Property of the
Lancaster City and County Medical Society
No
p
HS3
THE
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES,
EDITED BY
ISAAC HAYS, M.D.,
FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA ; MEMBER OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; AND OF THE AMERICAN PHILOSOPHICAL SOCIETY \ ASSOCIATE FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES, &C. &C. &C.
ASSISTED BY
I. MINIS HAYS, M. D.
NEW SEEIES. YOL. LX.
PHILADELPHIA:
HENRY C. LEA. 1870.
69486
Entered according to tlie Act of Congress, in the year 1870, by HENRY C. LEA,
in the Office of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania.
PHILADELPHIA : COLLINS, PRINTER.
TO READERS AND CORRESPONDENTS.
All articles intended for the Original Department of this Journal must be contributed to it exclusively. The insertion elsewhere of abstracts of papers read before societies prior to the publication of the entire paper in this Journal is a violation of this rule. As original articles are accepted only on this con- dition, we consider those who favour us with contributions to be bound in honour to conform to it.
Contributors who wish their articles to appear in the next number, should forward them before the 1st of August.
Compensation is allowed for original articles and reviews, except when illus- trations or extra copies are desired. A limited number of extra copies will be furnished to authors, provided the request for them be made at the time the communication is sent to the Editors.
Communications postponed for want of room shall receive early attention.
The following works have been received : —
Studien aus dem Institute fur Experimentelle Pathologie in Wien aus dem Jahre 1869. Herausgegeben von S. Stricker; 1. Mit 4 Holzschnitten ; und 2 Tafeln. Wien. Wilhelm Braumiiller, 1870.
Die Epidemische Diphtheritis und deren Schnellste Heilung; Nach Klinischen beo- bachtungen bearbeitet. Von Dr. Alban Lutz, Prakt. Arzt. in Munchen, Wurzburg : Stahel'schen Buck- und Kunsthandlung, 1870.
Essai sur les Maladies du Cceur chez les Enfants. Par le Dr. H. Rene Blache, Ancien Interne en Medecine et en Chirurgie des Hopitaux de Paris, etc. Paris: P. Asselin, 1869.
Dictionnaire Annuel des Progres des Sciences et Institutions Medicales. Par M. P. Garnier. Precede d'une Introduction par M. le Docteur Amedee Latour. Sixieine Annee, 1869. Paris: Germer Bailliere, 1870.
Transactions of the Obstetrical Society of London. Vol. XI. For the year 1869. London: Longmans, Green & Co., 1870.
Lectures on Surgical Patbology delivered at the Royal College of Surgeons of England. By James Paget, F. R. S., D.C.L. Oxon., Sergeant-Surgeon Extraordinary to Her Majesty the Queen, Surgeon to St. Bartholomew's Hospital, etc. Third edi- tion. Revised and edited by William Turner, M. B , London, Prof, of Anatomy in the University of Edinburgh. London: Longmans, Green & Co., 1870.
Chloroform versus Pain and Paracentesis of the Bladder above the Pubes. By the late J. H. James, F. R. C. S., etc. etc. London: John Churchill & Sons, 1870.
Prolapsus, Fistula in Ano, and other Diseases of the Rectum; their Pathology and Treatment. By T. J. Ashton, Consult. Surg, to the Marylebone Infirmary, etc. Third edition. London: John Churchill & Sons, 1870.
Lectures on some Subjects connected with Practical Pathology and Surgery. By Henry Lee, F. R. C. S., Surgeon to St. George's Hospital, etc. etc. In two volumes. Third edition. London: John Churchill & Sons, 1870.
On Hernial and other Tumours of the Groin and its neighbourhood; with Practical Remarks on the Radical Cure of Ruptures. By Carsten Holthodse, F. R. C. S., Surgeon to the Westminster Hospital, and Lecturer on Surgery at its Medical School, etc. etc. London: John Churchill & Sons, 1870.
Observations on Therapeutics and Disease. By Donald Campbell Black, M. D., F. R.C S., Edinburgh. London: John Churchill & Sons, 1870.
On the Law which Regulates the Relative Magnitude of the Areas of the four Orifices of the Heart. By Herbert Davies, M. D., F. R. C. P., Senior Phys. to and Lect. upon Theory, and Pract. of Med. at the London Hospital. London: 1870.
On Extraction of Cataract by Von Graefe's Peripheral Linear Section. By Henry Wilson, F. R. C. S., Assistant Surgeon to St. Mark's Ophthalmic Hospital, etc. etc. Dublin, 1870.
A Medical Report of the Yokohama Lock Hospital for 1869. By George Newton, Surgeon R. N. Yokohama, 1870.
s
TO READERS AND CORRESPONDENTS.
The Indigestions; or Diseases of tbe Digestive Organs Functionally Treated. By Thomas King Chambers, Hon. Phys. to His Royal Highness the Prince of Wales; Senior Consult. Phys. and Lect. on the Practice of Medicine at St. Mary's Hospital, etc. etc. Third American edition; revised. Philadelphia: Henry C. Lea, 1870.
Anatomy, Descriptive and Surgical. By Henry Gray, F. R. S., F. R. C. P., and Lecturer on Anatomy at St. George's Hospital Medical School; the drawings by H. V. Carter, Late Demonstrator of Anatomy at St. George's Hospital. With addi- tional drawings in the second and later editions by Dr. Westmacott; the dissections jointly by the author and Dr. Carter; with an introduction on general anatomy and development, by T. Holmes. M. A., Cantab., Surg, to St. George's Hospital, etc. etc. A new American, from the fifth and enlarged English edition, with 462 engravings on wood. Philadelphia: Henry C Lea, 1870.
Renal Diseases; a Clinical Guide to their Diagnosis and Treatment. By W. R. Basham, M. D., F. R. C. P., Senior Physician to Westminster Hospital, etc. Phila- delphia: Henry 0. Lea, 1870.
Obstetric Operations, including the treatment of Hemorrhage. By Robert Barnes, M. D., London, F. R. C. P., Obstet. Phys. to, and Lecturer on Midwifery and Diseases of Women and Children at, St Thomas' Hospital, etc. etc. With additions by Ben- jamin F. Dawson, M. D., late Lecturer on Uterine Pathology in Med. Dept. of the Univ. of New York, etc. etc. New York: D. Appleton & Co., 1870.
Surgical Memoirs of the War of the Rebellion. Collected and published by the United States Sanitary Commission. Edited by Prof. Frank Hastings Hamilton. New York : Published for the U. S. Sanitary Commission by Hurd & Houghton, 1870.
Liquid Glass (Silicate of Potash) as a Surgical Dressing for Immovable Apparatus, and Hair as a Suture and Ligature. By J. T. Darby, M. D., Prof, of Anatomy and Surgery in University of South Carolina. Charleston: 1870.
Microscopical Anatomy of the Human Liver. By H. D. Schmidt, M. D., of New Orleans. (From the New Orleans Journ. of Med. for October, 1869.)
Spinal Irritation. By William A. Hammond, M. D., Prof, of Diseases of Mind and Nervous System, and of Clin. Med. in Bellevue Hospital Med. College etc. New York: D. Appleton & Co., 1870.
Oxygen Gas as a Remedy in Disease. By Andrew H. Smith, M. D., Member of Academy of Natural Sciences of Phila., etc. New York: D. Appleton & Co., 1870.
Three Cases of Imperforate Anus. With Remarks. By J. H. Pooley, M. D. Yonkers, New York.
Tabulated Mortuary Record of the City of Savannah, from January 1, 1854, to December 31, 1869. By W. Duncan, M. D. Savannah, 1870.
The Relative Dangers of Anaesthesia by Chloroform and Ether, from Statistics of 209,893 cases. By E. Andrews, M. D., Prof, of Prin. and Prac. of Surgery ia Chicago Med. Coll. Chicago, 1870.
Sarcomatous Fibroma of Upper Jaw (Epulis?) successfully Operated upon. By R. A. Kinloch, M. D., Prof, of Surgery in Med. Coll. of State of South Carolina. Charleston, 1870.
Notes on the Physiology and Pathology of the Nervous System, with reference to Clinical Medicine. By Meredith Clymer, M. D. New York: D. Appleton & Co., 1870.
The Trial of John Reynolds Medico-legally considered. By M. Gonzalez Eche- verria, M. D., Prof, of Mental and Nervous Diseases at Univ. Med. College of New York, etc. New York, 1870.
Population; its Law of Increase. By Nathan Allen, M. D. Lowell, 1870.
On the Physiological Action of Magnetism. By John Vansant, M. D., formerly passed Assistant Surg. U. S. N., etc. etc. New York, 1870.
On the Etiology of Bright's Disease, with remarks on the Prophylaxis. By Gover- neur M. Smith, M. D., Physician to the New York Hospital, etc. New York: Bail- liere Bros., 1869.
Yesico-Vaginal Fistule, and its successful treatment, by the Button Suture. By Nathan Bozeman, M. D. Albany, 1869.
Thoughts on Chronic Inversion of the Uterus ; specially with reference to Gastro- tomy as a Substitute for Amputation of the Uterus. By Henry Miller, M. D., Prof, of the Med. and Surg. Dis. of Women in Louisville Med. College, etc. Louis- ville, 1870.
Letheomania; the result of the Hypodermic Injection of Morphia. By Henry Gibbons, M. D. San Francisco.
TO READERS AND CORRESPONDENTS.
9
The Correlation of Vital and Physical Forces. By Prof. Geo. F. Barker, M. D., Yale College. New Haven: Charles C. Chatfield, 1870.
List of Medical Officers in U. S. Army, with their Stations, as reported to the Surgeon General of the Army, April 1, 1870.
Annual Address before the Medical Society of the State of New York. By Prof. James P. White, M. D., of Buffalo, President. Buffalo, 1870.
Inaugural Address before the Medical Society of the State of New York. By Prof. James P. White, M. D., of Buffalo, President. Buffalo, 1870.
Proceedings of the Academy of Natural Sciences of Philadelphia. December, 1869. Jan., Feb., March, April, 1870.
Medical Communications with the Proceedings of the Seventy-seventh Annual Convention of the Connecticut Medical Society, held at Hartford, May, 1869. New Haven, 1869.
The Transactions of the Medical Association of the State of Missouri. St. Louis, 1870.
Transactions of the Minnesota State Medical Society. St. Paul, 1870.
Transactions of the South Carolina Medical Association, Annual Session, 1870. Charleston, S. C, 1870.
Annual Report of the Managers of the Alabama Insane Hospital for the year 1869. Montgomery, 1869.
Fifty-third Annual Report on the state of the Asylum for the Relief of Persons Deprived of the Use of their Reason. Philadelphia, 1870.
Twenty-seventh Annual Report of the Managers of the State Lunatic Asylum, for the year 1869. Albany, 1870.
Report of the State of the New York Hospital and Bloomingdale Asylum, for the year 1869. New York, 1870.
First Annual Report of the Trustees of the Willard Asylum for the Insane, for the year 1869. Albany, 1870. -
Seventeenth Annual Report of the Pennsylvania Training School for Feeble-Minded Children, Media, Delaware County. Media, 1870.
The Sixth Annual Report of the Managers of the Germantown Dispensary to the Contributors. Philadelphia, 1870.
Twelfth Annual Report of the Trustees of the Charity Hospital of Philadelphia. Philadelphia, 1870.
Sixth Annual Report of the Board of State Charities of Massachusetts, 1869. Boston, 1870.
Report of the Board of Health of the City and Port of Philadelphia, to the Mayor, for the year 1869. Philadelphia, 1870.
The following Journals have been received in exchange : — Archiv der Heilkunde. 1869. 2 Heft.
Archiv fur Anatomie, Physiologie, und Wissenschaftliche Medicin. 1870. 1 und 2 Heft.
Deutsches Archiv fur Klinische Medicin. 1870. 1 und 2 Heft. Centralblatt fur die Medicinischen Wissenschaften. 1870. Nos. 11 to 25. Medizinische Jahrbucher. 1870. 1 Heft.
Giornale Italiano delle Malattie Veneree e delle Malattie della Pelle. 1870. Margo, Aprile.
L'Imparziale. 1870. Nos. 4, 6 to 11.
Archives Gene'rales de Medecine. Avril, Mai, Juin, 1870.
Archives de Physiologie Normale et Pathologique. Mai, Juin, 1870.
Annales de Dermatologie et de Syphiligraphie. Tome 2. Nos. 3, 4, 1870.
Journal de Medecine Mentale. Fevrier, Mars, 1870.
Revue de Therapeutique Medico-Chirurgicale. 1870. Nos. 6 to 11.
L'Union Medicale. 1870. Nos. 22 to 30, 34 to 48, 52 to 69.
La Sante Publique. Nos. 61 to 73, 1870.
Gazette Hebdomadaire de Medecine et de Chirurgie. 1870. Nos. 6 to 17. Revue de Cours Scientinques de la France et de l'Etrangere. 1870. Nos. 16 to 28,. except No. 17.
Le Mouvement Medical. Nos. 15 to 22, 1870. La Tribune Medicale, 138.
The British and Foreign Medico-Chirurgical Review. April, 1870. The Medical Times and Gazette. April, May, June, 1870, The British Medical Journal. April, May, June, 1870,
10
TO READERS AND CORRESPONDENTS.
The Lancet. April, May, June, 1870.
The Practitioner. April, May, June 1870.
Edinburgh Medical Journal. April, May, June, 1870.
Medical Press and Circular. April, May, June, 1870.
The Dublin Quarterly Journal of Medical Science, May, 1870.
The Journal of Anatomy and Physiology, May, 1870.
The Journal of Cutaneous Medicine. June, 1870.
The Glasgow Medical Journal. May, 1870.
The Indian Medical Gazette. March, April, May, 1870.
The Indian Annals of Medical Science. No. 26.
Canada Medical Journal. March, April, May, 1870.
The Dominion Medical Journal. March, April, May, 1870.
The Boston Medical and Surgical Journal. April, May, June, 1870.
The New York Medical Journal. May, June, 1870.
The Medical Record. April, May, June, 1870.
The Journal of Psychological Medicine. April, 1870.
The American Journal of Insanity. April, 1870.
The Buffalo Medical and Surgical Journal. March, April, May, 1870.
The Medical Gazette. January to June, 1870.
The Medical and Surgical Reporter. January to June, 1870.
Half- Yearly Compendium of Medical Science. January, 1870.
The Cincinnati Lancet and Observer. January to June, 1870.
The Cincinnati Medical Repertory. February to June, 1870.
The American Practitioner. January to June, 1870.
The Chicago Medical Examiner. January to June, 1870.
The Chicago Medical Journal. January to May, 1870.
The Saint Louis Medical and Surgical Journal. May, 1870.
The Detroit Review of Medicine and Pharmacy. January to June, 1870.
The Medical Archives. January to May, 1870.
The Leavenworth Medical Herald. January to June, 1870.
The Pacific Medical and Surgical Journal. December, 1869, to June, 1870.
The California Medical Gazette. January to June, 1870.
Oregon Medical and Surgical Reporter. November, 1869, to May, 1870.
Michigan University Medical Journal. March, April, May, 1S70.
The Baltimore Medical Journal. January to June, 1870.
The Medical Bulletin. January to April, 1870.
The Richmond and Louisville Medical Journal. January to June, 1870. The Nashville Journal of Medicine and Surgery. January to June, 1870. The New Orleans Journal of Medicine. January, April, 1870. National Medical Journal. April, 1870. The Indiana Journal of Medicine. May, June, 1870.
The Journal of the Gynaecological Society of Boston. January to June, 1870. The American Journal of Syphilography and Dermatology. January, April, 1870. The American Journal of Pharmacy. January, March, May, 1870. The Druggist's Circular. January to June, 1870.
The American Journal of Science and Arts. January. March, May, 1870.
The American Naturalist. March, April, May, June, 1870.
Journal of Applied Chemistry. April, May, 1870.
The Bowdoin Scientific Review. April, May, June, 1870.
Communications intended for publication, and Books for Review, should be sent free of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as above, and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 King William Street, Charing Cross, London; or M. Hector Bossange, Lib. quai Vol- taire, No. 11, Paris, will reach us safely and without delay.
All remittances of money and letters on the business of the Journ al should be addressed exclusively to the publisher, Mr. H. C. Lea, No. 706 Sansom Street.
The advertisement sheet belongs to the business department of the Journal, and all communications for it must be made to the publisher.
CONTENTS
AMERICAN JOURNAL
OF THE
MEDICAL SCIENCES.
NO. CXIX. NEW SERIES. JULY 1870.
ORIGINAL COMMUNICATIONS. MEMOIRS AND CASES.
ART. PAGE
I. The Treatment of Syphilis by repeated Inoculations of Matter derived from Venereal Sores: so-called Syphilization. By Freeman J. Bumstead, M. D., Professor of Venereal Diseases in the College of Physicians and Surgeons, New York. (With a wood-cut.) 17
II. Orbital Aneurismal Disease, and Protrusion of the Eyeball from Yenous Obstruction; with Remarks and Cases. By Thomas George Morton, M. D., one of the Surgeons to the Pennsylvania Hospital and Wills Oph- thalmic Hospital, Philadelphia. Read before the Ophthalmological So- ciety of Philadelphia, March, 1870. (With three wood-cuts.) . . 36
III. Case of Traumatic Aneurism of Orbit, treated by Compression. By George C. Harlan, M. D. 46
IY. Form of Neuralgia of the Jaw-Bones, hitherto undescribed. By S. D. Gross, M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia. (With a wood-cut.) 48
Y. On a Rare Disease of the Joints. By Samuel Jackson, M. D., Emeritus Professor of the Institutes of Medicine in the University of Pennsyl- vania, &c. &c. ............ 51
YI. On the Coincidence of certain Nervous Symptoms with the Presence of an Excess of Urea in the Urine. By F. A. Burrall, M. D., of New York City . . .53
VII. On the Inhalation of the Nitrous Oxide Gas when the Lungs are Diseased. By E. Holden, M. D., of Newark, N. J 61
VIII. On the Proper Use of the Obstetric Forceps. By Ellerslie Wallace, M. D., Professor of Obstetrics and of the Diseases of Women and Chil- dren in Jefferson Medical College, Philadelphia 71
IX. On the Influence of Section of the Cervical Pneumogastrics upon the Action of Emetics and Cathartics. By Horatio C. Wood, Jr., M. D., Professor of Botany in the University of Pennsylvania. . . .75
X. Vesico-vaginal Fistules. Comparative Analysis of different Surgical Methods. Results, American and European. By Nathan Bozeman, M.D., of New York 100
XL Traumatic Tetanus. By Christopher Johnston, M. D., Professor of Surgery in the University of Maryland 112
XII. Elephantiasis Arabum : Amputation of Left Thigh at Junction of Upper with Middle Third. By Isaac Smith, Jr., A. M., M. D., late Asst. Surg. 26th Reg. Mass. Vols., &c. (With a wood-cut.) .... 119
XIII. Pathology of Alopecia Areata. By L. A. Duhring, M.D., of Phila- delphia 122
XIV. Bromides in Epilepsy. By Benjamin Swan, M.D., of San Francisco, California 126
12
CONTENTS.
TRANSACTIONS OF SOCIETIES.
ART. PAGE
XV. Summary of the Transactions of the College of Physicians of Phila- delphia . . " . . . .127
Compound Fracture of the Skull, with Aphasia. By Dr. Addinell
Hewson 127
Ulcero-Membranous Angina. By Dr. J. M. Da Costa. . . . 129 Chronic Laryngitis, presumably Syphilitic; .Asphyxia; Tracheotomy.
Complete Cure, with Restoration of Voice. By Dr. Wm. Pepper. 132 Acetic Ether as an Anaesthetic. By Dr. H. C. Wood. . . . 137 Excision of a Portion of the Lower Jaw. By Dr. Forbes. . . 137 Splint for keeping the Lower Limb at rest after Excision of the Knee. By Dr. Packard. ........ 139
XVI. Summary of the Proceedings of the Pathological Society of Phila- delphia 140
Suicidal Hanging. By Dr. Packard 140
Case of Dislocation and Fracture of the Body of the last Dorsal
Vertebra; the subject of the injury surviving a year, dying of
Pyaemia the 369th day after the accident. By Dr. Cleemanu. . 141 Fragments of a Bug removed from the External Auditory Meatus.
By Dr. Harlan 143
Rupture of Liver. By Dr. C. T. Hunter. . . . . . 144
Epithelial Cancer of the Hand. By Dr. Duer 144
Tumour in the Right Anterior Lobe of the Cerebrum. By Dr.
J. R. F. Bell 147
Enlarged Inguinal Glands. By Dr. R. M. Townsend. . . .148 Case of Excision of the Elbow. By Dr. John Ashhurst, Jr. . . 148 Chronic Inflammatory Deposit in Testicle. By Dr. C. T. Hunter. 149 Cancer of the Pancreas. By Dr. J. R. F. Bell. . . . .150 Rheumatoid Arthritis ; Eburnation. By Dr. Willard. . . . 151 Cystic Distension of Fallopian Tube. By Dr. William Pepper. . 151 Two Cases of Bony Deposit in the Eye. By Dr. Harlan. . . 151 Suppression of the Urine ; Jaundice. By Dr. Hutchinson. . . 153
REVIEWS.
