-
cine, August, 18GG. Ranking 's Abst.

On th.e Treatment of Scabies bg Oil of Petroleum. By Dr.

Decaisne.

From a report published in the Arch ires Medicahs Bdgcs,
we learn that Dr. Decaisne has used the oil of petroleum
successfully in upwards of six hundred cases of scabies.
In the great majority of the subjects the disease was com-
pletely cured after a single friction, in several after two,
and in a very few instances were three or four inunctions
required. The method failed in two or three cases only,
and sulphuret of lime was necessary to effect a cure.

It has been objected that oil of petroleum is an irritant
and produces rashes, but M. Decaisne remarks that the
remedy applied with proper precautions seldom causes
this unpleasant result.

11 At first the frictions were performed with rough tow-
els and brushes, and probably, in order to lacerate the
sulci, the oil was rubbed violently into every part of the
skin more particularly affected. The inevitable result was
the exposure of the dermis, and rashes consequent on the
mechanical irritation. Military surgeons have, however,
found from experience that this is unnecessary, and now
the inunctions are more gently performed. But even this
plan was open to improvement. It may be a matter of
indifference when the skin is healthy to use a brush, a
rough sponge, or a hard towel, but in the case of scabies
the vesicles are often broken, and the cuticle destroyed,

5$0 SrMPSON on Injuries of iht Spleen. [May

and the softest aquarelle brushes should be used to spread
the oil on the integument.

"Since brushes of this description have been used in
barracks, the secondary eruptions have all but ceased, and
when any have appeared they were the result of an error
of diagnosis which can not always be easily avoided in
case of some standing. Prurigo, eczema, impetigo, are
often mistaken for scabies, and in these affections the evil
effects of repeated and inopportune frictions are readily
accounted for."

M. Decaisne also adverts in his report to the disinfec-
tion of the clothing. Experiments instituted in the mili-
tary hospital and garrison at Antwerp have shown the
utter inutility of the measures in habitual use. Since they
have been discontinued, relapses have become less fre-
quent, and the inutility of disinfection is, therefore, now
fully demonstrated, and this expensive procedure, founded
on routine and not on scientific experience, should hence-
forth be abandoned. If it be even conceded for the sake
of argument that the acarus can continue to live elsewhere
than in its natural habitat, the operation would still be un-
necessary, because in resuming his wearing apparel the
patient exposes to the action of the petroleum with which
his person is saturated, the few sarcoptes which may re-
main in his clothes.

The treatment with petroleum oil thus combines with
its great efficacy the additional advantage of economy,
because the process of disinfection is dispensed with, and
the entire cost of the medication does not exceed for each
case three or four centimes. Jour, of Practical 31edicine
and Surgery, Jan., 1866. Ibid,.

On Morbid Conditions and Injuries of the Spleen in the Preg-
nant and Parturient States. By Sir James Simpson,
Bart.

In a paper read before the Obstetrical Society of Edin-
burgh, Sir J. Y. Simpson referred to three cases of fatal
rupture of the spleen, which had occurred respectively in
the pregnant, parturient, and puerperal states. He pointed
out the circumstance that, during pregnancy, there is
often, if not generally, an increase of the white particles
of the blood, or, in other words, a kind of normal or

1867] Demarquay on the Uses of Oxygen. 591

physiological leucocythemia. As in states of morbid
leucocythemia, the spleen was often enlarged ; so was it
also occasionally in pregnancy. Perhaps it would be found
in practice much more common than the silence of authors
on the subject might lead medical men to suppose. It
sometimes recurred in successive pregnancies. In one
patient of his, the spleen became enlarged to a very
marked degree in a series of successive pregnancies, and
this splenic enlargement disappeared always after de-
livery. Her youngest child is now about ten years old,
and during that time there has been no recurrence of the
splenic hypertrophy in the mother. A certain amount of
softening verjT frequently accompanies the hypertrophy of
the spleen, and predisposes to the laceration of the organ
under strong exertion and muscular effort, blows, etc.
The first case of rupture of the spleen in a child-bearing-
mother whieh he saw was a patient of Dr. Husban's. She
began to show symptoms of fatal sinking shortly after
premature labor set in, about the sixth or seventh month.
On opening the body after death, the enlarged spleen was
found lacerated, with effusion of blood into the peritoneal
cavity. Shortly afterward a patient of Dr. Wilson's who
had been delivered a week or two before, after making
some unusual muscular exertion, complained of abdom-
inal pain and sinking, and died. Rupture of the spleen
and effusion of blood were found on dissection. The late
Dr. Cunningham, of Currie, delivered a patient in Edin-
burgh, using the forceps. lie left very shortly afterward
to catch the railway train. The patient sank and died
within an hour or two. An inspection of the body was
ordered by the law authorities, when rupture of the spleen,
and consequent effusion of blood, were found to be the
immediate cause of death. Edinburgh Medical Journal,
Sept., 1866. Ibid.

On the Therapeutic Uses of Oxygen. By M. Demarquay.

M. Demarquay, who has devoted much attention to the
use of oxygen inhalation in medicine, says, in speaking of
its therapeutic indications, that, in the early stage of
phthisis, when there is no fever, and no fear of exciting
local action, when the patient is becoming emaciated, and
the emaciation is increased by persistent dyspepsia, oxy-
gen may have a salutary influence in modifying the state

592 Seidel on Peritoneal Friction-Sounds. [May

of the constitution and sustaining the organism. Asthenia
is the disease in which oxygen has been given by prefer-
ence ; of twenty-two patients treated by Beddoes, ten
were cured, and nine relieved. But the employment of
oxygen in asthenia meets with numerous contra-indica-
tions. Oxygen renders incontestable service in essential
anaemia. It is specially indicated in that form of chlorosis
of young girls which is characterized by obstinate ano-
rexia ; in the anaemia of convalescents, and in the anaemia,
often severe, of newly delivered females. The inhalation
of oxygen is also successful in anaemia arising from
haemorrhage or from fatigue, and is also a very energetic
remedy in the debility produced by prolonged suppura-
tion ; it stimulates the appetite, sustains the powers of the
patient, and enables him to attain to recovery. In diabetes,
under the influence of oxygen inhalation, the quantity of
sugar contained in the urine is remarkably diminished.
In surgery, oxygen stimulates weak and ill-conditioned
ulcers, and accelerates the production of granulations in
cicatrizing wounds. In senile gangrene, as long as the
circulation continues in the artery of the foot, oxygen is,
according to the observations of MM. Laugier, Demar-
quay, and Maurice Raynaud, the only remedy which in
advanced cases affords a chance of recovery. Gazette
Medicate de Paris, 13 Avril, 1866. Ibid.

^>

On Peritoneal Friction- Sounds. By Dr. Seidel.

Peritoneal friction-sounds, Dr. Seidel states as the result
of his observations, have been noted on a level with nearly
all the abdominal organs. Their signitication is very
variable. They indicate the existence either of a chronic
or an acute malady, but more rarely the latter. It is not
necessary for the production of a friction-sound that the
peritoneum should be supported, as it were, by a solid
part. In the majority of the cases the friction-sound was
somewhat rhythmical, under the influence of respiratory
movements, which were perceptible even in the hypogas-
trium. The perihepatic friction-sound, particularly when
occurring over the convex surface of the organ, might
easily be confounded with a pleuritic friction-sound. o
distinguish the one from the other, let the patient make
a forced inspiratory movement, the glottis being closed, a

1867] Editorial. 593

movement similar to those whicli accompany vomiting.
In this movement the inferior border of the lung is not
sensibly displaced whilst the liver is notably elevated. If
the friction-sound remains under these circumstances, it
is almost certain that it is of peritoneal, not pleural origin.
In no case has a non-rhythmical sound, arising from the
peristaltic movement of the intestines, been noted. Peri-
toneal friction-sounds are observed of every grade, from
an extremely slight rustling to a veritable rasp. Schmidt's
Jahrbiicher, 1866, No. 4 ; Archives Generates de Medecine,
Jain, 1866. Ibid.

EDITORIAL AND MISCELLANEOUS.

INFANTILE FEVERS.

It has long been a rule with me, and I have endeavored
to impress the precept upon my friends and patrons, never
to allow a child to have a second paroxysm of fever, if it
be possible to prevent it. Children in thi3 country are
subject to the same class of fevers as we find affecting
adults. That is to say, they very often have intermittent
and remittent fevers, which can be arrested after the first
paroxysm by the use of sulphate of quinine, and which,
if not thus timely treated, may prove fatal, by the super-
vention of convulsions, coma, or other unmanageable com-
plications. If a child or an adult have a paroxysmal
fever, he will most probably have a repetition of it a little
earlier on the following day, and sometimes one day later;
and although the first paroxysm may be comparatively
light, the next may be very serious. A sufficient quantity
of quinine administered some hours before the expected
return of fever, will make the child safe. It i3 true that
ehildren not unfrequently have a paroxysm of ephemeral
53

594 Editorial [May

fever which would have no sequence even if left to itself.
But there is no way in which we can distinguish these
fevers from those that will recur. It is therefore always
hetter to use the quinine, which may save the child's life
if the attack be of a malignant character, and which can do
no harm whatever if it be ephemeral. One grain of the
sulphate of quinine for each year of the child's age will
be found usually quite enough to prevent the return of
fever, and it may be given in divided doses or all at once,
care being taken to have the system under its influence
at the hour of the apprehended attack. Many persons
in as well as out of the profession give quinine in much
larger quantities; but I feel satisfied that while the pro-
portion above recommended is enough to obtain the
desired effect, larger quantities are very trying to children.
They certainly do not tolerate this remedy as well as
adults do. It affects their head unpleasantly and makes
them very nervous and fretful. It may not be amiss to
state that many children will reject quinine as often as it
may be given. In such cases it should be administered
per rectum ; the same quantity being used and given, all
at once, in a tea-spoonful or two of thin starch or mucil-
age. L. A.D.

A Manual of Medical Jurisprudence. By Alfred Swain e
Taylor, M.D., F.R.S., Professor of Medical Jurispru-
dence and Chemistry in Guy's Hospital, etc. ; with
notes and references to American Decisions, by Clement
B. Penrose, of the Philadelphia Bar.

This is the eighth English and sixth American edition,
and a glance at the table of contents shows that the per-
fection of the work is only limited by the imperfections
of the science. The arrangement of subjects in the
present volume is a decided improvement upon former

1867] Editorial 595

editions for, to make it a * convenient guide to medico-
legal practice " by the unskilled, it i8 eminently proper
to devote the opening chapters to instructions as to their
duties and responsibilities, and the nature of medical
evidence. Besides this change new subjects have been
introduced, with amplifying notes by the American editor,
thus making it one of the most valuable text-books of the
science known to the profession. Of these, the most im-
portant are trichiniasis and life-insurance : the former is a
new and fatal malady connected most prominently with
the ingestion of poisonous animal food, and of such pe-
culiar interest to the profession at present, that we will
presume to offer the following extract touching its history
and medico-legal relations :

"From these researches," says the author, "it is now clearly estab-
lished that the trichina is a viviparous parasite, which passes the
greater part of its existence in the chrysalis state in the muscular sys-
tem, until, by the consumption of this muscle as a food, it finds in the
stomach and intestines of another warm-blooded animal a favorable
medium for its full development into an intestinal worm. According
to Virchow and Henker, the trichina not only frequently presents itself
in the human organism, but this organism is most favorable to its de-
velopment. The period of incubation of the chrysalis in the stomach
and bowels of man or of warm-blooded animals, is from six to eight
days ; and during this time it there thrives and propagates to an
almost incredible extent. Dr. Keller states that in three or four days
the females produce one hundred or more young ones, which begin on
the sixth day to leave the parent animal; and he estimates that in a
few days after the ingestion of half a pound of meat, the stomach and
intestinal canal of a person may contain thirty millions of these minute
worms. M. Herbst found the muscles of two dogs which had been
fed upon parts of a badger containing wprms, to be loaded with these
parasites. When once introduced into the stomach and intestines, the
worms leave their capsules, become free, and produce young, which
migrate through the walls of the intestines into the muscles; there
they become encysted, and are ultimately found appropriating and
destroying the muscular substance to a greater or less extent. The
sudden liberation of a large number of these worms causes irritation
and inflammation in the bowels, attended by peculiar symptoms, re-
sembling in some respects those of poisoning.

596 Editorial. [May

It is worthy of note that trichina are more frequently found in pork
and articles of food derived from it, than in any other kind of meat,
measly pork appears to be something of a trichinous character. Fur-
ther, the vitality of the parasites is not destroyed unless the Wat or
other substances in which they are located, has been subjected to a
temperature equal to that of boiling water for a sufficient time to
insure that every particle has been exposed to this degree of heat.
Salting and smoking, or partial cooking, is not sufficient to destroy the
worms in all parts of the food, and they have even been found living
in putrefied meat. This may serve to account in some cases for the
serious symptoms which have followed the use of pork as food, also of
bacon, sausages, and German sausages, which are generally made of
raw ham.

The symptoms produced by the use of such food are, in the first
stage, those of intestinal irritation, loss of appetite, sickness, pain,
general weakness of the limbs, with diarrhoea, swelling of the eyelids
and of the joints, profuse clammy perspiration, and a wasting fever,
sometimes of a typhoid character. Death is either the result of
paralysis (from destruction of the muscular fibres) or of peritonitis
and irritative fever. During the perforation of the coats of the intes-
tines by these worms, the mucous membrane becomes irritated and
inflamed ; pus is formed on its surface, and bloody evacuations are
sometimes passed. No case is known in which trichiniasis, after having
once declared itself, was arrested by medical treatment/'

In the medico-legal bearings of the subject, the author
continues :

It is probable that some unexplained cases of death from irritation
of the stomach and bowels, simulating chronic irritant poisoning, may
have been the result of eating food containing trichina spiralis. Med-
ical men have been unable to group the symptoms under any known
form of disease, while the marks of irritation and inflammation in the
mucous membrane of the bowels have given strength to the supposi-
tion that poison must have been taken by the deceased, although
chemical analysis had failed to show the presence of any ordinary
poison in the fluids and solids of the body. In the course of many
years' practice, I have met with several cases of this description, and
there has been sometimes manifested a disposition to doubt the accu-
racy of chemical analysis. Dr. Lucke has related a series of fatal
cases which occurred in 1845, attributed at the time to poison, which,
as he suggests, were most probably caused by the use of trichinous
food. (Casper's Viertiljahrschrift, January, 1854, p. 102 )

As means of distinction from irritant poisoning may be pointed out
the long time which commonly elapses between the taking of the food

1867] Editorial. 597

and the commencement of the symptoms. The pain, vomiting, and
purging are comparatively slight; the pain is in the bowels rather
than in the stomach, and peritonitis, pneumonia, and fever are not
commonly the results of the action of irritant poisons, while they
appear to be constant symptoms in trichinosis. The absence of ordi-
nary poison in the food, in the urine, and the evacuations, at any
stage, may also be taken as conclusive evidence against irritant poison-
ing in its usual form.

In suspected cases, a new method of research must be added to
those already in use. If any of the food can be obtained, this must
be examined for the parasite by the aid of the microscope. If the
case prove fatal, the voluntary muscles of the deceased must undergo
a similar examination.

The American editor appends at this point the follow-
ing note, which will serve to awaken a lively personal
interest with our readers. It is evident that our only
safeguard against its epidemic prevalence in this country
is, as has been suggested, in the system of thorough cook-
ing to which our food is subjected :

A committee was appointed some time since by the Chicago Acade-
my of Sciences to ascertain, first, whether trichina actually exist in
the hogs of this country, and in those of the Northwest in particular ;
and, secondly, should they exist, to determine the extent of the danger
thereby incurred, and to ascertain the best means of averting it. For
the attainment of the first object, portions of muscles from one thousand
three hundred and ninety-four hogs in the different packing houses
and butcher-shops of Chicago have been examined, and the results
presented in tables.

These tables show that the committee have found trichina in the
muscles of twenty-eight hogs out of one thousand three hundred and
ninety-four examined. We may, therefore, conclude, that in the hogs
brought to Chicago, one in fifty is affected with trichinosis in a greater
or le68 degree. We must confess our surprise at arriving at this result,
which indicates, with little doubt, the startling fact that trichinosis in
pork is even more common in this country than in Germany, where it
caused so much suffering and death. For instance, in the city of
Brunswick, where a most careful inspection of nineteen thousand
seven hundred and forty-seven hogs was made in the years 1864-5,
only two were found to contain trichina in their muscles, the proportion
being one to ten thousand against one to fifty as before stated, in our
country. The comparative immunity from disease which our own
people have enjoyed, undoubtedly results from our habit of cooking

598 Editorial. [May

meat before eating it, while in Germany it is eaten raw by the poorer
classes, on account of the high price of fuel. The committee have
found the spinal muscles more liable to be infested with the trichina
than other muscles, (p. 163.)

The closing chapter of the volume upon the subject of

life-insurance is very instructive and interesting: we can

not notice it at length, but simply direct attention to it,

as a novel subject, of great importance to all classes of

the community. W. II. 1).

INFLUENCE OF MARRIAGE OX LONGEVITY.

The Boston Medical and Surgical Journal of March 7,
1867, contains an interesting article on " The Influence of
Marriage on Longevity," by James Stark, M.D., of Edin-
burgh, of which the following is an epitome :

What is the effect of marriage on male and female life ?
Is its influence, in so far as the death-rate is concerned,
favorable or not ? Is its influence limited to the female,
or has it, also, a marked influence on the duration of life
in the male ? These are important questions. Table II
includes married and unmarried men of each quinquen-
nial period of life in Scotland in 1863, deaths at the same
ages, and the percentage of deaths to the living at each
age, and shows results quite startling as to the immense
difference between the mortality of the married and un-
married.

It appears that from every age, from twenty to eighty-
five, the death-rate of married men is much smaller than
that of the unmarried. Reading the tables without deci-
mals, so as to make them more intelligible, of every hun-
dred thousand bachelors between the ages of twenty and
twenty-five years, one thousand one hundred and seventy-
four died annually ; but of the married men, only five
hundred and ninety-seven, or just one half. As the age

1867] Editorial 599

increases, the death-rate decreases, but slowly and regu-
larly. Thus, at the ages from twenty-five to thirty years,
when the number of bachelors and married men in Scot-
land is pretty nearly equal, of every hundred thousand
bachelors one thousand three hundred and sixty-nine
died annually, but of the married only eight hundred and
sixty-five. Without going in detail over every separate
age, but to mention one more even at the extreme ages
of eighty and eighty-five years, while nineteen thousand
six hundred and eighty-eight of the bachelors died, only
seventeen thousand four hundred married men did so.
These facts are rendered still more striking if we calculate
the mean age at death of the married and the unmarried
men. The result is, reckoning from the twenty-fifth year
to the close of life, that of the married was GO 2-10 years,
while that of the bachelors was only 47 7-10, giving
twelve and a half years in favor of the married.

This is a remarkable fact, and apparently a special
provision of nature to protect the father of a family, in
order that he may provide for his offspring and super,
intend their rearing. It is quite true that this special
protection from death is based on fixed laws of nature,
by which we see that the generally quiet and regular life
of the married man secures him from falling a victim to
diseases, to which the more irregular, and often more dis-
sipated life of the bachelor renders him prone. To Insur-
ance Companies statistics like these are invaluable,
because they point out to them an unsuspected source of
danger, whose influence for evil is as great as vicious
habits, or the existence of organic diseases, or .descent
from a scrofulous or consumptive family.

Similar tables, referring to women, are given, showing
valuable information, embracing the two consecutive years
of 1861 and 1862. "When the mean annual percentage of
deaths in the married and unmarried female at each quin-

600 Editorial. [May

queunial period of life is compared, it is noted that the
married die in a higher ratio during the three periods of
fifteen to twenty, twenty to twenty-five, and twenty-five
to thirty years ; but, that during the next two periods,
viz. : thirty to thirty-five, and thirty-five to forty years,
during which half the children are born, the married die
at a lower rate than the unmarried. At the age when the
usual "change of life" occurs, viz. : between forty and
forty-five years of age, the mortality of the married
slightly exceeds that of the unmarried woman a result
which might have been expected, seeing that the fatigues
of child-bearing, and nursing, and the harder labor con-
nected with the rearing of her family, somewhat weakens
the system. From forty-five to seventy-five years of age,
the married die in smaller proportion than the unmarried
woman.

It will be seen that at every quinquennial period of life,
the difference between the death-rates of the married and
unmarried women is very much less than that between
the married and unmarried men. It is thus demonstrated,
for the first time, that marriage exerts a much more pow-
erful influence on the male than the female ; for, whereas,
the influence of marriage on the female death-rate is
comparatively trifling, it is the most marked and potent
on that of the male. The common belief has always
been the reverse of this it being, that marriage, by
adding to the female the dangers of child-bearing, would
be found to increase her mortality ; but it was never once
suspected that it would make any difference in the mor-
tality of the male. These facts, however, whose correct-
ness there is no denying, disprove all this, and show that
marriage exerts a much more powerful influence on the
mortality of the male than all imagined sanitary improve-
ments could ever hope to effect.

1867] Editorial 601

At the three quinquennial periods of fifteen to thirty
years, married women died at a somewhat higher rate
than the unmarried. From fifteen to twenty years, in
every hundred thousand married women eight hundred
and sixty died annually, whereas, of the unmarried, only
six hundred and ninety-two ; from twenty to twenty-five
years, of the married nine hundred and eleven died, of
the unmarried seven hundred and eighty-three; from
twenty-five to thirty years, of the married nine hundred
and forty died, and of the unmarried eight hundred and
sixty-six. During the next two periods, however, married
women died in a lower ratio than the unmarried. From
thirty to thirty-five years, nine hundred and fifty-six mar-
ried died, and nine hundred and ninety-five of the un-
married ; and from thirty-five to forty years, one thousand
one hundred and eighteen married died, and one thousand
two hundred and six of the unmarried. It is an interest-
ing inquiry, to ascertain why it is that the mortality of
the married, under thirty years of age, is higher than that
of the unmarried women. Every man knows that the
risk to the mother is far greater at the birth of her first
child than at any subsequent delivery ; and it is extremely
probable that the whole extra mortality of the married
female under thirty years old, may be caused by the
greater dangers which attend the birth of her first child.

Table V includes the number of mothers in Edinburgh
and Glasgow in 1855 ; the number of these confined with
their first child, and the proportion per cent, of mothers
who bore their first child. The results are : between fif-
teen and twenty years of age, eighty-seven per cent, of
mothers gave birth to their first child ; from twenty to
twenty-five years, fifty per cent. ; from twenty-five to
thirty years, twenty per cent. It was only, then, at the
ages when a very large proportion of the married women
were giving birth to their first child, that the death-rate
54 '

602 Editorial. [May

rose higher than that of the unmarried women ; but the
moment that age was attained, when the great majority
of the women had got over the birth of their first child,,
viz., thirty years, the mortality fell even below that of the
unmarried women. This seems clearly to prove that it is-
bearing the first child which causes the higher mortality
of mothers between fifteen and thirty years of age.

Seeing these things are so, there is nothing to prevent
the higher mortality of the women under thirty years of
age being quite arrested. Medical men all know whence
the dangers of the first birth arise. The causes are almost
entirely removable : they are almost wholly due to our
civilization and faulty habits, which produce an over-
excitable, unduly-stimulated, yet worn-out frame, where
health and vigor ought alone to exist. F.

The Eighteenth Annual Meeting of the American
Medical Association will be held in Cincinnati on Tues-
day, May 7, 1867, at 11 o'clock, A.M.

Secretaries of all medical organizations are requested
to forward lists of their Delegates as soon as elected, to
the Permanent Secretary, Wm. B. Atkinson, M. D., 215
Spruce street, Philadelphia.

Watson Abridged: A synopsis of the Lectures on the
Principles and Practice of Physic, delivered at Kings
College, London, by Thomas Watson, M.D., Fellow of
the Royal College of Physicians, etc. Abridged from
the last London edition, etc., by J. J. Meylor, A.M.,
M.D. Philadelphia : Published by the Author, 1867.

The principles and practice of physic by the distin-
guished Sir Thomas Watson, have long been received
favorably in America, and we feel assured that the
abridgment by Dr. Meylor will be popular among stu-
dents, as a valuable aid to them in their medical studies.
We recommend it. F.

1867] Georgia Medical Association. 603

Injuries of the Spine ; with an analysis of nearly four hun-
dred cases. By John Ashhurst, Jr., A.M., M.D., Fel-
low of the College of Physicians of Philadelphia;
member of the Academy of Natural Sciences, etc.
Philadelphia : J. B. Lippincott & Co. London : Triib-
ner & Co., 1867.

We commend this small volume, as containing valuable
and interesting matter. The author has labored with
great zeal in making such a large collection of cases,
and suggests rational plans of treatment which are worthy
of note. F.

GEORGIA MEDICAL ASSOCIATION.

This Society met at Griffin, Ga., April 10th, at twelve
o'clock, and was called to order by its Presiding Officer,
Dr. A. Means.

Prayer, by the Rev. D. W. Gwin.

The hospitalities of the city were tendered to the Asso-
ciation in a neat and appropriate manner by Alderman
Nunnally. After which, the press and the city authori-
ties were invited to seats upon the floor during the session.

Next followed the recording of names and calling the
roll, when it appeared that about forty members answered
to their names.

The minutes of the last meeting were then read and con-
firmed, and the Society adjourned until 2J o'clock, P. M.

AFTERNOON SESSION.

The first business was the election of officers for the

^ensuing year, which resulted as follows :

Presider^tDr. Chartres, of Savannah.
1st Vice President Dr. T. S. Powell, Atlanta.
2d Vice President Dr. DeS. Ford, Augusta.
Corresponding Secretary Dr. Myers, Savannah.
Recording Secretary Dr. L. H. Orme, Atlanta.
Treasurer Dr. J. D. Fish, Savannah.

604 Georgia Medical Association. [May

The Valedictory of Dr. Means was then delivered in
his usual peculiar and forcible style of eloquence.

Dr. Chartres, the President elect, on assuming the
Chair, made a few brief but eminently practical remarks,
when the Society commenced the regular routine of
business.