XVII. Studien aus dem Institute fur experimentelle Pathologie in Wien aus dem Jahre 1869. Herausgegeben von S. Strieker. Wien, 1870.
Studies at the Institute for Experimental Pathology at Vienna, for the year 1869. By S. Strieker. Part I., with four wood-cuts and two litho- graphic tables, pp. 110. Vienna, 1870. 155
XVIII. Obstetric Operations, including the Treatment of Hemorrhage. By Robert Barnes, M. D., F.R.C.P., etc. With Additions by Benjamin F. Dawson, M. D., etc. 8vo. pp. 483. New York : D. Appleton & Co., 1870 165
XIX. Surgical Memoirs of the War of the Rebellion, collected and pub- lished by the United States Sanitary Commission. I. On the Wounds of Bloodvessels, Traumatic Hemorrhage, Traumatic Aneurism, and Trau- matic Gangrene. II. On the Secondary Traumatic Lesions of Bone : namely, Osteo-myelitis, Periostitis, Ostitis, Osteo-porosis, Caries, and Necrosis. III. On Pyaemia. By John A. Lidell, A.M., M. D., etc. etc. Edited by Prof. Frank Hastings Hamilton. New York : Published for the United States Sanitary Commission, by Hurd & Houghton, 1870. 8vo. pp. xl., 586. (With wood-cuts and ten coloured plates.) . . 174
XX. The Physiology of Man : designed to represent the Existing State of Physiological Science as applied to the Functions of the Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and Microscopy in the Bellevue Hospital Medical College, New York, etc. etc. etc. Secre- tion, Excretion, Ductless Glands, Nutrition, Animal Heat, Movements, Voice and Speech. 8vo. pp. 526. New York : D. Appleton & Co., 1870 182
CONTENTS.
L3
ANALYTICAL AND BIBLIOGRAPHICAL NOTICES.
ART. PAGE
XXI. Guy's Hospital Reports. Edited by C. Hilton Fagge, M. D., and Arthur E. Durham. Third Series, Yol. XV. 8vo. pp. xvii., 652. Lon- don : John Churchill & Sons, 1870 191
XXII. St. George's Hospital Reports. Edited by John W. Ogle, M.D., F. R. C. P., and Timothy Holmes, F. R. C. S. Yol. IV., 1869. 8vo. pp. viii., 354. London : John Churchill & Sons 203
XXIII. Transactions of American State Medical Societies.
1. Transactions of the Medical Society of the State of New York, for
the year 1869. 8vo. pp. 363.
2. Medical Communications, with the Proceedings of the Twenty-seventh
Annual Convention of the Connecticut Medical Society, held at Hartford, May, 1869. 8vo. pp. 208.
3. Transactions of the Medical Association of the State of Missouri,
from its inauguration, Dec. 1867, to the annual meeting, April, 1869. 8vo. pp. 198 214
XXIY. A Practical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Heart. By Austin Flint, M. D., Professor of the Principles and Practice of Medicine and of Clinical Medicine in the Bellevue Hospital Medical College, etc. etc. 2d edition. Thoroughly revised and enlarged. 8vo. pp. xiii., 550. Philadelphia: Henry C. Lea, 1870 219
XXY. Manual of Chemical Examination of the Urine in Disease: with brief Directions for the Examination of the most common Yarieties of Urinary Calculi. By Austin Flint. Jr.. M. D., Professor of Physiology and Microscopy in the Bellevue Hospital Medical College, New York ; etc. etc. 12mo. pp. 75. N. Y. : D. Appleton & Co., 1870. . . .220
XXYI. The Dispensatory of the United States of America. By George B. Wood, M. D., President of the American Philosophical Society, President of the College of Physicians of Philadelphia, Emeritus Prof. Theory and Prac. of Med. in Univ. of Penu., etc. ; and Franklin Bache, M. D., late Professor of Chemistry in Jefferson Medical College of Phila- delphia, etc. etc. etc. Thirteenth edition, carefully revised. 8vo. pp. 1816. Philadelphia: J. B. Lippincott & Co., 1870 221
XXYII. On the Product formed in the Bronchi and in the Air-cells of the Lungs in Cases of Inflammation of these Organs. On Fibrinous or Pseudo-membranous Bronchitis and Pneumonia. By Dr. Lebert, Pro- fessor in Breslau 221
XXVIII. Epidemic Diphtheria and its Treatment considered from a Clini- cal Stand-point. By Dr. Alban Lutz, of Munich. . . . .226
XXIX. Essai sur les Maladies du Cceur chez les Enfants. Par le Dr. H. Rene Blache, Ancien Interne en Medecine et en Chirurgie des HSpitaux
de Paris, etc. etc. 8vo. pp. 224. Paris : P. Asselin, 1869. . . . 227
XXX. Renal Diseases: a Clinical Guide to their Diagnosis and Treatment. By W. R. Basham, M. D., F. R. C. P., Senior Physician to the West- minster Hospital, and Lecturer on Medicine, &c. pp. xiv., 244. Lon- don : John Churchill & Sons, 1870 228
XXXI. A Treatise on Syphilis. By Walter J. Coulson, F. R. C. S., Sur- geon to the Lock Hospital, etc. etc. 8vo. pp. xx., 373. London: John Churchill & Sons, 1869 229
XXXII. Lectures on the Principles of Surgical Diagnosis : especially in relation to Shock and Yisceral Lesions. Delivered before the Royal College of Surgeons of England, by F. Le Gros Clark, F. R. C. S., Sur- geon to St. Thomas's Hospital, etc. etc. 8vo. pp. xiv., 345. London : John Churchill & Sons, 1870 231
XXXIII. The Indigestions ; or, Diseases of the Digestive Organs func- tionally treated. By Thomas King Chambers, Hon. Physician to H. R. H. the Prince of Wales, etc. etc. Third American edition, revised. 8vo.
pp. 383. Philadelphia: Henry C. Lea, 1870 233
14
CONTENTS.
ART. PACxE
XXXIV. The Membrana Tympani in Health and Disease. Illustrated by twenty-four chromo-lithographs. Clinical Contributions to the Diagnosis and Treatment of Diseases of the Ear, with a Supplement. By Dr. Adam Politzer, of the University of Vienna. Translated by A. Mathew- son, M. D., and H. G. Newton, M. D., Assist. Surgs. to Brooklyn Eye and Ear Hospital, &c. 8vo. pp. 183. New York: Wm. Wood & Co.. 1869. 233
XXXV. Anatomy, Descriptive and Surgical. By Henry Gray, F. R. S. The Drawings by H. V. Carter, M. D. ; with additional drawings in the second and later editions by Dr. Westmacott. The Dissections jointly by the author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holmes, Surgeon to St. George's Hospital. A new American from the fifth and enlarged English edition. With four hundred and sixtv-two engravings on wood. Imp. 8vo. pp. 876. Phila- delphia: Henry C. Lea, 1870 236
XXXVI. Prolapsus, Fistula in Ano, and other Diseases of the Rectum, their Pathology and Treatment. By T. J. Ashton, Consulting Physician to the Marylebone Infirmary, etc. etc. Third edition. Crown 8vo. pp. viii., 175. London : John Churchill & Sons, 1870. .... 236
XXX VII. Reports on the Progress of Practical and Scientific Medicine in Different Parts of the World. (For the year beginning June 1, 1868, and ending June 1, 1869.) Edited by Horace Dobell, M.D. 8vo. pp. 645. London : Longmans, Green, Reader, & Dyer, ] 870. . . . 237
XXXVIII. A Physician's Problems. By Charles Elam, M. D., M.R.C.P. 12mo. pp. 400. Boston : Fields, Osgood & Co., 1869 238
QUARTERLY SUMMARY
OF THE
IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES.
Anatomy and Physiology.
1. On the Functions of the Tra- chea in the Act of Respiration. By Dr. Leven 239
2. Physiology of the Blood. By
M. Savotti 240
3. Regeneration of Nerve-tissue.
By Herr Voit 240
Materia Medica, General Therapeutics, and Pharmacy.
Physiological Action of Hy- drate of Chloral.
Chloral as an Hypnotic. .
Production of Rapid General Anaesthesia for Short Opera- tions. By Dr. B. W. Richardson.
Experiments of the Indian Go-
240 241
241
vernment on the Therapeutic Effects of the Cinchona Alka- loids, Quinia, Quinidinia, Chin- chonidinia, and Chinchonia. Bromide of Potassium and its Impurities. By Mr. Arthur E. Davies 244
. 243
Medical Pathology and Therapeutics, and Practical Medicine.
9. Pathology of Morbus Addi- sonii. By Dr. Risel. . . 244
10. Nature, Origin, and Treatment of Hvsteric Diseases. By Dr. Robert Lee. .... 245
11. Convulsive Sneezing, and its Relationship with Migraine,
Bronchial Asthma, and Hay- Fever. By Dr. H. Ferber. . 245
12. Remarkable Disturbance of the Heart which occurs in Renal Disease. By Dr. Wilks. . . 246
13. Croupal Bronchitis terminat- ing favourably. By Dr. Roth. 246
CONTENTS.
15
PAGE
14. Intermittent Fever Latent for several Months. By Dr. W. Braune 247
15. Aphasia. By Dr. 0. Berger. 247
16. Hemiplegia in Children. By Dr. Finlayson. . .248
17. Rupture of the Heart. By Dr.
J. de Bary 248
18. Glycerine -Lymph in Vacci- nating. By Dr. E. MUller. . 249
19. Effects of the Secretion of Tears on the Circulation of the Brain. By Mr. Lund. . . 249
20. Some of the Functional De- rangements of the Male Genital Organs. By Mr. AY. F. Teevan. 250
21. Therapeutic Effects of Chloral
in Fever 250
22. Therapeutic Effects of Hy- drate of Chloral in Cerebral Diseases. By Dr.T.S. Clousten. 251
23. Hydrate of Chloral in Phthisis Pulmonalis. By Dr. J. Hughes Bennett 252
24. A purely Milk Diet in the
PAGE
Treatment of Diabetes Mellitus, Bright's Disease, Disease of the Supra-renal Capsules, Fatty De- generation, &c. By Dr. Arthur Scott Donkin. .... 253
25. Lactic Acid in Croup. By Dr. Wagner 254
26. Belladonna as a Remedy for Constipation. By Dr. F. B. Nun- neley. 254
27. Itch treated by Balsam of Peru. 255
28. Use of Sarsaparilla in Syphi- lis. By Dr. T. Clifford Allbutt. 255
29. Subnitrate of Bismuth in the Diarrhoea of Young Children.
By Prof. Heller. . . .255 30'. Local Paralysis successfully treated by Hypodermic Injec- tion of Strychnia. By Mr. Bar- well 255
31. Phenic Acid in the Treatment
of Smallpox. By M. Chauffard. 256
32. The Use of Hydrate of Chlo- ral as a Remedy in Epilepsy.
By Dr. Weidener. . . .256
Surgical Pathology and Therapeutics, and Operative Surgery.
33. Conditions which favour Se- condary Hemorrhages after Sur- gical Operations. By M. Ver- neuil. 257
34. Some Points in the Pathology
of Tetanus. By M. Verneuil. . 257
35. Etiology of Erysipelas from Wounds. By Dr. Koenig. . 258
36. Reproduction and Reunion of Divided Tendons. By M. De- marquay. ..... 258
37. Hydatids in Bone. By Dr. Kuster 258
38. Recovery from Pyaemia. By Dr. Joseph Bell. . . .259
39. Chloral in Tetanus. By M. Verneuil 260
40. Use of Hydrate of Chloral for the Relief of Pain in Cancer.
By Mr. F. E. Clarke. . . 260
41. Chloral for the Relief of the severe Pain of Burns. By M. Marjolin 261
42. Chloral for the Relief of the Pain from Surgical Injuries. . 261
43. Indications for, and Results of, Trephining. By Baron Larrey. 261
44. Elephantiasis of Scrotum and Leg, treated by Removal of the Tumour and Ligature of the Fe- moral Artery. By Dr. J. Fayrer. 262
45. Supracondyloid Amputation of the Femur. By Mr. Wm. Stokes. 262
46. Excision of the Joints for Dis- ease. By Mr. F. J. Gant. . 263
47. Analysis of 184 Cases of Stone in the Bladder of the Adult treated by Lithotrity. By Sir Henry Thompson. . . . 264
48. Lithotomy. By Mr. Holmes Coote 265
49. Necrosis of the Humerus; Re- section ; Recovery. By Dr. Be- rn arqu ay 265
50. Preventive Treatment of Sy- philis. By Prof. Thiry. . . 265
Ophthalmology.
51. Changes in Astigmatism under the Influence of Accommoda- tion. By Dr. Dobrowsky. . 266
52. Histology of Trachoma. By Dr.Wolfring 266
53. Rupture of Eyeball, with Loss of Lens and Iris; good Sight remaining. By Mr. John A. Nunneley 268
16
CONTENTS.
Midwifery and Diseases of Women and New-born Children.
PAGE
54. Mechanism of Production of Face Presentation. By Dr. J. Matthews Duncan. . . .269
55. Remarkable Case of Complex Labour. By T. Moore Madden. 269
56. State of the Pulse immediately before and immediately after Parturition. By Dr. Hemey. . 270
57. Chloral in Puerperal Convul- sions. By Baron Paul von Serg- dewitz. . . ... 272
PAGK
58. Fundal Endometritis. By Dr. Routh. . . . . 273
59. Acute Leucocythgemia in Preg- nant Women. By Dr. Paterson. 274
60. The Colpeurynter to remedy False Positions of Uterus. By Dr. Kuchenmeister. . . . 274
61. The Stethoscope as a Means of Ascertaining the Sex of the Child. By Dr. James Cumming. 274
Medical Jurisprudence and Toxicology.
62. Toxic Action of Pyrogallic . Acid. By M. J. Personne. . 275
63. Poisoning by Carbolic Acid.
By Dr. Wallace 275
64. Poisoning by Phosphorated Ether. By M. Marriotte. . 276
AMERICAN INTELLIGENCE.
Original Communications.
Treatment of Carbuncle by Pres sure. By M. L. Bennett, M. D. 277
Clot in the Heart during Parturi- tion. By W. F. Sanford, M.D. 277
Intra-uterine Meningeal Apoplexy, caused by Violence at Seven Months, producing General Pa- ralysis,Talipes Calcaneus of both Feet, and Deformity of both Hands ; Death one Hour after
Birth, by Apncea. By Charles
A. Leale. M.D. Renal Abscess, discharging exter
nally for six years. By J. Stock
ton Hough, M. D. Case of Congenital Absence o
Uterus and Ovaries. By S
Hertz, M.D. . Fibro-cystic Disease of the Ovary
with Post-mortem Examination
By S. L. Blatchly, M.D. .
278
280
280
281
Domestic Summary.
Bromide of Potassium in Saccha- rine Diabetes. By Prof. Austin Flint. . " . . . .282
Bromide of Potassium in Sick- headache. By Dr. L. P. Yan- dell 282
Permanganate of Potassa in Oxa- luria. By Dr. H. S. Thorne. . 283
Hydrate of Chloral. By Dr. Ed- ward H. Clarke. . . .283
Reliable Preparation of Conium. By Dr. J. C. Reeve. . . .283
Method by which After-treatment in Operation for Fistula in Ano is rendered unnecessary. By Dr. J. J. Chisolm. . . .284
Improvement of Cammann's Ste- thoscope. By Dr. Thomas G. Snelling. ..... 284
Induction of Premature Delivery
as a Prophylactic Resource in Midwifery. By Prof. T. Gaillard Thomas 284
Intra-uterine Medication. By Dr. J. C. Nott, . . . .285
Adipose Deposits in the Omentum and Abdominal Walls of Woman as a Source of Error in Diagno- sis. By Dr. George Pepper. . 287
Ovarian Tumour; Two Pregnan- cies during its Existence ; Ex- tirpation ; Recovery, and third Pregnancy following. By Dr. A. B. Crosby 287
Spasmodic Action of the Abdomi- nal Muscles simulating the Mo- tions of the Foetus in Utero. By Dr. C. G. Putnam. . . .288
Erectile Cancroid of the Vagina. Bv Dr. William Goodell. . . 289
THE
AMERICAN JOURNAL OF THE MEDICAL SCIENCES
FOR JULY 1810.
Art. I. — TJie Treatment of Syphilis by repeated Inoculations of Mat- ter derived from Venereal Sores : so-called Syphilization. By Free- man J. Bumstead, M. D., Professor of Venereal Diseases in the College of Physicians and Surgeous, New York. (With a wood-cut.)
The treatment of syphilis by the repeated inoculation of venereal matter, proposed by M. Auzias-Turenne in 1844, subsequently tested by M. Mel- chior Robert, of Marseilles, and practised to a large extent with doubtful results by M. Sperino, of Turin, has of late years been revived in Norway, where it has attracted great attention and called forth violent discussion. Rumours — nay, direct testimony as to its efficacy coming from impartial observers visiting this distant region, and the importance of certain patho- logical questions which it involves, demand that its claims should receive more attention than they have yet had either in this country or abroad.
The chief advocate of this system has been Prof. W. Boeck, of Chris- tiania, who, in 1862, under the auspices of the Norwegian Government, issued a large and laborious work, in which were reported 252 cases treated by " syphilization," and the results compared with those obtain- able by mercury and other modes of treatment.
In the autumn of 1865, Prof. Boeck visited England, and treated in this manner twenty-seven cases at the Lock Hospital of London, at the invitation of the attending surgeons. Messrs. Lane and Gascoyen were ap- pointed a committee to report upon the progress and result.1 These gentle- men, while acknowledging the disappearance of syphilitic symptoms under repeated inoculations, expressed the opinion that " syphilization is not a treatment which can be recommended for adoption ; that even if it could be admitted to possess all the advantages claimed for it by its advocates,
1 Medico-Chirurgical Transactions, vol. 1. No. CXIX.— July 1870. 2
18
Bum stead, Syphilization.
[July
its superiority over other modes of treatment, or in many instances over no treatment at all, would not sufficiently compensate for its tediousness, its painfulness, and the life-long marking which it entails upou the pa- tient." As may readily be supposed, this verdict was less acceptable to Prof. Boeck and his friends than to his opponents. In justice to the former, however, it should be observed that the prejudice against " syphili- zation" in England has from the first been very strong, and its claims have been listened to, if at all, by very reluctant ears. As an instance of this fact, it may be mentioned, that a copy of the favourable report of a Norwegian committee appointed to investigate " syphilization," which I shall hereafter quote, was sent to every medical journal of Great Britain, at the time of its publication, several years ago, but has not been noticed by a single one of them up to the present day.
About a year ago, Mr. Jonathan Hutchinson, of London, who is well known for his contributions to our literature of venereal diseases, and as an able and impartial observer, made a tour through Norway, and pub- lished in the numbers of the Medical Times and Gazette for 1869, ac- counts of what he saw of " syphilization," which must be regarded as decidedly favourable to the practice.
During the last seven months, Prof. Boeck has been in this country, and I have had the opportunity of observing his practice in my wards at Charity Hospital, where he kindly consented to take charge of a number of cases, and treat them by " syphilization." It may be well for me to remark at the outset that I have not become a convert to his practice, but he has enabled me to observe phenomena of no slight interest, and of great scientific importance, which I was before unwilling to believe on imperfect testimony ; and I desire above all to testify to the private worth and the earnest, simple sincerity of the man himself, and claim for him an impartial hearing. Whatever may be thought of the practical value of " syphili- zation," I venture to predict that it will in future be recognized as having added much to our knowledge of the pathology of venereal diseases.
The claims of Prof. Boeck and his friends are these, that syphilis may be cured by the repeated inoculation of venereal matter, and that the relapses after such treatment are by far less frequent than after any other method.
The number of cases treated at Charity Hospital was only five ; four in which no previous treatment had been adopted, and one old case of syphi- lis, in which all previous treatment had failed. One of the former cases eloped, so that the number of cases in which the treatment had a fair trial was really reduced to three. Of course this small number cannot be offered as a test of the value of " syphilization," except when taken in connection with those cases observed in England and with those reported in Norway, and it is only in this light that they are here reported.
Prof. Boeck insists upon the division of syphilitic cases into two classes,
1870.]
Bum stead, Syphilization.
19
those which have received no treatment at all, or at least no mercurial treatment, and those in which this mineral has already been administered. He regards the former class as alone adapted to experience the full benefit and exhibit the merits of his mode of practice. In the latter class, he maintains that the treatment is much more tedious, that relapses are more likely to occur, and the final result is uncertain. He occasionally under- takes them, but only at the urgent request of the patient, and upon the latter's responsibility. As an evidence of his strong feeling on this point, I will mention the fact that an interne in charge of a patient undergoing "syphilization" at Charity Hospital, gave him one day two compound cathartic pills to relieve constipation, and Prof. Boeck attributed to the mercury therein contained certain unfavourable symptoms which occurred several weeks afterwards.
" Syphilization" is never employed for a chancre alone before the devel- opment of secondary symptoms ; but the sooner it is resorted to after the appearance of the latter the better.
Matter employed for the Inoculations. — In his earlier inoculations Prof. Boeck employed only matter derived from chancroids. He states that for the last few years in Norway he has used the virus of " hard" (true) chancres, which, after the example of Mr. Henry Lee, of London, he has succeeded in inoculating upon the patient himself after first stimulating the sore to discharge a purulent secretion, by the application of dry lint or some irritant, as savine powder or ointment. If the inoculations do not take, they are repeated daily, and may succeed even after several weeks' failure. Some German physicians have resorted to passing a filiform seton through the indurated base of the sore in order to render its secretion inoculable, but Prof. Boeck regards this practice as dangerous. In some instances all these attempts to auto-inoculate the secretion of true chancres fail. When successful, a pustule is developed without incubation in the course of forty-eight hours; there is no induration of its base or of the neighbouring lymphatic ganglia ; the secretion is re-inoculable, and, in short, the phenomena are the same as if chancroidal matter had been used. Prof. Boeck believes, however, that when such matter is employed for M syphilization" that the duration of the treatment is shortened, and the effect rendered more certain. Dr. Gjor, of Christiania, has also succeeded, although with difficulty, in auto-inoculating the secretion of mucous patches, and has employed this matter in the "syphilization" of patients. In the cases at Charity Hospital, with one exception, the matter was de- rived from soft sores (chancroids). I shall refer to this point hereafter. The chancroidal^matter was always first auto-inoculated upon the patient bearing the chancroid, and the secretion of the pustules thus produced was afterwards transferred to the patient whom we wished to "syphilize."
How the Inoculations are made. — The sides of the chest are selected for the first inoculations, because on this part of the body the resulting
20
Bum stead, Syphilization.
[July
sores are found to be smaller and to show less tendency to phagedenic action than elsewhere. Moreover, the distance of lymphatic glands ren- ders the possible occurrence of glandular inflammation less probable. Three inoculations are made upon each side below the nipples. Pustules are usually developed within forty-eight hours, and, on the third day, matter is taken from one or more of these and re-inoculated. Care is taken that the successive inoculations are not too near each other, lest they should happen to coalesce and form troublesome sores. Thus, if the first were made just below the nipples, the second are made at some distance below, the third towards the right, the fourth to the left, and so on. In keeping a diagram of the inoculations, however, they are represented as approxi- mated for the sake of convenience. This process is further continued, always taking the matter from the last series every third day. It will occasionally happen that some intercurrent disease, as a severe cold, some febrile attack, etc., will prevent the success of the inoculations, in which case they are to be repeated daily, employing matter from the last pustules formed.
Continuing this process, it is found that the pustules and resulting ulcers gradually become smaller and smaller, until they are too minute to furnish matter for further inoculations, or that the inoculations fail altogether. Fresh matter from some other source is then obtained, and inoculated in the same manner as the first, as long as it will take. This series of inoculations will usually be found to be less severe and fewer in the number of its generations than the preceding. Virus from a third and fourth source may then be tried, but sooner or later the walls of the chest will cease to react under the stimulus of any matter whatever, and immunity of this portion of the integument is obtained.
The same process as that now described remains to be performed upon the arms, and subsequently upon the thighs. The matter may at first be taken from some of the old inoculations upon the chest, and, when this ceases to act, from other sources.
When, finally, these three regions, viz., the chest, the arms, and the thighs, cease to react under the insertion of venereal matter, the treatment is regarded as complete. Should any relapse of the syphilitic symptoms subsequently occur, a few inoculations, according to Prof. Boeck, will be sufficient to dissipate them, the complete immunity of the skin having meanwhile disappeared in most cases.
Such is a general description of the process of "syphilization." Prof. Boeck insists especially upon the importance of carrying out its details, a number of which are here necessarily omitted. He states that years of labour have been required for the full elaboration of his treatment. I once expressed to him the opinion that it would be extremely difficult for any one to carry out this process in a proper manner from any mere descrip- tion without having seen it done, and to this remark he gave his full assent.
1870.]
Bum stead, Sypbilization.
21
In order to be of any benefit, sypbilization, once commenced, must be followed up until complete immunity is attained. Tbe most frequent and effective argument employed by Prof. Boeck witb recalcitrant patients was tbat tbey would be left in greater danger tban ever if tbis mode of treat- ment were not pursued to tbe end.
Prof. Boeck's manner of keeping a record of the inoculations, of their success or failure, and of the source in each instance from which the virus was derived, is quite ingenious. A rough outline of the human frame is drawn upon a sheet of paper, and the inoculations are noted in the form of small circles, with the accompanying date. If any points fail to take, the corresponding circles are filled up with black, as shown in the accom- panying cut of Benner's case (see p. 23), where the numbers stand for the days of the month, and the letters are the initials of the respective months.
[If, in any instance a series of inoculations is not continued, although the chart shows that the last were successful, it is to be inferred that the amount of matter in the last pustules was not sufficient for farther inocu- lation.]
The following cases, in which " syphilization" was employed at Charity Hospital, are briefly reported : —
Case I. — Wm. Benner, aged 18, admitted Oct. 5, 1869. Discharged Feb. 26, 1870.
History. — First and only act of sexual intercourse July 27, 1869. Sore upon internal surface of prepuce appeared three weeks afterwards.
Present condition. — No previous treatment. Chancre nearly healed. Its induration still marked. Decided induration of glands in both groins. Roseola commencing on chest and abdomen.
Summary of inoculations. — Inoculations commenced Oct. 8, 1869, with matter from Alexander Johnson (soft), upon the chest. This ran through eight generations upon each side, when it failed.
New matter taken from John Finlay (soft), Oct. 31st, and inoculated upon the chests, ran through six generations on each side, and then failed. Subsequently matter from Downing (soft), and Gillum (soft), was inocu- lated upon chest, and was successful, although the pustules generally were small, through about eleven generations on each side, terminating Dec. 22.
174 Inoculations upon the chest, of which ^failed.
On Nov. 18th inoculations were made upon the arms with matter taken from inoculations upon the right chest of Nov. 12th, originally derived from Finlay. This ran through six generations on each arm, when the pustules became so small that there was not sufficient matter for further inoculation.
Matter was afterwards taken from Gillum and inoculated upon the arms, and ran through ten generations.
114 Inoculations upon the arms, of which 31 failed.
The thighs were first inoculated Dec. 7th, with matter from his own arms, which ran through twelve generations upon each thigh. Matter subse- quently inoculated from various sources succeeded for six or seven genera- tions. Fresh matter from Farrell failed.
Number of inoculations on thighs 153, of which 58 failed.
Progress and result. — Oct. 26th, eruption about the same. Has suffered
22
Bum stead, Syphilization.
[July
from diarrhoea, loss of appetite, and malaise, the last few days. Prof. Boeck ascribes to this fact the failure of a number of the inoculations. Nov. 1. Eruption improved.
21st. Iritis of both eyes, not severe. Ordered collyria of atropia. General condition, which for a time was much depressed, is now much improved.
28th. Iritis nearly gone.
Dec. 13. Roseola has disappeared, except upon the back. Jan. 6, 1810. No traces of the eruption. General condition excellent. Face quite fat.
12^. One of the scabs upon the patient's right thigh has been rubbed off, and the underlying ulcer has taken on phagedenic action and is sur- rounded by an inflammatory areola. Loss of appetite, and general febrile reaction. Ordered tinct. ferri chloridi gtt. xxx. every three hoars.
15th. Ulcer on thigh is about one and a quarter inches in diameter, and penetrates to the muscular tissue beneath ; its floor is covered with a thick and copious purulent secretion ; the skin surrounding it is highly in- flamed for the extent of an inch in breadth, and the surface of the thigh for many inches beyond is swollen and oedematous. The whole aspect of the sore is very alarming, and Prof. Boeck himself is quite anxious with regard to the amount of destruction of tissue it may involve.
18th. Ulcer on thigh is assuming a more healthy aspect.
2ith. Surface of ulcer has cleared off, and is covered with healthy granu- lations.
Feb. 26. Patient discharged. No traces of syphilis. General con- dition excellent. Some of the ulcerations produced by the inoculations not yet healed.
Case II.— John Finlay, aged 26, admitted Oct. 20, 1869. Discharged Feb. 10, 1870.
History. — No previous attack of syphilis. Had connection early in August. Chancre appeared upon glans penis about August 18th. No- ticed an eruption upon chest and abdomen September 20th. Was treated in the city for primary sore, but nature of remedies unknown.
Present condition. — Induration of glands of both groins, of epitroch- lear glands, and of one post-cervical gland, well marked. Chancre healed, leaving slight induration. An eruption of roseola covers the thorax, abdomen, arms, and thighs.
Summary of inoculations. — Inoculations commenced upon chest, Oct. 21, 1869, with matter from William Benner (previous case). This ran through eight generations on the right chest and seven on the left, termi- nating November 12th.
Nov. 15. Fresh matter was inserted in the chests from Downing (sup- posed to be hard). This ran through only three generations on one side and two on the other.
28th. Matter was again taken from Benner and went through three re- moves.
Dec. 10. Matter from Gillum (soft) ran through five generations on the right chest and three on the left.
Total number of inoculations upon chest 132, of which 55 failed.
Arms were first inoculated November 11th, with matter from Downing, which took for three removes on right and seven on left. Matter from
24
Bum stead, Syphilization.
[July
Gillum and from Benner afterwards went through nine generations on right and six on left.
Total inoculations on arms 104, of which 45 failed.
The thighs were first inoculated December 12th, with matter from his own arms. This succeeded in eleven generations on right and twelve on left. Upon three separate occasions afterwards matter was taken from Benner and inoculated upon thighs, but failed every time. Matter, how- ever, brought from Brooklyn City Hospital, and also that taken from John Groder (soft), succeeded in six generations.
Total inoculations on thighs 138, of which 52 failed.
Progress and result. — November 9, eruption fading on chest and abdo- men, but more marked in lower extremities. Appetite good.
Dec. 10. Complains of malaise and pains in knees, elbows, and other joints. Iritis is commencing in both eyes. Ordered collyrium of sol. atropiae.
13th. Iritis more intense and painful.
22d. Iritis disappeared without leaving adhesions of iris or other trouble in eyes. General condition good, although pains still continue in extremities.
Jan. 12, 1870. Another attack of iritis. Patient very despondent and restive under the treatment.
15th. Iritis better. General condition excellent. Face noticeably fat. 20th. Another sharp attack of iritis in left eye.
2ith. Iritis improved. No treatment whatever has been employed for these attacks of iritis, except instillations of atropia.
February 10. Patient discharged without any syphilitic symptoms.
Patient was seen by me May 3d, 1870. He had had no further trouble, and was looking remarkably well.
Case III.— Moses Foult, aged 32, admitted October 26, 1869. Eloped February 23, 1870, within a few days of the time when he would have been discharged.
History. — Chancre appeared two months ago, ten days after exposure. Condylomata made their appearance in the neighbourhood of genital organs ten days ago.
Present condition. — Chancre healed. Induration of inguinal ganglia. Condylomata abundant on integument of penis, scrotum, internal parts of the thighs, and perineum. Mucous patches upon tonsils, fauces, and in- ternal surface of upper lip. Engorgement of post-cervical glands, and epitrochlear gland of right arm. No previous treatment.
Summary of inoculations. — This case is remarkable from the short time required to obtain immunity under the inoculations. After the first series of successful inoculations upon the chest, a large proportion of those made subsequently upon the chest, arm, and thighs, failed. It will also be noticed that the syphilitic symptoms in this case were of a mild character, and consisted chiefly of condylomata and mucous patches.
Inoculations were commenced upon the sides of the chest, October 31, 1869, with matter taken from the inoculations of John Finlay (Case II.). This ran through seven generations.
Subsequently matter from Benner was successful in four removes ; and from Downing in seven removes; but in these last, out of six inoculations made upon any one day, three would usually fail.
Total inoculations on chest 189, of which 97 failed.
1870.]
Bum stead, Syphilization.
25
Inoculations upon patient's one arm, the other having been amputated at shoulder-joint, were commenced with matter from Downing, November 24, but failed to take effect. On November 28, matter from Benner also failed. On December 1, matter from Carlin (soft) succeeded and ran through six generations. Subsequently, matter from Benner, which had before failed, succeeded and went through five removes. Finally, matter brought from the city hospital, Brooklyn, and that taken from Groder, and from Finlay, were tried without result.
Total inoculations on arm 69, of which 36 failed.
Inoculations were commenced upon the thighs, December 12, and were continued with matter from various sources, but with very slight success. As a general rule, they would not take at all, or would succeed for only one or, at most, two generations.
108 inoculations in all were made upon the thighs, of which 85 failed.
Progress and result. — This case progressed very much as if the patient neither had syphilis, nor was undergoing the process of syphilization. His syphilitic symptoms gave him but little annoyance, and the ulcers arising from the inoculations were generally so small, that he had no reason to complain as all our other patients did. No local treatment was applied to the condylomata ; they were simply ordered to be kept clean. They showed little or no improvement until about December 13.
January 13, 1870. A few condylomata remain on internal surfaces of thighs and scrotum. Prof, Boeck advises " touching these with a crayon of nitrate of silver, since the result of recent inoculations shows that the patient is nearly cured." General condition very good ; has gained deci- dedly in weight.
February 12. Several mucous patches of the fauces have recently ap- peared. Prof. Boeck remarks that " they are very common towards the close of 'syphilization.' " Ordered to be touched with crayon of nitrate of silver.
23c?. Patient eloped. The condylomata about the genitals had disap- peared. A single mucous patch remaining on the lip, attributed by Prof. Boeck to his smoking a short pipe, was the only syphilitic symptom left.
Case IY. — Thomas Downing, aged 20, admitted September 20 ; eloped December 24.
This patient entered the hospital with a commencing chancre, which was followed by an eruption of roseola.
Inoculations with the secretion of his own ulcer were commenced upon his chest October 24, and were repeated daily. At first they proved en- tirely unsuccessful, but pustules followed the inoculations of October 31, which were found to be re-inoculable, and were continued upon his chest through eleven generations. Some of this matter was also employed, as already noted, in the " syphilization" of the cases previously reported. The early elopement of this patient prevented our observing the effect of the treatment.
The only interest that this incomplete case had, was with reference to the apparent success of the auto-inoculation of a true chancre. Unfortu- nately, the inoculations were made by Prof Boeck, as was his habit in all these cases of "syphilization," by means of one and the same lancet with which he would inoculate one patient after another, without washing the instrument, but simply wiping it upon a dry towel after every time it was used. This fact rendered any certain conclusion as to the source of the virus impossible.
26
B r m s te a d , Sypbilization.
[July
Case Y. — Mary Stapleton, aged 27, Patient has been an inmate of the hospital several times before, for secondary syphilis, which was con- tracted four years ago. She has been freely treated by mercury, iodine, cod-liver oil, Donovan's solution, etc. etc., but is still suffering sadly from her old complaint. Undoubtedly, the great obstacle in the way of her improvement has been her intemperate habits. She is now employed as nurse in the hospital, and having access to the stimulants ordered for the patients, is rarely seen when not more or less under the effect of liquor. This fact should be borne in mind in connection with the poor success of our attempt at " sypbilization, ■"' which, however, she was anxious to try, and which we consented to apply in spite of her infirmity.
Present condition. — A dry tubercular eruption occupies the back, ex- tending from the upper edges of the scapulas to the lumbar region, and from three to five inches in breadth. Both lips are swollen and their sur- face denuded of epithelial covering. The tongue anteriorly is hypertro- phied and ulcerated. General health deteriorated. Appetite poor, Bowels constipated.
Summary of inoculations. — In general, the inoculations took very poorly and it was often extremely difficult to obtain the slightest effect with any kind of virus in our possession. The sources from which the virus was taken (all of them soft) were so numerous, and so frequently changed that I shall not enumerate them.
In all, ST inoculations were made upon the chest, of which 45 failed ; 120 inoculations upon the arms, of which 90 failed ; and 114 inoculations upon the thighs, of which (39 failed.
Progress and result. — Xovember IS. Patient is improving in her gene- ral appearance. No change in the eruption.
December 5. Patient complains of nocturnal pains in the head. Prof. Boeck orders gr. x potassii iodidi three times a day.
loth. Eruption on back decidedly improved.
20th. General health still improving and eruption fading. The iodide of potassium is suspended on account of its producing a pustular eruption on face.
Januarys. Not doing so well. Now confined to the bed. chiefly in consequence of the soreness of the inoculations and the difficulty of motion. Several glandular swellings have appeared in the sides and back of the neck, of the size of an English walnut, and threaten to suppurate. There is also one directly in front of the left ear. Complains of entire loss of appetite and copious night-sweats. Her thighs are extremely sore from the ulcerations which are covered with ecthymatous scabs, an inch and a quarter in diameter. Water dressings ordered.
I asked Prof. Boeck for an explanation of the threatening abscesses in the neck. He replied that they were due to the "revolution (?) in her system ;" that they often occurred in old syphilitic subjects previously treated by mercury, and that they would do the patient good.
Jan. 20. Swellings in neck have failed to suppurate, and are subsiding.
Feb. 26. No inoculation has been made since the 6th of February. For the last two weeks patient has been taking a decoction of sarsapariila and senna leaves, with the addition of five grain doses of the iodide of potas- sium three times a day.
The back is still covered with the old eruption, slightly faded in some places, and in others covered with thick yellowish crusts or lamellated scales.
1870.]
Bum stead, Syphilization.
27
Two weeks ago a spot of ecthyma appeared on her leg, going on to ulceration, and forming a circular ulcer of one and a half inches in diame- ter. Its edges were inflamed, and its discharge profuse. This was treated by Prof. Boeck with an ointment containing a scruple of camphor to an ounce of simple cerate, with little improvement.
Subsequently to this, several ulcerations appeared on the tongue, and attained an inch in diameter. They gave rise to very profuse hemorrhage, lasting for several hours. The patient was perfectly blanched and appa- rently moribund. Bleeding, however, was finally arrested by the perni- trate of iron.
May 4. Syphilitic symptoms not changed.
The patient's habits have been of the worst character, and she has been daily under the effects of liquor, in spite of every precaution. Hence the unfortunate result of the treatment cannot fairly be charged to the inocu- lations.
Effect of " Syphilization." — As I remarked at the outset, these few cases are intended to illustrate, rather than prove, the effect of " syphiliza- tion." Their number is too small for the latter purpose. I maybe al- lowed, however, to state the impression which they formed upon my own mind, that these inoculations did have a decided effect in causing the disappearance of syphilitic manifestations, more especially those upon the skin, and that the influence upon the general condition of the patient was most favourable. I am referring, of course, to those cases which had not been subjected to previous medication, and in which, only, the treatment had a fair trial.
From a careful perusal of the cases reported by Prof. Boeck, of the cases given in the paper of Messrs. Lane and Gascoyen, and of those afforded by several other observers, I believe the following is a fair conclusion as to the immediate effect of this mode of treatment : —
Commonly no effect upon the syphilitic symptoms is perceptible for about three weeks. During the fourth or fifth week these symptoms im- prove, and especially the early eruptions upon the skin, which gradually fade away, and are the first to disappear. The lesions upon the mucous membranes and those situated near the outlet of mucous canals, as mucous patches, and condylomata, are more obstinate. Very much depends upon the habits of patients. If tobacco is avoided, if cleanliness is observed, mucous patches of the mouth and condylomata about the anus and vulva may also show a marked improvement. Otherwise, these may persist or even become aggravated, and still remain after the process of " syphiliza- tion" appears to be accomplished. [I would remark that this is also true after the mercurial treatment of syphilis.]
During " syphilization," attacks of iritis are common, and not unfre- quently occur towards the termination of the ease. No change of treat- ment is necessary, except the employment of a collyrium of a solution of the neutral sulphate of atropia (gr. ij-iv ad aquae gj) three or four times
28
Bumstead, Syphilization.
[July
a day, and the patient is not restricted with regard to ordinary exposure to light.
The effect of these inoculations upon the general condition of patients is certainly surprising. Their appetite improves; they increase in weight; and their whole aspect is changed for the better.
By the time the treatment is completed, as judged by the immunity to further inoculations, all syphilitic symptoms have commonly disappeared. [Prof. Boeck cautions us not to try to shorten the treatment by inocula- tions oftener than once in three days, lest immunity should be obtained before all the symptoms have had time to disappear. ] The time ordi- narily required for immunity, when mercury has not been given, is three and a half to four months.
In proof of the fact that repeated inoculations do exercise a favourable influence upon syphilitic manifestations, and that they effect their disap- pearance, at least for a time, it is unnecessary for me to refer to the testi- mony already alluded to, or that of others which has appeared in various medical periodicals. It is desirable, however, in justice to Prof. Boeck, to quote the conclusions of a report presented to the Medical Society of Christiania at its Session, April 22d, 1863, by Dr. Steffens, Physician to the Corporation of Christiania, Dr. Egeberg, and Prof. Yoss, M.D., "a committee appointed to investigate the merits of a system of treatment known as syphilization," especially as this report has never before been published in English : —
"The undersigned, invited by Prof. W. Boeck to act as a committee in at- tending a series of experiments in which syphilization was made use of, and more particularly for the purpose of attesting to the results derived from thig method of treatment, have, for a period extending from the beginning of the year 1856 until 1859, attended to this commission, through repeated visits to the particular wards in the hospital where said investigations were conducted. "We have recorded the symptoms of disease present at the commencement of treatment ; the changes which took place in the nature of the disease and con- dition of the patients during the influence of the same ; and, further, the state in which the patients were discharged from the hospital, or ceased to be ob- jects for our observation. We have, in most cases, personally seen and exa- mined each individual patient once in every three weeks during the time of his treatment, and we have further regarded it as an important duty incumbent upon us to obtain, as far as was practicable, reliable information as to the con- dition of the patients after they had left the hospital."