The following resolutions were then introduced by Dr.
L. H. Orme, of Atlanta:

Whereas, According to Article 1, Code of Ethics of the American
Medical Association, u Every individual, on entering the profession,
as he becomes entitled to all its privileges and immunities, incurs an
obligation to exert his best abilities to maintain its dignity and honor,
and to exalt its standing ;" and

Whereas, According to Article 4 of said Code of Ethics, "a regular
medical education furnishes the only presumptive evidence of profes-
sional abilities and acquirements, and ought to be the only acknowl-
edged right of an individual to the exercise and honors of his profes-
sion ;" therefore,

Resolved, That while the fact is recognized that there are in our
midst medical practitioners worthy, talented, and useful, who, from
lack of means, or other cause, have failed to obtain a diploma, yet as
the earning of the Degree of Doctor of Medicine furnishes the only
presumptive evidence of a regular medical education, the Georgia
Medical Association, fully alive to the honor, dignity, and true interests
of the profession, deems the admission, in future, of non graduates to
membership a violation of the spirit which governs the Code of Medical
Ethics.

Resolved, That hereafter no individual shall be entitled to member-
ship in this Association who has not received the Degree of Doctor of
Medicine from some medical school of known and acknowledged
respectability, and as such recognized by the American Medical Asso-
ciation.

Resolved, That the portion of the constitution which provides for the
admission to membership in the Georgia Medical Association of State
Licentiates be stricken out.

After some discussion, action was -postponed until the
morning session.

Adjourned till 9 o'clock to-morrow morning.

1867] Georgia Medical Association. 605

SECOND DAY.

9 o'clock, A. M., April 11.

Meeting called to order by the President.

Minutes read and adopted.

The order of business was then suspended for the ad-
mission of new members, when Dr. L. Strozier, of
Albany, was presented, vouched for, and elected.

Several resolutions were introduced and adopted.
, Order of business was suspended, and R. V. Reid,
M.D., was presented, vouched for, and elected.

On motion of Dr. Westmoreland, a committee was
appointed to revise the constitution.

On motion of Dr. Griggs, a committee was appointed
to report the Medical Topography of the State of Georgia.

Also, a committee to report on the medicinal properties
and uses of the various unofficinal indiginous plants of the
State of Georgia, and other States that they may be ac-
quainted with.

Several resolutions were then introduced and adopted,
among which were the following by Dr. Simmons, of
Atlanta :

Resolved, That the members of this Association highly appreciate
the cordial welcome they have received on the part of the city author-
ities of Griffin, and that their thanks are due and are hereby tendered
to the citizens, and especially to the ladies, for their kind offices in
contributing to the pleasures of this body during its session in Griffin,
in furnishing such entertainments as are ever agreeable, and -which
are esteemed as evidences of kind feeling and good will to the profes-
sion ; and

Resolved, That the thanks of this body are tendered to the vestry of
the Methodist Church for the use of their Lecture Room for its delibe-
rations.

Reports from the different committees were then called
for and received.

On motion of Dr. Ray, of Atlanta, Dr. Thomas, of
Savannah, was elected orator for the next annual meeting.

60t> Georgia Medical Association. [May

The rules were then suspended, and Dr. W. II. Touch-
stone elected a member.

The following resolution was presented by Dr. Banks,
and adopted :

Resolved, That the thanks of the Association be tendered to the
following Railroads of Georgia, which have kindly made concessions
in favor of members of said Association, viz.: Georgia Railroad,
Central Railroad, Macon & Western Railroad, Augusta & Savannah
Railroad, Western & Atlantic Railroad, Albany & Gulf Railroad, and
Macon & Brunswick Railroad.

Upon motion, Dr. DeS. Ford, of Augusta, was appointed
Chairman of the Committee of Arrangements for the
next annual meeting, to be held at Augusta, Ga.

On motion, the report of the late Treasurer was re-
ceived, and ordered to be placed on the minutes.

On motion of Dr. W. F. Westmoreland, it was

Resolved, That in the opinion of this Association, there is no breach
of the code of Medical Ethics which governs the profession, in physi-
cians contracting with the owners or agents of plantations for the
treatment of freedmen in their employ. Provided, that in each city,
county, or neighborhood, uniformity of charges be observed, and
underbidding avoided.

On motion of Dr. Word, Dr. II. L. Wilson, of Atlanta,
late Treasurer, was called upon for a full report.

On motion of Dr. Holt, of Macon, a vote of thanks
was tendered to the Recording Secretary and Treasurer
for the prompt and efficient manner in which they dis-
charged their duties.

Upon motion of Dr. Crawford, of Atlanta, the proceed-
ings were ordered to be printed in the Southern Medical
and Surgical Journal of Augusta (the organ of the
Association), and all other medical journals in the State.

There being no further business before the Association,
upon motion it was adjourned to its next annual meeting
on the second Wednesday in April, 1868.

L. II. ORME, Secretary.

1867] Works deceived. 607

WORKS RECEIVED.

Watson Abridged ; a synopsis of the Lectures on the Principles and
Practice of Physic. By Thomas Watson, M.D., F.C.P., etc., etc. ;
abridged from the last English edition, with a concise but complete
account of the properties, uses, preparations, doses, etc., with other
valuable additions, by J. J. Meylor, M.D. Philadelphia, 1867 ;
12mo., pp. 276.

Injuries of the Spine, with an analysis of nearly four hundred cases.
By John Ashhurst, Jr., A.M., M.D., Fellow of the College of Physi
cians of Philadelphia, etc., etc. Philadelphia: J. B. Lippincott &
Co., 1867; 12mo., pp. 130.

Cerebro- Spinal Meningitis ; being a report made to the Illinois State
Medical Society, June, 186G. By J. S. Jewell, M.D., Professor of
Anatomy Chicago Medical College, etc. Chicago: G.H.Fergus,
1866 ; pp. 68.

Two Cases of (Esophagotomy for the Removal of Foreign Bodies, with
a history of the operation. By D. W. Cheever, M.D., Assistant Pro-
fessor of Anatomy in Harvard University, etc. Boston : D. C. Clanp
& Son, 1867.

Researches upon Spurious Vaccination; or the abnormal phenomena
accompanying and following vaccination in the Confederate army
during the American civil war, 1861-1865. By Joseph Jones, M.D.,
Professor of Physiology and Pathology in the Medical Department
of the University of Nashville, Tenn. 1867.

Tableau of the Yellow Fever of 1853 ; with Topographical, Chrono-
logical, and Historical Sketches of the Epidemics of New Orleans
since their origin in 1796, illustrative of the quarantine question.
By Bennet Dowler, M.D., etc., etc. New Orleans, 1854.

Remarks upon Compound Fractures of the Thigh from Gunshots, treated
at Chimborazo Hospital, Richmond, Va. By S. E. Habersham, M.D.,
of Augusta, Ga. 1867. *

A Letter of the Corresponding Secretary of the New York State Inebriate
Asylum, to Hon. E. D. Morgan, Governor elect of the State of New
York. 1858.

A?i Appeal of the Trustees of the Inebriate Asylum, to the Churches of
the United States and the American public, in behalf of that Insti-
tution.

Annual Report of the City Registrar, comprising return of deaths, etc.,
for the year ending December 31, 1865. Charleston, S. C. : 1866.

Essay on Phosphate of Lime. By E. N. Chapman, M.D., etc.; with
notices of its forms of preparations, etc. By C. Mack & Co., New
York: 1865.

Bulletin of the New York Academy of Medicine. Vivisection : What
it is, and what it hag accomplished. By J. C. Dalton, M.D , Professor
of Physiology in the College of Physicians, New York. Balliere
Bros., 1867.

Fourteenth Annual Report of the Pennsylvania Training School for
Feeble-minded Children. Philadelphia, 1867.

American Journal of the Medical Sciences, Edited by Isaac Hays,
M.D. Philadelphia.

Atlanta Medical and Surgical Journal. Edited by Drs. J. G. West*
moreland, W. F. Westmoreland, and J. M. Johnson.

Boston Medical and Surgical Journal. Edited by Drs. S. L. Abbot and
Luther Parks.

Buffalo Medical and Surgical Journal. Edited by J. F. Miner, M.D.

rfOS Faculty of the Medical College. [May, 1867

Cincinnati Lancet and Observer. Edited by Drs. Stevens, Murphy,

Mussey, and Williams.
Medical and Surgical Pioneer. Edited by J. Keller, M.D. Kansas

C.:v. Mo.
Xasktille Journal of Medicine and Surgery. Edited by Drs. Bowling,

Ere, Jones, and Blaekie.
Xew Orleans Medical and Surgical Journal. Edited by Dre. Stone,

Jones, Herriek, Chaille. and Nichols.
Xetc Orleans Southern Journal of the Medical Sciences. Edited by

Htm, Brickell, Beard, Mitchell. Perry, and Holt.
JRccue de Therapeuiique Mtdico-C hirurgicale. Tar A. Martin Lauzer.

Paris.
University Journal of Medicine and Surgery. Edited by W. Pavne. M.

D. Philadelphia*.
American Xaturalist. Salem, Mass.
Briithtcaite's Betn;>spect.

Chicago Medical Examiner. Edited by X. S. Davis, M.D.
Dental Cosmos. Edited by Drs. McQuillen and Ziegler. Philadelphia.
Dental Beuister. Edited by J. Taft and G. Watt. Cincinnati.
Galveston* Medical Journal. Edited by G. Powell. M.D.
Medical Xetcs and Library. Edited by J. Havs. M.D. Philadelphia.
Medical and Surgical Smarter. Edite"d by S.*W. Butler, M.D. Phila.
Medical Becord. New York.
Banking's Abstract. Philadelphia.

Bichm.nl Modieai Journal Edited by Drs. Gaillard and McChesney.
^. Louis Medical Beporter. Edited by Drs. Alleyne and Potter.
Transactions of the College of Physicians of Philadelphia.
The Druggist's Circular and Chemical Gazette. New York.

FACULTY OF THE MEDICAL COLLEGE OF GEORGIA, AT AUGUSTA,

I. P. GARVIN. M.D..
Emeritus Professor of Materia Medica, etc.

L. D. FORD, M.D.,
Professor of the Theory and Practice of Medicine.

JOSEPH A. EYE. M.D.,
Professor of Obstetrics and the Diseases of Women and Infants.

L. A. DUGAS, M.D..
Professor of the Principles and Practice of Surgery.

H. F. CAMPBELL, M D ,
Professor of Operative Surgery and Surgical Anatomy.

G. W, RAINS, M.D.,
Professor of Chemistry and Pharmacy.

EDWARD GEDDINGS, M.D.,

Professor of Physiology and Pathological Anatomy.

DkSAUSSURE FORD, MJX,

Professor of Anatomy, general and descriptive.

WM. II. DOUGHTY, M.D.,

Prvfesaorof Materia Medica, Therapeutics, and Medical Jurisprudence.

JOHN S. COLEMAN, M.D.,

Demonstrator of Anatomy.

&* 41* 2>^>Bil3* Dean.

THE TRUE PHYSICIAN:

AN ADDRESS

DELIVERED BEFORE THE GRADUATIX* . THE ME1
1LEGE OF GEORGIA, AT IT:

A.V\UiL C0ME5CEIE5T. I&BCI isr, 1*17.

BY BEV, HENRY H. TUCKER. D.D.

puel:-hi: sy rehvzi.

E. H. PUGHE, BOOK AST) JOB PRDTTBE.

1867

:MIDI8YH'J HUfiT 3HT

ADDEESS.

Gentlemen of the Graduating Class :

The most recently-elected member of the Board of Trustees of the
Medical College of Georgia, I nevertheless think that I may claim for
myself that none can exceed me in the interest which I feel in the
success of its graduates, and in the prosperity and progress of the noble
science of Medicine. When I first saw the light, it wa3 the hand of the
Physician that received me, and welcomed me to life. Can I ever forget
that humane profession which was my earliest friend ? In my childhood
I was guided through fearful perils by its wise councils ; it watched by
my bedside, and more than once rescued me from the jaws of death. la
my earlier manhood, when smitten to the vitals and apparently not far
from the grave, I called for relief ou the medical profession, the friend
of my childhood, and to it I suppose I am indebted, under God, for the
breath I now draw, and for the power that enables mj to aidres3 you.
Can I ever forget ray obligations to medical science as long as I have a
heart-throb, when I know that in the Providence of God, every throb is
its gift ?

I have seen one of my little ones paling under disease, and just ready
to fall into the embrace of death, when the man of science came and put
rosea on the cheek of my cherub, and brightness in his eye, and restored
him I had almost said to life, certainly to health and to me. Cm I ever
cease to honor and love that profession which gave me back my boy
when I thought he was gone?

Once one of your own Faculty (can I ever forget him) by his very
smile, by his mere assurance that there wa3 nothing the matter with that
organ which seems to be the fountain-head of life, that the wheel was
not broken at the cistern so inspired the confidence of one very dear to
me, and so quickened her spirituelle, that from that hour, without pre-
scription and from the mere operation of subjective forces, there
began an improvement that hastened on with almost miraculous speed to
perfect health; illustrating at once the power of mind over matter, and
the power of that profession, whose listening ear applied to the chest,
eavesdropping at the door of nature, catche3 the secrets of nature, and
which repeats them, in no doubtful words a3 mere maiters of opinion,

but with the calm certainty of an exact science. Can I ever pay the
debt I owe to that science ? If it can so arouse the vis medicatrix
natural, and set its forces in operation by a word, does it not remind one
of the deeds of the Saviour who only spoke, and disease gave way to
health at the omnipotent word?

0, Genius of Medical Science, I honor thee 1 Thou hast given me my
children thou hast sustained my wife in her perils thou wert my
earliest friend thou wilt be my last when I lie upon my latest couch
thou wilt be there to smooth with thy gentle hand my dying pillow ! To
thine altar, 0 thou benefactor of mankind ! I bring this offering of an
appreciative and grateful heart.

And now, gentlemen, having said what I trust will be a passport to
your forbearance, will you allow me, as one of the Curators of your Alma
Mater, to give you a few words of counsel as you are about to depart
from its halls and enter upon your professional career. Perhaps these
words would have come better from one of your medical instructors ; but
as by their request, this service is to be performed by me, you will at
least learn from this that others besides themselves are interested in your
personal welfare ; that others besides themselves cherish the profession of
the healing art. Instructions coming from them, on this occasion,
might have the appearance of being merely professional. I speak to you
not as a physician, but as a man; It may be well for you to know how
your profession looks to an outsider, and to receive some counsel from
one who has no connection with the science or with the practice of
medicine, except to receive its benefits.

Your eye is now fixed on professional success. How is that success to
be achieved ? That is the great question. Perhaps I can best develope
what I have to say by giving counsel of a negative character. Let me
tell you what will not succeed a life of indolence. No man can be a
physician, in any proper sense of that term, without being a habitual
student. Your present attainments are sufficient with which to begin
life, but they are not sufficient -to carry you through life. No man at
your age ever could know as much as he ought to know when he is
twenty years older, or one year older. If it takes, as Blackstone says,
the viginti annorum lucubratio?ies, to make a lawyer, it takes at least as
long to make a physician. What immense fields of inquiry medical
science opens before you. When you shall have been gathered to your
fathers, and when a hundred generations of physicians shall have fol-
lowed you to death, those who are then alive upon the earth will not have
reached the boundaries of science. Your short life will reach but a little
way toward those boundaries. Think of the two or three years that you
have spent in studying medicine, and imagine that to be all the time to
be devoted to it, and your present knowledge to be not the beginning but
the conclusion of your attainments! Nor are these counsels needless.
There are men claiming to be physicians who seem to think that a

diploma is a license to indolence, and that, having orce graduated at a
Medical College, they are free from all further obligations to pursue the
science. There are men who have grown gray in the service, who are
now practicing medicine on the old effete systems which were exploded
thirty years ago ! There are men whose medical knowledge was as great
the day they graduated' as ever afterwards, and who having fallen into a
certain routine, practice medicine by receipts, such as might be found in
an almanac. A discredit to the profession, and an imposition on tie
public are these mountebanks; and it is to be. regretted that the strong
arm of the law can not reach them and punish them for obtaining money
on false pretences, and for criminal trifling with human life. A man has
no right to remain in the medical profession and accept its emoluments
and its honors unless he is willing to discharge its duties ; and its highest
duty perhaps is the duty of continuous, unremitting hard study. Gentle-
men if you are not ready, here on this altar, to pledge your vow3 to be
consecrate to medical science, you ought even now to surrender your
diplomas back to the authority whence they came.

When I speak of study 1 refer to. book*. Men of indolent habits
sometimes pretend to excuse themselves from the study of books on the
ground that their minds are engrossed with the nobler business of study-
ing things. Even if there were truth in this apology, which is seldom
the case, it would not be satisfactory. Xo man's life is Ion;: enough to
master the study of things without the study of books. By availing
ourselves of the labors of others, we can begin our researches where
they have left off, and use their experience as a sprin^ing-board from
which to leap out farther into the regions of the unknown. But for this,
each generation and each man would have nothing but the experience
and the knowledge of the individual, and the wisdom of the race an
such, could never be attained, and we should reduce ourselves to a level
with brutes, each one of which may learn his lessons and his tricks, but
can not teach them to his offspring.

All human knowledge is in books. To repeat the same thought in
other words a man who knows all that there is in books, knows all that
is known to the human race. When there are such treasures on our
shelves, bow preposterous are the pretensions of those who ignore them
or claim to be above them. Think of a man, perhaps of shallow attain-
ments, of course of shallow attainments, and of shallow brain, setting
up his narrow observation and his worthless judgment against the
combined wisdom of the world. When I speak of books I refer to the
standards, to those that have become classic, and are regarded by the
profession as authorities, Many of them are old, but in some respects
they will never be out of date. Yield not, gentlemen, to the temptation
of all times, to look down with supercilious eye on the wisdom of the
past. Having said this, it is necessary to mike a couuter remark to
guard against the opposite error. Let not the old authorities be regarded

as infallible, nor let them be the only objects of your study. There is
always in every science, and particularly to medicine, a current litera-
ture, without familiarity with which a man can not keep abreast of the
times nor fully up with his profession. If you were even masters of all
that is in the books now in print, and were to learn no more, you would
find yourselves In twenty years, or even in ten years, or in five, practicing
on plans which by that time will be inferior to those which the world will
then have discovered. In short you never can succeed as true physicians
without a knowledge of things both new and old, which can be found
only in the current and in the classic literature of your profession. Here
too, I must put in another caveat. While it is necessary that you
should use books, you must be careful not to let books use you. Books
are intended to aid your judgment, not to supercede it. If we tie our-
selves to what is written, we shall never rise above what is written ; and
in that case no more can ever be written ; progress will cease, and our
attainments in knowledge while very limited will still be concluded, and
coming generations will be in the hands of men long dead and forgotten.
This is not the use of books ; it is the abuse of them. They were never
intended to destroy independence of thought, but to stimulate it. We must
remember that books contain, for the most part, only general principles ;
not the application of them. Each case must be judged of on its merits,
and by its own idiosyncracies ; hence, a man who attempts to practice
medicine by a book, as some so-called doctors do, is not worthy the name
of a physician. A good book is a great thing, but it is no substitute
for a living, human brain. Gentlemen, you can never succeed as mere
book doctors. This leads me to remark, in additiou, that there can be
no true success without the study of things. With book in hand to aid
you, let your eyes be turned to the facts of nature ; investigate the
phenomena themselves not merely what others have said about them,
and make yourselves masters of the present situation. Thus only can
you have any opinions which can properly be called your own. There
can be no genuine success without original research.

You must remember, too, gentlemen, that however arduous your
studies, both of books and or" things, you can not succeed without dili-
gent attention to your profession as a business. The call, however
inopportune, must be attended to promptly the service, however disa-
greeable, must be rendered faithfully. When not at the bed-side of your
patient, or on the way to it, your office is the place for you, not the
street-corner. It must be known where you may be found, and that
always at a moment's warning (except when engaged with your patients)
your services may be obtained. Many a young doctor has made ship-
wreck of hia fortunes by dilatory response to professional calls, by
negligent and careless habits, and by being often seen in places of idle
gossip, where a man of business ought not to be. As for the physician
who is greatly given to amusements, who must finish his game of cards

or of chess before he can respond to the call of a patient, who is a
habitual frequenter of theatres or similar places, or who spends much of
his time gun in hand, indulging in the sports of the field, I need not say
that he can anticipate nothing but miserable failure. The true physician
is never a man of pleasure. Still less need I say that the physician who
is given to habits of dissipation, who approaches the bedside with nerves
trembling or mind beclouded by the influence of strong drink, can not
succeed, and ought not. If there is a man on earth who above any other
ought to be sober and always clear-headed and cool, it is the man who
holds the lives of his fellow-men in his hands. It may be more needful
to say, that if you would meet with the highest degree of success, you
must have no other business but your profession. Few men can attend
to more than one thing at a time, and any man who makes of himself a
good physician, has done as much as can be expected, or as is possible.
All the energy devoted to another business is that much taken away from
this, and as all your power is none too much, any less than all is that
much too little; you have robbed your profession of that much which
was its due, your patients of that which they had a right to claim, and
yourself of a certain degree of success, reputation, and real merit.

I must mention, too, that there are surreptitious and unprofessional
methods of attaining to success of a certain kind, which we trust that
all our alumni will avoid. There are those who advertise their merits as
merchants do their goods, reducing their talents to the mean level of
merchandise, and who immodestly make great promises through the
newspapers to cure all diseases, and who publish certificates of wonder.
ful cures performed by them when all other physicians have failed; whose
look dries up dropsies, whose touch cures cancers, and whose surgical
skill is ready for any operation, if it were even to cut off and tie up an
aneurism of the aorta. The true physician never boasts, never claims
superiority to others above all, he never claims to do what is impossible
to be done, and has no use for a newspaper as an advertising medium,
except to let his place of residence be known, and even for this only in
case of removal. The physician who figures in the public prims may
meet with success, but it is the success of the charlatan it is a success
for which he exchanges the respect of his professional brethren and the
confidence of the thinking part of the community.

Nor should there be any private electioneering for patronage. The
man who goes about seeking patients, proves, by that very fact, that
patients do not seek him, and that is the very best evidence that he is not
worth seeking. Above all should there be no endeavor to obtain practice
by detracting from the professional skill of another physician. No
success can be gained by this in quarters where success is desirable, for
such conduct proves not only that the guilty man is essentially worthless,
but also that he is essentially mean. Let there be no spoken nor acted
inuendo, not even, if possible, any suggestive silence in regard to the

8

doings of another physician, such as might turn patrouage from him to
you. You can better afford to do without patronage than to obtain it on
dishonorable conditions.

Another means of success resorted to by some, a means worthy only
of the meanest of mankind, is that of underbidding the profession and
offering to practice at reduced price. Nothing can be more unprofes-
sional, nothing can be more contemptible. As I am not a physician, but
have constantly to employ them and to pay them, I shall have credit for
sincerity when I say that I look with scorn upon a man who is willing
thus to degrade his own profession by letting its practice out to the
lowest bidder. If he has no respect for his profession I have none for
him ; and I take it for granted, moreover, that if he values his own
services at less than that of others it is because they are worth less ; and
when my life and health are at stake I want the best. 1 he expense in
dollars and cents is but a poor item in comparison with the interests I
have at stake. The man who offers to practice for me at half price
could not practice for me at any price. Owing my life to the
medical profession I owe it too much to be a party to its degra-
dation. Such, too, ought to be the sentiment of the community. If
one mountebank is patronized because he makes a low bid, another
one may come who will bid still lower, and another lower still, uutil at
last men of science will be driven from the profession, and it will fall
into the hands of quacks and murderers, who for the sake of money, and
that in pitiful sums, will trifle with the lives of their felbw-men as if they
were toys. Society owes it to itself as a matter of self-preservation to
banish and proscribe these mercenary enemies of mankind. Cheaper
far to pay high rates for good physicians than to have bad ones for
nothing. It is the duty of the patient to pay his physician's fees
promptly, cheerfully, and gratefully ; and it ia your duty, gentlemen, to
make your services worth to your patients more than they cost them.
You should remember, that the value of professional labor is not to be
estimated by the poor standard of money. If it is worth only as much
as it costs it is worth nothing.

There is another way of achieving a certain kind of success, which
may or may not be dishonorable, but it is always either dishonorable or
the result of narrow views.

There are those who adopt a pet theory or a pet remedy, and, losing
sight of everything else, magnify its excellencies, and by pushing it
vigorously, and making much ado about it, succeed in attracting the
attention of the gaping multitude, who are called upon, in due time, to
pay heavily for their own misfortune in being duped. Sometimes shrewd
and unscrupulous men get up some catholicon which professes to be good
for all the diseases in the world, with the express intention of deceiving
the unwary for the sake of gaiu. More frequently in private practice, a
man, from mere mental smallnesa, becomes filled with one idea his

9

mind is large enough to hold but one, and there is scarcely a form of
disease to which he does not contrive to apply his favorite remedy. Such
physicians are like Dr. Sangrado, of Spanish memory, whose great remedy
for all human misfortunes was blood-letting and warm water. For
diseases arising from plethoric habit and requiring antiphlogistic treat
ment, he prescribed, not with any view to th* facts of the case, but
simply because it was his habit, blood-letting and warm water. If a
man were fainting from diminished vitality, from a letting down of all
his forces, arising from insufficient nutrition or like cause, his remedy
was still blood-letting and warm water; and if the patient grew worse
it was plain that the treatment was not vigorous enough, and he must
have more blood letting and warm water. There is many a Sangrado
among us, who, if his remedy is not blood-letting and warm water, has
some other hobby which is equally unfortunate. Sometimes instead of
warm water and blood-letting, it is steam without the blood-letting;
sometimes it is cold water; sometimes it is a drug, which he expatiates
on the wonderful virtues of until the very mention of it becomes an
emetic; sometimes it is the absence of all drugs except the millionth
part of an atom ; and, indeed, if a man has determined to practice
wholly on one idea, this is certainly the most harmless that he could
possibly adopt. But aside from these which have become popular
hobbies, any practitioner is liable to fall in love, as it were, with certain
plans which he has seen succeed, aud persist in them afterwards, because
he is convinced that they ought to succeed, even if they do not. Little
as you may think of it, gentlemen, it is only by effort that you can keep
out of a routine which will eventually become a hobby.