*********
Here follow the records of observation in detail, and also a comparison with those resulting from a series of experiments simultaneously conducted by Dr. Hjort, upon the derivative plan of treatment. The committee con- cludes its report in the following words : —
"Taking into consideration all the above-mentioned facts, the committee arrives at this conclusion : That syphilization is a better method of treating the syphilitic disease than that of derivation, and, although it cannot positively assert that the former mode of treatment is in all cases curative, yet, all the members composing the committee fully agree in this opinion, that they are not aware of any mode of treatment in secondary syphilis which will accomplish
1870.]
Bum stead, Syphilization.
29
more, or equally as much, as will be accomplished by syphilization, applied to persons who have not previously been subjected to treatment including pre- parations containing- mercury.
" The committee having now completed its labours, cannot omit to render to Prof. W. Boeck the highest acknowledgment for the great skill and energy which he has evinced in the investigation as to the nature and treatment of syphilitic diseases."
Relapses. — Admitting the immediate effect of syphilization, the import- ant question remains as to the protection afforded for the future. As we shall see hereafter, this mode of treatment is attended with many draw- backs, to which the only possible palliation can be, a greater amount of security against relapses, and especially against the late distressing and dangerous manifestations of the disease. It is here that the advocates of " syphilization" believe they find their strongest argument. Prof. Boeck claims that the relapses after this treatment do not exceed twelve to four- teen per cent., and he supports his statement by the statistics of "over twelve hundred cases" occurring in his own practice. At a meeting of the Medico-Chirurgical Society of London, shortly after Prof. Boeck's visit to that city, Mr. Lee stated that Dr. Owre, of Christiania, had given him statistics with regard to the relapses after "syphilization," less favourable than the one furnished by Prof. Boeck ; that Prof. B. made out the per- centage as 12-13, while Dr. 0. found it to be 15. This charge was cer- tainly too trivial and puerile to deserve notice !
After the mercurial treatment of syphilis, Prof. Boeck estimates that the ratio of relapses averages about thirty to forty per cent., and I doubt whether any surgeon, who has an extensive venereal practice, will regard this statement as overdrawn ; provided no cases be taken into the account in which secondary symptoms have not already made their appearance, and the cases are seen in the early stage of the same period of the disease.
Having seen so few cases of " syphilization," and these also so re- cently, I cannot, of course, express any opinion upon this point, derived from my own observation. Nor is this difficulty likely to be removed in the future, since, in a large city like this, it is only by chance if a patient can be traced after leaving one of our large hospitals. The same difficulty will exist in other places containing a large population, even supposing the interest in medicine to be sufficient to lead to a trial of this novel treatment, requiring, as it does, a more thorough acquaintance with vene- real diseases than most physicians possess.
Prof. Boeck has spoken to me of the superior advantages possessed in a sparsely populated country like Norway to trace the origin, progress, and result of disease. The police regulations with regard to prostitution are equally strict as in Paris. The names of all the patients who have been treated by him in public practice are published in full, and the profes- sion in general throughout the country is requested, in the interest of science, to send information to headquarters if any one of these patients
30
B u m st e a d , Syphilization.
[July
applies for treatment, together with an account of his or her condition and symptoms.
Prof. Boeck's investigations as to "syphilization" have also met with severe criticism, not to say violent opposition, from some of his confreres. It is, probably, well for the cause of science that it has been so, since the observation of cases in a public hospital has thereby been rendered more exact, in a city where " syphilization" has, for years, excited greater in- terest in the medical profession than we, at this distance, can readily imagine.
Under these circumstances there is reason to believe, and the medical profession elsewhere has a right to expect, that the question of the per- manent effect of this treatment will first be decided beyond doubt, and its merits be estimated in comparison with other means, in that city in which it has chiefly been tried, and where the advantages for observation are claimed to be so great.
It should be mentioned that the opposition excited in Christiania with regard to " syphilization" has led to an extensive trial of letting syphilitic cases alone, in other words, to what is called a?? expectant plan of treatment, and also to treatment by means of a succession of blisters, or plasters con- taining tartarized antimony, with the hope of proving that repeated inocu- lations were simply equivalent to no treatment at all, or that they acted only as derivatives ; and it is claimed by a number at least of the col- leagues of Prof. Boeck, that the results are nearly or quite as favourable — especially when the treatmeut by derivation is compared with that by syphilization.
I have before me the report of a discussion which took place on " syphi- lization," in the Medical Society of Christiania, at one of its sessions of 1869,1 in which the general opinion expressed was still decidedly favourable to the method, although some of those present thought that the results were no better than those obtained by derivation.
For instance, Dr. Hjort, of the army, stated that " he had treated some cases with syphilization, and afterwards some with plasters, a method now generally known by the name of derivation ; and the difference between the time required for syphilization and for derivation he thought too little to be of any moment. From the number of relapses it was also difficult to come to any conclusion as to which was to be preferred." Similar testimony was also given by others.
On the other hand, Dr. Bidenkap " still stuck to the opinion that syphi- lization was the best method of cure that he knew," and Prof. Yoss and others made the same statement.
Theories as to the action of 11 Syphilization" — The early advocates of " syphilization," as Auzias-Turenne and Sperino, maintained that the
1 Nordiskt medicinskt Archiv, 2 Hft., 1869.
1870.]
Bum stead, Sypbilization.
syphilitic virus was absorbed from their successive inoculations, until finally the system became saturated, and refused to receive any more ; further inoculations proved unsuccessful, and immunity was attained.
No authority of any note at present entertains this view of saturation, so far as I am aware, and we need not dwell upon it. Let us proceed to the opinions of the more recent advocates of the method.
I regret to say that, in the numerous conversations I have had with Prof. Boeck on this subject, his views have appeared to me vague, indefi- nite, and unsatisfactory ; but, in justice to him, I am bound to say at the outset that he himself attaches little importance to his theories, and asks only that his facts be accepted. The opinions, however, of a man who has been the chief advocate of this method, and who has devoted many years of laborious, enthusiastic labour to its advancement, cannot be passed over in silence. I trust that, when these pages meet his eye, he will pardon the following condensed and imperfect summary of what I have gleaned in many pleasant hours of personal conversation.
Prof. Boeck says that he believes " syphilization" acts, and acts only, through the absorption of the virus inserted in the repeated inoculations.
I ask him for any proofs that absorption takes place.
Upon the first occasion of my putting this question, he adduced as an argument that the glands in the neighbourhood of the inoculations often become swollen and inflamed. This did not occur in a single instance at Charity Hospital, and, if it had, certainly no one would regard it as any evidence whatever of absorption into the general circulation !
Subsequently Prof. B. based his theory of absorption chiefly on the ground that after the inoculations had died out upon one part of the body, as the chest, the pustules resulting from inoculations afterwards com- # menced upon the thighs would be small.
I replied, that if this were due to the absorption of the virus, affecting the system at large, the inoculations ought not to take at all upon the thighs, as soon as they had ceased to affect the part first inoculated.
To this objection he, at the time, made no answer, but, just as these pages are going to press, Prof. B. has stated to me, as confirmatory of his view, that if, seven days after vaccination with the vaccine virus, a person be re-vaccinated in two places — upon the arm in the neighbourhood of the first inoculation, and also upon the thigh — the former will fail while the latter will succeed, although imperfectly. I have had no opportunity to put this to the test. But further —
T said to Prof. Boeck, "If you believe in absorption, you of course believe that the amount of the virus in the system is increased ?"
To my surprise the answer was " No."
I inquired how it was possible that virus could constantly be added without an increase ?
Prof. B. replied that he could not tell.
32
Bum stead, Syphilization.
[July
]Now, this is a faithful summary of the conversations held by Prof. Boeck and myself upon this subject, and I submit to the reader whether or not the theory of absorption in the mind of Prof. Boeck is based upon anything more than a mere assumption.
In his published articles on " syphilization," Prof. Boeck says he believes that this process acts by " assisting nature in passing through a course which too often is but imperfectly accomplished through her forces alone."1 This, it is needless to say, is no explanation of the modus operandi, although it looks very much like a belief in depurative action, from which, however, Prof. Boeck dissents.
For my own part, I cannot believe that there is any absorption whatever of the virus employed in 11 syphilization." How is it possible that syphi- litic symptoms should vanish under the constant increase of the very cause to which they owe their existence ? There is certainly no other known instance in pathology in which the addition to the system of a larger quantity of a virus producing a certain disease will cause the symptoms of that disease to abate.
Let us inquire also into the nature of the pustules and ulcerations pro- duced by the inoculations. It makes no difference whence the virus was taken, the phenomena attending the success of these inoculations are always the same. Pustules appear in the course of forty-eight hours, or, in other words, without incubation. These pustules cover ulcers, with sharply-cut edges, a purulent secretion, and a soft base. The secretion of these sores is readily auto-inoculable, reproducing their like over and over again. Surely these are the characteristics of an affection which we call a " chancroid," and which we daily see in many persons, without the latter ever showing any evidence of the absorption of a virus.
But a more severe and a decisive test remains to be applied. If the virus employed in the " syphilization" of syphilitic subjects is absorbed, this same virus when inoculated upon a person who has never had syphilis, will even more readily enter the general circulation and produce its cha- racteristic effects ; since it is admitted by every one that one infection is a decided obstacle to a second.
Cases in which this test can be applied must necessarily be rare, since persons who have never had syphilis will seldom consent, and will seldom be subjected by others, to inoculations of this kind ; instances, however, are not wanting, and, for the present, I shall confine myself to those fur- nished by the advocates of " syphilization" itself, or by those who have had the best opportunity to observe this process.
Danielssen, of Christiania, thought it might be possible by means of " syphilization" to effect such a change in the system of the miserable lepers of Norway, who are incurable by any other known means, that their
1 American Journ. of Sypliilography and Dermatology, vol. i. p. 14.
1870.]
Bum stead, Syphilization.
33
condition might at least be relieved. For this purpose he selected six, who had never been infected with syphilis, and subjected them to succes- sive inoculations of the same virus which is used in " syphilization" and which is supposed to act in consequence of its absorption. It would naturally be supposed that whether these lepers derived any benefit or not as regards their leprosy, they would at least have contracted syphilis. Not at all ! No symptoms of this disease ever appeared in them, with one exception, and this was the case of an individual who had already passed through nearly four hundred inoculations with impunity, when fresh matter chanced to be taken directly from a true chancre. His previous four hundred inoculations proved no protection against syphilis, and the insertion of this virus was followed by a chancre and secondary symptoms.1
But I am indebted to the kindness of Prof. Boeck for three other simi- lar cases, which possess special value coming from this source. The cases occurred in the wards of Dr. Gjor, of Christiania, who gave a succinct ac- count of them in a letter to his friend Prof. Boeck, a translation of which, made by Prof. B. himself, is now before me. Since the cases are similar, an abstract will serve for all.
Dr. Gjor, as already mentioned, had succeeded after much difficulty in inoculating the secretion of mucous patches upon the persons bearing them, and, with matter thus obtained, was carrying on the process of " syphilization" in his wards. Under these circumstances, there could be no question that the virus originated in a syphilitic and not a chan- croidal lesion. It so happened that there were three women, inmates of the ward, in which these inoculations were going on, who had never had syphilis and who were there for other and simple diseases. But imagining* that if syphilization was good for others it would also be good for them, these three women, without the consent or knowledge of Dr. Gjor, inocu- lated themselves with t!?e matter described taken from the other patients. The inoculations were successful so far as producing pustules, but no one of these three patients afterwards showed any symptoms of general syphilis, although kept under observation from six to eighteen months ! No stronger evidence than this is necessary to prove that the virus inserted in the inoculations of " syphilization" is not absorbed.
Other views have been maintained on this subject. Some assert that "syphilization" is after all mere expectant treatment, and that the symp- toms diminish and disappear under good diet and attention to the general health, in the same manner, whether inoculations are employed or not, From my own observations at Charity Hospital I am convinced that this is not the case. All of the cases there, in which mercury had not been used, certainly exhibited more marked improvement than would have oc- curred under mere hygienic measures.
1 Medico-Chirurgical Review, Jan. 1859, p. 98.
No. CXIX.— July 1870. 3
34
Bum stead, Syphilization.
[July
Another and more probable view is that "syphilization" has only an eliininative or depurative action. That agents of this kind do have a favourable effect in the control of syphilitic symptoms is a fact which has long been known, and such remedies enter in as important parts of a number of the older methods of treatment, as the sweating process which has been so much resorted to in Germany, the baths and large potations of water at various mineral springs, etc. More recently, also, since this subject has attracted attention, extensive trials of derivation have been made in Christiania and elsewhere by means of a succession of blisters, plasters con- taining tartarized antimony, etc., and the results attained by such treat- ment are claimed by many to be as favourable as those from " syphilization."
Without regarding the question as fully settled, my own opinion is decidedly inclined to this view, that " syphilization" acts only through the process of suppuration that it sets up, and that the immunity which is obtained is simply in accordance with the general law, that the skin will finally cease for a time to react under the repeated applications of any class of irritants.
Certain pathological points of very great interest are involved in this subject of " syphilization," but cannot now receive more than a passing notice.
The first that I would mention is the fact that the susceptibility to the action of the chancroidal virus varies in different persons, and also in the same person at different times.
As an example of the variation in different individuals, we have the small number of successful inoculations in the case of Moses Foult, above reported, compared with any of the other patients.
With reference to the variation in the same individuals at different times, my observation of the cases at Charity Hospital fully confirms Prof. Boeck's statement, that the intervention of any acute disease will for the time interfere with or entirely prevent the success of the inoculations. We had one very interesting case of this kind on the Island, at the Smallpox Hospital. The patient had been going through the process of " syphili- zation" at the German Hospital of this city, when he was attacked with variola, and was removed to Blackwell's Island. During the height of his intercurrent attack, all inoculations failed, but succeeded again as he began to improve.
It is not necessary for me to refer again to the failure of the inocu- lations made with one kind of matter, after a certain number have already been performed, and to the less perfect success of the subsequent intro- duction of a similar matter. As before intimated, this fact is not as novel as it might at first appear.
But there is a still more interesting question involved in the present subject : I refer to the alleged successful auto-inoculations of the secretion of true chancres, the artificial production in this manner of pustules and
1870.]
B um stead, Syphilization.
35
ulcers, which in their symptoms, course, and termination, fulfil all the con- ditions which we daily regard as sufficient to establish the existence of chancroids. I hope to consider this subject in a future paper, and can only say at present that if the facts as stated shall be confirmed by further observation and experiment, the theory of M. Clerc will be proved, viz : that the chancroid is a derivative of syphilis, due to the modification of the virus in consequence of being implanted upon a subject already in- fected. Practically, M. Clerc is a dualist, for although he admits the possibility of a chancroid reverting to syphilis, yet he states that he has never met with such an occurrence in his clinical experience. So that if his views, advanced, with very imperfect evidence, in 1854, about two years after the publication of Bassereau's work, should, strange to say, be found at this late day to be correct, the rules now recognized in the diag- nosis, prognosis, and treatment of venereal diseases will remain un- changed.
Is " Syphilization1 1 to be recommended for general adoption? — In the preceding pages I have said much in favour of this method of treatment, and I have endeavoured to give it its full credit. From what I have personally witnessed, and from the accounts of others, I believe that it is a very effec- tive method for the treatment of syphilis. I cannot say that I am fally convinced of the very small number of relapses after " syphilization" al- leged by its advocates ; not that I for a moment doubt their honesty, but results so favourable as this should be confirmed by others less enthusiastic, and less interested, before demanding implicit belief. Should further exa- mination and experiment show that only twelve or fourteen persons out of every hundred infected with syphilis and treated by repeated inoculations, ever exhibit any return of the disease, this method will have established very high claims in the treatment of syphilis, whenever circumstances will permit its being carried out, as it may be in our hospitals and other elee- mosynary institutions.
But, judging from what I have seen of the practice, nothing less than a very strong probability, in case I myself had syphilis, that the disease, if left alone, or if treated by mercury, would terminate disastrously, could induce me to undergo the personal discomfort, and for the length of time, which I have witnessed in the patients at Charity Hospital.
This debit side of the account, I cannot believe, is fully appreciated by the advocates of " syphilization" in their enthusiasm for the credit. The former, in fact, is apparently not regarded by them as deserving of men- tion. Upon inquiry of Prof. Boeck, I am told that this plan of treatment is usually carried on without any interference with the patient's ordinary avocations ; that the inconvenience is even so slight, that a husband or a wife who has gone astray and contracted syphilis, may undergo this series of repeated inoculations extending over a period of three or four months,
36 Morton, Orbital Aneurismal Disease. [July
and yet be able to pass off the resulting pustules and ulcerations, covering the chest, arms, and thighs, as common "boils!"
What I have seen of " syphilization," as practised by Prof. Boeck him- self, would make it appear a less agreeable process than the above state- ment would imply. To be sure, the treatment was new at Charity Hos- pital, and the patients were probably aware of the fact and more or less suspicious. Yet they kept their beds during the greater part of the three or four months that the inoculations were going on, although they had every inducement to be up and out upon the grounds ; and it often re- quired all our powers of persuasion to lead them to consent to a continu- ance of the inoculations, so great was their discontent. Indeed, I never made a visit to the hospital without the fear that some of them had eloped, as actually happened in three instances. They represented that the sore- ness of the ulcerations was so great that they could scarcely endure the contact of the bedclothes, much less that of their daily dress, and the ap- pearance of the sores corroborated their statement. I cannot well imagine how persons in their condition could have been about attending to their daily business. When they left the hospital they bore scars over the chest, arms, and thighs, which they will doubtless carry with them to their graves. Moreover, the serious tendency of an ulcer upon the thigh, in the case of Benner, to take on phagedenic action, shows that this practice is not devoid of danger. In short, I feel obliged to subscribe to the opinion ex- pressed by Messrs. Lane and Gascoyen, that " syphilization is not a treat- ment which can be recommended for adoption.'*
Art. II. — Orbital Aneurismal Disease, and Protrusion of the Eyeball from Venous Obstruction; with Remarks and Cases. By Thomas George Morton, M. D., one of the Surgeons to the Pennsylvania Hos- pital, and Wills Ophthalmic Hospital, Philadelphia. Read before the Ophthalmological Society of Philadelphia, March, 18t0. (With three wood-cuts.)
In December, 1864, I ligated the common carotid for aneurism involving the right ophthalmic artery ; and reported the case in a paper on Orbital Aneurisms published in this Journal for April, 1865, together with the statistics of the operations upon the carotid for this disease. Pour cases of vascular disease of the orbit have since come under my notice, illustrat- ing several varieties of orbital aneurism and vascular exophthalmos. In two of the cases the origin of the affection was traumatic, and in the other two anastomotic and congenital. The histories of these, with a brief review of my first case, now five years since the operation, and a few re-
1870.]
Morton, Orbital Anenrismal Disease.
marks upon the diagnosis and classification of these rare and interest- ing diseases may appear not unworthy of the attention of the Society.
It is well known that difficulties have arisen in effecting a diagnosis in regard to the nature of pulsating exophthalmia; and that errors have occurred after most carefully conducted examinations, and apparently con- vincing proofs of the disease being purely aneurismal. In Mr. Bowman's case the carotid was ligated for supposed aneurism of the orbit : death occurred on the eighteenth day. The arteries were found to be normal ; while the ophthalmic vein, where it entered the cavernous sinus, was filled with a coagula. Mr. Hulke, in reporting the case, remarks : —
tl The internal carotid may have been partially compressed by the swollen walls of the cavernous sinus against the side of the body of the sphenoid bone, giving rise to the bruit. The plugging of the trunk of the ophthalmic vein .... accounts for the protrusion of the eyeball, and perhaps also for the pul- sation, .... because each diastole of the ophthalmic artery must have been attended by a general momentary increase of the whole quantity of blood in the orbit, because its exit through the ophthalmic vein was cut off, and the resisting bony walls of the orbit could permit a distension in front only." — Soelberg Wells, p. 642, Philadelphia, 1869.
Mr. Travers' case1 in 1809, described as "aneurism by anastomosis," is the first reported instance of aneurism of the orbit. It was probably a true aneurism, or a diffuse one following upon rupture of the former. Next is Mr. Dalrymple's2 in 1813, which was very similar to Mr. Travers' ; and this is also described as an "aneurism by anastomosis." Mr. Scott's3 case, in 1834, was traumatic. The patient, a lad twelve years of age, fell into a ship's hold, striking his head; symptoms of concussion super- vened, with extravasation of blood in the orbit and protrusion. The aperture in the vessel which permitted the blood to escape probably did not close, as further protrusion followed, with pulsation ; the carotid was then tied with success. In 1829 Dr. Warren performed two similar operations, one with success, for aneurism of the orbit. Then Mr. Busk,4 in 1839, de- scribes a case of aneurismal tumour of the orbit, following injury; and believes that the cases of Travers and Dalrymple must have been instances of true aneurism. Dr. Dudley,5 of Lexington, Ky., in 1839, tied the carotid successfully for true aneurism of the orbit. The operations of Jobert, Velpeau, Herpin, Petrequin, and Nunnelly follow; while successful cases of ligature in infants for congenital aneurismal disease of the orbit, anas- tomotic in character, are reported by Wood, Mott, and Walton. Van Buren, Curling, Syme, Bell, Buck, Lawrence, Hart, Nunnelly, Halstead, and Foot have each operated upon aneurisms of the orbit, or upon pulsating exophthalmia. In the last case that was reported by Williams, in 186*7, Dr. Foot tied both carotids at intervals of thirty days for the relief of pulsating exophthalmia, and with perfect success. Mr. Nunnelly
1 Med.-Chir. Trans., vol. ii. p. 1. 2 Ibid., vol. vi. p. 111.
3 Ibid., vol. xxii. p. 134. 4 Ibid., vol. xxii. p. 124.
5 Ibid., vol. xxxvii. p. 221.
38
Morton, Orbital Aneurismal Disease.
[July
has reported no less than seven cases of orbital disease of a vascular nature, and he has proposed the term ''Vascular Protrusion.''1 Two of these were traumatic, four spontaneous, and one due to cancer in the orbit, and cavernous sinus. Mr. Nunnelly believes that "in a great majority of such cases of protrusion of the eyeball there is no disease whatever in the orbit; the seat of it is most commonly intra-cranial. The protrusion of the eyeball is passive, and the other distressing symptoms are secondary, depending upon obstruction to the return of blood through the ophthalmic vein."1 In the post-mortem examination in Mr. Guthrie's case,2 which ter- minated fatally without operation, with symptoms similar to those of Travers and Dalrymple, true aneurisms the size of a large nut were found upon each ophthalmic artery ; no distinct tumour could be felt in the orbit although the eye protruded almost beyond that cavity, with the hissing noise; vision was scarcely affected ; the vena ophthalmica cerebralis was greatly enlarged and obstructed near where it passes through the foramen lacerum orbitale superius.
True aneurism of the ophthalmic artery might at first produce only slight exophthalmos with bruit and pulsation, and with no very serious symptoms for perhaps a considerable period ; yet with rapid growth or rupture of the sac, or if associated with venous obstruction, as probably would be the case, 'excessive protrusion, such as has been frequently de- scribed, would undoubtedly occur. Exophthalmos in some cases is doubt- less due to the presence of the aneurismal tumour in the orbit, while in many cases the disease is post-orbital, as Mr. Nunnelly has stated, and the protrusion directly owing to venous obstruction. Case Y. pre- sents an interesting illustration of marked exophthalmos in each eye, but from different causes. Traumatic aneurismal disease is present in the right orbit with a comparatively slight protrusion; while excessive exophthalmos in the left eye is due simply to venous obstruction ; pressure on the right carotid controlling the whirr and protrusion in the former, but pressure on the left side producing no effect upon either globe.
In true aneurism of the ophthalmic artery the bruit appears more pro- minent and positive during the diastole, with a momentary intermission ; while in the cases of aneurism by anastomosis, which I have observed, the sound is continuous and vibratory, being of continued whirring character, although increased during diastole, occasionally quite feeble, and then re- sembles the sound produced when a large shell is held close to the ear.
Intra-cranial aneurisms, if situated near the sella-turcica would, as has been previously described, produce a bruit, and give rise to orbital pro- trusion from obstructing venous circulation.
Exophthalmos with bruit, and pulsation to a greater or less extent, may arise from several causes; while protrusion without the bruit may occur, as
1 Med.-Chir. Trans., vol. xlviii. p. 30.
2 Guthrie, Operative Surgery of the Eye, 2d ed.
1870.]
Morton, Orbital Aneurismal Disease.
39
has long been recognized, simply from any cause interfering with the venous current. We may have vascular exophthalmos from —
1. True aneurisms of the orbit.
2. Diffuse aneurisms of the orbit.
3. Aneurisms by anastomosis.
4. Obstructed venous circulation, intra or post-orbital.
1. True aneurisms of the ophthalmic artery in the orbit may, according to the size of the tumour, produce exophthalmos, pulsation, and bruit ; while the presence of the aneurismal tumour may possibly be detected by the finger. With advance of the growth, come oedema, great protrusion of globe, pain, etc. ; the pulsation and bruit being controlled by pressure on the carotid.
2. Diffuse aneurisms of the orbit, traumatic or consecutive, in which all the coats of the vessel, or the sac of a previous aneurism may have ruptured ; or where the cellular tissue alone forms the sac. Symptoms are sudden : the patient often states having heard the report of a pistol or gun, imme- diately followed by an intense aneurismal whirr, thrill, and bruit, and pulsation of the globe, the protrusion gradually increasing. The whirr is synchronous with the diastole of the heart, with the momentary in- terruption. Gradual impairment of vision follows, and with the increase of the protrusion, loss of vision, and sloughing of the globe, and fre- quently intense pain. Pressure on the carotid controlling the bruit.
3. Aneurism by anastomosis. — In these cases the disease is generally congenital ; and the orbit is often secondarily involved from the disease creeping in from integumentary naevi. The venous capillaries and trunks are affected by the extension of the disease, and the arterial network is also highly and morbidly developed. The face and scalp are so prone to this disease that we find more examples of this affection in these parts than all the rest of the body together; so that it is not surpris- ing for the disease to involve the loose orbital tissues. Case III. (see Fig. 2) presents an unusually marked example of this disease, not only involving the orbit but the entire side of the face, and including the lower jaw and tongue; the protruded globe being forced outwards and down- wards, and projected at least an inch. This affection may be limited to the orbit, and we should then have exophthalmos with or without pulsa- tion and thrill, excessive or not, according to the development of the dis- ease ; but the latter symptom is continuous in character, and generally much less marked than in the two preceding forms. If there is an ill- defined tumour of varicose vessels this may be compressed and nearly emptied, filling up when pressure is removed. The disease advances gradu- ally and often appears stationary after having attained considerable size : there is seldom pain, the patient being able to continue with ordinary work, and not experiencing any excessive cephalic noise. In case of free
40
Morton, Orbital Aneurismal Disease.
[July
communication with vessels from the opposite side, or when the growth advances from the orbit, a marked thrill is the result.
4. a. Vascular protrusion from venous obstruction.
b. Exophthalmos with bruit and pulsation ; Graves's disease.
In the former the protrusion is due to distension of the orbital vessels from blocking up of the ophthalmic vein previous to its opening into the cavernous sinus, or to aneurism of the ophthalmic artery at its origin, or from any cause whereby the venous flow from the orbit is interfered with by tumour or otherwise. When the vein is obstructed, pressure being exerted upon the artery by the hardened vein, a bruit may be produced. In cases of aneurism of the ophthalmic artery previous to its entering the orbit, we would have symptoms of true aneurism ; but the protrusion would be passive from the obstruction of the venous circulation, yet the bruit would be, as above stated, as it is found in true aneurism. In vascular pro- trusion the vision is often more or less impaired, while occasionally after duration of years, vision has not been 'greatly interfered with or even de- stroyed. Yenous dilatation alone forming a tumour in the orbital cavity may produce exophthalmos without bruit. An interesting case of this disease of several years' duration, is reported by Dr. De Ricci,1 in which great protrusion occurred. In this case the globe was finally removed by Dr. Bowman to reach the tumour, which was then found to be composed of a mass of convolutions of veins dilated into sacculi.
Dr. Parrish, one of the former surgeons of the Wills Hospital, has also reported a case2 of traumatic vascular tumour of the orbit, without pulsa- tion or bruit, in which an attempt was made to remove the growth by ligature; after three ineffectual efforts the treatment was abandoned, and at the last report the disease was progressing. It was thought in this case that the arteries and veins were alike involved. In Graves's disease or ex- ophthalmic goitre, for instance, we may have protrusion of the eyeballs to such an extent that the lids cannot, by any effort of the patient, be brought together over the cornea, which may lose its transparency ; and vision, being consequently lost or greatly impaired, the eyeballs may finally become atrophic. Anaemia, with violent action of the heart, and gastric symp- toms, usually accompany the bronchocele and exophthalmos. There is also a peculiar puffy condition of the eyelids similar to that observed after the administration of arsenic; and in the bronchocele there is frequently observed a distinct diastolic murmur. About a year ago I had under care a lady with this form of exophthalmos, excessive in character and asso- ciated with anaemia and bellows murmur, but no bronchocele; the globes were almost dislocated; the patient was presbyopic, but had no other difficulty with vision ; only slight improvement followed the administration of tonics and stimulants. In Graves's disease "the exophthalmos
1 Dublin Quart. Journal, 1865, Nov. p. 338.
2 American Journal of Medical Sciences, p. 357, October, 1841.
1810.]
Morton, Orbital Aneurismal Disease.
41
is due to hypertrophy of the adipose cellular tissue of the orbit, and to a
hyperoemic swelling of this tissue."
" It was supposed by some authors that the pressure of the enlarged thyroid upon the cervical bloodvessels caused the protrusion of the eye. In opposition to this view it may, however, be urged that we often meet with very large bronchoceles, without any exophthalmos, and, on the other hand, as has been shown by Prael, the latter may exist without any enlargement of the thyroid gland .... It is, however, far more probable that the affection is due to an irritation or neurosis of the sympathetic nerve, producing hypertrophy of the adipose tissue of the orbit and dilatation of the veins." — Wells, p. 621.
The involvement of the orbit by aneurismal tumours, true, false, or dif- fuse (spontaneous or traumatic), has been frequently observed; and for these the term aneurismal appears correct ; while venous obstruction alone in many cases is the true cause of exophthalmos.
Treatment. — As but little can be expected from the internal administra- tion of remedies, our attention must be directed either to the orbit or to the arrest of the circulation by pressure or ligation of the main artery in the neck. Electro-puncture was unsuccessfully tried by Petrequin in 1845. Injection of coagulating fluids into the orbital tumour has been followed by success in many cases ; but it appears to be a dangerous operation un- less the sac can be readily and certainly punctured.
Dr. H. D. Noyes, of New York,1 reports six cases of cure. The in- jections consisted, in two instances of tannin ; in one, of the acetate of iron ; in three, of the sesquichloride of iron.
Compression of the carotid has been tried in very many cases, and seve- ral successful results of this treatment have been recorded, with, however, a preponderance of failures.
Gioppe, in 1856, employed compression intermittingly applied for four days with a complete success; he was followed by Scarramuzza in 1858, who used pressure for eighteen days intermittingly (7 hours and 20 min- utes) with a like result; and again by Freeman in Canada. Five cases, three in England, one in France, and one in Poland, have since failed. In a recent case of pulsating exophthalmos with bruit, at the Wills Hospital, pressure was abandoned, after a most faithful trial. A large number of aneurisms and varices of the orbit have been subjected to ligation of the carotid, the success attendant upon this operation having been quite un- usual. When there is danger of the eye being compromised, or even with- out this, when the disease is increasing, and compression has failed, ligation should be resorted to.
In excessive hypertrophy, with great protrusion, as in Case III., although not advancing, where there is great danger of immediate increase and possi- ble hemorrhage, the carotid should be ligated. Even in suspected malig- nant disease, with exophthalmos, bruit, pain, disturbed vision, and rapid growth, ligation would be quite justifiable if not demanded. The disease
1 New York Medical Journal, March, 1869.
42
Morton, Orbital Aneurismal Disease.
[July
would probably be temporarily arrested, and pain would be alleviated by the diminished congestion.
Of the 32 cases of all forms of orbital aneurism which I collated in 1865, 30 were subjected to ligation of the carotid artery. Three of these were partially successful, two were unsuccessful, three died, 22 were cured.
Dr. Noyes has tabulated in the New York Medical Journal, March, 1869, 45 cases of carotid ligation from all sources; of this number, three were partially successful, five were failures, five were followed by death, 32 were cured, showing equally fair results.
Case I. True Aneurism of the Ophthalmic Artery successfully treated by tying the Common Trunk of the Bight Carotid. — This opera- tion was performed upon the patient before you (Mrs. P.) on the 4th of December, 1864. The earliest symptom of the aneurismal disease was observed during the month of May of the same year, when she was two months pregnant; her attention then was directed to a slight noise in the right temple, which gradually increased. In the early part of November, just before her confinement, she awoke in a fright from a sound sleep with what she supposed to be the report of a pistol ; but was assured by her sister, who was with her at the time, that it was only a dream ; from this time the noise became much more marked and distressing in character. The eye now began to protrude, the vessels about the orbit became promi- nent, and vision was somewhat involved. Some weeks after delivery, which was accomplished without any difficulty, I was consulted ; the protrusion was very marked, and pulsation of the globe had become a very prominent symptom; the globe was pushed upwards and forwards; pupil dilated; con- vergent squint and double images; vision impaired; the vessels adjacent to the orbit were enormously distended and pulsated strongly. The thrill was distinctly aneurismal in character, with the momentary intermission, being similar to the puffing of a locomotive, to which the patient herself compared the noise. True aneurism of the ophthalmic artery in the orbit was diagnosticated, this being concurred in by my colleagues of the Pennsylvania Hospital, and others who saw the case. The carotid having been tied the ligature dropped on the 17th day; the wound closed up firmly, and on the 24th day vision was normal and all evidences of the original disease had vanished.
The patient has ever since continued well; there is no impairment of vision, and the fundus of each eye, is found to be normal. The patient has been again confined, in December, 1867, without experiencing any difficulty either prior to or after delivery. The right side of the patient's face is observed to be decidedly less full than the left ; the tissues are appa- rently less nourished, and a slight atrophic state has resulted. Upon the left side of the face free perspiration occurs, while the right side exhibits quite the contrary condition.
The patient was exhibited to the society.
All the symptoms of true aneurismal disease were present in this case; and had ligation of the artery been delayed, the same excessive exophthal- mos, with symptoms described in first recorded cases, would have undoubt- edly occurred.
1870.]
Morton, Orbital Aneurismal Disease.
4:)
Case II. Aneurism following a Blow upon the Brow ; Orbital Tu- mour, Exophthalmos, Pulsation, and Bruit. — J. L., set. 25, native of Ire- land, has been in this country since June last (1869), has always been healthy. Four years ago he received a blow with the end of a loaded whip, directly over the left eye ; considerable ecchymosis resulted, the tissues in and about the orbit being much infiltrated ; a month afterwards this infiltration had very much disappeared and no further trouble was expe- rienced for some twelve months afterwards, when a slight swelling or lump appeared which could be grasped by the fingers. This tumour was soft and compressible; the growth advanced slowly during the next two years, the eye being gradually displaced downwards and outwards.
During the past year the growth has increased rapidly, having doubled in size within the last six months ; he has also experienced for a long time a slight hissing or purring noise, more at night when lying in bed, or when at work in a stooping posture.
Vision has been gradually diminishing ever since the tumour began to develop, and the eye has been almost hidden from view.
Present Condition. — Exophthalmos strongly marked ; a tumour above the eye extending backwards, soft, compressible ; with some effort the globe can be forced partly within the orbit, the tumour diminishing, and with the removal of the pressure the growth slowly regains its size. There is a slight pulsation, with a feeble bruit. Pressure on the carotid does not entirely control the whirr. Left eye is projected forward and downward
Fig. 1.
one inch ; the globe above is flattened horizontally ; the lower border of right iris is on a level with upper border of left ; pupil active ; external ciliary vessels engorged, especially over the lower and outer section.
Ophthalmoscopic Examination. — In the left eye the arteries are ex- ceedingly minute ; veins full and dilated ; disk atrophied, and irregular ; fundus pale. Right eye, fundus pale; disk slightly irregular; normal vision.
Morton, Orbital Aneurismal Disease.
[July
Left or diseased eye, F= TJg. Right eye, normal acuity of vision. Left side, bruit heard most distinctly over globe, and also slightly over globe of right side by transmission. Left eye projects forward with each pul- sation.
In this case some of the vessels of the orbit were ruptured, which ac- counted for the sudden and excessive effusion ; absorption then occurred ; the vessel or vessels, arterial and venous, which were ruptured, became dilated, and an aneurism by anastomosis has gradually developed ; with slight bruit, pulsation, and thrill, forming a compressible, varicose tumour. In regard to operative interference, a partial removal of the tumour with the knife, and ligation of its deeper portion would probably be sufficient.
The patient was exhibited to the Society. Fig. 1.
Case III. Aneurism by Anastomosis, with Orbital Tumour; Involve- ment of the Entire Side of Head and Face by the Extension of the Dis- ease.— L. L., set. 25, married, general health good. Soon after birth, the left side of his face was observed to be rather more fully developed than the right ; as far back as he can remember the left eye has been prominent. Many years ago he noticed a rushing sound in his head and eye, which is more intense at times, the protrusion and noise being increased by heavy work or the stooping posture.
Present Condition. — The right eye is normal as regards vision and position. The left presents excessive exophthalmos; the conjunctiva is chemosed, highly vascular, and thrown into folds; the upper part of the cornea being on a line with the lower edge of the cornea of the sound eye
Intense pulsation and marked thrill are perceptible to the touch on the temple and eyeball, and the noise can be heard at some distance from the patient's head. A considerable tumour, irregular in shape, flattened above, can be felt deeply in the orbit and at the inner angle of the eye ;
Fig. 2.
1870.]
Morton, Orbital Aneurismal Disease.
45
in this tumour the thrill is very marked and intense in character. The orbital portion of the tumour is globular, readily compressible, but with removal of constriction filling up instantly. Pressure applied to the carotid entirely controls the aneurismal thrill, quickly produces a marked diminution in the size of the tumour, and stops all pulsation. Left eye can count fingers with great difficulty at about one foot; all movement of this eyeball is lost ; a marked continuous bruit can be traced in the vessels of the face, while the left side of the tongue is enormously hyper- trophied ; this varicose aneurismal condition invades the entire side of the head ; the mucous membrane of the tongue and mouth is thrown into folds, while the opposite side is quite normal.
Pressure upon the left carotid controls all bruit and thrill with imme- diate lessening of the orbital tumour and exophthalmos. Ligation of that vessel has been advised as the affection is increasing, and the risks of hemorrhage are considerable.
The patient was exhibited to the Society. Fig. 2.
Case IY. Aneurism by Anastomosis involving the Orbit at the Inner Angle. — Miss P., set. 12 years, although otherwise a healthy girl, has had a tumour growing gradually since infancy at the inner side of the right orbit. More recently it has been projecting beyond the angle, and form- ing a growth a little more than an inch in diameter. It is larger at times and more prominent under excitement. The pulsation is slight in the tumour, and sometimes can scarcely be felt. The child says she feels or hears a sound in her head all the time. The tumour can be forced by pres- sure almost away, after which it gradually refills ; the exertion of going up stairs produces great prominence. The eye is not displaced nor is vision interfered with.
This case (photograph shown) is one of anastomotic aneurism. The slight pulsation, the subsidence of the tumour under pressure, the con- tinued noise in the head, the absence of all very active symptoms, and the slow growth, with its congenital character, all indicate the nature of the affection. In this case, unless the disease is arrested in its early growing stage, there is every probability of its assuming a more serious character. Injections of coagulating fluid, excision of the tumour, or ligature, would probably prove successful.
Case Y. Traumatic Aneurism of the Bight Orbit, associated with extreme Exophthalmos of the Left Eyeball, from Venous Obstruction. — S. G., set. 25, received a violent blow on the right side of the head, on the 20th of June, 1868. Immediate protrusion of the right eyeball fol- lowed, and the left became prominent eight weeks afterwards. A hissing sound was noticed in the right orbit, directly after the accident, perceptible only with each stroke of the pulse. When admitted into the Wills Hos- pital in August, 1869, both eyes presented exophthalmos (see Figure 3). The left globe was almost dislocated, but could be easily pressed back into the orbit, and readily held there ; but when pressure was removed it imme- diately bulged out, but presented neither pulsation nor the slightest bruit.
The right eye pulsated strongly, and resisted pressure ; there were intense thrill and bruit which could be controlled by pressure on the carotid of the same side, and under this pressure the globe could be placed almost in its normal position. Pressure on the left carotid produced no effect on either eye.
The case was diagnosticated as aneurism of right orbit, with vascular pro-
46
Harlan, Traumatic Aneurism of Orbit.
[July
trusion of the left, simply from venous obstruction, being thus an illustra- tion of two forms of exophthalmos. Compression of the right carotid
Fig. 3.
allowed the globe on that side to be replaced to a considerable extent, thus favouring the view that an intra-orbital tumour existed, which was partially, or entirely emptied, along with the cessation of all the aneurismal symptoms, when the arterial circulation was controlled.
Complete notes of this case, of which a mere abstract has been here given, were read before the Society. The detailed history will be found in the present number of the Journal in the report by Dr. Harlan, who had charge of the patient, and to whose paper the reader is referred.
Art. III. — Case of Traumatic Aneurism of Orbit, treated by Compres- sion. By George C. Harlan, M.D.