Another fictitious success is sometimes achieved by means the opposite
of this, when men profess to practice on eclectic principles, and pretend
to combine theories which are antagonistic. I will not say of these tricks
that they are merely unprofessional; it is but doing them justice to say
that they are disgraceful.

One other unworthy resort only will I mention. Sometimes a physician
discovers, or thinks he discovers, a new and valuable remedy, and instead
of giving it to the world, he applies to the Patent Office, and thus sells
himself as well as his physic, for money. A man is a traitor to his
profession who thus keeps a secret from it which never kept a secret from
him. The world has poured out at his feet all its treasures of scientific
knowledge, and he is not willing to give in return the single iota or
discovery which he may have made. There is a vile ingratitude in it
and a base disregard of the claims which humanity has upon all who can
relieve its woes. If his remedy is valuable, he is defrauding the world
by keeping back the secret; if it is not valuable, he is taking the
people's money without giving them an equivalent. The true physician
does nothing in a corner. The profession of medicine has no secrets.

10

"Whatever it does, it does for the world. Her's is a pure disinterestedness,
a broad philanthropy, and a generous hand.

But I have given cautions enough, and pursued the negative line of
thought perhaps too far. Let us take more positive views and answer
the question, so practical a question with you, gentlemen how is a
genuine success in medicine to be legitimately achieved?

An eminent jurist once said to a young man about to enter the
profession of law : M If you want to succeed, make yourself neces-
sary make yourself such a lawyer that no man involved in liti-
gation can afford to do without you : make every man feel that he
must have your services."' Gentlemen, I can not improve on this
advice. Make yourselves a necessity to the community where you
reside. Make yourselves so thorough iu your profession that no man in
reach of you can afford to do without you. Have no fears that your
merits will remain long undiscovered. You could not keep thein secret
if you would. The world has a way of finding out where the good
lawyers and where the good doctors are, and there are always enough
people in the world who desire able professional service to sustain all who
are worthy of being sustained. Have 'no fears of competition. Make
yourselves what you ought to be, and you might open your humble office
in this very city, in the midst'of the distinguished men who have been
your instructors in medicine, and in due time you would take your proper
rank ar.d receive your full share of the practice. It is unmanly to fear
competition. Never run away from it. Rather court it ; and the more
able it is, the more it will develope your own manhood, and add to your
mental power and professional ability.

I said, gentlemen, in my opening remarks, that your eye is fixed on
success, and that that is now the great object of your lives. Let me now
rise on this thought and take a superior view. It may be that success is
the great object of your life, but iet me assure you that it ought not to
be. Is a man true to his profession who studies it only in order that he
may succeed ; whose motive is either mercenary or ambitious, in either
case personal and selfish ? If a man studies even logic or philosophy
merely for the sake of the money ihat he can make out of it, or for the-
reputation that he may achieve by it, and not for the love that he has for
it, he ought not to succeed if he does, and he never will succeed in com-
manding respect nor in holding honorable rank among men of letters.
The true soldiers of science, of any science, are all voluuteers, and
enter the service from enthusiasm in the cause, and not as conscripts
drafted iuto the service by necessity, nor as hirelings paid by the day.
Such hirelings as these are but a wretched substitute for the true soldier
moved by nobler impulses, nor is it likely that they will achieve any
great distinction, or wear many of the laurels. When they have obtained
the dollar, which is all that they came for, they will leave the field, and
retire to some obscure corner to count over their gains. But if it be

11

unworthy of any profession to U3e it as a mere means of making money,
it does seem to be especially so in the humane profession of medicine.
The practice of such a profession ou^ht to develope the tendere3t and
the noblest elements in our nature. What a shocking prostitution when
its almost sacred duties are performed from mere cupidity. Ju3t think of
a man endeavoring to mitigate a human pang, or save a human life,
from no higher motive than that he expects to get a dollar for it! Oh,
should I see such a creature standing by the bedside of one dear to me,
how quickly would I wish to thrust him out of doors. The case would
be equally bad, though not quite so disgusting, if his motive were per-
sonal distinction. Gentlemen, a success which is aimed at, is not a true
success when it is attained. That only is a genuine success which comes
unsought which is the result not of efforts to obtain it, but the result of
ardent zeal and of a consecrated life. He on'y is a professional man
who studies his profession from the love of it who makes it an end, not
a means. The man who is not in love with his profession, and who does
not throw himself into it with the glowing euthusiastn of a youthful
lover, and pursue it for its own sake, regardless of its revenues of emolu-
ment or of glory, is not worthy of it, anl ought to be spurned from its
brotherhood. Gentlemen, if you are not willing to devote yourselves to
medicine for its own 3uke, and fur nothing else, I beseech you to lay
down your diplomas as soon as you have received them, and enter upon
some business that can inspire your zeal. ^larry your profession; marry
it not for its money, but for itself, and success, brilliant and enduring,
though unsought, will be won, and it will bring honors with it such as
none can wear but the true physician.

Your great object should be not to achieve personal success, but to
discharge personal duty, leaving results to take care of themselves. In
order to do your duty as true physicians, there are several things which
should be borne in mind, some of which I shall mention.

Remember, in the first place, that your profession is progressive. What
wonderful developments have been made in medical science in the last
thirty years. In that time the art of auscultation ha3 done its work.
True it was germinated by Lannaec some years before, but it is oa!y
recently that it has fructified and brought such abundant fruit. Who
would have thought, thirty years ago, that the first indication of a new
life coming into the world would address itself to the ear? For nearly
six thousand years nature had been whispering as distinctly as now,
" Another soul is coming, " but it is only recently that we have caught
the whisper. How astonished the Frenchman just named would be to
know this surprising result of his own theory.

What an immense amount of human agony has been saved by the
anaesthetic agents now in almost universal use. The knife of the
surgeon glides through the quivering flesh without even disturbing the
sweet slumber of the sleeper. The curse pronounced upon woman is

12

half removed, when, in the last agony, she passes off into sweet uncon-
sciousness, while the muscular contractions needful to her relief go on
undisturbed. But a few years ago these wonders of science were unheard
of. More recently means have been discovered of producing local
anaesthesia, without affecting the general system, and I learn from our
best surgeons that the practice is a perfect success. How speedy the
action of remedial agents introduced directly into the circulation ; and
if this hypodermic mode of treatment is not very general, and indeed not
usually proper, it may yet lead to great results, and in certain cases save
life where no other treatment would avail. The application of organic
chemistry to medicine, with its multiform results, is but a recent thing ;
the medical uses of the microscope are an era in the science, and it is a
thing of yesterday. In the preparation of medicines, many improve-
ments have been introduced, almost as great as the improvement of
quinine on peruvian bark. Some of the mott valuable and popular
articles of our present materia medica, as, for example, iodine, the great
sorbefacient in its various combinations, were wholly unknown but a
very few years ago. In the department of surgery, too, new operations
are performed far superior to those formerly in use. What a blessed
thing fuf woman that ever Dr. Sims, of Alabama, originated the opera-
tion now in use for vesico-vaginal fistula, the result of which is that
success is the rule, and failure the exception, instead of the reverse
as was formerly the case. His silver cord is almost like that of which
the prophet speaks the cord that binds to life.* But, it is needless, gen-
tlemen, for me to be recounting to you the improvements in the healing
art, when they are much more familiar to you than to me. It is only a
little that I know of these things the little that I have picked up in
general reading and observation, whereas, you, of course, know all about
them. But I briefly allude to these things, simply because they suggest
that, if your profession has been progressive, so, also, it will be, and that
it is your duty not only to keep up with this progress, but to contribute to
it. Shall the profession do all for you while you do nothing for it? Are
you to be carried as so much dead weight in the car of progress instead
of being one of those whose power propels it ? No man is fit to be a
physician unless he at least has desires and makes efforts to improve his
profession. Allow me here, however, to caution you aeainst an error
into which an overweening desire for progress is liable to lead you.
Yielding too much to this spirit you are apt to seize upon all novelties as
improvements. You should remember, gentlemen, that where one of the
novelties proposed is a real improvement, a dozen or fifty of them may
be fictitious, and that it requires a wise discrimination, and a mind fully
awake and in the highest activity, to be able to distinguish between
them. The general tendencies of your minds should be sober and con-

*It is but justice to Dr. Bozeman, of Columbus, Ga., to mention his improvement' on
Dr. Sims' method.

13

eervative. Be not in haste to accept every so-called improvement, nor to
fall in love with every upstart theory that may thrust itself upon public
attention. The safest physicians are those "who hasten slowly. Wiih all
such, there is a philosophic reluctance to accept novelties in science. The
philosopher knows, in the first place, that many of these things are not
novel, but are the mere ghosts of follies, killed in conflict with truth long
ago, and now returned to visit the scene of their discomfiture. He
knows, in the second place, that admitting them to be really new, they
are only efforts of the human mind at improvement ; that many of these
efforts are made by ignorant men, who are capable of nothing but
blunders, and that even if made by the best of men, there must be many
efforts made to every success achieved ; in other words, that in pushing
our investigations even with the most philosophic spirit, we make many
more failures than successes, and that, consequently the chances are
always largely against a novelty being an improvement. Hence the true
philosopher is reluctant to accept novelties, and never does accept them
except after patient inquiry and fair trial. But having said this, it is
necessary that I should caution you against the opposite extreme. There
is such a thing a3 unphilosophic reluctance to accept novelties'; and
perhaps the Faculty will pardon me if I say that we outsiders sometimes
think that the medical profession is peculiarly slow and sometimes almost
culpably tardy in accepting real improvements on established practice.
There is a pride in the profession which prompts it to reject anything
that does not originate with itself, reminding us of him of whom Terence
speaks, when he says: " Imperitus, nisi quod ipse facit nihil rectum
putat.'1 But it would be more in keeping with the characteristic magna-
nimity of the profession if truth and facts were accepted, no matter
where they come from. Sometimes discoveries made even by members
of the profession, are for a long time rejected by the profession. It was
a long time before Harvey was forgiven by his brethren for having dis-
covered the circulation of the blood ; and Jenner suffered no small per-
secution for his sublime achievement in depriving small-pox of its terror.
How ridiculous a figure do these old opponents of novelty present to the
present generation. Be careful, gentlemen, not to place yourselves in
the same attitude, for coming generations will review your conduct, and
hold you to account for any unphilosophic opposition which you may
have made to progress.

In short, there is a golden mean to be pursued. On the one hand be
not carried away with every wind of doctrine; on the other hand be not
stubborn be not even tardy to accept facts, when well-established. If
your theory is contradicted by facts, let it be so much the worse for your
theory; and do not say, as 1 have heard that a man once said, ' So
much the worse for the facts."'

Remember, gentlemen, that it is for you of the medical profession to
decide questions of this kind for the whole world, and that it requires a

14

irind well balanced, ever active, and thoroughly trained, to be adequate
to such responsibilities. Study with these objects in view, without regard
to personal success, which should be but a feeble motive by comparison,
if indeed it is not an unworthy one.

This reminds me to say that you should ever bear in mind the respon.
sibilities of your profession. One of these I haye just referred to. Now,
more particularly let me fay, that the lives of your fellow-men are in
your hands. Oftentimes & man's life hangs by a hai", and the keen edge
of your knife is on that hair. The least trembling of your nerve might
be fatal to him. I refer, not as my figure would seem to indicate, to
surgical practice alone. You may stand by the bedside when the least
disturbance of your mental equipoise may be the death of your patient.
Perhaps from careless observation, or from careless reading, or neglect
of reading, you are ignorant of a certain item which an accomplished
physician ought to know. That ignorance may be the negative cause of
a hundred deaths. It is a fearful thing to be thus fatally iguorant, shall
I not say murderously ignorant. What a powerful stimulant to a life
of study and of consecration to medical science is such a consideration
as this ; and how the thought of mere personal success dwindles to
insignificance by comparison.

Be ever-mindful also, gentlemen, of the dignity of your profession.
Dignified because of the objects which it proposes the alleviation of
human suffering and the lengthening of human life. Health and life
are the two great blessings without which all other temporal gifts
cease to be blessings, and of these two greatest treasures of the human
race, you are the conservators. Dignified, because of the motives in
which it had its origin, and in which lies its life. Benevolence is the
fountain-head from which the stream of medical science flows; if
there had been no such thing as a loving heart in the world a heart
that throbbed for humanity, the healing art would have been for ever
unknown. And to the honor of the profession be it said, that the
pure, the noble, the god-like motive which gave it existence, has ever
been kept in lively exercise by its members. There is none so poor
but that he can command, as indeed he ought, the very best medical
attention. The miserable mendicant in squalid cabin, needing sur-
gical aid, can secure it from the same skillful hand, or needing
medical advice, can have it from the same accomplished sources as the
wealthiest men in your city. Freely and without price are blessings
thus doubly priceless bestowed by the profession on the poor. And
even where poverty is not extreme, and where practice on the mere
ground of charity would scarcely be acceptable, there are few of the
honorable and humane profession who do not know how, delicately and
generously, to diminish the bill and accept the semblance of payment
for what is virtually a gratuity, thus enacting a double benevolence
first in conferring the favor, and afterwards in accepting insufficient

15

remuneration as if it were sufficient, to save the feelings of the bene-
ficiary. Gentlemen, I trust that you will keep up the honor of your
profession in this regard, and while, as already said, you should never
undervalue your services for the sake of extending your practice, on
the other hand he mindful of the necessities of your patients give
no place to cupidity, remembering that the emoluments of yon r profes-
sion are only its incidents, and not Us oljects that its great object is to
do good, and not to get it. Remember this dignified, this exalted
position of the profession and ever maintain it.

Dignified is your profession, also, because its deeds are like those of

the Saviour of mankind. He came to save life, not to destroy it. lie
went about doing good, doing good to the bodies of men as well as to
their souls. There were brought unto Him all sick people, and those
that were taken with divers diseases and torments, and He healed
them all. The palsied trembler walked away with firm step as well as
light heart ; the poor leprous wretch was made sound and whole ; the

; emaciated form of smitten childhood was restored to its plumpness
its blanched cheek to its bloom ; the hearts of the afflicted were made
glad by the Great Benefactor, by the Great Physician who scattered
blessings with a hand as generous as it was omnipotent. Jt is a great

i thing to be engaged in the same work with Jesus of Nazareth. Re-
member, gentlemen, who it is that stands at the head of yuur profes-
sion ; and I would that while your work is like His, your motives might

rbe as noble, as disinterested, and as pure. Your professional life
requires you, that far, at least, to be like Jesus. I would that you
might be like Him in all your inner life.

And now, gentlemen, I must bid you adieu. I wish you all personal

j success. I wish you more than that I would that each of you may

j be a true physician, and that is the highest wish, of temporal nature,

that one can make for you. When you are sick, I trust that some true
! physician may stand by your bedside to do skilfully for you what you
I have done for others. When you come to die, I trust that some true

physician may be there, not to deceive you with false hopes, which a
true physician never does, but to make your dying easy. I trust, above
all, that your spiritual health may be in the keeping of the Great
Physician, and that He may give to each of you eternal life. When
you have finished your humane and philanthropic work, and lay your
bodies down, let there be many tears shed by grateful patients over
the grave of the much loved family physician; and may your spirit
be received to the bosom of Him who is the father of your profession,
1 as He is of all that is good. In that blessed world you will cease from
the labors of your calling here, for there "the inhabitants never say
that they are sick," but you will still retain its motive its motive is
love and for ever enjoy the rewards of a well-spent life.

SOUTHERN

iiiliSiiSliipl

AUGUSTA, GA

Vol. XXL] JULY, 1867. LNo. 6

ORIGINAL AXD ECLECTIC.

On the Treatment of Fractures of the Femur ; read before
the Medical Society of Montgomery. By William J.
Holt,* M.D.

Montgomery, Ala., Feb. 4th, 1867.

Having recently had an opportunity of testing the
efficacy of an apparatus of my device -or if you will,
my modification of an old apparatus I have thought
that an examination of it by you, with a discussion upon
the mechanical treatment of fractures of the femur, would
not be uninteresting. I do not claim perfection for this
apparatus, but improvement, and hope that your criti-
cisms will be free, and that I may elicit something in the
discussion of this subject which will give us the desired
perfection.

By the mechanical treatment of fractures, I mean the
use of such appliances as will give sufficient support to

* Dr. Holt was a distinguished Surgeon in the Russian army during the Crimean war, and
subsequently in the Confederate service. He informs us that since writing this article ha
has used the method here recommended in several other cases with complete success. Ed.

55

610 Holt on the Treatment of [July

the fractured limb, while the healing process is going on,
and prevent undue deformity. For the proper perform-
ance of our duty, then, as Nature's Assistants, there are
two indications of prime importance to be met.

First. The reduction of the fracture, or, in other words,
the placing the fractured ends of the bone in apposition,
or in the event of comminution with loss of bone, the
placing them in their proper direction.

Second. The fixing them in a state of coaptation or
holding them in their normal direction until a callus be
formed and become sufficiently strong to permit us to
dispense with artificial support to the limb.

But as nature is sometimes very slow in doing her work
of repair, and as tedious months of suffering must be
looked for, especially in cases of compound comminuted
fractures, there are two other indications of great impor-
tance, and absolutely requisite for the perfection of treat-
ment. These are, so to say, almost antagonistic to the
second indication, and are-
First. The comfort of the patient while confined to his
bed, admitting of change of position, thereby preventing
bed-sores and other discomforts of a long-continued
position on the back ; and,

Second. The frequent inspection of the diseased limb,
enabling us to cleanse it, make the necessary topical
applications, open abscesses, remove spicule, and in fact
to meet any emergency which may arise in the progress
of the case.

"We thus have four indications, which may be summed
up as

1st. Reduction.

2d. Securing the reduction.

3d. The comfort of our patient.

4th. The inspection of the limb.

1867] Fractures of (he Femur. 611

The importance of meeting these indications with a
suitable apparatus has been felt since the earliest ages,
and the means proposed are as various as man's ingenuity.
I will spare you a historical discussion of the subject,
but must say that in this branch of our profession
-the skill of the nineteenth century can boast but little
over the common sense of Hippocrates. In all cases, but
more especially in military surgery, a very important part
of the treatment consists in the proper removal of the
patient from the place at which he receives his injury to
his bed, as the result of the case may thereby be very
materially influenced. Before removal is attempted, the
limb should be firmly supported by splints and compresses,
so that the fractured ends of the bone may not unduly
lacerate the soft tissues. In an emergency, shingles, a
fence-board, or even round sticks may be used.

While making preparations for the expected attack by
the Federal army at Corinth, in the Spring of 1862, the
the idea of making splints of bark was suggested to me
by seeing the soldiers take the bark from the trees for
the purpose of shelter. The best splints were procured
from young poplars eight or ten inches in diameter, and
being prepared by taking off the rough outer bark and
drying it under press, it proved to be both light and
strong, and with a natural curvature which easily encased
the limb. Much also has been said of the bed, and very
ingenious contrivances have been made, but the best one
is that which will be perfectly horizontal, sufficiently hard
to obviate inequalities, and not too hard for comfort. I
have sometimes prepared the bed by cutting the mattress
as high as the body, and after taking away one half its
width, filling the vacuum by a series of bran bags, three
or four inches in diameter, one on the other for the length
of the entire limb. By this arrangement the bed-pan can
be used with comparatively little discomfort, and by

612 Holt en the Treatment of [July

taking away the bags in succession the whole limb may
be inspected with but little motion, and unsupported for
not more than the diameter of the bag. After having
placed our patient upon as comfortable a bed as possible,
we now begin the treatment proper, and must meet the
first indication, the coaptation of the fractured ends of
the bone or the placing them in their proper direction.
Without fatiguing you with a recital of the many appa-
ratus suggested for this purpose, they may be summarily
classed into such as have the body the fixed point, or point
of counter-extension, making extension upon the limb,
and such as have the limb fixed or counter-extended, and
the body as the point for extension. As a type of the
first class I will mention Physick's modification of De-
sault's splint ; and as types of the second, the inclined
plane and Smith's anterior splint. Of these I greatly
prefer the first mentioned, and think that any apparatus,
based upon the principle of extension by the body, radi-
cally faulty. In meeting the second indication a most
ingenious innovation was made by the Arabs, who insti"
tuted the use of plaster, by which the limb is encased in
a perfect mould, thus retaining the parts in a state of
immobility. I have seen the plaster apparatus used in
one case, and I do not like it, from the fact that it isr
when complete, a ponderous, unwieldy affair, the material
not always at hand, and it presents no advantages over
the immovable starch bandages. Immovable agglutina-
tive apparatus were in use in the time of Hippocrates ;
they gave way to other methods, and were almost in dis-
use until revived by Larrey, who was an enthusiastic
advocate of the immovable starch apparatus. His band-
age, however, only meets the second and third indica-
tions, and is of itself, I think, very incomplete and
inadmissible in compound fractures, though he vaunted
it very highly in those cases. The method of Mayor, as

1867] Fractures of the Femur. 613

also the anterior splint of Smith, I think inefficient in
meeting this as well as the first indication, for the body
can not make sufficient extension to retain in coaptation
the fractured bones, if the patient is allowed to enjoy the
mobility which is claimed as the greatest advantage in
those apparatus. To meet the third indication, the im-
movable starch apparatus of every kind certainly possess
the greatest advantages, though the apparatus of Mayor
and of Smith are much better than any system of mova-
ble splints. For the fourth indication, all movable appa-
ratus are preferable to the immovable. Thus we see that
no apparatus will meet all of the indications mentioned,
though some one of the indications can be filled by any
of them. Hence, in the treatment of a case, we must
endeavor to blend the advantages possessed by each.

If called upon to treat a recent fracture of the thigh, I
would apply Physick's apparatus, and keep up constant
traction upon the fractured limb until the contractile
power of the muscles should be overcome as much as
possible, and the oedema disappears. When this stage
(which may be termed the acute) has been passed, and
the patient begins to suffer from the constant confinement
to one position, I would recommend the application of
the apparatus of which the one I now present for inspec-
tion is a very imperfect model. Though it may be applied
immediately, and as the oedema disappears, it can be re-
duced in size by paring the edges. I have tried it in two
cases of compound, and one of simple comminuted
fracture, with gratifying success, and- would like to see it
further tested.

The first case was that of a Sardinian officer, wounded
in Cardigan's famous charge at Balaklava, by which the
femur was badly comminuted by a canister shot which
entered about two inches above the external condyle of
the femur, and, ranging upwards and inwards, lodged

614 Holt on the Treatment of [July

under the skin of the perineum. I first saw him about a
month after the reception of the wound, and found him
upon a double inclined plane, of which he complained as
being insupportable. I removed that, and for more con-
venience in inspecting and dressing, placed the limb upon
the bran bags (spoken of before) and supported it with
two long splints. Soon after this I was taken sick, and
when I again saw him, six weeks later, I found him
wearing Larrey's starch bandage, applied by PiragofY. His
condition being exceedingly critical, with strong symp-
toms of pyemia, this apparatus was removed in two
longitudinal halves, and some fragments of bone extracted.
He was again placed upon the bran bags with some relief
but his incessant complaints of his back, upon which
there was an immense bed-sore, urged me to devise some-
thing for his relief, and this apparatus is the result of my
labor. It was su^^ested bv an examination of the halves
of the old apparatus of Larrey, which were still in his
room. I immediately applied it with the paper modifica-
tion, and as soon as it was completed and my patient
placed upon his side, he overwhelmed me with expressions
of gratitude for the relief he felt. Up to that time there
was no evidence of bony union, and while applying my
. apparatus, I extended the limb powerfully with Physick's
apparatus. He began to improve soon after using this
apparatus, and in six months after the reception of his
wound he could walk unaided and with but little short-
ening of the limb.

The second case was that of a young man who had his
thigh fractured obliquely at its upper third by a minnie
ball at the battle of Murfreesboro. In this case I first
used Physick's apparatus, and about ten days from the
reception of the wound I applied this. lie convalesced
very rapidly, and was going about on his crutches in a
month after he was wounded. He left me in about two

1867] FracUcns of the Femur. 615

months, with no shortening of the limh. A short time,
however, after leaving me, he fell violently forward on
the steps while making a leap with his crutches. The
limb was unsupported at the time no effort was made to
arrest the overlapping of the fractured ends of the bones
caused by the violent breaking up of the callus, and the
result is some shortening.

The last case is the one upon whom was placed the
splints before you. About the 25th of October, 1866, I
was called to the country to see R. S., a colored man,
aged about fifty-three, whom I found with a comminuted
fracture of the upper third of the thigh, caused by a fall
from a height of fifteen feet upon a log. Wishing to
have him more constantly under my eyes, I had him
brought to the city, and with the assistance of Dr. Gaston
applied this apparatus. Before applying this he had worn
Physick's apparatus for several days, and continued to
wear it until this was completed. Xothing occurred to
impede his convalescence, and, yielding to his entreaties
to return home, he left me about the middle of December
and before the callus was firm. Before leaving, an accu-
rate measurement was taken of both limbs by Dr. Gaston,
and there existed absolutely no shortening. Soon after
leaving me he opened the apparatus, as you see, at the
ankle, to relieve pressure; and hence deprived the appa-
ratus of one of its greatest virtues. The result is about
half an inch shortening, when there should have been
none. But even as it is, I know of no apparatus which,
under the circumstances, would have been attended with
so good a result.

The manner in which I usually proceed to apply the
apparatus is as follows: After preparing a sufficient
number of strips of brown paper (the unglazed paper is
the best) from one to one and a half inches wide, and
long enough to pass round the limb, I cover them with

616 Holt on the Treatment of [July

flour paste, or other agglutinative substance, on both sides,
and place them upon a piece of cloth wide enough to
support the strips and long enough to extend from the
upper margin of the pelvis to a few inches below the
heel. Commence at the upper extremity and place the
first strips from the perineum to the upper margin of the
ileum diagonally, to fit more snugly the pelvis, and let
each strip cover two thirds of the preceding one, and
thus continue as far below the heel as it is desired to
cover the foot. Then recommence a second layer, and,
if desired, a third, and when completed the three layers
will make nine thicknesses of paper. Before applying, it
is well to cover the layers of paper with strips of dry
cloth, to protect the limb from the paste. When this part
of the work is completed, the patient should be carefully
raised and the whole placed accurately under him. Then
apply the strips of cloth like the bandage of Skultetus,
and after that the paper in the same manner, taking care
to apply them with exactness, more especially about the
foot and perineum.