S. Gr., set. 25, a brakesman on Pennsylvania Railroad, was admitted to the Wills Ophthalmic Hospital on the 14th of August, 1869. On the 20th of June, 1868, while standing on the platform of a car in motion, he received a violent blow upon the head from another car moving in the oppo- site direction on a side track, which fractured the lower maxilla on both sides and inflicted several scalp wounds. He stated that he was partially insensible for three weeks, and that when he returned to consciousness his right eye was very prominent and swollen, and that he heard " a roaring sound like falling water in his eye" with every stroke of the pulse, which he had never been free from since. A "red tumour" which had appeared
1870.] Harlan, Traumatic Aneurism of Orbit. 47
on the right eye partly covering the pupil and interfering with vision, had been cut out by his medical attendant. A cicatrix in the conjunctiva at the inferior palpebral fold, proved the tumour to have been a chemosis. The left eye commenced to protrude in about two months.
He was able, in a few weeks after the recovery of consciousness, to resume his occupation, and had suffered no inconvenience beyond the deformity and the annoying sound which he referred very positively to the right eye.
At the time of his admission there was great exophthalmos of both eyes — greater of the left which seemed almost dislocated, the equator of the ball being in front of the edge of the orbit. The left ball* could be pressed back to its proper position and easily held there without pain to the patient, but immediately bulged forward again when the pressure was removed. The right eye resisted pressure, its position could not be altered, and strong pressure gave pain. He had excellent binocular vision. In the right eye V— § §, in the left §J — accommodation in each = \. Pupils freely movable and ophthalmoscopic appearances normal. In addition to the "sound in the eye" referred to, he felt every arterial pulsation "like a little jerk all over his head," and coincidentally there was a slight appa- rent motion of any object that he looked at steadily. On auscultation, a loud aneurismal murmur could be heard over any part of the head or face, most distinctly over the right temple. This murmur, as well as the sound heard by the patient, was entirely stopped by pressure upon the right carotid, and there was perceptible pulsation of the right ball, with slight darting pain, when the pressure was suddenly removed ; never any pulsa- tion of the left ball. During the pressure on the artery the right ball could be pressed back. No effort was produced upon either eye by pressure upon the left carotid, or upon the left eye by pressure upon either artery.
On consultation of the surgeons of the hospital, it was decided to give a thorough trial to treatment by compression of the carotid, as the pulse was full and strong, and excited by prolonged examinations and the pros- pect of surgical treatment — beating at the rate of nearly 100 per minute — tinct. veratrum viride was given several hours before compression was com- menced, and repeated at intervals. The resident surgeon, Dr. James C. Wilson, assisted by Mr. Landis, an advanced student of medicine, and the patient himself, who was an intelligent man of unusual endurance and in- domitable perseverance, kept up continuous and complete compression from 3 P.M. until 11 P.M. — a period of eight hours — the pulse ranging in the mean time, under the influence of the veratria, from 44 to 56.
The murmur though still perfectly distinct, was much lower in tone and altered in character. The patient stated that the •'roaring sensation was fainter and had a shriller sound. After this, intermittent pressure was applied from four to six hours daily, principally by the patient him- self, who learned to control the artery better than any one else ; he accom- plished it sometimes by the thumb, sometimes by a tourniquet I had made by Mr. Kolbe for the purpose, and which acted very well for an hour or two at a time, and sometimes by means of a contrivance of his own, consisting of a stick about a foot long with the end properly shaped and padded, which he pressed against the artery and held in his hands or rested against a table. The improvement in the sound continued, and the exophthalmos was decidedly diminished, particularly of the left eye, making an evident change for the better in the patient's appearance.
This treatment was continued for five weeks, during the last two of
48
Gross, Neuralgia of the Jaw Bones.
[July
which no progress was made. Rather for the sake of confirming the assurance that all had been done that could possibly be accomplished by pressure, than with any decided hope of further improvement, continuous pressure was tried, being kept up by relays of students for twenty-four hours, but with scarcely any effect. The patient then left the hospital, ex- pressing himself satisfied that the degree of improvement attained fully compensated him for all he had endured. A few weeks ago he wrote to me to say that he had resumed his occupation as brakesman, and that the former condition of his eyes had returned, that he was no better than when he entered the hospital. He will probably return to undergo the operation of ligation' of the carotid.
Art. IV. — Form of Neuralgia of the Jaw-Bones, hitherto undescribed. By S. D. Gross, M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia. (With a wood-cut.)
There is a form of neuralgia of the jaw-bones, which, as far as my information extends, has not hitherto been described, though, judging from the great suffering which attends it, it has doubtless been observed by other practitioners. Its seat is in the remnants of the alveolar process of eden- tulous persons, or in the alveolar structure, and in the overlying gum, and is met with chiefly, if not exclusively, in elderly subjects. It is also more common in the upper than in the lower jaw. The part affected is usually very small, often not exceeding a few lines in extent. The soft tissues around do not seem to suffer, at least not in the same degree, as is so fre- quently the case in the more ordinary forms of neuralgia of the jaws and face. On the contrary, the morbid action is generally limited to the osseous structure. In rare instances there may possibly be some involvement of the gum, which is nearly always exceedingly hard and dense, grating more or less under the knife, and adhering with extraordinary firmness to the atrophied alveolar process beneath.
The pain is generally paroxysmal, coming on in fits and starts, very much as in ordinary neuralgia, the slightest causes being sufficient to pro- voke it, as talking, mastication, the contact of hot or cold fluids, degluti- tion, or mental excitement. Sometimes it is momentary, coming and going with the rapidity of lightning ; occasionally it lasts for hours together, and cases occur, although they are rare, in which it continues, with but little mitigation, for an indefinite period. The pain varies in character. Thus, it may be sharp and darting, dull, heavy, aching, boring, or gnawing. Pressure generally relieves rather than aggravates it. Now and then, when it is uncommonly severe, there may be more or less spasm of the muscles of the face, but this is rare.
1870.]
Gross, Neuralgia of the Jaw Bones.
49
The pathology of the affection seems to be compression of the minute nerves distributed through the wasted alveolar process, dependent upon the encroachment of osseous matter upon the walls of the canals in which they are naturally inclosed. In the natural state the nervous current passes along without any hindrance, but in this condition of the canals in question its transmission is interrupted, and more or less pain, known as neuralgic, is the consequence. That this explanation is true does not, I think, admit of the slightest doubt. The osseous structure, as previ- ously stated, is always abnormally hard from the deposit of new substance which imparts to it almost an ivory-like consistence.
The disease usually comes on gradually, and proceeds from bad to worse, until, in many cases, the suffering is rendered nearly intolerable. The general health, at first unaffected, is eventually materially impaired ; the appetite is deranged ; the countenance wears an anxious expression ; the sleep is disturbed and unrefreshing ; the bowels are habitually constipated; digestion is imperfectly performed ; the extremities are almost constantly cold, and there is terrible depression of spirits. Loss of sleep, fatigue, exposure to cold, irregularity of diet, mental distress, and, in short, what- ever has a tendency to lower the vital powers is sure to aggravate the pain and to prolong the paroxysms. Sometimes the disease would seem to be of a malarious origin, the attacks coming on periodically very much as in intermittent fever.
The subjoined cases will serve more fully to illustrate the nature of this affection, as well as to suggest the proper treatment for its relief.
Case I. — W. D. H., set. 64, had all his upper teeth extracted eighteen years ago, and wore a plate with comfort for fifteen years ; but three years since, previous to which time he had always enjoyed excellent health, he felt a sharp, cutting pain dart through the alveolar process of the left upper jaw, which was, however, confined to the portion posterior to the situation of, the second bicuspid socket. From this date he was subject to excruciating paroxysms of pain which lasted from one to five minutes, and were always excited by movements of the mouth, as in speaking or eating. These attacks lasted for a week or ten days, when relief occurred for a similar period ; but, although there were intervals of freedom from these paroxysms, yet he always experienced a dull, unpleasant pain in the af- fected parts, which were not, however, sensitive to the touch, nor did they present any signs of inflammation. The frequency and violence of the paroxysms were generally somewhat lessened by the exhibition of large doses of quinia.
On the 16th of September, 1869, 1 carried an incision along the alveolar ridge as far forwards as the second bicuspid socket, which enabled me to turn aside the soft parts, including the periosteum, and to remove, by means of the cutting pliers and the gouge, the affected bone to a level with the palatine process. There was no evidence of disease either in the bone or in the soft parts.
Mr. H. called upon me six months after the operation, from the effects No. CXIX.— July 1870. 4
50
Gross, Neuralgia of the Jaw Bones.
[July
of which, as he informed me, he rapidly recovered. He has not had any severe paroxysms of pain since, and his health never was better.
Case II. — J. McN"., a labouring man, set. 51, presented himself at the clinic of the Jefferson Medical College, September 22d, 1869, on account of neuralgia of the right upper alveolar process, which was edentulous, the teeth having been extracted forty years ago. In the autumn of 1862, while on a sea voyage, he contracted a severe cold, and suffered from his first neuralgic attack, which involved the alveolar process from its posterior limit as far forward as the situation of the first bicuspid socket. Since that time he has been the subject of intermittent paroxysms of excruciating pain, during the existence of which the mastication of the softest food, or the mere act of swallowing, was attended with an increase of the suffering, while rough handling and the mastication of the hardest articles of food could be borne with impunity during the absence of the paroxysms.
The affected parts were freely removed by an operation similar to that described in the preceding case. The gum was tuberculated and very firmly attached to the adjacent bone, which was of unusually dense con- sistence. Entire freedom from suffering up to the present time, April 27th? 1870, has followed the operation.
Case III. — A lady, nearly seventy years of age, a patient of Dr. Nordman, of this city, had suffered for a number of years with severe pain of the left upper jaw, involving hardly three-quarters of an inch of the alveolar process. The cuspid and the two small grinders had been extracted long ago, the gap in the bone left by their removal being much atrophied. The paroxysms of pain were frequent and severe, and had effectually resisted a great variety of remedies employed for their relief. The health was a good deal impaired ; the body was very susceptible to cold ; the counte- nance had a woe-begone expression, and there was great mental depression. Excision of the remnant of the alveolar process put a speedy stop to the disease ; and, with the aid of a mild tonic, the woman soon regained her former health.
Case IY. — A lady, upwards of eighty years of age, had always enjoyed excellent health, with the exception of an occasional attack of asthma, and, latterly, of a severe neuralgic affection of the left upper jaw, in the situation of the three large grinders, which had been extracted upwards of fifteen years previously. The pain was generally of a dull, aching, or gnawing character, but at times it was sharp and shooting, and exceedingly distressing, having of late left her very little sleep or comfort of any kind. She was habitually peevish and fretful, and often expressed a desire to die, so great was her suffering. Some tenderness existed at the seat of the disease, but the neighbouring parts were apparently free from involvement. All the remaining teeth on that side were sound. Excision of the alveolar process was atteuded with a good deal of bleeding, coming on some hours after the operation, but the pain was at once relieved, and never returned.
Case Y. — A widow, ast. 33, consulted me last summer on account of a neuralgic affection of the left side of the lower jaw, under which she had la- boured for upwards of three years, her sufferings having at times been ex- tremely severe. The pain was greatest at the side of the two small and first large grinders, which had been extracted several years before on account of caries. It commonly came on in paroxysms, of variable duration, their violence being always aggravated by eating and talking, by disorder of the
1870.]
Jackson, Rare Disease of the Joints.
51
menstrual function and by damp states of the atmosphere. The general health was good, but the lady was habitually nervous, and much depressed in spirits. The appetite of late had been considerably impaired. The gum at the edentulous gap was often tender to the touch ; pressure with the finger usually provoked a severe fit of neuralgia. Various remedies had been fruitlessly employed. The treatment, after the case fell into my hands, was the same as in the other patients. The pain at once disap- peared, and has never returned.
The first of these cases occurred upwards of ten years ago. A number of similar examples have fallen under my observation, but as they offer nothing of special interest it is unnecessary to describe them. From all that I know of this complaint, I am free to believe that the only effectual remedy is excision of the affected alveolar process. No particular attention need be bestowed upon the after-treatment. A mild course of chalybeate tonics may be required when the patient is anaemic, or affected with flatu- lence and indigestion.
The annexed cut affords a good illustration of a pair of forceps, made
at my suggestion by Mr. Kolbe, for the removal of the alveolar process when affected with this painful disease.
Art. V. — On a Bare Disease of the Joints. By Samuel Jackson, M. D. , Emeritus Professor of the Institutes of Medicine in the University of Pennsylvania, &c. &c.
Several cases of a rare form of disease resembling rheumatoid arthri- tis, if they be not uncommon examples of that affection, have fallen under my observation in the course of my practice, an account of which may prove interesting to the profession. The peculiarity of the affection, as seen in these cases, is, that it is confined to a single tissue — the ligamen- tous— whilst the general health of the patient is not at all disturbed. I have not been able to find any similar form of the disease described, and when in London I consulted Sir Benjamin Brodie in regard to it, who confessed that it was entirely new to him.
The first case I met with was that of a gentleman residing in this city. At the time I heard of it he had been suffering for some years, and I called to ask his permission to examine his disease, which was readily granted.
52 Jackson, Rare Disease of the Joints. [July
The affection was of one of the joints of the wrist and hand, all of the bones of which were dislocated ; at every attempt to move the hand the joint was moved, but in no determinate direction, the members lying loose. The gentleman was dressed daily, and I was therefore unable to make a close examination, but I believe all of the joints were similarly diseased, though as it occurred soon after my graduation, I made but a superficial examination. He appeared to be in good health, was not emaciated, and his nutrition was apparently perfect. I made occasional inquiries, and found that the case was protracted for years.
The second case was that of a lady residing in the interior of this State whose wrists, when she consulted me, were dislocated at every movement. The late Prof. Horner, at my request, accompanied me in a visit to her, and after a careful examination we were both convinced that the cartilage had disappeared, and that the bones had been worn smooth by friction upon themselves. The patient attributed her sufferings to a cold con- tracted in sweeping snow from the piazza of her house, and had then, at the date of my first seeing her, been under treatment for over a year with- out deriving any benefit from it. Her disease gradually progressed for three years, when she died of a pulmonary affection.
The third case occurred in a lady of this city whom I found confined to bed, with every joint dislocated and stiffened. Her general health was unimpaired; she was entirely free from any disease save that in the joints, and she enjoyed an entire immunity from suffering except on any attempt at motion. She finally perished from a fever after having been incapable of any motion for years.
The fourth case was also that of a lady of this city, who sent for me on account of an acute pain in her wrist. The lady was of a fine consti- tution and a good liver, and I at first regarded the affection as gout, but from there being no alleviation resulting from the treatment which usually controls that disease for a certain time, and as the pain extended up the arm to the shoulder, and finally to the back of the neck, where it seated itself beyond the control of all the remedies employed against it, I came to the conclusion that it was another one of the cases of this form of dis- ease, and gave up her case. The disease has continued slowly to progress until, at the present time, all of her joints are affected and she can barely move.
About October, 1853, I was called to see a married lady in a family I attended, who had just returned from their country seat. She supposed herself to be labouring under a rheumatism in the right knee, which had come on in the middle of the summer. Upon making an examination, I found that the knee was considerably enlarged, and the seat of a very se- vere and constant pain. I also ascertained that the right ankle was also affected in the same manner, and that the wrists were becoming stiff and painful. The patient was otherwise in excellent health. I thought I re- cognized it as belonging to this form of joint affection, and instituted a very active course of treatment, which appeared to retard the progress of the complaint, though it did not arrest it. Finding the case obstinate, and regarding it as a rheumatism, I advised the lady to go to Havana to spend a winter there. She also visited a spring of great repute at the southern extremity of Cuba, but without obtaining any relief. From there she went to Key West, and after her residence there, visited. Charleston, where she was under treatment. She then returned to this city, where she re- mained till late in the year 1863, when she sailed for Brazil, whence she
1870.] Burrall, On Nervous Symptoms, with Excess of Urea. 53
returned in the following year. During all this time the disease gradually progressed, stiffening the joints until she became incapable of motion, and had to be always carried about, fed like a child, and waited upon as one incapable of any exertion, no matter how small, or of what nature. And yet her general health is perfect and has always been so; her organic functions are unimpaired, and her spirits not affected. She has been for some years in this condition without a prospect of improvement.
The sixth case presented itself in a young lady who lived here. The disease had progressed so far as to stiffen her ankle and knee-joints and prevent her walking, when I ordered the use of Penny's bath. She had not taken many when she removed to the country, and, by my advice, lived upon a milk diet. After some time she returned to the city, and, to my great surprise, was able to walk to see me, a distance of several squares from her residence, She remained free from any symptoms of this disease for three years, when she returned to the country and relapsed. I do not know her condition at this time.
When visiting a family I was requested to see the wife of a gentleman residing in Germantown, who was on a visit there. At the time she con- sulted me I found that the knee-joint was stiffened and enlarged, and the wrist becoming painful. The ankle-joint was also threatened. I saw at once that I could not benefit her, and, though her family were very desirous I should attend her, my health was too feeble to undergo the fatigue of visiting her at such a distance. I saw her on but that one occasion, though I understood that her disease continued to advance. She went under hydropathic treatment, which did not afford any relief, and died in a few years.
The last case was a young English lady, who was brought to my notice by one of the graduates of the course of 1863. She was then in the last stage of the disease. I saw her lying upon a couch to which she was re- moved from her bed every day. In lifting her, great care was taken to prevent a dislocation of the hip-joint. All of the joints of her hands were displaced. She was suffering great pain, and was so much reduced that it was evident she was approaching the termination of her sufferings. She died in about ten days after my visit. I endeavoured to obtain an inspection of some one of the joints, but the family obstinately refused.
Art. YI. — On the Coincidence of Certain Nervous Symptoms with the Presence of an Excess of Urea in the Urine. By F. A. Burrall, M.D., of New York City.
In this paper are narrated a few cases which have fallen under my own observation in which a peculiar variety of nervous symptoms was accom- panied by a marked excess of urea in the urine. To these are added some extracts upon the same subject, which have as yet been imperfectly elabo- rated, and further, certain considerations upon the etiology and treatment of the disease.
The following case is from my note-book December 21, 1868. Having
54 Burr all, On Nervous Symptoms, with Excess of Urea. [July
been struck with the relation which uric acid and the urates bear to a large number of diseases, I had made notes of this and other similar cases, with a view, if possible, of grouping those affections in which a uric acid dia- thesis seemed to exist.
Case I. — The patient was a middle-aged gentleman of sanguine tem- perament who had for some time been suffering from various disagreeable nervous symptoms, such as depression of spirits, excessive irritability, tin- nitus aurium, and general malaise. His appearance was that of average health. There was an antecedent history of gout, though in a distant rela- tive (mother's uncle), and the patient was what is termed a meat-eater. The appetite was not excessive, there was a marked tendency to acidity, and the bowels were regular. Cold bathing could not be borne ; in fact the pa- tient was very susceptible to cold, and perspired with difficulty. He suf- fered occasionally from pain in the lumbar region. His nervous symptoms were so severe as to render him at times very miserable. He had been in the habit, so common with many men of business in New York, of hastily drinking spirits, or malt liquor, several times during the day. This cus- tom seems to prevail in this city partly as a habit, and partly to brace up a weary system for the excessive strain which is peculiar to the activity of business life in New York. An examination of the night and morning urine mixed, showed it to be sherry-coloured, slightly cloudy, acid, and having a specific gravity of 1030. There was no deposit on boiling. Half a drachm of pure nitric acid was placed in a watch glass with a drachm of urine, not concentrated or evaporated, when a copious deposit of nitrate of urea soon appeared. A similar change was also observed under the micro- scope when a drop of nitric acid was added to urine on the slide. The de- posit in the watch glass gave the urine the appearance of being partially frozen. The patient was not in the habit of passing an unusual quantity of water.
The treatment was commenced by a discontinuance of stimulants and the use of the "Vichy with lithia" water. Three grains of bicarbonate of soda and a grain of ipecac were ordered to be takeu at bedtime every other night, and a pill containing a grain of sulphate of quinia, one-fifth of a grain of ext. of nux vomica, and one-half of a grain of sulphate of iron, to be taken three times daily.
January 5, 1869. Patient feels much better. The deposit in the urine on a recent examination was found to be less. Ordered to stop pills and powders and continue the Vichy water. The pill was intended as a substi- tute for stimulants.
IZth. Patient complained of a " swollen" feeling in his head, although his general health was improved. He stated afterwards that he derived much benefit from a pill of valerianate of quinia combined with quinoidia which I then gave him.
March 4. General health has continued to improve, disposition and spirits seem much changed, and the tinnitus has disappeared.
2bth. A few days since patient, who had been feeling well previously, ate veal and lobster salad at dinner. He was at this time under some mental anxiety. Next day he suffered from a great pain over the sacrum and a sensation at the vertex described as a "jerking pain" which was also felt in the left eyebrow ; these sensations were accompanied by intense misery, for this language is not too strong to use in describing the mental condi- tion. On coming to my office he brought a bottle of urine passed March
1870.] Burr all, On Nervous Symptoms, with Excess of Urea. 55
23. This specimen contained a copious deposit (urates) which disappeared on boiling. At this time his visits were discontinued.