In the next case I have, I shall place a small compress
over the patella before applying the paper, as all of
my patients have complained of pressure at that
point. In my first case I had some difficulty in cut-
ting the apparatus in two when dry, and since then I
have removed it only when sufficiently dry to preserve
its form. It should be divided into two longitudinal
halves, as nearly equal as possible, and when removed
their edges well adapted and held together by strips of
paper pasted across their seams, and after covering this
artificial limb well with a bandage, the cavity should be
filled and strongly packed with bran or sand to prevent
the edges turning in, or other warping, and to retain the
form of the limb until it is perfectly dry. When dry the

1867] Fractures of the Femur. 617

bandage may be removed, and the process of layering
conducted to any desired thickness. I would here suggest
that in pasting the paper several aids be engaged, and the
layering rapidly done, so that the strips of paper may
not become too dry and stick together, thus rendering
their application the more troublesome. The bandage
should extend sufficiently high on the foot to support it and
should embrace well the pelvis and perineum. The applica-
tion of the paper should be made with the limb completely
extended, and the traction on the limb should not be
lessened until the paper becomes hard or is removed.
Thus we have an apparatus light and strong, by no means
difficult of application, and when completed, there is
comparatively little trouble in treating the most pro-
tracted cases.

I claim that my apparatus meets more nearly all of the
indications than any other, and by the aid of Physick's
apparatus in completing it, it meets them all. Being-
applied while the limb is perfectly extended, and allowed
to harden on the limb, grasping the foot firmly and fitting
snugly in the perineum, it keeps the limb permanently
extended, thereby meeting the second indication. Fitting
as it does closely all of the inequalities of the surface,
and holding fixed and extended the muscles and the ends
of the bone in exact apposition or in their proper direc-
tion, the patient is enabled to change his position in bed,
sit up, or even walk about, thereby filling the third indi-
cation. By cutting open the apparatus by a longitudinal
section on its anterior and posterior aspects, two complete
troughs are formed, either of which by confining the
limb to it is sufficient to retain immovable the fractured
ends of the bone. By removing in turn each half, the
whole limb may be inspected, and thus is fully met the
fourth indication. The apparatus may be securely held

56

618 Holt on Fractures of the Femur. [July

together by three or four bandelets tied at equal distances
apart.

In the case of a compound fracture, a fenestrum should
be made for the escape of pus. I would suggest that
when completed the apparatus might be painted or var-
nished, or covered with some other substance which
would render it impervious to water, and admit of the
application of water dressings. I have never used any-
thing but flour paste, but I can imagine several substances
which might be preferable, though none so easily ob-
tained.

I have spoken of my apparatus as applied to fractures
of the femur, but the principle may be applied to many
other cases. I have applied it with great benefit in two
cases of resection of the head and portion of the shaft of
the humerus, and once made a very comfortable apparatus
for a fracture of the bones of the forearm with news-
papers. Besides its other advantages, I claim that the
facility of obtaining tjie materials for its manufacture
constitutes a very important advantage, for cloth may be
substituted for paper. I have stated that this might be
called a modification of an old apparatus, but I claim that
the modification is important enough to give it individu-
ality. I especially recommend its use in cases of com-
pound fracture, though when used in simple fractures
(especially where there is much contusion of the soft
parts) it will contribute very much to our peace of mind
by permitting us to examine occasionally the work that
is going on under our appliance, and it will certainly add
to the comfort of our patient to sponge the limb from
time to time.

1867] Wm. I\ Holt on Persistent Eclampsia. 619

Persistent Eclampsia: Forced Delivery Accomplished by
Bilateral Incision of the Cervix Uteri. Read before the
Georgia Medical Association. By Wm. P. Holt, M.D.,
of Macon, Ga.

I was summoned at 6 p. m., on March 9th, 1867, to see
Mrs. , a prima para, aged nineteen, stout, robust, and
very plethoric ; was informed by her that she had "grind-
ing" pains at regular intervals of fifteen or twenty
minutes since 11 a. m., and that she was under the im-
pression that she was not at full term. I made an exami-
nation, and found the os very high up, undilated and rigid.
She stated that she had had an unusual fulness about her
head for the past three weeks, that her limbs were swollen
and that the pain in her arms was so great at night as to
prevent her from sleeping, that about ten days since,
while going down the steps she fell, but experienced no
inconvenience from the fall, not even soreness.

The pains continue to increase in severity, and at 10 p.
m. she had heavy bearing down pains, when I again made
an examination and found the os in the same position and
condition. Up to this time there was nothing unusual in
her appearance. Expressing a desire to empty her bladder,
I retired from the room, leaving her in charge of her
husband and nurse, and was informed upon my return to
her chamber that she had voided urine, and had sat up
before the fire, warming her feet (which, notwithstanding
the application of hot irons, continued cold), and that
while up there was a wild expression about her eyes.
I detected a slight twitching about the facial muscles and
at once bled her sixteen or twenty ounces, and dispatched
a messenger for my friend Dr. D. W. Hammond.

He arrived at 12 m., when she had a violent couvulsion.
Upon consultation we determined to apply mustard sin-
apisms to her head, and to try the effect of chloroform,
the free inhalation of which seemed to modify, but not

620 Wm. P. Holt on Persistent Eclampsia. [July

arrest the convulsions. Examination revealed no change
in the condition of the os ; ordered the following:

R. 01. Reeini jr.* 01. Terebinthena gtt,

which she retained, though she had been vomiting occa-
sionally all night. Dr. H. and myself both remained with
her until 7 a. m., when I was summoned home, leaving
her in his charge, and promising to return at 8J o'clock,,
and to invite Dr. C. B. Nottingham to see her with us.

I returned at the specified time, and was informed by
the Doctor that during my absence she had thirteen con-
vulsions, and that each one was more terrific than its
predecessor, that her face became livid, breathing sterto-
rous, and in fact she was almost comatose. AVe deter-
mined to make an effort to force the finger through the
os, and if possible rupture the membranes, which was
accomplished after much difficulty, the contraction being
so firm that it was almost impossible to move the finger.

At 9 a. m., Dr. Nottingham arrived, when the patient
had another convulsion, which seemed as if it would
terminate her existence. Upon examination (there being
no change in the condition of the os) we determined to
bleed her again, which I did copiously, and to wait until
12 m. for further developments, at which time Drs. H.
and N. were to see her. After the loss of blood she was
more quiet,\ although her breathing was heavy and
labored. At 11 a. m. she became restless, tossing to and
fro, requiring two or three attendants to keep her in bed.
At 11:20 she had another convulsion, followed at short
interval by another; a few minutes before 12 another,,
when the Doctors arrived, and determined that something
must be done, and speedily ; patient insensible, and os
still undilated; agreed upon bilateral incision of cervix
uteri; drew her to the edge of the bed, limbs drawn up
and supported by Dr. N. and myself; Dr. Hammond

1867] WM. P. Holt on Persistent Eclampsia. 621

proceeded to divide with a probe-pointed history the un-
dilated neck of os in a lateral direction on each side,
cutting toward the right and left acetabulum, and then
forcibly dilating with linger, introduced a hook, caught
the foetus in the groin (being a breech presentation), drew
it down, and In a few minutes delivered her of a dead
female foetus about seven months ; patient still insensible,
and circulation very feeble ; placenta taken away entire,
but uterus not contracting well, introduced the hand,
removed a quantity of clots, and inserted a piece of ice;
put her to bed, and ordered feet kept warm, head cool,
and flaxseed mucilage kept constantly applied to her
tongue, which was very much swollen from being bitten
during convulsions, although efforts were made to prevent
it by the introduction of a piece of wood and a spoon
between her teeth ; to meet at 5 p. m., during which time
she had no more convulsions ; condition comparatively
comfortable ; drew off urine with catheter.

March 11th, 8 J a. m. Again used catheter; patient
seems rational, and answers questions by nod or shake of
the head, tongue being too much swollen to articulate.
5 p. m. Ordered 01. Recini 3i. ; 01. Terebinthena? Ji'. ;
used catheter; circulation 100; has a more natural ap-
pearance.

March 12th, 8 J a. m. Quiet this morning; bowels
well acted on by the oil; did not use catheter, urine
having been voided. 5 p.m. Restless; pulse 112; or-
dered anodyne draught.

March 13th, 8 J a. m. Did not sleep well ; complains
of pain in breast, which are distended and hard ; ordered
light diet, and to rub the breast with camphor soap
liniment; mind entirely clear, but does not remember
what has happened.

March 14th. Improving.

622 Wm. P. Holt on Persistent Eclampsia. [July

March 15th. Restless; ordered forty drops elixir
opium.

March 16th and 17th. Doing well.
March 18th. Discharged.

Remarks. The foregoing case has thus been minutely
described, because to my mind it was an extraordinary
and peculiarly interesting one, from the protracted and
persistent, unyielding rigid os uteri, and from the novel
but successful mode adopted for its relief. " Under the
head of difficult labor, may properly be considered all
cases where, from any cause, the delivery is retarded or
rendered dangerous."

In this case the delivery was not only retarded but
rendered imminently dangerous by the rigid and unyield-
ing condition of the os uteri. The remedies, according
to the best standard authors, are blood-letting, nauseants,
the use of beladonna to the parts, and, above all, anes-
thetics. Recently it has been suggested in slow dilatation
of the os to divide to a limited extent a portion of the
circular fibres, but I believe has not met with much favor
from the profession, because it is considered dangerous
and rendering the patient liable to rupture of the uterus.
Opiates have been recommended when the labor is
tedious, its advocates claiming that it quiets the contrac-
tions, thereby giving time for the circular fibres to dilate.

In the case under consideration the patient had been
nauseated and vomited frequently, was bled copiously, and
kept under the influence of chloroform for several hours,
all of which had no influence in dilating the os uteri. The
beladonna was not applied, because the writer has never
seen any good effects from its use, and this opinion has
been corroborated by the experience of his personal
friends in the profession. A full opiate would have been
given (as the patient was persuaded she was not full term)

1867] Word on the Obligations of the Public. 628

had it not been for the hyperemia of the brain which to
my mind clearly contra-indicated its use.

Here, then, we have a case in which all the remedies
have been employed that have been recommended, where
the os does not dilate, all of which had no effect. The
patient in imminent danger of dying from convulsions,
and this bilateral incision of the cervix uteri was per-
formed, which not only arrested the convulsions having
removed the cause but terminated successfully, the
patient having not one threatening symptom, but a speedy
recovery.

Not having seen this particular operation reported, I
desire to impress upon the profession the facility with
which it can be performed when n<cessar>/, and that, too,
with a reasonable hope of success.

ittrn

Obligations of the Public to the Medical Profession. Read
before the Georgia Medical Association. By R. C.
W\Ord, M.D., of Atlanta, Ga.

It is proposed in this paper to submit a few thoughts in
relation to the want of appreciation by the people, of the
peculiar difficulties which, to the medical profession, more
than any other, have resulted from the late unfortunate
war. The cause of medical science, not less than the
interests of the practitioner, is jeopardized, and it would
seem, therefore, a duty, both to the public and the pro-
fession, to speak out upon this subject.

In former times the principles of medical ethics, by
which wTe were governed, were in some degree understood
and acquiesced in by the more intelligent in the com-
munity. These principles recognized certain reciprocal
obligations between the members of the medical profes-
sion and the public, and both were expected to perform
their part; now, however, the rule appears to be changed

624 Word on the Obligations of the Public [July

the physician is expected to perform his obligations,
while the people seem to regard themselves released from
theirs.

We think it may be said, without boasting, that the
true men of the medical profession in Georgia, and indeed
throughout the whole South, are endeavoring to discharge
their duties to science, and to the public, and are moving
onward, despite the adverse circumstances of the times,
in the same noble and benevolent spirit which has ever
characterized medical men as a class.

The existence of the Medical Association of Georgia
is, of itself, evidence of a spirit of investigation and
progress amongst the members of the profession in the
State. Its labors are devoted to the cause of science and
to the public good. There are two medical journals in
successful operation in Georgia, and several others in the
South, and the work of collecting statistics and useful
facts, from the records and experience of the war, is being
diligently prosecuted.

On the other hand, what can we say of the conduct of
the public toward the profession ? Amid the turmoil and
confusion of business pursuits, and the anxieties incident
to the present disturbed state of the country, men seem
to have lost sight of those great principles and rules of
action which look to the general welfare. One of these
rules which should govern the conduct of every good
citizen, is the furtherance of science, and the advocacy of
truth.

The great progress of medical science in the last half
century, and the discoveries resulting therefrom, have
proven of incalculable benefit to mankind. Take the
single article of chloroform, and reflect upon the relief it
afforded to the thousands of our suffering soldiers during
the late horrible war, not to mention the suffering it has
prevented in private practice, and who can place an esti-

1867] Word on the Obligations of the Public. 625

mate upon its value ? In the treatment of disease, in
surgery, in chemistry, in public hygiene, and, in fact,^
every department of medical science, the public is reap-
ing the benefits of a rapid and unprecedented advance-
ment.

Is it the desire of the people that this work of progress
and improvement shall continue ? If so, they should not
neglect the true men of the profession. The sober, the
educated, and the conscientious members of the profes-
sion should be sustained ; for to them the country looks
for the promotion of medical science, and they are the
true conservators of the public health. Upon them alone
can the people safely depend in cases of trying and
critical emergency, and their presence furnishes a safe-
guard and protection to life and to health which should
not be lightly estimated.

How often does it happen, especially in this day of
accidents by steam and machinery, that cases occur in
which the highest skill and science alone can avail to save
life cases wherein impudence and humbuggery can not
cloak the ignorance and inefficiency of the imposter, and
wherein the life of the sufferer absolutely depends upon
the prompt attendance of the skillful and educated
physician ? The presence of the intelligent medical man
in a community is, then, a matter of serious importance,
for critical cases, of the kind alluded to, may happen at
any moment, and, indeed, are far more frequent than is
supposed, for they are not always palpable to the non-
professional observer, even in surgical cases, much less in
ordinary diseases. It is in the latter class of cases that
the quack so well succeeds in getting the people who,
while acknowledging the necessity of calling upon the
man of science in these rare and critical cases, never-
theless too often bestow upon the quack the' more lucra-
tive, because the more frequent, emoluments of the
57

626 Word on the Obligations of the Public. [July

daily practice. Such a course on the part of the people
is .both wrong in principle and suicidal in policy; and it
is well that the public be advised of the fact that it is
driving from the profession those who are morally and
intellectually best qualified to practice its humane and
responsible duties.

But patronage to quackery over legitimate medicine is
not the only evil of which we complain : there is yet
another which is forcing many worthy men from the
practice of medicine into other channels. It is that
medical bills are not paid, and that medical men are not-
allowed by public sentiment to present their bills for
collection, and require prompt payment thereof, as is done
in other departments. Custom has invested the medical
profession with a dignity which places it in a different
position from other avocations in the matter of collecting
debts. If the physician drives his patrons he lowers
himself in their estimation, and not unfrequently gives
offence. "Why is this, and why is it considered a lower-
ing of professional dignity for the physician to demand
his pay? The cash system now holds in every other
department. How is the physician to meet the cash
demands that are daily made upon him when he is re-
quired to credit indefinitely any and everybody ?

When the medical man applies for credit at the store,
or the provision market, he finds that deference to pro-
fessional dignity does not avail to relieve him from the
demands of the cash system, and the merchant plainly
tells him, " Sir, my rule is cash ; we let no goods go
without the money." This, it will be said, is right. Grant
it. But reverse the case, and let this identical merchant
send for the physician, who replies to him, " Sir, my
rule is cash ; I visit no case without the money." Would
not the merchant be highly offended, and would he not

1867] Word on the Obligations of the Public. 627

ever afterwards regard this physician as an exacting and
unfeeling man, and unworthy of patronage.

It is a fact well known, and one to which the public
mind should be directed, that hundreds of the best men
in the profession are being literally starved out by this
unjust and ungrateful discrimination. We say ungrateful,
because the conscientious medical man has claims upon
the community far beyond the amount due by the few
who are willing or able to compensate him for his ser-
vices. He is a public benefactor in the highest sense of
the word. The people are strangely insensible to the
fact, that the physician does an amount of gratuitous
labor far surpassing that of all other callings combined ;
and as the burden of caring for the poor should re3t
equally upon all classes, the undue proportion which the
physician sustains should be placed to his credit as against
the communitv. The argument that these charities are
incident to the profession he has chosen, and must, there-
fore, be borne, is too illiberal and unjust to merit a reply.
Yet it is evident that such is the light in which their
services are viewed, and that little or no merit is attached
to their performance. To such an extent, indeed, has
this feeling grown upon the popular mind, that the phy-
sician seems to be regarded as a mere philanthropist,
whose duty and pleasure it is to act for the public, and
who requires, and is entitled, to no compensation.

In Germany, and in other European countries, the Gov-
ernment provides for the medical treatment of the poor ;
but here the Legislature not only refuses to compensate
the practitioner, but hightens the infliction by imposing
upon him a heavy specific tax.

In 1860 the Medical Association of Georgia, in a me-
morial to the Legislature in reference to the injustice of
the specific professional tax, thus alludes to the gratuitous
services of the physician :

628 Word on the Obligations of the Public. [July

At all seasons, and in all kinds of weather, in the dark hours of
night when others are asleep, the medical man passes from one scene
of distress to another, bestowing his labor, impairing his health, and
dispensing drugs to the indigent sick. To this course he is impelled
by two powerful forces ; the first and greatest is the demand of hu-
manity, which, to a conscientious man, leaves often no alternative by
which to escape the call. The second is the force of public sentiment,,
which will not 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 insolent customer, and
it is well ; but the physician who exercises this liberty brings upon
himself the severest censure, and consequent injury to his 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, skill, and benevolent agency, he relieves large numbers,
and oftentimes rescues them from impending death. When under
analogous circumstances a party is snatched from a burning dwelling
or a watery grave, the individual who performs the deed is esteemed 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 having performed a mdre commonplace
duty, and scarcely meets with a passing commendation; and such is
the tyranny of custom and law, that if he refuses to respond to every
call, he encounters the indignant frown of the community, and failing,
from the want of facilities or other cause, to adopt the most scientific
treatment, he becomes liable to prosecution and heavy damages.

When the cholera or other destructive malady rages as
an epidemic in a community, the physician remains at
his post facing danger and death for the puhlic. In the
medico-legal investigations, at coroner's inquests, and in
post mortem inspections, the services of the physician are
required, and yet the State has made no adequate provi-
sion for his compensation.

If in the days of peace and prosperity these burdens
bore unequally and hard upon the medical man, what are
they now, when the proportion of poor to be treated has

1867] Word on the Obligations of the Public. 629

increased ten fold, when the proceeds of the negro prac-
tice has been cut off, and when increased specific taxes by
the State, the County, and the Federal authorities are
extorted from the practitioner ?

Medical men, as a class, are proverbially benevolent
and kind, and have ever borne with patience the heavy
responsibilities of the practice and the exactions of the
public; but the time has arrived when in consequence o
their own destitution, and the impoverished condition of
the masses, they feel constrained to protest against the
vast inequality of the burdens they are called upon to
bear.

Other facts could be adduced in proof of the positions
assumed, and to show that the physician is a public bene-
factor, and is entitled to the gratitude and support, instead
of the censure and neglect, of the public. But we con-
clude by recapitulating the points we have endeavored to
establish.

1st. There are reciprocal obligations between the public
and the members of the medical profession.

2d. The medical men are nobly discharging their duties,
but the people are unmindful of their obligations, which
require them, both as a matter of principle and of policy,
to support the true men of the profession.

3d. Medical men are not paid : they are forced to adopt
the old credit system, which is but little better than star-
vation, as the result of which many good men are leaving
the profession.

4th. Medical men are benefactors to the public, for
which neither the Legislature nor the masses of the people
have any just appreciation.

630 Ford on Femoral Aneurism. [July

A Case of Femoral Aneurism treated by Ligation. By De-
Saussure Ford, M.D., Professor of Anatomy in the
Medical College of Georgia.

In September, 1864, William, a negro, twenty-three
years old, was wounded by a load of buck shot; a few
minutes after, four or five of them were extracted from
.'the posterior part of the left thigh, wThere they entered.

The patient made the following statement : there was
free hemorrhage immediately after he was shot the
wounds, after suppurating for three months, finally healed
there was no tumor noticed until after the healing was
completed, but, soon after, a small tumor was discovered
in the inner part of the thigh. January last he came to
this city for treatment. There was a large aneurismal
tumor, fi.ve inches in diameter at the base, which occu-
pied the lower angle of Scarpa's triangle. Treatment by
compression was commenced, but the pain was so exces-
sive the patient refused to submit to it, and returned to
his home in Madison, Ga.

He presented himself again in February, the tumor
very much more enlarged. After recovery from an attack
of tonsillitis, he consented to submit to an operation.

The wound having been inflicted from the rear, there
was some doubt whether the femoral or profunda artery was
wounded. After consultation with other members of the
Faculty of the Medical College, I determined to cut down
to the femoral artery in Scarpa's triangle, and if pressure
on the vessel below the profunda arrested the pulsations
on the tumor, to ligate; accordingly, on February 13th,
at the Freedman's Bureau Hospital, assisted by members
of the Faculty, and in the presence of the students of the
Medical College, chloroform having been administered, I
made the usual incision for reaching the vessel in the
upper part of Scarpa's triangle, and succeeded in ligating

1867] Eulenburg on Nervous Pathology. C31

the femoral artery about an inch below the profunda,
which was given off rather higher than usual, a fortunate
circumstance for the favorable result. After the wound
was dressed, the limb was enveloped in a flannel bandage,
from the toes to the hip, and the temperature carefully
noted, with the thermometer, for thirty-six hours. The
anastomatic circulation was so rapidly established that
there was little diminution in the temperature of the
limb.

Four days after the operation, William was attacked by
variola, and was removed to the Small Pox Hospital.
During the progress of this disease, which was of a mild
form, the ligature came away March 1st, fifteen days
after the operation. The tumor had decreased so per-
ceptibly, with every indication of its early absorption, and
the wound made by the operation so nearly healed, he
was allowed to return to his home March 21st.

William dates a letter May 13th, three months after the
ligation, in which he says : " The place you operated on
my leg is going down very fast; it is not more than half
the size when I left Augusta. Dr. Knight has examined
it twice since I came home, and says it is getting along
very well."

The Restraining JS7crves, a Contribution to Nervous Pathology.
By Drs. A. Eulenburg and L. Landols.

Although until recently only two great groups of nerves
were recognized, the sensory and motor, yet latterly a
third group, the restraining nerves, has been added to the
former. The elucidation of the diseases of these restrain-
ing nerves is the subject of the present paper.

Under restraining nerves are included all those that
interrupt, anywhere or anyhow, irritation produced or
movement originated elsewhere. Their function, there-
fore, consists in the staying of movement. These nerves,
like all others, are liable to disorder, both in their active
and in their conducting apparatus. Besides these central

632 Eulenburg on Nervous Pathology. [July

ganglia and fibres, the restraining system possesses also
special peripheral terminal organs, to which the restrain-
ing impulse excited in the centre or in the conductor is
directed, and in which it is fulfilled. The terminal organs
appear to be ganglia, standing in relation to the motor
apparatus.

The nature of the disorders may be either to increase
or diminish the proper function, as in the nervous system
elsewhere.

The range of these nerves comprise four systems, in
which the restraining action has at present been clearly
shown by physiology. They are :

1. The restraining system of the heart movements
(cardiac, or that of Weber and Budge).

2. The restraining system of the intestinal movements
(respiratory, or Rosenthal's).

3. The restraining system of the intestinal movements
(peristaltic, or Pfliiger's).

4. The restraining system of the reflex movements
(reflex, or Setschenow's).

Corresponding to these are restraint neuroses of the
heart, the respiration, the peristaltic movements, and of
reflex action.

1. The restraint of the heart.

Their physiological basis is the experiment of Weber
and Budge, showing that irritation of one or both vagi
diminishes or wholly arrests the heart's action.

In pathological conditions a restraint producing irrita-
tion of the vagus can be excited at many points, although
a direct irritation is uncommon, and an indirect or reflex
one much more frequent. The direct irritation is seldom
excited in the trunk of the nerve, or in its centre in the
medulla oblongata, more frequently in the peripheral
ramifications of the cardiac branches in the heart itself.
In central irritation the violent further symptoms that are
produced, obscure the characteristic signs of vagus irrita-
tion. The same occurs also in case of the so-called heart
poisons, such as the salts of gallic acid, cyanide of potas-
sium, and others ; and in complicated brain disorder, such
as concussion and tubercular meningitis. Keuroses of the
vagus from a part of the diseases comprised under the
vague term, " angina pectoris."

The physiological type of a reflex heart neurosis is fur-
nished by the well known crushing blow experiment of
Goltz. In this the irritation proceeds from the sensory

1867] Eulenburg on Nervous Pathology. 633

nerves of the abdominal organs. Pathological cases that
admit of the same explanation are sudden deaths from
concussion of the abdomen, or from the passage of a
catheter. To the same category belong many cases of
angina pectoris due to irritation of abdominal organs, and
attended by lowering of the heart's action, anguish, syn-
cope, cold pale skin, and fallen countenance. So also do
the effects of wounds of the intestine, many cases of
(especially toxic) gastritis, of nervous gastralgia with low-
ering of the circulation, of stoppage or intussusception of
the bowels with similar symptoms, of colic from biliary
or renal calculi, and of peritonitis. The slow pulse of
lead colic also depends upon vagus irritation. In all such
cases death ultimately depends upon paralysis of the ab-
dominal vascular system, as Goltz, in his blow experi-
ment, has clearly proved. Mention should further be
made of certain forms of nervous shock to the heart,
with diminution of its functional activity from some ab-
normal irritation of the genitals, as onanism and hysteria.

2. The restraint neuroses of the respiration.

The physiological facts that underlie these disorders
are not so free from doubt as those that relate to the
heart; but they are, nevertheless, certain enough. They
rest upon the experiments of Rosenthal, which teach
that slight irritation of the superior laryngeal nerve di-
minishes the frequency of the inspirations ; that stronger
irritation entirely stops them, with relaxed diaphragm
and closure of the rima glottidis; and that the strongest
irritation produces contraction of the expiratory muscles.
In this way cough is occasioned, and, in the higher de-
grees of irritation, spasmodic cough.

Rosenthal considers the superior laryngeal to be a res-
training nerve for the inspiratory movements of the dia-
phragm. Its excitation is not centrifugal, like that of
others, but centripetal ; and its restraining centre is cer-
tainly not, like theirs, in the peripheral organ, but in the
medulla oblongata, so that an analogous direction of
action is maintained.

Pathological conditions dependent upon restraint neu-
roses of the laryngeal nerve are numerous. Prominent
among them are spasmodic coughs, both the hysterical
(a pure neurosis) and whooping-cough, which the authors
hold to be an infectious neurosis. Again, there are the
attacks of cough brought on by foreign bodies and by
material changes in the air-passages.

58

634 Eulenburg on Nervous Pathology. [July

3. The restraint neuroses of the intestinal canal.

These have their physiological analogues in the stop-
page of the peristaltic movement, and the relaxed state of
the intestinal walls from irritation of the splanchnic
nerves, as first observed by Pfliiger, and since confirmed
by others, between the muscular layers of the intestine,
and that supplies the intestine with motor fibres. The
characteristic of neuroses of the splanchnic nerves is the
diminution or arrest of peristaltic action, producing re-
tarded evacuation or complete stoppage of the bowel.
These symptoms, however, correspond to those of paraly-
sis of the motor nerves. It is, therefore, difficult in con-
crete cases, to decide which of the two cases is in opera-
tion. Very often there is a combination of both.

An example of irritation of the splanchnic nerves is
furnished by the typical symptoms of lead colic, which
are pain and obstinate constipation. The first may be
very well attributed, in part, at least, to irritation of the
splanchnic nerves, since they contain sensory fibres. This
irritation may itself strengthen the restraining influence
by reflex excitation. The active character and the source
in irritation of the costiveness are shown by the familiar
therapeutic action of the anti-spasmodics. It would cer-
tainly have the same character if caused, as some assume,
by spasm of the intestinal muscles ; but in such case it
could only be reflex, and excited through the attacks of
colic, and it would probably only occur periodically, and
not occasion constipation of so obstinate a kind.

Besides the attacks of pain, and the relief afforded by
anti-spasmodics, the presence of irritation of the splanch-
nic nerves is further denoted by a similar action upon
other restraining nerves, especially the vagus ; from
which, in half the cases of lead colic, we find marked
retardation of the pulse. The distention of the abdomen,
again, indicates paralysis of the intestine. The reputed
spasmodic contractions are probably only consequences of
the pains, and are partly only apparent, and only affect
the large intestine, upon which the splanchnic nerves
appear to have no restraining influence. They may also
be produced secondarily, through the irritation of the
mechanically-distended bowel, as we see in cases of inter-
nal obstruction.

It is probable that the psychical influences that modify
the intestinal movements (as in hysteric meteorismus)
follow the track of the splanchnic nerves, although their

1867] Birkett on Cancer Statistics. 635

centripetal course, beyond the thoracic sympathetic
ganglia to the cerebrospinal centre, is not certainly
known.

4. The restraint neuroses of reflex action.

The restraining action of the will upon reflex move-
ments, and their promotion by decapitation, have long
been known. Setschenow was, however, the first to de-
termine experimentally the reflex restraining centre in
the brain of a frog, in the corpora quadrigemina, and
optic lobe. An analogous office is, in the highest degree,
probable in mankind. The diseases of this restraining
apparatus may serve to explain many spasmodic condi-
tions such as epilepsy, chorea, tetanus, and paralysis
agitans. According to Malkiewicz, we may consider the
spasms produced by poisoning with strychnia, alcohol,
and opium, to be results of paralysis of the reflex res-
training centre, upon which all these substances exert a
decidedly paralysing influence. Wien. Med. Wochenschr.,
1866 ; Schmidt's Jahrbucher, 1866.

The Residts Attending the Removal of the First Growth of
Cancer. By Mr. Johx Birkett, Surgeon to Guy's
Hospital.

"What advantage does a patient obtain in submitting to
the removal of a cancerous tumor? The answer which
Mr. Birkett gives to this question is too full of interest to
be curtailed. He writes :

" The facts upon which to base a reply to this inquiry
are derived from the investigation of a hundred and fifty
cases carefully recorded by myself; and although I have
not always performed the operation, I have seen the
patient and examined the growth after its removal. A
majority of the patients are dead ; for it should be borne
in mind that this collection of cases was commenced
eighteen years since, and that not a little difficulty arises
in being able to follow out patients who survive several
years.

" Also, it must be stated, that I have not made any
selection of the cases with the view to uphold or support
any particular statement. The sufferers who succumbed
to the disease were placed in the order in which death
occurred, and therefore some allowance should be made
in those cases in which death ensued very rapidly after

636 Birkett on Cancer Statistics. [July

the development of the disease appearing on the tables in
greater numbers than those which survived the same
thing many years.

" The above consideration, as well as others, render
what are termed statistical tables, and deductions there-
from by means of averages, most fallacious guides to
treatment.

" Table A is arranged to show the length of time during
which one hundred and fifty patients were free from any
indications of the local recurrence of the disease after the
removal of the first growth.

A. Table showiny the length of time during wkich a hundred and fifty
patients were Free from Indications of the Local Recurrence of the
Disease after Operation.

Cases.

Before the expiration of the first year 87

Between expiration of first year and close of second.... 15

Between second and third 7

Between third and fourth 7

Between fifth and sixth 5

Between sixth and seventh 2

Between seventh and eighth. 1

Between eighth and ninth ?>

Between ninth and tenth 1

Between tenth and eleventh 3

Between fourteenth and fifteenth 1

Between fifteenth and sixteenth 1

Sixteen years 2

Patients died free from local disease in parts first affected
(see table) 15

150
" Before the expiration of the first year, eighty-seven
patients showed, signs of a new development of the
growth, either in the portion of the mammary gland not
removed, the integuments in the neighborhood of the
cicatrix, in that structure itself, or in the axillary lymph-
atic glands.

" After the expiration of the first year, and before the
conclusion of the second, fifteen patients showed that a
cancerous growth was again developed in one or other of
the regions above mentioned.

"Now, this large proportion of the cases in which re-
currence occurred, might be taken as a significant fact to
demonstrate that the cases submitted to operations were
badly selected; that, indeed, an operation was scarcely
justifiable. But, in many of the cases, the operation was
undertaken in the hope of removing a source of great

1867] Birkett on Cancer Statistics. 637

local pain and mental distress; of alleviating the misery
and to abate the annoyance attending an ulcerated and
sloughing surface, and at the earnest solicitation of the
sufferer.

"In some, I confess, little, if any, advantages were
gained. In others, although life was not prolonged by
many months, the existence of the individual was ren-
dered more tolerable, since the attendant circumstances
before described were sometimes absent. Life was de-
cidedly prolonged in a few cases, in which it was rapidly
ebbing in consequence of repeated hemorrhages and
deeply sloughing masses.

" Further, we may be allowed to suggest that many of
the cases in this category might have been operated upon
at a much earlier period after the discovery of the tirst
growth, and with every probability of a happier result.
But, in hospital cases, and a large majority were of that
class, it too often happens that patients apply to such
institutions as a last resource only.

" We may now turn to a somewhat brighter picture.
To be free from such a disease as cancer for periods of
time extending between three and sixteen years, is a fact
surely sufficient to justify almost any means to accomplish
such a desirable end. The risk to life attending the ope-
ration is not great, and now much of the horror of such
a proceeding is mitigated by the employment of anaes-
thetics.

"In the wards of a hospital, even where the chances
against the recovery of the patient are greater than in
private practice, I calculate the death-rate at only seven
per cent. During the last seventeen years, two hundred
patients have been operated upon by my colleagues and
myself in Guy's Hospital. Either the whole or a portion
of the breast-gland was removed on account of a carcino-
matous growth. All of these recovered from the effects
of the operation, with the exception of fourteen, who
survived it between three and thirty-six days only. It
must be admitted that the operation was more or less the
excitiug cause of the disease which terminated life. These
fatal diseases were erysipelas, followed by bronchitis;
inflammation of the pleura, terminating in effusion ;
pyeemia; haemoptysis; and vomiting; in tact, the too
common causes of fatal complications after operations
upon the poorer classes, inhabitants of large cities.

638

Birkett on Cancer Statistics.

[July

"But in private cases the mortality is so trifling that,
admitting the risk to which every person submits who
undergoes any operation, I am inclined to calculate it at
not more than three or four per cent. I have lost only
one patient, of forty-one cases operated upon for cancer.

" To proceed with the remaining cases. Of the pa-
tients, thirty-three in number, who survived the operation
without any local recurrence of the cancer for periods
varying between two and sixteen years, assuredly many
of them must have died of the complaint within those
periods; and all of them would certainly have been
compelled to endure the mental anguish, if not the local
suffering, accompanying the existence of this terrible
malady, assuming that they had survived equal periods.

" Lastly, fifteen of the patients died without showing
external signs of recurrence of cancer in the region first
allected.

B. Cases in ivhich the Cancer did not Reappear in the part Jirst
affected with that growth.

Cases

Survived
Operation

Cause of Death

Condition of local disease at operation

I

6 months

Hepatic disease

Integuments infiltrated

2

10 months

Thoracic disease

In same condition

%

1 1 months

Hepatic disease

As above

4

13 months

Carcinoma in calvaria

Mammary gland only infiltrated

5

15 months

Disease of ovary

As above

6

2 years

Cerebral disease

Tnteguments infiltrated

7

2 yrs. 2 m.

Hepatic diiease

Integuments infiltrated and ulcerated

8

3 years

Thoracic disease

Mammary gland infiltrated only

9

4 yrs. 3 m.

Cerebral disease

v^ame as above

10

6 years

Thoracic disease

Integuments infiltrated

11

6 years

Cerebral disease

Integuments infiltrated and ulcerated

12

riyrs. 6 m.

Exhaustion

Mammary gland infiltrated

13

6 yrs. 8 m.

Thoracic disease

Integuments infiltrated

U

10 yrs. 6 m.

Cachexia

Integuments ulcerated

15

11 years

Cachexia

Mammary sland infiltrated

" The Table B shows the length of time each individual
survived the operation. This was between six months,
the shortest time, and eleven years, the longest. In
another column is stated the cause of death in each case,
which was the development of cancerous growths in the
viscera of either the cranium, the thorax, or abdomen, as
determined by well-marked indications during life or by
post-mortem examinations.

" I have introduced, in the same table, as brief a de-
scription as possible of the condition of the local disease
at the time of the operation ; and it should be noted that
it had made considerable progress in some of them. The

1867] Birkett on Cancer Statistics. 639

integuments were infiltrated with cancer; in some, ulcer-
ation of the surface existed. Under these conditions, we
are justified in assuming that some of the patients would
speedily have fallen victims to the ravages of the com-
plaint, and that all must have endured more or lees of the
suffering accompanying its progressive stages.

" By the removal of the growth, these fifteen patients
were exempt from the misery inseparable from the ac-
tivity of the local disease. *

"Let us next inquire if the life of individuals afflicted
with cancer of the breast is prolonged by the removal of
the part first involved by the disease.

C. Table to show the number of years a hundred and -fifty patients
survived the Discovery of the Disease after the Removal of the First
Growth.

Above 10 years 2

Above 11 years 2

Above 12 years 1

Above 13 years 1

Above 14 years 2

Above 15 years 1

About 23 years 1

About 29 years 1

About 32 years 1

Under 1 year 8

Above 1 year 24

Above 2 years 38

Above 3 years 17

Above 4 years 21

Above 5 years 7

Above 6 years 5

Above 7 years 10

Above 8 years 4

Above 9 years 4

" I have arranged Table C to show the number of years,
one hundred and fifty patients survived the discovery of
the disease after the removal of the first growth. Rather
more than one half died before the expiration of the
fourth year, or in the ratio of fifty-eight per cent. ; the
majority dying before the completion of the third year.

" Thirty-three died before the expiration of the seventh
year, or in the ratio of twenty-two per cent.

"Eighteen died before the conclusion of the tenth
year, or in the ratio of twelve per cent.

" Twelve survived about ten years, or in the ratio of
eight per cent. One person lived about thirty years after
the discovery of the disease.

" In order to form some comparison between cases sub-
jected to the above treatment, and those in which the
disease was allowed to pursue its natural course, with the
exception of using local palliatives and constitutional
measures, I calculated the average duration of life of a
hundred patients.

" Fourteen of these patients died within the first year
after the observation of the disease ; three survived its

640 Nunn on Cicatrization of Sluggish Sores. [July

discovery above ten years, two of them having lingered
under its slow progress about twenty-six years.

" The average duration of life I believe to be about
three and a half years.

" Of the cases, then, which have fallen under my ob-
servation, it is quite certain that the longest survivors
have been those from whom the first growth was re-
moved.

u Whether the duration of life was really essentially
due to the removal of the first growth, I would not ven-
ture to assert dogmatically ; for there are many collateral
circumstances which require to be taken into considera-
tion, for which the time is insufficient upon the present
occasion.

" In conclusion, I trust that I have demonstrated to my
sceptical professional brethren that a certain proportion of
cancer patients can receive benefit by submitting to the
removal of the first growth of the disease; and that the
benefit derived from the operation is twofold viz. : 1st,
prolongation of life ; 2d, exemption from disease for a
considerable period of time in many instances/' British
Medical Journal.

On the Employment of Galvanism on Promoting the Cicatri-
zation of Sluggish Sores. By Mr. Nunn, Surgeon to the
Middlesex Hospital.

Mr. Nunn records the following cases. In treating
ulcerations he finds it indifferent whether an induced or
continuous current be used. He has often used Pulver-
macher's galvanic chain with advantage in obstinate
sinuses.

Case 1. W. F., aged twenty-three, had benign fungus
of the testis, the sequence of strumous abscess. There
was a circular perforation of the scrotum on the left side
as large as a florin, and it had existed during twelve
months. The fungus was about the size of a walnut;
there was a free discharge from it of yellowish glairy
purulent fluid.

October 12th. Galvanism of weak intensity (from a
single cell), to be applied for five minutes every morning.
The effect of the galvanism was most remarkable ; the
fungus receded, and the edges of the perforation con-
tracted over it, after a few days.

1867] Nunn on Cicatrization of Sluggish Sores. 641

27th. A slightly stimulating lotion of nitrate of silver
was ordered (half a grain in the ounce of water).

30th. The solid nitrate of silver was brushed round
inside the sore, which had now nearly closed ; and nitric
acid and decoction of bark were ordered to be taken three
times daily.

November 6th. The patient was discharged, the sore
being quite healed.

Case 2. H. D., aged five years, was admitted with an
unhealed sinus, probably caused by caries of one of the
cuneiform bones. The swelling was chiefly on the inner
side of the foot, in front of the instep. The tarsal end of
the metatarsal bone of the great toe was enlarged. There
was the history of a sprain; -and the child's parent be-
lieved the disease of the foot to be due to the sprain. An
incision had been previously made in the part, and some
unhealthy bone scooped away by another surgeon. The
child had a scrofulous appearance, and its belly was tumid.
Mr. Xunn ordered nitric ether in half-drachm doses, with
syrup, three times a day a medicine which he believes
to exert the most useful influence in promoting the nutri-
tion of cachectic children, and to have the power of di-
minishing that distention of the abdomen so characteristic
of deficient nutrition from sluggishness of the mesenteric
glandular system. Iodide of potassium ointment was
also prescribed to be rubbed into the belly. These
measures were carried out from January 27th to February
11th, without much change in the appearance of the
sinus, when galvanism was ordered to be applied for five
minutes three times a week. The effect of the galvanism
was at first to diminish the angry redness of the part, and
also the amount of discharge from the sinus. By the
end of the month the sinus had scabbed over, and the
patient was discharged on the 7th of April, convalescent.

Case 3. Jane D., aged twenty-two, admitted December
12th with angular curvature of the spine. She was healthy
up to the age of fourteen years, when she began to suffer
from rheumatic pains " all over her." There was at the
date of admission an opening in the upper third of the
right thigh, about the apex of Scarpa's triangle. Four
years since there was some swelling and stiffness of the
thigh; two years since, at the seat of the opening, a
swelling as large as an egg. The spine projected in the
lumbar region; there was some tenderness on either side

59

642 Bartholow en Bromide of Potassium-. [July

of the spinous processes; and occasionally at night, and
at a change of weather, pain in the part was severe.

Iodide of potassium, in three-grain doses, three times a
day, was ordered ; and directions were given to double
the dose in the event of increase of pain at night. Iodine
paint to the back.

On the 26th, galvanism was directed to be applied twice
a week, the current being passed from the thigh to the
spine. This was continued until February 13th, when
the patient was discharged, much improved. The sinus
in thigh had nearly closed.

Case 4. Agnes D., aged four, admitted November 14th,
having a superficial strumous ulcer, with somewhat exca-
vated edges, surrounded by .small pustular elevations, on
the dorsum of the left hand. There were similar sores
on the foot and face. Iodide of potassium in one-grain
doses, twice a day, with cod-liver oil, were prescribed.

On the 17th, galvanism for Rye minutes was ordered to
the foot, twice a week; on the 28th, to the hand and face
also. This was followed almost immediately by a change
to a healthy action in the sores. The patient was dis-
charged, convalescent, January 9th. The Lancet, July,
1866.

Experimental Investigations into the Action of the Bromide of
Potassium. By Dr. Roberts Bartholow.

The author's investigations were conducted in three
directions: 1st, The chemical properties; 2d, The physi-
ological effects; and 3d, The therapeutical uses of the
salt.

The physiological effects of the salt when taken into
the stomach, Dr. B. sums up as follows :

" 1. It proves irritant in large doses to the mucous
membrane of the stomach.

" 2. It is rapidly absorbed into the blood, and may be
detected soon after in the urine.

" 3. It acts upon the nervous centres, producing seda-
tion, sleep, reduces the action of the heart and arteries,
lowers the temperature, and diminishes the retrograde
metamorphosis of tissue."

The prolonged administration of the bromide of potas-
sium produces, according to Dr. B., the following effects :

" 1st. It diminishes and ultimately entirely neutralizes
the sexual appetite.

1867] Bartholow on Bromide of Fotassium. 643

" 2d. It produces weakness of the muscular system.

" 3d. It is irritant to the stomach if given in considera-
ble doses ; and

"4th. It interferes with the secondary assimilation,
lessening the retrograde metamorphosis of tissue."

In regard to its therapeutical uses, Dr. Bartholow extols
it as a disinfectant and deodorizer, as an eschar otic in slough-
ing and gangrenous ulcer, phagedenic chancres, hospital
gangrene, epithelioma, etc.

"The actions of the bromide of potassium, physiologi-
cally considered," Dr. Bartholow states, " consists in a
sedative or contra-stimulant effect upon the nervous
centres, producing as secondary phenomena, sedation of
the heart, ansemia of the brain, anaphrodisiac effects, and
diminution of the retrograde metamorphosis of tissue. It
has come into use in various functional and organic
nervous disorders, and in certain sexual diseases where a
calmative and sedative influence is desired."

This salt Dr. Bartholow considers to be indicated as a
hypnotic in states of nervous excitement without conges-
tion of the nervous centres; in hysterical insomnia; in
delirium tremens ; in the insomnia of excitable business
men, or, in general terms, in those forms of insomnia
dependent upon excitation without increased blood supply.
He has found it especially useful in irritable bladder, and
the chordee of gleet.

From a careful survey of all the facts, Dr. Bartholow
gives the following as the methodus medendi of the salt in
question :

" 1st. The bromide of potassium acts by absorption into
the blood.

" 2d. Its effects are expended upon the nervous centres,
or the cerebro-spinal axis.

" 3d. Sedation of the heart and circulation, and the
various local sedative effects are secondary results of the
impression made upon the nervous centres.

" 4th. Its physiological effects are not very decided, and
are easily modified by any local disturbance.

" 5th. Its therapeutical action is still more decidedly
influenced by local morbid processes.

" 6th. It is indicated where a sedative to the nervous
system is required in insomnia ; in great reflex excita-
bility; nervous and spasmodic affections of the larynx
and bronchi, sexual excitement, and in an irritable state
of the sexual organs.

644 Williams on the External Ear. [July

M 7th. It will be effectual in the foregoing conditions,
in proportion to the degree in which structural lesions
are absent, or, in other words, in proportion to the degree
in which these morbid states are functional rather than
organic."

The bromide, Dr. Bartholow asserts, possesses none of
the peculiar alterant properties of the iodide. Whilst
this fact is true, it is undoubtedly the case that the brom-
ide relieves the congestion of certain organs, diminishes
their bulk, or, as it may be styled, produces resolution of
an engorgement. Such action, apparently alterative or
resolvent, is not really so. It has been exhibited mainly
in certain states of the uterus and ovaries states of
hyperemia dependant upon sexual excitement, or upon
the monthly nisus. The apparent resolvent power is, in
this case, due to the sedative impression of the remedy
upon the sexual organs and upon the vaso-motor nerves.
Cincinnati Lancet and Observer ; American Journal of the
Medical Sciences, January, 1866.

How to Examine and Syringe the External Ear. By A. D.
Williams, Cincinnati.

The reason why we can not see down to the bottom of
the ear, is because we " always stand in our own light."
When our eyes are placed in a proper position for look-
ing in the ear, our heads cut off or prevent the entrance
of light from without. Hence, the first thing to be done
in order that we may examine the external meatus, is to
illuminate it. The principle by which we light it up is
precisely the same as in the illumination of the eye, that
we may see its fundus. As to the source of light, we
may use either the direct sun-light, common gas-light,
coal oil lamp, or the light from a small window that looks
out, not against another building, but into free space,
toward the clouds or sky. Such a light affords perhaps
the best light, but either of the other three sources may
be employed very weir. The direct sun-light makes the
ear feel quite warm when thus concentrated upon it, and
if used for a considerable time, might even burn it. The
gas or lamp-light makes the membrana tympani look
redder than natural, and might even lead to deception
from this fact.

1867] Williams on the External Ear. (>45

Before whatever source of light we choose to use, or
have at our command, we place the patient with the ear
to be examined turned away from it. His head is inclined
a little forward and toward the light. A speculum (Gru-
bers or Toynbee's) is introduced gently (in all manipula-
tions with the ear, gentleness is the first law) down as far
as it will go into the meatus without pain. The speculum
corresponding exactly with that of the meatus. It is now
held in position by the left hand. In the right hand the
surgeon takes a mirror (three inches in diameter and six
inches focus), made expressly for illuminating the ear, and
throws the light through the speculum into the bottom of
the aural canal. In the centre of the mirror is a little
hole, similar to that in the ophthalmoscope. Placing his
eye behind the mirror and over this small opening in the
same, the operator looks through it, down to the bottom
of the ear, just as we look into the eye with the ophthal-
moscope. In this way the whole outer ear is thoroughly
lighted up, and we are thus enabled to see and examine
all its natural structures most minutely and most per-
fectly. If we wish we may magnify them simply by
holding a convex glass, Xo. 3 or 4, before the speculum ;
but this is rarely necessary, even for the most perfect
examination. It enables us to see and judge of things
deep down a little better than without it.

The old method of examining the ear by letting the
sun-light fall directly into the speculum was rather im-
practicable and quite unsatisfactory, for the simple reason
that its natural structures could not always be distinctly
seen, besides the sun-light was not at all times to be had.

The above described method of illumination by means
of the mirror, first introduced and practiced by Dr.
Troelch, of Wurtenburg, is very far superior to it in con-
venience and distinctness, and should be adopted by even-
one who, for any purpose, examines the ear. I will not
just here describe in detail what is to be seen in the
external meatus. I take it for granted that every one
knows what is to be found there, and can easily dis-
tinguish what is pathological and what is natural.

I therefore pass to the second part of the subject

HOW TO SYRINGE THE EAR.

The more common anything is the more it deserves to
be noticed. This is my only apology for introducing such
a common topic.

6i6 Williams on the External Ear. [July

The meatus auditorius externus is the way or tube
that leads down to the bottom of the external ear, that is,
down to the membrana tympani, which is the partition
wall between the outer and middle ears. Its general
course is inward, a little downward and forward, but not
in a straight line. There are several minor deviations
from a straight line, but only one that deserves special
mention in connection with syringing the ear. Practically
considered, the anterior and posterior walls may be re-
garded as straight ; the upper makes perhaps a very small
gradual curve with the concavity looking downward. The
lower wall makes a decided angle, a little beyond its
middle, with the angular point projecting into the meatus
from below, and corresponding, to some extent, with the
general concavity of the upper wall. The direction of
the inner portion of the lower wall is such that it makes,
with the membrana tympani, quite a pocket at the bottom
and lower portion of the meatus. In order that a stream
of water may reach thoroughly the bottom of the ear, it
is necessary lirst that the way that leads to it be straight-
ened as far as possible. For this purpose take hold of the
auriculum, or external portion of the ear, and draw it
pretty firmly directly upward, and in this way the upper
and lower wall are brought as nearly as possible into
straight lines. Holding the ear in this position with the
left hand, take the syringe in the right and inject the
water gently, yet with a little force, into the ear, directing
the point, which should be introduced a little into the
external orifice of the meatus, inward, a little downward
and forward in the general direction of the tube. Of
course a cup must be pressed against the face, beneath
the tragus, in order to catch the water as it escapes. It is
recommended to have two cups, one to contain the clean
water to be injected, and the other to catch it. The best
syringe for the ear that I have ever seen, is what is known
as the ear syringe, made of gutta percha, which is very
light and very convenient, as well as durable. The
syringing operation is to be continued till its object is
attained, which is always cleanliness.

Better use simple warm water, without any soap, which
is supposed to irritate considerably. It may be repeated
as often as necessary for the attainment of the object in
view. Some persons are not affected at all by syringing
the ear, while others, who are in perfect health ad who
are anything else but nervous, faint from it.

1867] Monroe on Treatment of Opium Poisoning. 647

It sometimes has a very peculiar effect upon the nervous
system. In consequence of syringing the ear, stout,
robust men reel and stagger like drunken men, and
sometimes even fall flat upon the floor. If ladies should
tumble over in this way, and from such a cause, inex-
perienced persons might be swift to call them hysterical.
But the imputation would be false, for there are no hys-
terics about it. Then be careful how you make such
charges against women, for men sometimes faint from
the same cause. Cincinnati Lancet and Observer.