Case II. — A merchant 45 years old had for two years been suffering from uneasy sensations in the head, resembling vertigo and described as a feeling of heat at the nape of the neck followed by a sensation as of a wave passing up on the head and producing a sense of insecurity and fear of apoplexy. His temperament was a mixture of the bilious and nervous. Tongue was furred, but although the patient had a habit of eructating he was not conscious of suffering from dyspepsia. He was a moderate eater, did not drink to excess, but occasionally took a glass of whiskey before retiring. He was easily chilled and liable to tremble or shiver when in the cold air. He slept badly, was much depressed in spirits, and feared either mental derangement or apoplexy. There had been occa- sional attacks of what, from his description, seemed to be muscular rheu- matism. The amount of urine passed daily was from one to three pints, which was frothy when discharged. An examination of the night and morning urine mixed, showed it to be sherry-coloured, acid, with a specific gravity of 1080, and containing a thick whitish cloud which disappeared on the application of heat. The microscope revealed an abundance of urates in the form of very minute round bodies. On pouring some of the urine, which had neither been concentrated nor evaporated, into a watch-glass, and adding pure nitric acid in the proportion of one of the acid to about two of the urine, nitrate of urea soon appeared in abundance. There was no sugar visible in another specimen of the urine submitted to Trommer's test. Patient was ordered to be careful in his diet, and a mixture prescribed of bromide and iodide of potassium to be taken three times daily. It should be added that the use of stimulants was not interdicted, but a recommendation was made that the quantity should be lessened.
Nov. 27. Patient sleeps well. He has had scarcely any unpleasant symptoms. An examination of the urine showed it to be acid, and with a specific gravity of 1024. There was a slight cloud on boiling, which disappeared on the addition of nitric acid. Under the microscope were seen only a few epithelial and mucus cells.
Dec. 1. Had a return of some of his " head symptoms" two days since, which seemed to have been produced by mental anxiety. An examination of the urine passed this morning for urea showed a deposit of crystals round the edge of the watch-glass, but somewhat less than on the previous examination. Urine was sherry coloured, and had a specific gravity of 1024.
Uh. Has not suffered from uneasy sensations in his head, but does not sleep well. He was ordered to continue the mixture previously used, and to take every other night a pill containing calomel, ipecac, aloes, and extract of colchicum, each a grain.
Jan. 5. Pill acted very freely, and patient was directed to diminish the dose one half, as there were no clear indications for the use of purgatives. He was also ordered to continue the mixture as before. He has given up stimulants, and has no head symptoms.
\Wi. Urine of night and morning mixed, has a specific gravity of 1020, and is of a paler hue. It contains a cloud which disappears on the addi- tion of heat. When mixed with nitric acid in a watch-glass in the pro- portion of one of acid to three of urine and allowed to stand, only two
56 Burr all, On Nervous Symptoms, with Excess of Urea. [July
small points of crystallization appeared after it had stood for an hour. Patient is greatly improved in health and spirits.
Case III. — In October, 1868, I was consulted by a gentleman about fifty years old, who had long been subject to acidity, and suffered from what he supposed to be (that extremely vague disease) biliousness. He had not suffered from neuralgia or rheumatism, but took cold easily, and if he committed any errors of diet when suffering from a cold, was liable to violent and sudden colic. He had occasional attacks of vertigo, did not sleep well, and frequently experienced extreme depression of spirits, which sometimes made him fear mental derangement. Circulation languid, flatulence often present, and the stools small and rather dark. At that time the case seemed to me to be one of chronic dyspepsia, and he derived some benefit from the use of bicarbonate of soda. Recently an oppor- tunity offered of making an examination of his urine, which I did, inform- ing him previously that I expected to find the condition which is the sub- ject of this essay. The urine examined was that of night and morning mixed, and the quantity passed during the twenty-four hours was about a quart. There was no pain in micturition. The specimen was dark sherry coloured, with a well-marked urinous odour ; acid, had a specific gravity of 1030, and a cloud appeared on the application of heat, which disap- peared by adding a drop or two of nitric acid. Tro turner's test gave no reaction of sugar. On testing for urea, as in other specimens, with one- third part of nitric acid, the crystals of nitrate of urea began to appear in ten minutes, and in half an hour were abundant. It should be stated that stimulants did not agree with this patient, and he was quite a mode- rate liver.
A short time since I informed my friend, Dr. Farnham, of this city, concerning this class of cases, and on calling at his office subsequently he showed me a copious deposit of nitrate of urea from a patient labouring under intense nervous depression. This patient also slept badly. He was not addicted either to smoking or drinking. The urine was frothy, with a strongly urinous odour, of a high amber colour, with a specific gravity of 1025.5, and holding a slight mucous cloud. There was no albumen and no sugar with Trommer's test.
The literature of this subject is scanty. The observations in this essay
are, I believe, the first which have been reported by an American physician.
In Roberts on " Urinary and Renal Diseases," page 92, it is stated : —
" Dr. Prout believed that there existed a peculiar morbid state characterized by an absolute and relative increase of the excretion of urea, unaccompanied by pyrexia. To this condition Dr. Willis, who adopted the view of Prout, gave the name of azoturia. The subjects of this form of disease, according to Prout, had usually a frequent and urgent desire to pass water, both by night and day.1 This seemed principally due to an irritable sensation referred to the neck of the bladder, occasionally extending along the urethra, but in some cases it was due, at least in part, to real diuresis. In almost every instance the quantity of urine voided in the twenty-four hours was somewhat above the na- tural standard. The quantity was also particularly liable to be increased by causes which would scarcely affect a person in perfect health, at least to the same degree ; such as by a chilly state, mental emotion or excitement, etc.2
1 Not observed in the eases reported in this Essay.
s Prout : Stomach and Renal Diseases, fifth edition, p. 97.
1870.] Burrall, On Nervous Symptoms, with Excess of Urea. 57
" In addition to the direct urinary symptoms there was sometimes a sense of weight or dull pain in the back, accompanied by disinclination to bodily ex- ertion ; there was no remarkable thirst nor craving for food, nor emaciation. Moreover, the functions of the skin appeared to be little deranged.
" Such is a summary of the description of Prout. He does not supply any details as to the daily flow of urine nor the daily amount of urea. At the time Prout wrote, very little was known as to the natural (physiological) variations in the excretion of urea, and the opinion he held as to urea being chiefly the final product of the metamorphosis of the gelatinous tissues, has since been proved to be erroneous. Looking at the question from the standing point of the physiological doctrines now in the ascendant, it is difficult to admit the ex- istence of a condition characterized by the incompatible coincidences of an increased excretion of urea with absence of thirst, absence of excessive feed- ing, and absence of emaciation.
'* Precise facts in support of Prout's view are wanting. "Willis' description is too loose to give much confidence, and subsequent writers have contented themselves with a reference to Prout and Willis."
Farther on Dr. Roberts adds : —
" Nevertheless, some facts, rarely observed, have left an impression on my mind that Prout's description is not altogether fanciful."
Beale writes : —
" Lehmann, I think, states that he had not seen a case in which crystals of nitrate of urea were thrown down upon the addition of nitric acid without previous concentration.''1
Beale also says : —
" There are some peculiar and very uncommon cases in which the urine con- tains this excess of urea ; and at the same time more than the healthy amount is excreted in twenty-four hours. The patient is weak and grows thin in spite of taking a considerable quantity of the most nutritious food. He feels languid, and indisposed to take active exercise. In some cases digestion is impaired ; in others, the patient eats well, experiences no pain or uneasiness after food, and perhaps has a good appetite. Sometimes there is lumbar pain. It would seem that most of the substances taken as nutrient material become rapidly converted into urea, and are excreted in that form. The waste of the tissues is not properly repaired, and the patient gets very thin. To refer these symp- toms to the existence of a particular diathesis affords no explanation of the facts. The pathology of these remarkable cases has not yet been satisfactorily investigated."2
It is evident that the observations of those writers who have in late years given especial attention to urinary deposits are incomplete with regard to this subject, and an interesting field seems open for study.
In the Medico- Chirurgical Transactions for 1868 (vol. li.)3 is a mas- terly article on this subject by Dr. Henry William Fuller, physician to St. George's Hospital. It is not necessary to add that anything from his pen is entitled to careful consideration. He states that within the last two years he has detected urea in excess in twenty-seven cases, " and so well marked and peculiar are the symptoms by which that condition of the urine is accompanied," says he, " that now, if the features of the patient's malady induce me to suspect its existence and to examine the urine with
1 Kidney Diseases and Urinary Deposits, page 186. See also No. of this Journal for April, 1868., p. 533.
2 Page 187.
58 Burrall, On Nervous Symptoms, with Excess of Urea. [July
a view to its discovery, I am seldom disappointed in obtaining the charac- teristic crystals of nitrate of urea."
In another part of the article he writes : —
"All the instances which have come under my notice have had several features in common. With one exception, that of a lady aged 43, the patients have all been males, varying in age from 23 to 54. Most of them have been essentially meat eaters, partaking sparingly of bread and other varieties of farinaceous food, but five of them ate meat only twice daily, and one, a member of our own profession, declared, not only that he never touched meat except at dinner, but that even then the principal part of his meal consisted of vegetable and farina- ceous food. Without exception the patients have been tolerably healthy in appearance, and often somewhat florid, though in some instances they have lost flesh slightly ; indeed their aspect has been so little indicative of disease, and their complaint of suffering has been so urgent, that any practitioner who did not examine the urine for urea would have surely regarded them as simply hypochondriacal. Usually the pulse has been quick and rather weak, and the patient's complaint has been of languor, flatulence, restlessness at night, and extreme nervousness. They have been afraid of encountering the rubs of every day life, and in some instances have for the time lost their pleasure in society ; they have eaten fairly, though with less than their usual relish, and the feeling of languor which has oppressed them, and of fatigue which has followed even a moderate amount of exertion, has led to their abstaining almost wholly from exercise. They have usually complained of extreme depression in the morning, with a sense of heat about the eyes, muzziness in the head, and weariness after breakfast — feelings which have in some measure passed off as the day has ad- vanced, and they have partaken, as usual, of stimulants."
Further on he writes : —
" Dr. Parkes, referring to Dr. Prout's observations on these cases of azoturia, distinctly states, 'I have never seen a disease of this kind.' It is obvious, therefore, not only that this condition of the urine has, in many instances, escaped recognition, but that the form of derangement on which it depends requires careful investigation."
In examining those cases of the disease which have been reported with a view to ascertaining its etiology, the exciting cause, in some instances, seems to have been mental anxiety, in others, it has apparently arisen from defective assimilation which has produced the characteristic nervousness and depression. In all cases the mental condition has probably reacted upon the disease, while the disease has tended to prolong the morbid mental state. In one of my own cases the commencement of the mental symptoms was attributed to a nervous shock.
We must look to pathology for aid in endeavouring to discover the essen- tial nature of the affection, and probably there is no better guide than the writings of Dr. Bence Jones, who, in his "Lectures on' Pathology and Therapeutics," has studied morbid processes with a view to add new light to the intelligent treatment of them. Taking his views as a basis, it would seem as if this were a malady of suboxidation, and in some respects similar to the diseased condition which is present in gout, for he says on page 130 : —
" When analysis shows that an excess of uric acid is thrown out of the body, this is a proof that the gouty diathesis is ready to form whenever the kidneys cease to remove the excess from the system. The presence of any urates at all in the urine is a sign that oxidation is not so perfect as it might be, and the
1870.] Burrall, Ou Nervous Symptoms, with Excess of Urea. 59
more urates in the urine the more imperfect the oxidation in the system must be considered ; but as long as the products of the imperfect oxidation are thrown out by the kidneys or skin no gouty diathesis is produced."
" Thus, then, first, excess of urea in the urine ; secondly, oxalate of lime with excess of urea ; and thirdly, urates in excess, by analysis, constitute the three tests of the different degrees of suboxidation which precede the establishment of gout."
This is one of those diseases in which we should hesitate before using stimulants in our treatment, a point of great importance. The physician would be very likely to recommend them in consequence of the depression and apparent weakness which are present, but alcohol interferes with oxi- dation. In one of the cases which came under my notice, stimulants had been prescribed with the effect of aggravating the symptoms, and in another, the patient found that giving up stimulants had been of more service than any other element of treatment. It may be that they will sometimes be required and then the light Rhenish wines should have the precedence. Of course it is very important that the mind should, as far as possible, be pleasantly occupied and the patient's thoughts diverted from himself. A certain degree of relief will in some instances be afforded by demonstrating to the patient that his morbid sensations are associated with a visible lesion, for nothing is more dreary to a sick person than to feel that he is suffering from a disease supposed by others to be imaginary and with regard to which he often receives but little satisfaction from those whom he consults. With this demonstration can also be held out a hope of relief. The diet should be easily assimilable and regular exercise be recommended. One of my patients had been much benefited by systematic rubbing, which proba- bly improves oxidation by increasing the activity of the circulation, and hastening chemical changes. As is well known, alkalies have for years beeu found useful in correcting the gouty diathesis, and experience would naturally suggest the use of them. "Alkalies," says Dr. Bence Jones, "assist in the oxidation of organic substances, not by giving oxygen, but by promoting the formation of vegetable and animal acids, and ultimately forming carbonates out of the burning matter." It is worthy of notice that those who have mentioned this class of cases have used a somewhat similar treatment without clearly established indications. Dr. Fuller con- siders the disease to be "a perverted nervous action in consequence of dis- turbed assimilation." He recommends "neurine tonics, such as arsenic, quinia, strychnia, iron, and zinc, together with the mineral acids, the shower-bath and the dripping sheet." These, with alterative doses of blue pill and colchicum, he has usually found to afford relief. In one or two cases of extreme nervousness he has used the bromide of potassium in conjunction with iron, and occasionally the hypophosphite of soda. In a case mentioned by Dr. Roberts, which, he says, " seems to have been one of those Prout had in view," the treatment consisted of vegetable tonics with citrate of potassa, under which the patient's health greatly improved.
60 Burr all, On Nervous Symptoms, with Excess of Urea. [July
The advantage of studies like that which composes this paper is, that they tend towards increased knowledge of the essential nature of disease, and remove our practice farther from empiricism. Besides, we often feel the necessity in treatment of keeping the diathesis of our patient in view without looking for a particular set of symptoms which only appear when the diathesis is fully developed. Our nosology is in many instances a grouping of names which are but the names of symptoms. Who can believe that such terms as inflammation, or dyspepsia, or gout will always answer to an increased knowledge of morbid processes. Already we see diseases such as dyspepsia and consumption split up into various varieties, and we can hardly realize that smallpox and measles and scarlet fever were formerly confounded together. We see pneumonias which, so far as treat- ment is concerned, closely resemble rheumatism and a large variety of pains which are the expression of different conditions of the constitution.
The test for nitrate of urea is one which may be employed by any general practitioner, for " a specimen of urine which yields crystals of nitrate of urea, when an equal bulk of nitric acid is added to it in the cold without having been previously concentrated is said to contain excess of urea."1 The quantity of urea sometimes found is also very striking. It is of course important to know how far the quantity of urine passed in the twenty-four hours approaches the normal standard. The test is also valuable in differ- ential diagnosis as aiding us to distinguish between nervous symptoms resulting from anasmia and those which accompany an excess of urea in the urine.
This study also suggests the necessity of examining the urine in cases of vertigo, to see if this symptom may not be one of the many in which uric acid or its congeners may manifest itself. It would also be well to see how far sleeplessness may, in some cases, depend upon a similar cause. Here it may be mentioned, as showing how this group of excretions pre- sent themselves in various diseases, that in 1860 I found a very marked excess of urea in the urine of a patient who suffered from intolerable headaches, and here, after trying a number of remedies in vain, the appli- cation of leeches to the nape of the neck gave very marked relief. I have also found the spiculated crystals of urate of soda in the urine of puerperal mania.
We may, besides, be led to inquire as to how far those alkaline remedies, such as muriate of ammonia, valerianate of ammonia, and bromide of potassium, often so efficient in nervous disorders, owe their effects to the combination, with a nervine, of one of those alkalies which combine with or dissolve uric acid. We leave the subject without entering upon an undue length in its consideration, since we trust there are some points of
Kidney Diseases and Urinary Deposits, 3d edition, page 185.
1870.] Holden, Inhalation of Nitrous Oxide Gas. 61
novelty here presented, which may at least awaken the inquiries of others, and we would bear in mind the quotation " that the increase of knowledge is not like that of other things, being often accompanied by a considerable diminution in bulk."
Art. VII. — On the Inhalation of the Nitrous Oxide Gas when the Lungs are Diseased. By E. Holden, M. D., of Newark, N. J.
The cases which form the basis of the following article will probably commend themselves as of some interest to any physician called often to answer the question, " Can I inhale gas at the dentist's with impunity ?" The observations from which the cases are selected have been numerous, and the cases themselves are, in a measure, typical of classes.
The availability of this gas for slight and brief surgical operations — its speedy action and the equally speedy disappearance of all effects of anaes- thesia, are making its use so common that all information regarding it must prove of value, and especially so in view of the awakened interest in the subject of inhalation of gases as curative agents. I may be pardoned . for parenthetically stating that, while my own experience with nitrous oxide as a therapeutic agent in phthisical cases has been anything but favourable, and I have seen haemoptysis immediately follow a carefully con- ducted inhalation of oxygen, yet I by no means felt assured that their inhalation per se was especially injurious at the commencement of the present investigation. Nitrous oxide in its purest state produces rapid venosity of circulation ; the great founder of the German medico-anatomi- cal school, Rokitansky, asserts that a condition of venosity is inimical to tubercle (p. 241, vol. ii.) ; theoretically, therefore, the gas should be bene- ficial in tuberculosis. Oxygen produces, of course, the opposite condition.
Tuberculosis, according to not a few brilliant labourers of the present day, is but a commencing death of organism — an excessive retrograde metamorphosis of tissue-destruction without adequate repair, and which the oxygen of mountain air and of unrestrained out-door life is credited with power to arrest ; theoretically, therefore, oxygen should be beneficial by inhalation. M. Demarquay has recently experimented in this direction, and paradoxical as the ideas in the cases as stated may be, they are easily reconcilable by the belief that neither of the gases as used has been, or is likely to be, curative. The general effect, however, of the agent under consideration, when persistently and frequently inhaled as a therapeutical means, has little to do with the answer to the question already quoted, and which can be more pertinently rendered, " Can I, having diseased
62
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lungs (and especially if subject to haemoptysis), inhale nitrous oxide gas at the dentist's with safety ?"
Most of the cases from which the following have been selected have been observed at the dental rooms of Dr. J. B. Da Camara, in this city (Newark, N. J.), whose extensive experience with the gas is probably second to none in this country. The gas was made in the ordinary way by heating nitrate of ammonia in a retort, maintaining a temperature of 400° to 500°, and thoroughly washing through successive jars of water. The ammonia was selected with especial care, in order to avoid accidental contamination with hydrochloric acid, the presence of which invariably results in an ad- mixture of free chlorine with the peroxide, and consequently in an irritant effect upon the lungs. It is well to observe that frequently persons presented themselves who had at other places tried inhalation in vain, violent head- aches, convulsions, suffocating sensations, &c, had invariably necessitated abandonment of the effort ; yet they succumbed with greatest ease when the pure gas was administered. This point is the more important, since none of the effects noted in the subjoined cases can be attributed to im- purity of gas.
From the washing-jars the gas was conducted to large metallic retorts, holding from 400 to 500 gallons, and made fresh every day, since it is a singular fact that age seems to impair its anaesthetic power, and gives rise to symptoms never observed when the gas is used in freshness and purity. This impairment is far more marked when rubber bags are used as holders, and seems to admit of explanation in such cases ; but in metallic receivers suspended in water already saturated with all the gas possible to be absorbed (three-fourths of its bulk), without escape and without diminu- tion of volume, reason for loss of anaesthetic power is not so apparent.
The inhalation was performed with total exclusion of atmospheric air through a mouthpiece of silver which fitted accurately about the cheeks and lips, expiration being performed through a valve in the same piece. The patient was always in the sitting posture, to facilitate easy and fre- quent auscultation and percussion.
The two following cases may be interesting as illustrative of the general effects of inhalation upon a healthy person.
Case I. — A girl, set. 12 years ; ruddy complexion ; about average size ; lungs, heart, and indeed all organs, in sound condition ; no nervousness or apprehension ; pulse 65, after steady inhalation for one minute ; pulse accelerated without increased number of respirations ; rapid discoloration of lips, then of extremities ; no distension of superficial veins ; marked lividity of whole face ; eyes remaining open (not a universal rule, but rather unusual) disclosed slow dilatation of pupil ; eyeballs visibly receding as after death, and the countenance corpse-like ; anaesthesia complete before expiration of second minute, and preceded by slight struggling as if to prevent suffocation ; pulse 80, soft and regular ; inhalation discontinued ;
1870.] Holden, Inhalation of Nitrous Oxide Gas. 63
duration of anaesthesia fifteen seconds ; time from instant of complete anaesthesia to complete and perfect recovery, between one and two minutes.
Lungs in this case not examined during anaesthesia ; as a result, how- ever, of many examinations of others, the following statement may be considered illustrative : —
The first change, and one that usually occurs after the third or fourth full inhalation, is a marked softening of bronchial air sounds, and intensi- fication of the vesicular, followed by speedy intensification of the former and obliteration of the latter. Then follows the sub-crepitant rhonchus indicative of mucus in the finer bronchial tubes, then rapidly the sounds of air-bubbles in the larger tubes, prolonged respiration, and vocal resonance.