Treatment of Opium Poisoning by a New Method. Head
before the Xorfolk District Medical Society, May 9,
1866, by A. LeB. Monroe, M.D., of Medway.

I was called in consultation to the wife of a clergyman,
a lady about forty-four years of age, who was in a state
of ultimate narcosis from laudanum. She was insensible
upon her bed some three hours previous. Her family
physician, Dr. H., was called, and immediately com-
menced a series of efforts to restore consciousness. A
two-ounce vial, which had contained laudanum, was found
in the room empty. After her recovery, she said that she
procured two ounces of laudanum of a respectable apoth-
ecary, and about four o'clock p. m., she took nearly one
half of it, and the remainder about half an hour after-
ward. Emetics of sulphate of zinc, ipecac, etc., had been
given without effect. Powerful irritation of the surface,
tickling of the fauces with a feather, etc., had been em-
ployed without any improvement; on the contrary, she
was sinking, or had sunk, into a hopeless state. The
pulse very slow, not over forty-five, and very weak, soft,
and irregular. The respiration extremely infrequent and
stertorous, with frothing at the mouth. The skin was
cold and clammy; face pale and cadaverous; in fine, she
was in a state of profound coma, which was apparently
soon to end in death. The stomach pump had not been
used. I applied it and drew off the contents of the
stomach, which had a strong smell of laudanum. The
operation of passing the tube and thoroughly washing
out the stomach did not rouse her at all. No galvanic
battery could be had, and if it could have been obtained,
I should have applied it with little confidence in its power

648 Monroe on Treatment of Opium Poisming. [July

to restore the patient. Dr. IT. and her husband regarded
the case as hopeless.

Years before I had read a book which gave some ac-
count of the tortures of the Spanish Inquisition, and
among them all there was one which was represented as
causing to the miserable victim an agony more intense
and excruciating than any other method that could be
contrived by those devils incarnate. It was the dropping
of cold water, from the height of several feet, upon the
naked pit of the stomach. I determined to see if the
method used by inquisitors to torment and kill heretics
would not save the life of the wife of a Calvinistic
preacher. I proposed it to him and Dr. II. They assen-
ted, with little faith in its success.

We placed her upon her back on the floor, with her
head elevated a little upon a folded sheet; slipped her
clothes down below her waist, leaving the chest entirely
naked. A pail of cold water and a pitcher were brought
in. I placed myself in a chair, and raising the pitcher,
tilled with water, to the ceiling, eight or nine feet from
the floor, I allowed the water to fall in a small stream
upon the epigastrium. By the time the first pailful was
exhausted, the breathing had evidently become a little
more frequent and equable, and the stertor less. The
second pailful was brought in, and soon, to my great joy,
I could see that the deathly pallor of the face was being
lighted up by the flow of the vital current from the heart.
A blush, barely perceptible at first, gradually and steadily
spread over the before pale and expressionless features,
until it warmed into the full glow of life and health. (My
feelings at this stage of the proceeding must have been,
in some respects, not unlike those experienced by Pygma-
lion when his beloved statue of ivory began to live and
breathe under his warm embrace.) By degrees other
manifestations of returning life appeared. She began to
make efforts to move away from the pouring stream,
weak at first, but increasing in power, until she could
turn partly over and interpose her hands to break the
force of the stream. At length, after about three pailsful
of water had been used, her struggles to escape from
what was now evidently torture, was quite severe ; and
about this time, to our infinite satisfaction, she began to
beg for quarter in long-drawn, drowsy syllables, increas-
ing in energy and force, until they were uttered in a tone
and manner which evinced a considerable decree of

1867] Monroe on Treatment of Opium Poisoning. 649

passion, and even anger, at the strange and cruel treat-
ment to which she was subjected. But even now she
would fall asleep immediately if let alone. Having con-
tinued it as long as we thought it necessary, we desisted,
and rubbed her dry with warm cloths. "We then raised
her up and walked her about the room, or rather about
an adjoining room, which was dry, for an hour or more,
resting at intervals. This was no easy task, for she was a
full, well-developed woman, weighing one hundred and
forty or one hundred and fifty pounds. She would beg
piteously to be let alone and to lie down, and in spite of
us she would often slip from our hands upon the floor.
This forced exercise was continued until we deemed it
unnecessary. She recovered without any permanent ill
effect. It was the last attempt she made to destroy her-
self. She had been subject to periodical fits of insanity,
in consequence of some catamenial derangement. She
has had no return of insanity since then, and has lived a
blessing to her family and society.

The methodus medendi in this case will not be difficult to
understand, when we consider the anatomical and physi-
ological relations of the parts immediately and mediately
impressed by the cold stream of water. The pit of the
stomach is one of the most sensitive portions of the body;
it has a peculiar sensibility, which will not tolerate even
a slight blow without suffering. The semi-lunar ganglion
and great sympathetic, with its extensive and important
connections, is powerfully excited, and the over-charged
heart is roused to action by the direct and reflex nerve
force. The effect is compounded of shock, to an extreme
degree, and a permanent powerful excitation of the vis
nervosa, causing more or less intense pain and distress,
dependent on the length of time it is applied. The heart
is compelled to contract and send forward its dark blood
to be aerated in the lungs, and then to be distributed over
the whole system, carrying life and activity to all its
functions. Galvanism could do no more. Indeed, I do
not believe it would do as much. Besides, a battery is
not always to be had, while water is always at hand, and
if applied as in this case, I believe it will be more
effective in the cure of extreme cases of opium poison-
ing than anything else. Doubtless it would be as effectual
in poisoning by other narcotics, and possibly in some
cases of suspended animation. Boston Medical and Surg.
Journal.

60

650 Salisbury on Newly-Discovered Shin Diseases. [July

A Brief Description of what appears to be Two Newly -
Discovered Skin Diseases ; one originating in the Cat and
the other in the Dog. Both Cryptogamic and Contagious,
and both capable of being transmitted from the Animal to
the Human Body. By J. H. Salisbury, M. D., Profes-
sor of Histology, Physiology, and Cell Pathology, in
Charity Hospital Medical College, Cleveland, Ohio.

1. Trichosis Felinis. This is a skin disease originating
in th^ cat, and readily transmissible to the human subject.
It resembles in appearance trichosis furfuraceee, and, like
it, has a cryptogamic cause. It is produced by a species
of fungus that develops in the fermentation of cat's milk.
It develops on kittens while nursing; first around the
lips, nose-, face, and eyes, and spreads to the head and
body. It forms, with the epidermic cells, circular patches
of thin rusty scurf on the face, nose, lips, and head. The
hair soon sickens, curls up, dies, and crumbles away, and
the eyes become sore and gradually close. Often the eyes
become entirely shut. After nursing ceases, this growth
gradually disappears. It often lasts, however, two or
three months, and may be longer, after weaning.

This disease is contagious, and is readily transmissible
to the human subject from the kitten, and from one
person to another. It is contracted more readily by young
children than by grown persons, yet it is readily con-
tracted at all ages. On infants and young children it
spreads rapidly, attacking all parts of the body alike. It
spreads rather more rapidly on the hairy than on other
parts of the body. The plants attack the hair follicles, in
which they develop luxuriantly, sending off branches
abundantly through the epidermic and cuticular layers.
The spores and filaments of this mucedinous growth
resemble those of trichosis farfuraceai. They however
develop much more rapidly on the human body, causing
the disease to spread in isolated patches to all parts of the
surface often in a few days' time.

The patches on the scalp do not differ materially from
those of ordinary trichosis furfnraceee, save that the sur-
face is, perhaps, slightly more raised and inflamed, and
produce more irritation. On parts of the body not cov-
ered with hair they spread less rapidly, starting from a
single point or hair, follicle, and extending in all direc-
tions, forming circular and oval patches of greater or less

1867] Salisbury on Newly-Discovered Skin Diseases. 651

size. The patches are slightly elevated above the sur-
rounding surface, red, and covered with scales and little
elevations marking the position of the hair follicles. The
color of the patches is deeper, and the irritation and
itching more severe than in ordinary trichosis.

In less than a week after a kitten affected with this
disease comes in contact with a child, the eruption begins
to show itself upon some parts of the surface of the
latter, usually about the hands, arms, and face, especially
if the child has been caressing the kitten. Soon after,
patches appear on the limbs and body and rapidly spread,
producing an intolerable itching, which is only partially
relieved by rubbing and scratching the patches. This is
purely a local disease, it being contracted alike readily by
the healthy and diseased.

Pathology. The cells of the hair-follicles, and of the
epidermic layer between them, are shrunken and shriv-
elled, and the hairs, diminished in size, become brittle,
and break off and crumble away. The deeper parts of
these follicles become enlarged often, and the hairs die,
shrink, and fall out.

The capillary vessels in the papillary layer of the skin
beneath the diseased surface become congested and en-
larged, producing a reddening of the skin and a slight
elevation of the diseased surface. The epidermic cells of
the follicles and plane surfaces are robbed of their nour-
ishment, become diseased and shrivelled, and finally die
and fall off in dry scales. Frequently the irritation is so
great that pus is formed in little vesicles, which become
broken by scratching.

Cause. The cause is purely local, and has nothing
necessarily to do with constitutional derangement. It is
simply a fungus, a mucedinous growth, that develops
primarily in the epidermic cells saturated with the fer-
menting milk of the cat, which, during nursing, becomes
smeared over the faces of the kittens. It does not appear
to be readily transmitted from the kittens to the old cat.
It does not appear, so far as at present traced, to be a
disease prevailing to any great extent among cats, save
during the period of nursing, and from ofie to three
months succeeding. Tnis plant is unlike the species that
develops in human milk. For the purpose of distinguish-
ing it I have given it the specific name, Felinis. This
fungus finds a nt soil for its growth in the skin of persons
of all ages. The cells of the epidermis, however, of the

652 Saliseury on Neicly-Discovercd Skin Diseases. [July

young are more tender, and better supplied with nourish-
ment than those of the mature and old. Hence this
disease more readily attacks, and more rapidly spreads
over the surface of the former.

In ordinary ringworm (trichosis furfuracece), the fungoid
cause exists mostly in the spore state. The plant does
not advance beyond its cell condition. Its growth seems
to be confined simply to cell multiplication by pullulation.
In this disease the plant cells multiply by pullulation, and
these advance to the filamentous stage of growth. These
filaments are found running through among the cells of
the epidermic layer.

Treatment This being a disease produced by a crypto-'
gamic cause, any substance which retards the growth of,
or destroys this kind of vegetation, becomes a more or
less useful remedy. Among the agents of this class may
be mentioned tr. ferri chloridi; tr. iodini; dilute sul-
phuric acid ; dilute nitric acid ; dilute hydrochloric acid ;
dilute nitro-muriatic acid ; ointment of the per nitrate of
mercury; dilute ointment of per nitrate of mercury,
made with cod-liver oil; creosote; solutions of sulphu-
rous acid ; solutions of soluble sulphites ; strong solutions
of quinia, etc. In short, all anti-fermentative substances ;
or, all those bodies that prevent yeast from exciting fer-
mentation in saccharine and farinaceous materials, or that
tend to prevent animal tissues from undergoing fermen-
tative changes, become useful remedial agents in diseases
caused by parasitic fungi. Under ordinary circumstances
this plant, probably, will not grow upon the healthy body.
It is quite likely that it only becomes capable of develop-
ing in such situations, after becoming animalized so to
speak by developing either in the dirty or milk-smeared
and saturated epithelial tissues of the cat.

One of the most ready remedies for perfectly eradi-
cating this eruption is the tr. ferri chloridi. This should
be painted over the eruption. A single thorough appli-
cation will most generally destroy completely the vegeta-
tion, and effect a cure. The application of tr. ferri is
attended with considerable pain in persons of thin and
tender skin. When the patient is not willing to endure
the smarting of this remedy, others of a milder character
may be substituted. On young children, the oint. of the
per nit. of mercury, made with cod-liver oil and the dilute
citrine ointment, will be found excellent remedies. The
mineral acids, when used, should be sufficiently diluted,

1867] Salisbury on Newly-Discovered Skin Diseases. 653

so as not to cauterize, or produce too much irritation.
They may be painted freely over the diseased surfaces
morning and evening. A few days' application will
suffice to effect a radical cure.

2. Triehosis Caninis. This is a skin disease, affecting
dogs. The eruption begins by a small pustular elevation,
covered with epithelial scales; other little pustules appear
around this, and, beyond these, others soon arise. In this
way the disease gradually extends in all directions from
the starting-point, from follicle to follicle, producing
circular and oval patches elevated above the surroun ding-
healthy surface about one line, and covered with dry
epithelial scales, rolled and twisted up. The patches
extend, and have a shape like that of tricliosis furfuraeece,
on the human subject. Like the last-named disease, this
is cryptogamic. It is produced by a parasitic mucedinous
growth, which develops among the epithelial cells of the
epidermis, passing down among the cells of the hair,
sweat, and fat follicles of the skin, depriving them of
nourishment. This causes them to sicken, shrivel, and
dry up, die, become detached and fall off in dry scales.
The cells from which the hair is supplied with food and
cell elements becoming diseased, the hair becomes im-
perfectly nourished, shrivels up, dies, and falls from the
follicles. This disease attacks all parts of the surface of
the dog. Young dogs are more susceptible to it than old
ones; yet no age is exempt. It resembles closely the
triehosis felinis of kittens ; but appears to differ from it in
this particular, to wit : that the fungus appears more lux-
uriant, large, and is more confined to its filamentous stage
of development. It attacks less the hair follicles than the
felinis, and extends more generally to all parts of the
epidermic cell surfaces.

These diseases may, however, be both produced by the
same specific cause, the difference arising mainly from
the difference in the animal cell surfaces in which they
are developed. On account of this and other character-
istics, I have designated these diseases by two distinct
names. The development of these two growths, to their
fruiting stage, will alone settle the question as to the
identity or difference of the cause in these two diseases.
This part of the investigation is now in progress, and I
hope to soon be able to say positively whether there is or
is not a difference as to cause between these diseases.

654 Salisbury on Newly -Discovered Skin Diseases. [July

- Pathology. The cells of the epidermis, deprived of
their normal nourishment, become shrivelled, dry, and
smaller in size, and separate from each other to a greater
or less degree. This drying and separation of the cells
causes the diseased surfaces to rise above the surrounding
healthy parts, the dead, dried, and curled-up cells separate
and fall off, presenting a bran-like appearance. The cells
of the hair follicles are affected in the same way as the
plane surfaces; the hairs sicken, become small and
shrivelled, die, and fall from the follicles, leaving the
surface bare and inflamed.

Cause. This is purely a local disease, produced by the
development of the cells and mycelium of a mucedinous
fungus among the cells of the epidermic layer of the skin.
The mycelium is found developing more abundantly than
the cells. The mycelium sends out filaments in all direc-
tions, branching and rebranching, forming a close net-
work in the cell layer. As the fungoid filaments extend
in all directions from the starting-point the disease ex-
tends. The development of this fungus deprives the
epidermic cells both of the plane surfaces and the follicles
of their nourishment. This causes them to sicken, die,
shrivel up, separate, and exfoliate.

Treatment. This disease is readily cured by the appli-
cation of the tr. ferri chloridi. A few applications suffice.
One application each day is sufficient. After several
applications of the tincture, it may be well to apply the
dilute citrine ointment, morning and evening, till the
surfaces become soft and healthy. The mineral acids,
the soluble sulphites, creasote, and all anti-fermentative
substances, are curative agents in this disease.

This disease is transmissible to the human subject; but,
so far as examinations and investigations have at present
gone, it is much less readily communicable than the tri-
chosis felinis. It is much more readily transplanted upon
children than upon the mature and old.

It attacks all parts of the body alike readily. It usu-
ally, however, first attacks the hands, arms, and face ;
other parts of the body being more or less protected with
clothing.

History of Investigations. Without troubling the reader
with the tedious details of the investigation, I will here
briefly state that this disease was first noticed by myself
to be peculiar in the summer of 1864, while treating it in

1867] Fox on Herpes Circinatus from Favas in Cat. 655

an orphan asylum, where some thirty small hoys were
affected with it. During the following year quite a num-
ber of cases of the disease were under my care. It was
not, however, till July and August, 1866, that I com-
menced studying the disease with the view of tracing its
source.

I had noticed that in most families where it prevailed,
the children were playing with kittens that had diseased
faces. On comparing the mucedinous growth on the
kittens with that on the diseased children, they were
found to be apparently identical in the shape of the
spores, and in the arrangement of the epidermic cells.
My next experiment was to procure a number of diseased
kittens, and distribute them to families where there were
no cats, and where the children were all free from the
disease. In every instance, in from five to ten days after
the children began playing with the diseased kittens, they
commenced breaking out with this eruption. The next
step was to inoculate myself with the spores of this
fungus from the cat. In about three days they began to
develop rapidly, and send out filaments in all directions
among the epidermic cells, producing a disagreeable
itching, and forming circular and oval patches of erup-
tion precisely like the disease previously described. The
eruption yielded readily to treatment.

I now inoculated myself with the spores from the
patches of eruption on a healthy child, to whom I had
given, about two weeks before, a diseased kitten. The
characteristic eruption followed, extending in all direc-
tions from the points of inoculation. Many other ex-
periments were made, connected with the disease, both
on the cat and dog, a detail of which would be here
uninteresting and unnecessary.

Without further comment or apology this brief descrip-
tion is offered to the profession, hoping the subject may
be of sufficient interest to induce others to make investi-
gations in the same direction. Am. Jour. Med. Sciences,
April, 1867.

Herpes Circinatus from Favas in the Cat.

Dr. Tilbury Fox exhibited to the Pathological Society
of London, November 13, 1866, several specimens of
parasitic fungi sent to him by Dr. Purser, of Dublin
one from a favus patch on the paw of the cat, the others

656 Begbie on Bromide of Potassium. [July

from herpes circinatus (tinea eircinata) of the arm pro-
duced by inoculation with the fungus (achorion) from the
favus of the cat. It appears two cats were affected l>y
favus, the one already mentioned, and a second about its
nose ; attempts were made by one of the ladies in the
house to rub off the crusts from the diseased places in
these cats, and very shortly afterward tinea eircinata
showed itself about her hands, arms, and shoulders;
three other inmates (females) were similarly attacked.
The disease was most carefully diagnosed, and not a
feature of favus showed itself. Dr. Purser then inocu-
lated his own arm, and produced what was pronounced
to be tinea circinati (herpes circinatus) ; he sent some of
the scales to Dr. Fox, which were exhibited. There was
an absence of spores, but mycelial threads were very
abundant. They were smaller, less branched, and more
devoid of granules than the achorion-tubes, characters
which belonged to trichophyton. The cases were inter-
esting as showing that favus may give rise to other forms
of parasitic disease, a view which Dr. Fox holds against
many authorities, and he remarked that DeBury's recent
experiments show conclusively the difficulty of getting an
interchange of characters between varieties of the same
fungus. Med. Times and Gazette, Nov. 17, 1866.

[The above statements are to a considerable degree
confirmatory of the researches of Professor Salisbury,
related in the present number of this journal, pp. 379-
383. It is but justice to Dr. Salisbury to say that his
paper was sent to us early in November of last }rear, and
was intended for the January number of this journal, but
in consequence of the impossibility of having the wood
cuts done in proper season, it was laid over till the present
number. [Ed. Am. Jour. Med. Sciences, April, 1867.

Therapeutic Effects of the Bromide of Potassium.

Dr. James Begbie in an interesting article (Edinburgh
Medical Journal, December, 1866), states that after some
years' use of the bromide of potassium he has become
satisfied of its great value in the treatment of many
diseases, but more especially in disorders of the nervous
system, affections of centric origin, or of remote parts
through reflex action.

1867] Begbie on Bromide of Potassium. 657

1. He asserts, and this assertion can be confirmed by
all who have employed the bromide of potassium, that it
is a valuable sedative and hypnotic, and it will often
tranquilize when narcotics fail. A dose of from twenty
to thirty grains dissolved in a wineglassful of water, or of
orange-flower water, given at bed-time, repeated in the
morning, and persistently employed for days or weeks,
will often produce tranquillity in the sleeplessness during
convalescence, and after surgical operations.

" 2. In those distressing nervous affections, the offspring
of overtaxed brain, which we are ever and anon called
upon to combat in the case of the earnest student, the
plodding man of business, or the speculating merchant,
cases where, by rising early and sitting up late, neglecting
regular hours of diet, and abandoning exercise in the
open air, the whole machinery of life and health have
been deranged, and the unhappy victims contemplate
nothing short of the wreck of mind and bodv : in these
circumstances, next to rigid hygienic rules imposed by
the physician, and carefully carried out by the patient,
will be found the amelioration and. ultimate removal of
the evil, in the use of remedies which have a calmative
effect upon the nervous system. Of these the bromides,
in my experience, are the safest and the best. * * *
Associated with the cerebral disorder of giddiness and
sleeplessness, we often find perversion of the external
senses, such as rushing, ringing sounds in the ears, etc.
These I have found to be quelled and silenced by the use
of the bromide, which may be successfully administered
in all cases of hyperesthesia."

3. In that distressing nervous disorder brought on by
masturbation, he has repeatedly satisfied himself that the
remedy in question is a trustworthy agent.

4. In various shades of epileptiform disorder, and even
epilepsy itself, resulting from the nervous condition
brought on by the practice just alluded to, Dr. B. states
that the bromides exercise a powerful influence. Dr. B.
has never seen any evil result from its long continuance ;
the system acquires a tolerance of its employment.

5. In acute mania and delirium tremens he considers
that for procuring calmative and sedative effects, the
bromide will be found safer than opium, antimony,
aconite, and digitalis. "I have seen," he states, " in two
recent cases of violent maniacal excitement, a dose of
thirty grains of the bromide of potassium, administered

^61

658 Begbie on Bromide of Potassium. [July

every second hour, reduce to quietness the restless sub-
jects, and lay them down in sleep, of which they had for
day 8 been deprived. I have not much experience of the
remedy in delirium tremens, but I know that it is now
on this trial, and I entertain little doubt that it will be
successful. In one case its use has been followed by
satisfactory results, quickly calming the agitation and
excitement, and inducing sleep. In nymphomania, the
bromides have been employed with marked success, and
Dr. James Struthers informs me that he has obtained
most satisfactory results from the administration in puer-
peral mania. This experience is confirmed by that of
other physicians engaged in obstetric practice. In melan-
cholia, attended with fixed delusions and great restless-
ness, I have found the bromide a powerful calmative. "

6. In several affections of the larynx and bronchi, which
there is reason to believe have a cerebral origin, or, at
least, an intimate connection with the nervous centres, as
hooping-cough, laryngismus stridulus, spasmodic croup,
and spasmodic asthma, he has found the bromides to
possess anaesthetic powers not inferior to any of the nar-
cotics. In spasmodic asthma, Dr. B. has obtained the
most satisfactory results from the employment of the
bromides. " In two cases of long standing, which had
resisted all approved methods of treatment, and where
the patients had renounced all hope of benefit from drugs,
the use of the bromide of potassium in full doses, night
and morning, was followed by a remarkable remission of
the fit the patient in one case having slept for several
consecutive nights without the return of the asthmatic
paroxysm, a circumstance which had not occurred for
years. In the second case the result was equally satis-
ffcetorp."

7. Dr. B. has found the bromide useful in certain cases
of vomiting, and in other affections in which the gangli-
onic nervous system is disturbed.

8. Considering the nervous element present in diabetes,,
and the sedative effects on the nerves of the bromide of
potassium, Dr. B. was induced to hope for beneficial
effects from this salt in that disease, and he briefly relates
four cases in which it had been employed. " These
cases," he remarks, "sufficiently show that there are
forms of diabetes in which the functional derangement
of the liver, and the production of sugar, are arrested by
an agent whose operation is that of a sedative to the

1867] Begbie on Bromide of Potassium, 659

nervous system. It would be premature at the present
moment to speculate on the amount of success that may
attend the exhibition of the remedy in the varying cir-
cumstances in which the disease presents itself."

" 9. The phenomena of cholera, in its earlier stages,"
Dr. B. remarks, " point to its intimate connection with
disorder of the ganglionic system of nerves, with irri-
tation of the nerve-centres and vaso-motor nerves, and
with spasm of the capillary vessels, and obstructed circu-
lation. To arrest this condition as early as possible
seemed a clear indication of treatment ; and the bromide
of potassium, as possessing decided power in allaying
irritation of the nervous system, and of relaxing spasm
of the muscular fibre, was proposed by me as a possible
means of allaying at least some of the more urgent symp-
toms of the disease. It was introduced into practice upon
no empirical ground, and with no expectation that it was
to be found a cure for the disease. The very first trials
of it in the Leith Cholera Hospital were such as to justify
the confident hope that it would be found useful ; and its
subsequent employment there, as well as in the Edinburgh
Cholera Hospital, has not disappointed expectation. In
the two institutions named, the former under the super-
intendence of Mr. Niven, the latter under that of Dr.
Stevenson Smith, and also in private practice, I have had
many opportunities of witnessing its effects, and am now
prepared to say that the bromide of potassium, though
not possessing the properties of an antidote to the poison
of cholera, though not a specific to the'- shock of this
terrible disease, has certainly stript it of some of its
terrors."

10. In the treatment of the nervous element in fever,
we have, Dr. B. says, in the bromide of potassium an
excellent substitute for opium, and antimony, henbane,
camphor, and other sedatives. " A sufferer from quo-
tidian.ague, after large and repeated doses of quinia dur-
ing the interval, had his regular accession of cold,
and hot, and sweating stages unaffected by the specific.
The sweating stage was usually protracted and exhaust-
ing, and at the end of a fortnight no mitigation was
effected. He was advised to take a full dose of the
bromide of potassium every three hours during the re-
mission, and, with one imperfect paroxysm, he got quit
of his malady."

660 Editorial [July

11. In obstinate cases of neuralgia, which have resisted
the usual remedies, "when no palpable or suspected
organic mischief gives rise to the want of success in the
use of well-tried and approved remedies, and wThen no
constitutional diathesis 6tands in the wTay of well-directed
skill to overcome ; in those anomalous forms of neuralgia
let me ask a trial of the bromide of potassium. It will,
now and then, in its own gentle way, reprove the employ-
ment of the more heroic treatment which had anticipated
its use, and demonstrate that a calmative, in such cases,
frequently succeeds better than a counter-irritant."

12. Lastly, Dr. B. has tried the bromide in two cases
of "exophthalmic goitre" with the effect of calming the
system, though without curing the disease.

Dr. B. has used a gargle composed of one ounce of the
bromide of potassium in a pint of water in irritable sore
throat with marked advantage. Am. Jour, of Medical
Sciences , April, 1867.

EDITORIAL AND MISCELLANEOUS.

[The following "Suggestions" having been received too late to be
inserted among the original communications of this issue of our
Journal, vre take the liberty of presenting it to our readers in this
place, in order that it may prove useful to those engaged at this season
in the preservation of medicinal plants. Ed.]

Suggestions on the Preservation of Plants and Vegetable Sub-
stances. By George W. Rains, M.D., Professor of
Chemistry and Pharmacy in the Medical College of
Georgia.

The usual method of preserving plants and flowers for
pharmaceutical purposes, by drying them in hot cham-
bers, and afterwards storing them in boxes or cases of tin
or wood, or in glass or earthen jars, is open to several

1867] Editorial. 661

objections as commonly performed. Too often but a
remnant of the more delicate odors and flavors remain
after the process is completed, and even this is mainly
lo6t after being kept for a few weeks or months.

It is well known that the actinic or photogenic rays
accompanying light have a strong effect in producing
chemical action, and hence many vegetable colors are
speedily injured by exposure to too much light. Thisy
whilst it stimulates and is altogether necessary for the
growth of the plant and formation of its odors and active
principles, produces in many cases the reverse effect after
the vegetable has been deprived of its vital forces. This
is a fact more or less familiar to all, hence it is evidently
necessary to properly preserve vegetable colors and prop-
erties that the plants or substances should be as far as
practicable excluded from light.

To dry flowers and plants in the sun's rays would be
obviously wrong, whilst if dried in the shade, or in a cool
room, there is too much time for chemical action in the
juices, producing a material change of properties in many
cases. ,

A dark hot chamber is certainly better, but in this case
a considerable loss of the more volatile substances is
experienced.

Probably the most perfect drying arrangement is that
used in the chemical laboratory for desiccating com-
pounds which would be injured by heat, viz. : being
placed into glass vessels over dishes of strong sulphuric
acid in a vacuum.

In case an air pump is not at hand, then the plants
might be placed in a close box having the dishes of acid
at the bottom, the whole being kept at blood heat. Quick
lime may be employed in place of the acid, but the latter
is preferable from its stronger absorbing power for watery

6b#2 Editorial [July

vapor, and not being injured by the operation, becoming
only slightly diluted, there is no loss in the process.

After the vegetable substance or plant has been thor-
oughly dried, it should be immediately excluded from
air and light as perfectly as practicable ; to effect this in
the best manner, requires some consideration. By ex-
posure to air not only is there a slow volatilization of the
aroma of essential oils, but also there is a gradual com-
bination with the oxygen of the air to the detriment or
destruction of some of the most valuable properties.

Packing closely the dried substance in a glass vessel or
tin box, would in general answer, if it were left undis-
turbed, but if portions be wanted for use from time to
time, the case must necessarily be opened and an air space
left above the article, which becomes larger and larger as
more is abstracted ; hence the exclusion from air in such
case is a failure.

The packing box or envelope should evidently be of
such a nature or construction as to be able to accommo-
date itself to the decreasing bulk of material as portions
are taken for use, and thus prevent a vacant air space
being left.

I have found an excellent envelope in the common
India rubber cloth, which seems to answer all the require-
ments remarkably well excluding effectually both air
and light, as well as accommodating itself to the decreas-
ing volume of the dried substance as portions are used,
and allowing ready access to the material. Through its
agency I have succeeded in preserving even the very
delicate aroma of parched and ground coffee berries for
several months without material loss, and can strongly
recommend its general employment for such purposes.

1867] Editorial. 6GS

ERRORS IX RELATION TO LIVER COMPLAINTS.

To attribute a great variety of symptoms to affections"
of the liver is one of the commonest errors of the age.
" My liver is out of order," is one of the first announce-
ments made to the physician who asks his patient " what
is the matter ?" The liver is held accountable for head-
aches, pains in the shoulder, sides, back, and limbs ;
dyspepsia, diarrhoea, dysentery, constipation, foul tongue,
coughs, etc., etc. A very sensible lady consulted me the
other day for her child who had an ordinary sore throat,,
and insisted upon being permitted to administer a dose of
calomel, for she knew that the child's " liver was out of
order," and that nothing else would relieve it Upon
being asked how she knew that the liver was out of
order, she promptly replied that she knew it because the
child had a foul tongue and no appetite ! A gentleman
brought me his son, about seven years of age, and stated
that he had called to get me to decide what was the
matter with the boy. He knew that his son either had
worms or that his liver was out of order, for he was puny,
did not rest well at night, and had withal symptoms of
St. Vitus' dance. He had intended to administer a dose
of calomel, " for that is good for the liver as well as for
worms;" but his wife had persuaded him to consult me,
and he, as a dutiful husband, had yielded to her request.
A physician of standing seriously declared to a gentleman
who was prematurely grey, that this was due to the fact
that the liver wras out of order, and that if he would take
a few large doses of calomel his hair would cease to turn
white. The gentleman being in perfect health, and not
overly fond of physic, preferred to remain as he was, and

664 Editorial. . [July

science has accordingly been deprived of the result of so
interesting an experiment !

We might multiply such cases ad infinitum, and perhaps
ad nauseam. But what is the reason of this strange dis-
position to overlook what is patent, and to grope in search
of the occult? Why ignore what is evident, to look for
what is hidden ? Is it because the naked truth is too
simple, and that our vanity is flattered by the idea of
being able to unveil the concealed mysteries of nature ?

With the exception, indeed, of the variations in the
quantity of the biliary secretion, the diseases of the liver
are by no means easily detected. The secretion of bile
is only one of the functions of this organ, and the affec-
tions which do not modify this act, are of difficult diag-
nosis, even to accomplished physicians. It is easier,
therefore, to prefer charges against the liver than to re-
fute them, and this affords a safe refuge for ignorance. It
is not our purpose to deny the existence of hepatic affec-
tions; but to expose the fallacy of attributing other dis-
eases to the liver. Nearly all medical writers believe
hepatic affections to be more common to warm than to
cold climates, and if this opinion were restricted to modi-
fications peculiar to our fevers it would undoubtedly be
correct. But, according to my observation, all the other
forms of liver disease are more common in the Northern
States of this Union, and in London and Paris, than they
are in this latitude. The works on pathological anatomy
are full of illustrations obtained in colder climes, which
we scarcely ever see in this section of country. I saw
more of such affections during my attendance upon the
hospitals of Europe than I have seen in the whole of my
professional career here. L, A. I).

1867] Editorial. 665

The ftrlriciplek and Practice of Obstetrics. By Hugh L. Hodge, M.D.,
Emeritus Professor ot Obstetrics and Diseases of Women and Chil-
dren, in the University of Pennsylvania ; Consulting Physician to
the Philadelphia Dispensary; Fellow of the College of Physicians
of Philadelphia ; Member of the American Philosophical Society,
otc, etc. Illustrated with 150 Lithographic Figures from original
Photographs, and with numerous Wood Cuts. Philadelphia: Henry
C. Lea; 1866.

The Principles and Practice of Obstetrics. By Ccnxixg S. Bedford,
A.M.. M.D., Professor of Obstetrics, the Diseases of Women and
Children, and Clinical Obstetrics, in the University of Xew York ;
Author of " Clinical Lectures on the Diseases of Women and
'Children." Illustrated by four Lithographic Plates and ninety nine
Wood Engravings. Third Edition, carefully Revised and Enlarged.
Xew York: William Wood & Co.; 1866.

Obstetrics; The Science and the Art. By Charles D. Meigs. M.D.,
Lately Professor of Midwifery and the Diseases of Women and
Children in Jefferson Medical College at Philadelphia, and one of
the Physicians to the Lying In Department of the Pennsylvania
Hospital: Member of the Society of Swedish Physicians at Stock-
holm ; Member of the American Philosophical Society, etc., etc.
Fifth Edition, Revised ; with 13d Illustrations. Philadelphia: Henry
C. Lea; 1867.

During the past and present year, the above most val-
uable contributions have been made to obstetric science
and literature.

Professor Hodge's work on -the Principles and Practice
of Obstetrics we believe to be the most complete and
perfect system of midwifery ever published, in the English
or any other language.

Dr. David D. Davis' Obstetric Medicine is a much
larger and more comprehensive book, two large quarto
volumes, comprising dissertations on the diseases of
women and children, as well as midwifery proper. Prof.
Hodge's work is one very large quarto volume, containing
live hundred and fifty double-column pages, confined
strictly to the principles and practice of obstetrics, illus-
trated by numerous plates, splendidly executed.

Of the merits of this work we can not say too much.
It is too extensive for a text-book for medical students,
and indeed for many physicians, in the present impover-
ished state of the South; but it ought to occupy a place
62

666 Editorial. [July

in every public and college library; and we consider it
indispensable to every practitioner who aspires to useful-
. ness or distinction as an obstetrician. It will long endure
as a monument to the genius, talents, and untiring indus-
try of the truly good and able author.

We would gladly furnish a more extended notice of
this comprehensive and excellent work, but it is unneces-
sary; the name of Hugh L. Hodge, North, East, South r
and West, is a sufficient guaranty for the worth of what-
ever may emanate from his pen.

* * * * * *

The high estimation in which Dr. Bedford's work is
held by the profession, is very satisfactorily attested by
the fact that, notwithstanding the numerous good treatises
on midwifery published, or republished in the United
States, during the last decade, this, the third edition, has
been called for, which the author has carefully revised
and corrected.

A strong proof of the good opinion of obstetric teachers
is its adoption as a text-book by nine colleges previous to
the present improved edition.

When received last October, without observing that it
had been adopted by other colleges, after examining its
merits, we cordially recommended it as a text-book to
the class in attendance on the lectures in the Medical
College .of Georgia.

This work is very creditable to the author, evincing
extensive reading, careful study, close observation, and
great practical experience. A most valuable book, both
for students and practitioners.

*******

In April we were very much gratified at receiving, from
the publisher, a copy of the fifth edition of Professor
Meigs' erudite and excellent treatise on the Science and
Art of Obstetrics.

1867] Editorial 667

We were delighted to find our venerable friend, and
former fellow-citizen, though " old and weary with ser-
vice," still warm with zeal in the cause of humanity, and
full of devotion to that noble profession to which he has
always been an honor, and which has ever delighted to
honor him ; when his great age and long labors might
well entitle him to an honorable discharge from service,
and to the enjoyment of sweet repose, blessed as he is,
with all "that which should accompany old age."

" As honor, love, obedience, troops of friends," it is
glorious to behold " the old man eloquent," with indom-
itable energy and untiring industry, by day and by night,
laboring to perfect his benefaction, and render his last
donation to humanity, an offering worthy the illustrious
donor.

The original edition is already so extensively and fa-
vorably known to the profession that no recommendation
is necessary; it is sufficient to say, the present edition is
very much extended, improved, and perfected.

Whilst the great practical talents and unlimited ex-
perience of the author render it a most valuable acquisi-
tion to the practitioner, it is so condensed as to constitute
a most eligible and excellent text-book for the student.

J. A. E.

Practical Dissections. By Richard M. Hodges, M. D., formerly
Demonstrator of Anatomy in the Medical Department of Harvard
University. Second Edition, thoroughly revised. Philadelphia :
Henry C. Lea ; 1867.

We have carefully examined this very neatly bound
volume, and advise its use to students, who will be aided
by it very mucb in their dissections. The author's
reasons for the absence of plates are worthy of conside-
ration. F.

6t>8 Editorial [Jnly

A Treatise on the Principles and Practice of Medicine ; designed for
the use of Practitioners and Students of Medicine. By Austin Flint,
M.D., Professor of the Principles and Practice of Medicine in the
Bellevue Hospital Medical College, and in the Long Island College
Hospital, etc., etc. Second Edition, revised and enlarged. Phila-
delphia : Henry C. Lea, 18G7 ; 8vo. ; pp. 970.

This work has the merit of having heen written by a
practical physician, possessed of more than ordinary
industry and powers of observation. His previous pro-
ductions had already placed him on vantage ground with
the profession in this country, when the first edition of
his Practice of Medicine made its appearance. This
second edition will confirm his dairies to a position with
the foremost as an able teacher and safe practitioner.

L. A. D.

On the Action of Medicines in the System. By Frederick William
Headland, M.D., B.A., F.L.S., Fellow of the Royal College of
Physicians^ etc., etc. Fifth American from the fourth London
Edition. Revised and Enlarged. Philadelphia: Lindsav &l31aki?-
ton, 1867; 8vo., pp. 431. ,..4

This excellent book may now be said to have became'
classical, for it has been firmly established as- the best of
its kind, and is therefore entitled to a place in every
library, after having been careful?*/ read. We can not
recommend it too'highly. L. A. J).

Guide for using Medical Batteries: Being a compendium from his
larger work on Medical Electricity and Nervous Diseases, showing
the most approved apparatus, methods, and rules for the Medical
employment of Electricity in the treatment of Nervous Diseases. By
Alfred C. Garratt, M.D., Fellow of the Massachusetts Medical
Society, and member of the American Medical Association. Phila-
delphia: Lindsay & Blakiston, 1867 ; 8vo., pp. 180.

The use of Electricity in the treatment of diseases is
daily becoming better understood and systematized. Its
beneficial effects, which long remained doubtful, are con-
sequently now generally conceded. This " Guide " will
be found essential to those who may desire to avail them-
selves advantageously of this interesting agent.

L. A. D.

1867] Editorial 669

The Science and Practice of Medicine. By William Aitkex, M.D.,
Edinburgh, Professor of Pathology in the Army Medical School;
Corresponding member of the Royal Imperial Society of Physicians
of Vienna, etc.. etc. ; Formerly Demonstrator of Anatomy in the
University of Glasgow, etc. In 2 vols. From the fourth London
Edition, with additions by Meredith Clymer, M.D., late Professor of
the Institutes and Practice of Medicine in the University of New
York, etc., etc. Vol. II. Philadelphia: Lindsay & Blakiston, I860 ;
royal 8vo., pp. 1,078.

We have had occasion to notice this work upon the
reception of the first volume. The second volume has
just been received, and it affords us pleasure to recom-
mend it to the profession. The additions of Dr. Clymer
to this volume alone exceed 300 pages. The work alto-
gether contains such an extensive expose of practical
medicine that it may he consulted with advantage even
by the most experienced physician. L. A. D.

An Index of Diseases and their Treatment. By Thomas Hawkes
Tanner, M.D., F.L.S., Member of the Royal College of Physician?,
etc. Philadelphia : Lindsay & Blakiston, 18G7 ; royal 8vo., 397 pp.

This is the very counterpart of the large work of Dr.
Aitken and yet it is not without value, if used only as a
remembrancer by one already well versed in his profes-
sion. But if adopted by students as a short road to that
minimum of knowledge required in the "green room," it
can not be otherwise than injurious. L. A. D.

Why Not'/ A Book for Ecery Woman. The Prize Essay to which
the American Medical Association awarded the gold medal for 1865.
By Horat.o Robinson Storer, M.D., of Boston, Surgeon to the
Franciscan Hospital for Women ; Professor of Obstetrics and the
Diseases of Women in the Berkshire Medical College, etc. Issued
for general circulation, by order of the American Medical Associ-
ation, etc. Boston: Lee & Shepard ; 18G7.

The subject of criminal abortions is becoming one of
intense moment, and this small volume, from the pen of
so eminent a medical man, should be accepted as a warn-
ing to all who may be tempted to commit the crime. It
comes adorned with the seal of the American Medical
Association, and the world should receive and endorse it
as a book calculated to do much good. F.

670 Editorial. [July

MEDICAL ASSOCIATION OF GEORGIA.

The note3 furnished us of the proceedings of the recent
meeting of the Medical Association of Georgia, convened
at Griffin, Georgia, were imperfect, and we now renew
the subject, a fuller report having been furnished since
the publication of our last number.

The paper read by Dr. Wm. P. Holt, of Macon, Ga.,"
which is published in this number, elicited an interesting
discussion.

Dr. Fie well en reported a plan, extemporized by him
some years ago, to accomplish forced delivery, which he
thought would generally obviate the necessity for this
unusual and dangerous operation of section of the cervix
uteri.

It was in the case of a lady about seven months ad-
vanced, who, without any other apparent cause than that
of pregnancy, was seized with obstinate and uncon-
trollable vomiting, which persisted for several days, in
spite of all efforts to arrest it, and until it became evident
that she must die without the accomplishment of speedy
premature delivery.

To effect this, a toy balloon of pure india rubber was
procured, a portion of its wall cut away, a flexible cathe-
ter introduced through the aperture, and the india rubber
bag drawn over the end, or laid in plaits as smoothly as
possible the distance of several inches along the catheter,
and tied around it so securely as to prevent the passage
of fluid.

The catheter thus surmounted was passed through the
cervical canal, the cervix resting about midway the bag.
The nozzle of a suitable syringe was then adjusted to the
external open end of the catheter, and cold water grad-
ually forced through it thus expanding the rubber bag
into the form of an hour-glass the constriction repro-

1867] Editorial 671

senting the part within the canal, and the bulbous parts
the expanded extremities of the india rubber sac one
being within the internal, and the other without the ex-
ternal os uteri.

Dilatation and speedy delivery were accomplished with-
out bad results.

Dr. DeS. Ford, of Augusta, mentioned a case of the
kind, where the hypodermic administration of a grain and
a half of sulphate of morphia, introduced at intervals
within three hours, succeeded in dilating the os and per-
mitted forced delivery. The woman was a prima para,
thirty-eight years of age, and was fast sinking, having
been in labor five days. The operation of bilateral
incision of the cervix uteri, he believed, was not 60 dan-
gerous as is generally supposed.

Dr. Powell, of Atlanta, discussed the subject at some
length : stated that the operation, under many circum-
stances, was certainly justifiable; but the necessity for
such interference should be determined by a thorough
knowledge of the symptoms, which indicate that the
labor, if left alone to nature, would jeopardize the safety
of the mother; alluded to many of the circumstances or
obstacles justifying and even requiring the operation.
Unyielding rigidity of the cervix, in a healthy condition,
may require surgical interference ; but generally the knife
will not be required, unless the extensibility of the fibres
has been destroyed by disease, or become undilatable in
consequence of cicatrices. The propriety of the opera-
tion in case reported by Dr. Holt, was clearly proven.
He also stated, that the principle of Dr. Flewellen'6 mode
of producing premature labor was old ; but the plan was
new, practical, and ingenious.

Dr. Thomas, of Savannah, said that the plan suggested
by Dr. Flewellen was of considerable importance to the
profession, in connection with the production of abortion.

672 Editorial [July

He then gave his views at some length on the ease re-
ported by Dr. Holt. He congratulated the Association
on the prospect of a return to its legitimate work the
discussion of scientific subjects connected with the medical
profession.

Dr. W. F. Westmoreland remarked that the case just
reported by Dr. Holt, of Macon, Ga., was one of great
interest; and as there had been, by members, some
doubts expressed as to the propriety of the bilateral sec-
tion of the os uteri, he felt that every member who had
been called to treat cases requiring such mechanical inter-
ference, should give the Association the result of their
experience.

Impressed with this duty, he now proposed to give a
brief report of a case in which, in connection with Drs.
L. II. Orme and J. F. Alexander, he performed the same
operation.

The subject was a prima para, twenty-five years of age.
From Dr. Orme, who had charge of the case for the first
six days of the labor, he obtained the following history of
the case :

On Saturday, the 25th November, 186b\ labor com-
menced, and continued with more or less intensity until
the following Wednesday, when the membranes were
ruptured. There was no dilation of the os up to this
time.

After the " waters " were discharged, the pains in-
creased in intensity until they were almost unendurable.
At no time, notwithstanding the most terrible pains, did
the os dilate to more than the size of a Mexican dollar.

On Friday, the seventh day of the labor, he saw, with
Drs. Orme and Alexander, the case for the first time.
The patient, at that time, was greatly exhausted, a little
delirious, with frequent and feeble pulse; the os was
dilated to the size of a silver dollar, the edges thick and
rigid, presenting a cartilaginous feel.

1867] Editorial,. 673

It resisted every effort at mechanical dilatation. Upon
consultation, it was decided to make a bilateral section of
the os uteri, and deliver with the forceps. He made the
section with a pair of scissors, extending the incisions
from an inch and a half to two inches on either side. It
was not found practicable to deliver with the forceps, and
craniotomy was then resorted to ; and after considerable
difficulty, delivery of a well-formed child was finally
accomplished. The patient did not rally, but continued
to sink; and died in ten hours after the operation.

In this case, as in that reported by Dr. Holt, the woman
would have certainly died with the child in ntero, but for
some mechanical interference.

The choice in such cases is between a section of the os
and Caesarian section.

It was unnecessary to discuss the relative dangers of
the two operations to the mother. He did not regard the
section of the os uteri, under such circumstances, as a
formidable operation. That Dr. J. Marion Sims had
demonstrated that complete section of the neck of the
uterus could be made without inducing any unpleasant
symptoms ; that in sterility, the result of some forms of
mechanical dysmenorrhea his favorite plan of treatment
was the bilateral section of the neck, extending to the
internal os. AVhile he admitted that there would be more
risk in making a section of the gravid than the non-gravid
uterus, still, Dr. Sims' operations upon this organ has
taught us that such operations are not so formidable as
was once supposed.

The fear of wounding the peritoneum should not deter
us, as the portion of the uterus incised corresponds to the
neck in the non-gravid uterus, and has no peritoneal
covering.

He suggested that four or five sections or incisions
would perhaps give more space for the passage of the
63

674 Editorial [July

child's head than the bilateral section ; that in the next
operation of the kind that he was called on to perform,
he should adopt this plan.

Dr. Charters, our worthy President, then yielded the
chair to Dr. T. S. Powell, first Vice President, for the
purpose of giving his views on the subject.

Dr. J. F. Alexander reported a singular case of a citi-
zen of Atlanta, who, upon entering his room, began
combing his whiskers, and thousands of sparks were
emitted and fell to the floor ; and farther, that when he
would grasp a common glass tumbler with his hand, it
would break in pieces.

Dr. A. TV*. Griggs, of West Point, was then conducted
to the stand, and entertained the Association in an able
and eminently creditable manner upon the subject of
electrical forces as connected with intermittent fever.

A Committee was appointed to prepare an Address to
the Public on the true relations of charletans and their
nostrums to legitimate medicine, to report at next meet-
ing. Committee Drs. McDowell, Holt, and Crawford.

A Committee to revise the Constitution of the Medical
Association of the State of Georgia, to report at next
meeting. Committee Drs. W. F. W, Westmoreland,
Griggs, Ray, Banks, and Myers.

A Committee to present a report of the Medical To-
pography of the State, to report at next meeting. Com-
mittee Drs. Griggs, Thomas, Flewellen, Alexander, and
DeS. Ford.

A Committee to report upon the medicinal properties
and uses of the various unofficinal indigenous plants of
the State of Georgia, and other States with which they
may be familiar. Committee Drs. J. G. Westmoreland,
Charters, Crawford, Geddings, and Hammond.

1867] Editorial. 675

STANDING COMMITTEES.

Committee to prepare sketches of the life and character
of those members of the Association who have died since
the meeting of 1861 Drs. DeS. Ford, Banks, and Logan.

Committee to examine Prize Essays Drs. Banks, J. Gr.
Westmoreland, DeS. Ford, Drewry, and O'Keefe.

Committee to memorialize the Legislature on resristra-
tion of births and deaths Drs. Habersham, Westmore-
land, and Word.

The Association offers One Hundred Dollars for three
Essays Fifty Dollars for the first, Thirty Dollars for the
second, and Twenty Dollars for the third or medals,
amounting to the same, as the Essayist may prefer.

We sincerely trust that the members of these Com-
mittees, thus appointed, will become so much interested
in the annual meetings of our Association that they will
prepare full reports, which will undoubtedly prove of
o^reat instruction and value.

Lithotomy in a Female. By John Stone, M.D., of Linton, Ga.

We have received from Dr. Stone a letter in which he
gives us an account of an interesting operation for the
removal of a large calculus from a woman, by means of
an iucision of the urethra and the use of a pair of
ordinary bullet forceps. We regret that lack of room
.prevents us from giving the details in full. [Ed.

676 Miscellaneous. [July

Pathology of Cerebral Softening.

Two Parisian hospital internes, MM. Prevost and Cotard,
have diligently availed themselves of the opportunities
afforded them during their residence at the Salpetriere,
of studying the pathology of cerebral softening. In
addition to noticing the appearances presented in the
brains of persons dying with softening of the brain, they
have, by the advice of M. Vulpian, produced artificially
in animals some of the symptoms attending this morbid
condition. Their researches, and the conclusions derived
therefrom, were last year communicated to the Societe
de Biologie, and have appeared in various numbers of the
Gazette Medicate de Paris for the present year. Their
object, the}7 state, has been to determine the true relation
of obstruction of the blood-vessels to cerebral softening.
No one, they say, denies in the present day, the part
which obliteration of the vessels plays in the production
of softening of the brain ; but are all cases of softening
to be attributed to this cause ? Having related and com-
mented on a number of experiments and post mortem
examinations, and given a general summary of the results,
MM. Prevost and Cotard remark, that they have not
studied every point in the history of cerebral softening.
This was not their intention ; their purpose has been to
offer some new considerations, and to elucidate some still
obscure points. They have taken no notice of the various
kinds of inflammatory softening. The following are the
principal conclusions at which they have arrived.

Experiments on animals (consisting in the injection into
the vessels of lycopodium or snuff) has enabled them, by
means of these artificial emboli, to produce softening
identical with that which is observed in man, and to
follow its progress through various stages. In this way
they have been able to study the hyperemia which is first
produced, and necrobiotic degeneration which follows,
and, finally, the production of connective tissue and the*
formation of yellow patches which belong to the third
period of softening. Analogous experiments have already
been made by MM. Virchow, Cohn, Panum, etc. ; but the
procedures employed by them have produced death too
rapidly to allow them to study softening in its different
phases. Prom their experiments, MM. Prevost and
Cotard have ascertained that ordinarily a distinct conges-

1867] Miscellaneous. 677

tion is produced at the points where the obstructed artery
is distributed. The cause of this hyperemia it is difficult
to determine at present ; but, whatever may be its me-
chanical cause, the hyperemia of red softening must be
considered as of an entirely different nature. As early as
the third day, there are present well-defined granular
bodies, and a large number of fatty granulations not yet
agglomerated; these are collected around the capillaries,
forming, as it were, a sheath to these vessels. In some
instances, the walls of the capillaries have presented
consecutive granular and fatty degeneration ; and, in one
case, dissecting aneurisms were formed. In a dog which
survived the experiment fifteen days, a true yellow patch
was found in the cerebral convolutions.

The study of cases at the Salpetriere, in which cerebral
softening has been found after death, has led the authors
to consider the process very analogous to that which they
have artificially induced in animals. The necrobiotic
process has appeared to them almost always to depend on
arrest of the cerebral circulation, varying in origin; and
they have observed a certain relation between the various
forms of disturbance and the characters of the softening.
The disturbance of the circulation sometimes arose from
obstruction of any artery by a thrombus or embolus;
sometimes from atheromatous degeneration of the cere-
bral arteries;- sometimes, perhaps, from more or less
general capillary embolism. In two cases, no cause could
be ascertained; but perhaps the arterial obstruction
escaped notice. Xone of their observation's have led
them to infer with certainty that softening has been due
to atheromatous degeneration of the capillaries : this
degeneration may be consecutive.

Phenomena of irritation are sometimes added to the
process which essentially constitutes softening. In some
instances, inflammation and suppuration took place around
the infarctus formed in dogs ; and the authors endeavor
to trace a relation between these phenomena and the pro-
duction of false membranes on the dura mater at the level
of old foci of softening.

In speaking of the symptoms, they point out that the
attacks of vertigo and the apoplectiform paroxysms fol-
lowed by rapid death without lesion of the nervous cen-
tres, which most authors have ascribed to congestion, are
due to impeded cerebral circulation. They endeavor to
establish a direct relation between the intensity of the

678 Miscellaneous. [July

attack and the extent of the interference with the supply
of blood ; and they show that both thrombosis and em-
bolia may give rise to sudden death. Regarding paralysis,
spasm, and other symptoms of softening, they have but
little to add to what has already been said by other
authors. The paralysis, they find, most frequently sets in
suddenly, and rarely follows a progressive course; hence
no diagnostic value can be attached to this symptom.
Examination of the temperature of the rectum in some
instances, and the information on this point which the
authors have derived from M. Charcot, leads them to
conclude that the temperature of the body is not essen-
tially raised during cerebral softening ; and hence that, if
inflammation have any share in the process, it must be
altogether secondary. It would, they observe, be inter-
esting to make a similar series of observations in cases of
inflammatory softening. Am. Jour. Med. Sciences, April,
1867, from Gaz. Med. de Paris, July 14, 1866.

Apoplexy of the Medulla.

M. Levier, after describing a case of apoplexy in the
lumbar region, comments on the cases of medullary
apoplexy hitherto reported. In the medulla oblongata,
there have been nine cases, four only being pure ; the
results were, loss of consciousness, involuntary epilepti-
form movements, and sudden death. Of apoplexy in the
spinal cord there were seventeen cases ; in two thirds of
these, the lesion was in the upper part of the medulla.
The attack was rarely sudden ; it was generally preceded
for a week or a fortnight by pain in the spinal cord and
symptoms of congestion. The first symptom is paralysis,
which often occurs during sleep, and affects the sphinc-
ters; its progress is rapid, and it is not accompanied by
contractions of the limbs; its extent depends on the seat
of the apoplexy. Reflex excitability is destroyed. There
are ordinarily greatly impeded respiration, feeble cough,
difficulty in expectoration, aphonia, and impairment of
speech. Paralysis of sensation generally follows that of
motion; sometimes there is hyperesthesia ; the spine is
not tender on pressure. Both sides, or one only,. may be
paralyzed ; in three instances of the latter which occurred,
there was paralysis of sensation on the opposite side.
There is elevation of temperature in the paralyzed parts.

1867] Miscellaneous. 679

The duration of the disease varies from a few hours to
some months. The diagnosis may he difficult. In
meningeal apoplexy, there are convulsions ; the paralysis
of motion is less complete; moreover, it is generally
secondary, occurring in the course of tetanic or convul-
sive affections. Congestion of the medulla is distin-
guished by the short duration of the paralysis, the
slightness of the symptoms, and the rapid return of
health. Ibid.

Treatment of Diseases of the Heart.

Dr. S. 0. Habershon, in an interesting paper in the late
volume of Guy's Hospital Reports, lays down seven prin-
ciples of treatment in all cases of heart disease.

The first is, as far as possible, to lessen its work ; and
this may, to some extent, be effected by mechanical rest,
by a recumbent position, and by the avoidance of sudden
changes of temperature.

The second is to insure regularity of action, by avoiding
mental excitement, by guarding against indigestion, and
by never allowing constipation to continue.

The third is to lessen distension, especially of the right
side of the heart, by purgatives, diuretics, and by me-
chanically diminishing the quantity of fluid in circulation.

The fourth is the prevention of syncope. With this
view, sudden muscular movements must be avoided ;
stimulants may be required, as ammonia, brandy, etc. ;
and sedatives must be withheld or cautiously adminis-
tered.

The fifth is to strengthen -the muscular fibres of the
heart, by suitable nourishment, a bracing air, if other
conditions allow ; chalybeate medicines, and if the patient
be exhausted by want of sleep, this symptom must, if
possible, be relieved.

The sixth is to prevent fibrillation of the blood. For
this purpose carbonate of ammonia will often be useful ;
other alkalies, as potash, soda, and their salts may be
beneficial, but, if long-continued in considerable doses,
Dr. H. says, they depress the action of the heart. The
acetate and' iodide of potash may be advantageously
combined with the carbonate of ammonia, or perhaps the
hydrochlorate of ammonia.

680 Miscellaneous. [July

The seventh is to prevent secondary complications, and
to relieve them when produced. These complications are
1st, broncho-pneumonia and pleuritic effusion; 2d,
pulmonary apoplexy and other hemorrhages; 3d, visceral
engorgement, as hepatic and- renal congestions, with
ascites and anasarca. By freely acting on the bowels, the
portal congestion is greatly diminished, and the liver is
enabled to act in a normal manner. Thus a free mercu-
rial purge is of great value. The kidneys may be excited
to a more vigorous action by a combination of mercurial
medicine with squill and with digitalis, when the latter
can be borne. Salivation should be avoided. Diuretics
are useful. An effectual way of diminishing the anasarca
is by puncturing the skin on the thighs. The pulmonary
engorgement is sometimes greatly reduced by applying
cupping-glasses between the shoulders, or by the applica-
tion of a blister to the chest. Ibid.

Etiology of Eczema.

Dr. Frank Smith, of Sheffield, has recently made some
very important observations in reference to the etiology
of. eczema in its' relation to some disorder of the renal
function, as shown by the presence of indican in the
urine. In nine out of ten cases Dr. Smith lias detected
indican in pathological quantities. Indican is supposed
to be due to a retardation of the process of declension
from the complex to the more simple of the products of
function and secretion. Its own highly complex formula
is a strong evidence in favor of this opinion, in addition
to the ease with which it is broken up into leucine, indigo,
and glucine. Dr. Smith suggests that this retardation is
due to accumulation of urea and other products of waste
in the blood, owing to deficient renal secretion; for he
has detected urea in considerable amount in the serum of
eczematous patients. Indican occurs in the urine in the
reaction stage of cholera and in Bright's disease. The
spectrum of the solution prepared from the urine for the
detection of indican is the same as that of common
indigo. These observations are exceedingly important
and suggestive. Am. Jour. Med. Sciences, April, 1867,
from Lancet, Feb. 2, 1867.

18G7] Miscellaneous. 681

Importance of Preservation of the Periosteum in many
Operations.

Dr. William Stokes, Jr., Surgeon to the Meath Hos-
pital, Dublin, in his introductory lecture, remarked :

" M. Oilier, of Lyons, as I mentioned previously, has
directed especial attention to the importance of periosteal
preservation and transplantation in many operations. In
three cases he has removed large portions of the diaphyses
of the long bones with favorable results. In his other
cases an epiphysis of the bone had to be removed. One
of these I had an opportunity of seeing, in which the
upper half of the humerus was removed, with complete
restoration of bone. From his experiments, therefore,
and clinical experiences, as well as from those of some
others who are deeply interested in this subject, and from
the cases of Dr. Moon and Professor Langenbeck, the
following propositions may be stated :

1. That in sub-periosteal resections the reproduction of
bone is more complete and effected with greater rapidity
than after total removal of both bone and periosteum.

2. That the osseous reproductive properties of the
membrane vary according as it is taken from the long
or the short bones, being greater in the former than in
the latter (Oilier).

3. That the normal form of the joint is better preserved
when this precaution of leaving the periosteal covering is
taken.

4. That the sub-periosteal resections involve less danger
than when conducted on the old principle. This propo-
sition is grounded on the result of experiments on the
lower animals, the number of unfavorable results which
followed when the membrane was removed being much
greater than when it was left.

5. That the difficulties attending the separation of the
membrane in the dead subject are not to deter us trom
attempting the operation on the living, inasmuch as the
membrane is less adherent in the latter, and also in the
diseased than on the healthy bone.

6. That resections performed in this manner are more
conservative, inasmuch as re-formation of the part re-
moved is effected, and, being attended with less risk to
life than the ordinary resections, a greater quantity of
bone can be removed, and in this way in a number of

64

682 Miscellaneous. [July

oases the necessity for amputation is diminished. The
cases I have alluded to of Dr. Moon in America, and
Professor Langenbeck are illustrative of the truth of
this.

7. That the chances of much shortening of the limb
are diminished by this method, as shown by the results
of the ankle-joint resections during the late Schleswig-
Hol stein war.

8. That in addition to 'these the modified Rhino and
Urano-plastic operations demonstrate that the happiest
results have been obtained by this application of experi-
mental physiology to practical operative surgery." Am.
Jour. Med. jScienees, April, 18(17, from Med. Press and Cir-
cular, Dec. 12, 1866.

Diabetic Gangrea i .

M. Verneuil lately brought under the notice of the
Surgical Society of Paris the subject of gangrene oc-
curring in diabetic patients, of which he had met with
six instances in the course of three months. In the first
case, he was called to perform amputation in a person
affected with gangrene of the foot and lower part of the
leg. On inquiry, he found the patient diabetic. The
man, a seller of wine, had been of somewhat intemperate
habits. The gangrene was said to have originated in the
pressure of the shoe on the little toe, and to have been
soon followed by the appearance of other gangrenous
spots on the foot and leg. The man ultimately died; Mi
Verneuil having abstained judiciously from any surgical
interference.

In the second case, that of a man aged fifty, the patient
had for some time had bunions, one of which became
ulcerated. As the sore observed no tendency to heal, M.
Verneuil examined the urine-, and found sugar. The
patient ultimately died, worn out with profuse diarrhoea,
marasmus, and low delirium.

In the third case, ;i patient in the Laribosiere Hospital
had an ulcer of the heel, of the size of a linger, with
sharply-defined edges, and (edema of the leg. The heart
and liver appeared healthy; but the urine contained both
sugar and albumen, This patient also died: but nothing
in the kidneys could be found that was capable of ac-
counting for the albumen.

1867] Miscellaneous. 683

The fourth case was that of an ecclesiastic of high
rank, about sixty-six years old. He had diabetes, with
gangrene of the little toe, several eschars on the great
toe, and dorsum of the foot, and an extensive carbuncular
phlegmon on the sole.

In the fifth case, that of a lady, there was a carbuncle
on the back. Incisions made into this producing no im-
provement, M. Verneuil examined the urine and found it
diabetic.

In the sixth case, that of a man aged fifty -five, paralytic
and subject to intermittent fever, there was a gangrenous
eschar in the groin, with offensive discharge. This
patient, alone of the six, so far improved under an alka-
line treatment as to recover; in the other five, death
occurred in a few days or weeks after the appearance of
the local disease. Such cases as those related, M. Ver-
neuil observes, point to the advisability of examining the
urine before operating in cases of gangrene of the lower
limbs. Am. Jour. Medical Sciences, Aj>ril, 1867, from
IS Union Medical, Dec. 1, 1866.

On "Glyconinc" a netc (il/jcerole.

To obtain this compound, M. Edniond Sichel employs
four parts (by weight) of yolk of egg, and five parts of
glycerin, which he mixes simply in a mortar. It has the
consistence of liquid honey, and is unctuous like the
fatty substances, over which it has the advantage of being
easily removed by water. It is unalterable, a specimen
having been left exposed to the air for three years with
impunit}^. Applied to the skin, it forms on the surface a
varnish, which protects it from the contact of the air.
These properties render it serviceable for broken surfaces
of all kinds, particularly for burns, erysipelas, and cuta-
neous affections, in which it soothes the itching, and also
for sore nipples; its harmlessness prevents, in the latter
case, any interruption of suckling. Boston Medical and
Surgical Journal, March 21, 1867,' from the bulletin (ft
Therapeutique.

684 Miscellaneous. [July

Syphilis Extensively Projxiffated by Vaccination, in Fra/n-c

In the western department of France (Morbihan) some
villages have been the theatre of severe syphilitic symp-
toms upon more than thirty children, who had all been
vaccinated from a little girl with six punctures on each
arm, the child herself having been operated upon from
another who had been vaccinated from lymph preserved
between two plates of glass obtained from the authorities.
This misfortune created so much sensation that the
Academy of Medicine of Paris sent down the Commis-
sioners, Messrs. Henry Roger and Depaul. These gentle-
men have just presented their report to the Academy,
and this important document ends with the following
considerations : 1. Several of the children we examined
were undoubtedly suffering from secondary syphilis. 2.
We see no way of explaining this contamination but by
vaccination ; and we are confident that the cases we have
seen were really syphilis engendered by vaccination. 3.
As to the origin of the virus, it is very probable that the
poison is traceable to the lymph, preserved between two
pieces of glass, supplied by the authorities. As primary
symptoms were also observed among the children, Mr.
Ricord begged the commissioners to insert that fact in
their report, which these gentlemen agreed to do. Here
we unfortunately have again repeated the sad occurrences
which took place at Rivalta, Italy, a short time ago.
Lancet

Cholera and Contagion.

In noticing a pamphlet of Dr. E. Ilearne, of South-
ampton, on the non-contagious nature of cholera, the
editor of the Brit. Med. Jour, quotes the following:

"M. Grimand relates that during the late epidemic at
Marseilles, there were employed at the post-office twenty-
two persons in the bureau for dispatching, and nine in the
bureau for receiving letters. Amongst the former there
was no sickness at all, whilst amongst the latter there
were eight persons sick, and one death. He whose
business it was to open letters from the east was attacked
with cholera; four others engaged in the same business
were attacked one alter the other." Med. and Surgical
Importer, Dec. 29, 1866.

1867] Miscellaneous. 685

Ingrowing Toe-Nail.

At a meeting of the Norfolk (Mass.) District Medical
Society, the President, Dr. Cotting, as per report in the
Boston Medical Journal, alluded to his method of opera-
tion for the relief of ingrowing toe-nail. He had never
found it necessaiy to remove the nail, and in one of the
cases recent!}' operated on, the nail had been removed
some years before without any good effect, His method
is to remove a portion of the sound, as well as diseased
flesh, from the side of the toe, say three quarters of an
inch long, half an inch wide, and as thich as the member
will admit of. Two cases, so operated on since the last
meeting, succeeded perfectly. Dr. Stedman stated that
he had recently performed the operation with complete
success. Med. and Surg. Reporter, Jan. 12, 1867.

Croup Treated by Sulphur.

The Brit. Med. Jour., quoting from the Gaz. Med. de
Paris, states that M. Laganterie, from observing the effect
of sulphur on the oidium of vines, has been led to ad-
minister it in several cases of croup. He mixes a tea-
spoonful in a glass of water, and gives the mixture in
teaspoonful doses every hour ; the effect he describes as
wonderful. The disease is, in effect, cured in two days,
the only symptom remaining being a cough, arising from
the presence of loose pieces of false membrane in the
trachea. Mr. L. says that he has followed this plan in
seven cases, all being severe, especially the last, in which
the child was cyanotic, with protruded rolling eyes, and
noisy respiration. Med. and Surg. Beporier, Feb. 23, 1867.

Potent Disinfectant.

The Dublin Medical Press states that Dr. DeWar, Kir-
caldy, has discovered that "for the disinfection of inani-
mate material, the addition of a little nitre to sulphur,
and the combination of these fumes with the steam of
boiling water, improvises a disinfectant at once the most
powerful, most searching, and most efficacious that can
be obtained, utterly destructive at once of any latent
contagion, and of every form of insect life." Med. and
Surg. Reporter, March 9, 1867.

(38G Faculty of the Medical College. [July, 1807

" Patent Deodar Vessel.''

We have received, from the Trenton Pottery Company,
a specimen- of- a new chamber-vessel, with a hollow lid,
intended to* hold a liquid disinfectant, which is exposed
when the vessel is used, for the purpose of neutralizing
the foul emanations. The idea is an excellent one, and
will be found to be very useful in practice. A recipe for
an excellent disinfectant accompanies the vessel. We
understand that the Company will immediately put these
vessels on the market. Med. and Sure/. Reporter, Jan.
12, 1867.

Napoleon having been informed that every pro-
fession but that of medicine was represented in the
French senate, determined that this anomaly should no
longer exist, and accordingly promoted his physician, Dr.
Conneau, to a seat in the Luxembourg. Med. and Surg.
Reporter, Jan. 12, 1867.

FACULTY OF THE MEDICAL COLLEGE OF CEORCIA, AT AUGUSTA.

I. P. GARVIN, M.D.,

Emeritus Professor of Materia Medica, etc.

L. D. FORD, M.D.,
Professor of the Theory and Practice of Medicine.

JOSEPH A. EVE, MP.,
Professor of Obstetrics and the Diseases of Women and Infants,

L. A. DUGAS, M.D.,
Professor of the Principles and Practice of Surgery.

H. F. CAMPBELL, M.D.,
Professor of Operative Surgery and Surgical Anatomy.

G. W. RAINS, M.D,

Professor of Chemistry and Pharmacy.

EDWARD GEDDINGS, M.D..
Professor of Physiology and Pathological Anatomy.

DeSAUSSURE FORD, M.D,
Professor of Anatomy, general and descriptivp.

WM. II. DOUGHTY, M.D,
Professor of Materia Medica, Therapeutics, and Medical Jurisprudence.

JOHN S. COLEMAN, M.D,

Demonstrator of Anatomy.

& ilo IDWC^ilQa Dean.

INDEX TO VOL. XXI

Page

Acute Disease, temperature in 586

Aitken's Practice 669

American Medical Association 602

Amputation, statistics of. 134

Anatomical subjects, injections, etc. 521

Anatomical Controversy 72

Apoplexy of medulla 678

Axillary artery, ligation of 560

Bailey, A. W., on knee joint resec-
tion 460

Baxley, J.B., on ligation of axillary. 560

Bedford's obstetrics 665

Bibliographical notices 352

Bromide of potass, action of 642

Bromide of potass, effects of 656

Brown, J. P. II., ou protoxide of

nitrogen 557

Brown, J. P. H., on diseased teeth..299

Bullet probe 444

Bullets, searching for 493

Cancer, statistics of. 635.

Caustic 445

Cerebral softening ...676

Children, power to bear disease 510

Chloroform, death Irom 517

Cholera and eontagion 684

Cholera, contagiousness of 346

Cholera 146, 159, 357, 365, 561

Conf. States Army, statistics of 127

Congenital marks 317

Colic in babies 506

Con-ervative medicine . 428

Croup, treatment by insufflation ...486
Croup treated by sulphur 683

Daniels, W. C, on rice culture 151

Daniels, \V. C, on introduction of

shad 158

Death, sudden in Dentist's chair. ..519

Diabetic gangrene 682

Diagnosis, thermometer in 469

Diarrhoea, mercury in 561

Disarticulations, statistics of 134

Disinfectants, how to use thorn 305

Disinfection, process oi 182

Disinectant, potent 685

Doughty, \V. H., on ligation ol

subclavian 30

Doughty, W. H., on physical geo-
graphy of ocean 369

Doughty, W. 11., on medieal sta-
tistics of C. S. ho-pitals 4 19

Page

Deodor vessel 686

Dugas, L. A., on suppuration 36

Dugas, L. A., on congenital marks..317
Dugas, L. A., on fracture of os

femoris 395

Dugas, L. A., conservative medi-
cine 428

Dugas, L. A., on surgical pocket

case 461

Dugas, L. A., crying babies 50 fi

Du^as, L. A., jolting infants 509

Duuas, L. A., diseases in children. .510

Dugas, L. A., infantile fevers 593

Dugas, L. A., liver complaints,

errors about 663

Dysmenorrhcea, incision and dila-
tation in 570

Dysentery, mercury in 561

Ear, mode of examination of. 644

Eclampsia, persistent, etc 619

Eczema, etiology of. 680

Editorial 164, 428, 500, 593, 660

Epithelial structures 529

Epilepsy, bromide of potassium in. .465
Erysipelas, iodide of potassium in. .465

Faculty Med. Col. of Ga 6S6

Femur, fracture of

135, 141, 148, 395, 397, 609

Femoral aneurism, treatment of 630

Fevers, treatise on 419

Flint's practice of medicine 66S

Ford, DeS., on femoral aneurism. ..630
Ford, Da*., on fracture of 08 fe-
moris 397

Ford, DeS., on gunshot wound of

spinal cord 286

Fungi, action of. 399

Galvanism, in treatment of ulcers. .640

Garratt's guide for batteries 60S

(je<!dmgs, Edward, on epithelial^

structures 629

Georgia Medical Association 603

Glyconine 683

(J un shot wounds 129, 520

Gunshot wounds, ligation of arte-
ries in 137

Habersham, S. E., on spurious vac-
cination 1

Habersham, S. E., on wounds ol
knee -joint 328

Index to Volume XXL

[July

Page
Hamilton, F., on military surgery.. 88

Headland, action of medicines 668

Heart, gunshot wound of 520

Heart, disease of 679

Herpes circinatus 655

Hodge's obstetrics 665

Hodgea'b practical du-section!- 667

Holt, W. J., on treatment of frac-
tures of femur 609

Holt,W. P., on persistent eclampsia 619

Hospital gangrene 55

Humerus, dislocation and reduction

of 524

Hygienic experience in JSTew Or 77

Hypodermic injections 492

Infants, new-born, dressing of 4i>0

Infants, new-born, jolting of 509

Infantile levers 593

Infeeundity, monthly period of, 576

Ingrowing toe-nail 6S5

Insanity, treatment of. 57S

Joints, wounds of 11, 185

Jones, Joseph, on pneumonia 220

Jones, Joseph, on hospital gang.... 55

Kidneys, sign in diseases of 526

Knee-joint, amputation at 581

Knee-joint, penetrating wound of..32S
Knee-joint, resection of 292, 460

Legal status of profession in Ga...456
Liver complaints, errors in relation. 663

Malaria and epidemical diseases. ..305

Malaria at Fort Gibson 343

Malignant tnmors, removal of 483

Maughs, on fracture of femur 141

Med. Association of Ga...35l, 500, 670
Medical Society of Augusta, G.1....29S
Medical College of Gcorgia..,.18l, 527
Medical statistics of C. S. hospitals

449, 496

Medical profession, obligations to. .623

Meigs' obstetrics 665

Mercury in cholera, dysentery, etc.561

Military surgery 88, 608

Monster 515

Navel, bleeding at 441

Necrological notices 360

Nerves, restraining system of. 631

Night blindness in Confed. ar:ii3'...471

Nitrato of silver in croup 4S6

North Pacitic ocean, geography of..369

Opium poisoning, treatment of 647

Organic remains 526

Oxygen, uses of. 590

Paste to adhere to any substance. ..499
Patella, fracture of and treatment.. I 12
Peritoneal friction sounds 592

Page

Periosteum, preservation of. 6SI

Petroleum, operation in Alabama...l59

Petroleum in scabies 5S9

Physician in French Senate 686

Plants, preservation of. 660

Pneumonia, treatment of. 220

Porcher, P., suggestions to Medical

Department 24S

Potassium, bromide of on nervous

system 443, 642, 6-56

Potassium, bromide of in epilepsy. .465
Potassium, iodide of in erysipelas. .526

Poultices, use and abuse of. 513

Prognosis, thermometer in 469

Rains, G. W., on malaria, etc 305

Rains, G. W., on preservation of

plants, etc 660

Rains, G. J., on malaria at Fort

Gibson 343

Read, J. B..on wounds of large jis..185

Rice, culture of 151

Resection, statistics of. 134

Resection, at knee-joint 292,460

Scabies, treatment of. 589

Sexes, production of at will 476

Shad, in Southern waters 158

Shoulder-joint, dislocation of 480

Simpson, on injuries to spleen, etc.. 590

Skin disease, newly discovered 650

Soda, hyposul. in malarial fever.. ..444

Solvent 525

Sorrel, on gunshot wounds, 129

Spinal cord, gunshot wound of ?85

Spleen, injuries to 590

Stone, on lithotomy 675

Storer's "Why Not" 669

Strychnia, poisoning by 519

Subclavian artery, ligation of ... 30

Sulphur in croup 685

Suppuration 36

Surgical pocket case 461

Syphilis, non-mercurial treat, of.. ..495
Syphilis from vaccination 684

Tanner's index of diseases 669

Temperature in acute diseases 586

Teeth, diseases of 299

Thermometer, in diagnosis and

prognosis 469

Trichinia and trichinosis 5S4

Tubercle, inoculability of. 518

Vaccination, spurious 1, 165

Vaccine from Cow 180

Vegetables, preservation of. 660

War Dep't U.S. A. Circular, No.4..100
Word, R. C, obligations of public. 62:?

Works received 184, 368, 446,607

Wounds, absorption of. 517

Zinc, sulphate of in hydrocele 444

33

,

Date Due

ftPR 9 H

LIBRARY BUREAU FORM 1137.3

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Southern Medical and Surgical Journal
N. S. 21 - 1867