In several cases suffering from the commonly-styled " stuffed" feeling that often ushers in a subacute attack of bronchitis, and in which a marked sibilant character was observed in the passage of air through the finer bronchi prior to inhalation, a remarkable cessation of such sound was observed after a few inhalations, whether correctly or not, and was attributed to sudden relaxation of bronchial spasm. This peculiarity will be again referred to in connection with Supplementary Case II.
The second of the cases designated illustrative is more rare, because anaesthesia is peculiarly rapid, and unaccompanied by lividity or other noticeable symptom.
Case II. — Male, set. 27, unmarried; temperament sanguine; complexion fair; health good, and believed sound in all respects, but mother died of consumption, and party had suffered from (strumous) necrosis of femur, and might, perhaps, be said to be more than usually susceptible to influ- ences of temperature.
Examination prior to inhalation revealed weakness of vesicular quality, want of proper breeziness and tone to general respiration, a condition sug- gestive also of imperfect resilient power of lungs, but no disease ; pulse 72.
One inhalation produced incoherence of speech, and four anaesthesia. Examination during inhalation gave results similar to those stated as common to sound lungs, but no lividity of extremities or lips existed ; vesicular quality of respiration absent during the whole period of anaes- thesia, however, and gums and inside of cheeks of clearly venous hue ; pulse 80 to 95, and variable. Anaesthesia prolonged two minutes ; re- covery complete in two minutes, and normal condition of lungs restored within that time.
The following notes also, taken at intervals during the five months occu- pied in the investigation, may be of interest : —
a. Nitrous oxide inhaled in the manner indicated produces no tendency to laughter, admixture with atmospheric air being essential to the devel- opment of this well-known characteristic.
b. There is usually considerable struggling at the approach of anaes- thesia, occasionally suggestive of desire to escape suffocation, but which is probably owing to an automatic impulse occasioned by the thought of pos-
64 Hold en, Inhalation of Nitrous Oxide Gas. [July
sibility of suffocation already existing in the mind of the patient, since the subject last in the mind becomes the foundation of any dream that may occur ; for example, the bubbling of water produces in the semi-uncon- sciousness just preceding and following anaesthesia a dream of music ; the steady tick of a clock, the roar of the surf on the beach whispers of plea- sure or pain, the scenes or instruments that usually give rise to these emo- tions. It is probable, also, that in this way we may explain the evident erotic tendencies that are so frequently developed, the most chaste and virtuous being liable to gestures and movements which, if not so evidently automatic, would be considered most lascivious. (See Supplementary Case I.)
This tendency is, without doubt, the result of the thought of possible violation ; for the subject of it is almost universally a female, and there are few who sit down in a dentist's chair who have not heard or read of the stories regarding such attempts upon females while in a state of un- consciousness, and almost always where this erotic excitement is developed there are none but males present, the patient partly reclines with feet some- what elevated, and a fear, perhaps only momentary, that there is danger, would be a most natural one.
c. There is almost always intensification of the senses, especially of sight and hearing, just prior to unconsciousness, and in spite of the seem- ing contradiction in the statement this intensification may possibly con- tinue in many cases throughout (the faculties of memory and coordination being in abeyance), for however oblivious upon recovery a person may be of having suffered pain, yet the contortions of countenance and occasional screaming show that feeling is not destroyed ; of course it is not asserted that anaesthesia cannot be made so complete as to utterly destroy feeling, but usually this is not the case, although to all intents and purposes un- consciousness is perfect, and no memory of pain exists upon recovery. I am indebted to the dentist, at whose office many of these experiments were made, for a suggestion which is probably a correct one in reference to the anaesthesia produced, which is that there is simply a lightning-like flow of ideas with impairment and in many cases obliteration of memory, for a person may stand erect and gradually inhale sufficient gas to produce com- plete oblivion, and experience all the minute shades of thought and feeling that belong to every-day life, and this through an apparent series of days and weeks and even years, live, travel, be ill and recover, enjoy, suffer, and in fact undergo a distinct existence, and yet recover consciousness in time to prevent falling. If in this ecstasy a tooth be drawn, or other surgical operation be performed, the painful sensation is intruded upou with such lightning-like rapidity, and is so speedily merged into the tissue of the dream, as to be overwhelmed and forgotten.
d. Vision is, as I have said, frequently intensified, and perhaps invariably so long as a state of semi-consciousness is maintained ; the minute twigs
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G5
on somewhat distant trees, the fine letters upon street signs, faces out of recognizing distance, &c, are brought within range often to an astonish- ing degree. Hearing is also intensified, although greater care is necessary to maintain only a certain amount of aesthesia, for the line is easily crossed, and dulness of hearing is the consequence.
e. There is occasional (not invariable) dilatation of pupil.
f. There always exists an increased tendency to bleed, whatever be the condition or temperament of the patient, and whatever be the part of the body cut or abraded. The case of the young girl cited first, as illustra- tive, was the subject of severe hemorrhage from the gums during the ope- ration of extracting teeth, and at intervals, for three weeks following (on two occasions to syncope).
g. Three patients, the subjects of epilepsy, hysteria, and epileptiform hysteria respectively, came under observation, in regard to which the fol- lowing extracts are made from notes: —
The first, a girl of 19, who had been subject to convulsions since child- hood, exhibited no tendency to convulsion during, or subsequent to, anaes- thesia, although she had suffered from attacks as often as ten or twelve times a week for several weeks prior to inhalation.
The second, an octoroon aged 21, had been the victim of as frequent attacks of epileptiform hysteria; she had two convulsions in quick suc- cession upon the approach of unconsciousness, and several immediately after (no dilatation of pupil, and no lividity).
The third, typical of a very large class of patients, exhibited violent hysteria immediately upon regaining, or rather approaching, consciousness, and for several hours suffered recurrence of attack.
h. While an antipathy that may be termed idiosyncratic may actually exist to the inhalation of the gas, inability to produce anaesthesia almost invariably arises from impurity of the anaesthetic, or from its staleness, and a large majority of all the headaches and subsequent bad feelings that are sometimes complained of, undoubtedly arise from the same cause. Case TV. is, however, an exception to this rule.
Case I. — Male, set. 35, 5 feet 10 inches high, 140 pounds weight, florid complexion, healthy appearance, had occasionally raised blood last winter and ten years ago, at each of these periods, covering a space of six weeks ; had also had two attacks of unconsciousness attributed to sunstroke; has often inhaled the gas.
Examination of lungs prior to inhalation showed disease of one apex probably tubercular, incipient, and quiescent. Five full inspirations pro- duced marked lividity of lips and speedy anaesthesia, with twitchings of muscles, and symptoms of threatened convulsions. Examination during unconsciousness showed in vicinity of disease first, rapid extension of area of dulness, accompanied by increased resonance of bronchial air sounds, intensification of vocal resonance (the occasional moans of patient being transmitted with singular acuteness), then fine crepitation in vicinity of disease gradually appearing also in healthy portions of both lungs and becoming a marked coarse rhonchus at apices with total disappearance of vesicular murmurs.
No. CXIX.— July 1810. 5
66 H olden, Inhalation of Nitrous Oxide Gas. [July
Upon withdrawal of the anaesthetic, recovery was remarkably rapid (30 seconds).
Examination immediately after return to consciousness gave a generally intensified respiratory murmur with diminished vesicular quality, and rales more or less pronounced, bronchial murmur tubular, two points in one lung near the base an occasional twang as of a snapped guitar string, restoration of normal quality and condition too rapid to permit proper percussion (45 seconds), restoration of natural colour to lips and face equally rapid.
Examination twenty-four hours after inhalation showed normal condition restored in healthy portions, and no marked change at point of disease.
Patient states that having had occasion to inhale frequently both in this and a former winter, he had been subsequently troubled with raising of blood and irritative morning cough, which discontinued upon renouncing the practice.
Case II. — Male, set. 54; mastication of food impaired by loss of teeth, and therefore dyspeptic; has a cold, states that lungs were always weak ; never raised blood, has the appearance of moderate health. Examination prior to inhalation : Right lung sound, left gave pronounced bronchial breathing at apex ; expiratory murmur jerking and wavy; vocal resonance behind scapula over a space of two square inches, no signs of softening or vomicae; pulse 90.
Under inhalation, nervous struggling somewhat during second half minute; lips and nails livid ; becoming partly unconscious, tore away the inhaler; after two minutes again inhaled; unconscious in one and a half minutes; recovery commenced almost immediately upon withdrawing gas ; laughter and crying; volubility with connected and intelligible speech two to three minutes, during which, examination was again made; pulse 100.
Examination during unconsciousness gave duplication of sounds stated under Case I.
Examination after discontinuing inhalation gave bronchial breathing well marked and iuclined to tubular, over whole of upper portion of both lungs ; vesicular character of inspiratory act replaced by sibilant murmur ; crepitation in vicinity of solidified tissue ; gradual return to normal char- acter ; party expresses a sense of great relief in breathing, and feels gene- rally better than before inhalation.
Case III. — Young lady aet. 24, states that she has weak lungs ; never raised blood ; takes cold easily ; is subject to pain in left shoulder ; com- plexion good ; appearance that of average health.
Examination before inhalation : right lung sound ; left, under scapula, shows vocal resonance, pronounced bronchial breathing, prolonged expira- tory murmur, and in short the evidences of consolidation of tissue without softening or local inflammatory action.
Under inhalation pulse ran down rapidly, becoming weaker, till almost imperceptible ; much gas required ; lividity not marked ; nervous twitch- ing and convulsive struggling considerable.
Examination after anaesthesia (two minutes) confined to spot above re- ferred to : Breathing amphoric ; fine crepitation in vicinity of consolidation (vesicular murmur elsewhere clear and distinct) ; no increase or change in sensitiveness of part ; sounds strongly suggestive of the accession of dis- eased action upon a latent phthisis, such as is usually ascribed by the patient to a new cold.
1870.] Holden, Inhalation of Nitrous Oxide Gas. 67
Case IV. — Female, set. 35 ; has had occasional attacks of dyspnoea upon exertion, referred by her physician to disease of heart ; has tried before to inhale nitrous oxide without success.
Examination prior to inhalation showed signs of incipient phthisis in both lungs at apices ; heart sounds suggestive of dilatation (weak action and heightened systolic pitch) ; apex beat, however, distinct ; no undula- tory impulse, no prolonged post-systolic silence.
Inhalation of more than a few breaths of gas impossible, although pulse remained unchanged, and no signs occurred of systemic obstruction ; upon removing the tube patient gasped convulsively for about a minute.
Examination during inhalation gave simple respiratory murmurs, puerile in character, with no other change; heart sounds more forcible with less quickness, exaggerated but not sharpened, giving to the ear a sensation of fulness or roundness.
Inability to inspire seemed to arise from loss of control over respiratory muscles, the pulse not accelerated nor heart's action laboured.
The same phenomena occurred at two previous inhalations.
Case V. — Female, married, set. 36, delicate in appearance, had taken gas before with no ill effect ; knows one lung to be weak ; no preliminary examination.
Examination during inhalation and while recovering consciousness : Right lung presented sounds common to well lung under anaesthesia (i. e., exaggeration of respiratory murmurs, the tubular character of bronchial air column predominant) ; left lung gave all the sounds of cavity with progressive softening and singularly modified metallic tinkle ; as patient was recovering consciousness she moaned, and vocal resonance was found well marked ; great dulness on percussion, and apparent consolidation over large portions of upper lobe of left lung.
These sounds gradually changed, and in two minutes it was evident that no cavity existed, but that a small space of lung tissue was impervious to air and had been or was the seat of disease.
For several minutes the evidence of vascular congestion of the vesicular capillaries was well marked, and for five minutes after commencing to re- cover fine crepitation in the vicinity of consolidation showed an increased secretion of mucus.
Lividity of lips and finger-nails not' well marked, and pulse fluctuated, probably from involuntary struggling. This patient had at times been troubled with severe cough and expectoration ; never raised blood, but was subject to paroxysms of coughing upon rising in the morning.
Immediately after recovery and examination inhaled again to anaesthesia ; auscultation and percussion gave same result as stated.
Case VI. — Female, aet. 40, plump, well nourished, ruddy complexion, healthy looking, married. To my surprise found prolonged expiratory murmur under left scapula, vocal resonance and dulness at posterior apex and above scapula. Patient said " that lung is weak and sometimes have had pain in it." Liable to colds and cough ; never raised blood, but once had a long cough with free expectoration ; under clavicle on left side found prolonged expiration and general puerility of character of respiratory murmur.
Patient inhaled quietly and rapidly ; lost consciousness without strug- gling ; lividity slight and anaesthesia brief, but at the instant of uncon- sciousness my ear, being under left scapula near its superior portion, heard
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distinct metallic tinkle ; a snapping at short intervals as of a wet guitar string ; and rhonchus speedily followed by moist crepitation and pectori- loquy.
Examination after recovery (several times within five minutes) : Crepi- tation coarser but still well marked ; transmission of voice sounds proba- bly from stagnating circulation through vesicular capillaries and occlusion of air cells, but suggestive of dilatation of bronchi and pressure of air vesicles toward the thoracic walls, slowly disappearing, however.
No bad effects experienced beyond an attack of hysterical crying.
Case TIL — Lady, aet. 33, frail looking, with hectic flush on each cheek ; has had short hard cough for several months on rising in the morning ; occasional pain through the right shoulder and heavy feeling on the chest in front ; had also haemoptysis somewhat profuse one year ago, was then in apparent health ; has since had uterine troubles ; emaciation not marked ; is better now than for months ; had once tried to inhale nitrous oxide from a rubber bag, and under unfavourable circumstances, "was almost suffocated, not put to sleep ;" has recently been examined by a physician of some prominence in town, and pronounced (party says) sound.
Examination before inhalation : Vocal resonance and dulness behind left scapula with prolonged expiratory murmur ; the right lung, the supposed seat of former hemorrhage (since a burning sensation in that lung had re- sulted), considerably diseased ; unable to decide without more critical exa- mination whether there was cavity, but suspected it from hoarseness of bronchial note and voice sounds ; pulse rapid and quick (95) ; under care- ful administration of gas the pulse rapidly assumed an hemorrhagic feeling ; patient gasped and paled to an alarming degree ; ear at lung detected sounds detailed in previous cases in lower left lobe, the upper giving simply exaggerated voice and breath sounds ; the right lung at point of chief disease (apex) gave coarse crepitation and rhonchus, then scarcely any re- spiratory sound whatever. This fact, in connection with pulse and aspect of patient, decided us to abstain from giving more gas. Anaesthesia in- complete. Patient upon recovery was exceedingly alarmed, faint and gasping, clutching at the right and left breast alternately, and presenting all the impression of a person labouring under haemoptysis. No blood however came, and in about five minutes patient recovered completely and the lungs assumed the condition noted in the preliminary examination ; no headache or bad feeling resulted.
Case YIII. — Male, set. 3*7, has been a soldier, lost one leg and endured considerable hardship ; raised blood about once a year for several years ; has had for a long time a slight cough, and eight years ago was told by a consultation of physicians that one lung was almost gone and the other full of cavities, but since then has made up his mind to live, and has been steadily improving.
Pound on preliminary examination that the lungs were in tolerable con- dition, one sound, the other diseased at the apex (left) with apparently a small cavity, but without the sounds of active disease.
During inhalation no marked change occurred, yet party was fully under the influence of the anaesthetic ; face and lips livid ; stertorous breathing as if from chloroform ; eyes open, and a strong tendency to clonic spasm. (This stertor was noticed in none of the preceding cases.) Party upon rousing up was wild and incoherent for about a minute.
Critical examination during return to consciousness enabled me to detect
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no change beyond a very slight exaggeration of respiratory murmur, and this not confined to the point of former disease.
Examination after recovery showed still no change; party felt well and exhibited no effects whatever of his recent anaesthesia.
Case IX. — Female, aet. 30, medium appearance as regards health ; states that she has weak lungs and knows one lung to be seriously diseased or at least has been told so by physicians.
Never raised blood, but has long had a short cough and aching pains about the shoulder-blades ; has no strength, &c. Upon examination prior to inhalation found at posterior portion of middle lobe of right lung a circumscribed spot of perceptible dulness with roughness of murmur and evident deficiency of resilient power in pulmonary tissue; some vocal reso- nance also and impairment of vesicular character. Examination during inhalation over point of morbid sound showed roughness and vocal reso- nance exaggerated, and heart sounds clearly transmitted ; after a few minutes coarse crepitation and sounds like the stretching of rubber bands ; much gasping, lividity, struggling, and stertor with complete loss of con- sciousness. (Had tried gas before in St. Louis, and dentist had been obliged to desist.)
Upon recovering was unconscious of having struggled, and in a few minutes felt perfectly well with no headache or other ill feeling. After ten minutes the condition noted in preliminary examination was restored.
Case X. — Female, married, ast. 36, delicate in appearance, and thinks both lungs diseased ; has had cough over a year, and hectic fever within six months, but of short duration. Has been gaining flesh and strength under cod-liver oil and wine ; able to be constantly about ; never raised blood.
Examination before inhalation : Disease of one lung at apex and of considerable extent with small cavity ; no circumscribing dulness or con- solidation in vicinity of the cavity ; no evidence in short of progressive deposit or new breaking up of tissue.
Inhalation gave sense of great relief and lightness in the chest.
Examination during inhalation : Rapid enlargement of area of dul- ness; coarse crepitant rales and speedy disappearance of vesicular murmur throughout diseased lung.
Sound lung affected in a peculiar manner; apex, which had before ap- peared healthy, presented all the evidences of incipient phthisis, the remain ing portion of the luug being affected in the manner indicated as common to healthy lungs.
After return of consciousness the sound1 lung speedily cleared itself of morbid sounds ; the other much more slowly.
The above cases given in detail would be left without comment but for the fact that as they are copied almost verbatim from notes made at the
1 During the ensuing four weeks this case was repeatedly examined ; several inhalations were indulged in for the pleasurable relief obtained, the demand grow- ing more urgent and at shorter intervals ; pulse, always somewhat accelerated, gradually maintained a persistent celerity that demanded a discontinuance of the practice. Contrary to advice, she continued (secretly) inhalatious elsewhere under assurance of an empiric that she would thereby become permanently cured. After two weeks of rapid failing was found having hectic fever and exhibiting ad- vancing disease in both lungs ; pulse constantly above 100, and emaciation very rapid.
70 Holden, Inhalation of Nitrous Oxide Gas. [July
time of observation their important features are not made prominent The observations of which the cases are designed to be illustrative indicate to my mind, although they by no means prove the following facts, and from them it is easy to deduce an answer to the question proposed to be an- swered at the beginning of this article.
1st. Inhalation of nitrous oxide is in some degree likely to prove inju- rious in cases of phthisis.
2d. That inasmuch as pulmonary congestion is almost a necessity to anaesthesia by this agent, and is concomitant with a well-marked tendency to increase of hemorrhage from any cut or abraded surface, its inhalation is somewhat hazardous in cases where haemoptysis has occurred or where there exists an hemorrhagic diathesis.1
3d. That the sense of relief frequently experienced by those having dis- eased lungs is alluring simply and does not indicate benefit, and believing it to be due to an annulling of the hyperaesthesia of the bronchial nerves, the inference follows that the agent may prove curative or at least pal- liative in asthma and in affections accompanied by bronchial spasm.
Supplementary Case II. is referred to as an example of its effect.
The two cases following are appended as of interest.
Supplementary Cases. — I. Female, aet. 62, feeble, supposed to have heart disease, complexion pallid, pulse irregular, subject to " faint spells preliminary examination showed no evidence of disease of heart ; irregu- larity of pulse, probably due to nervous excitement.
Respiratory murmurs markedly puerile.
Under anaesthesia pulse became regular, then gradually imperceptible ; face livid and peculiarly corpse-like ; puerile character of respiration gradu- ally gave place to soft vesicular murmur and normal condition found in sound adult lungs ; evident erotic excitement with motions as of sexual intercourse just prior to and following complete anaesthesia.
II. Boy, aet. 12, with the contracted chest, distended superficial veins, and peculiar look of an asthmatic.
Preliminary examination showed quite extensive emphysema of right lung with bronchitis of both, of chronic character and eccentric hypertrophy of the heart (right ventricle dilated) ; apex beat two and one-half inches from proper place toward median line ; area of dulness hard to define owing to contiguous dulness of lower left thorax, but estimated at three and one-fourth in transverse and four and three-fourths in vertico-oblique diameter, or about the size of the heart of an adult ; pulse irregular ; wheezing and tracheal rattle particularly well marked ; has frequently raised mucus streaked with blood ; had attacks of asthma since the age of five years. Examination during inhalation, which was not pushed to anaes- thesia, showed gradual freedom of respiration, and was accompanied by a sense of great relief. After two minutes the air penetrated freely without wheeze or rattle to every part of both lungs • a portion of left lung where
1 I have been credibly informed of cases where haemoptysis has occurred in the dentist's chair, and have known of others following the inhalation of the gas.
1810.] Wallace, Proper Use of the Obstetric Forceps.
vocal resonance had been noticed before inhalation assumed healthy sounds and resonance disappeared.
Examination ten minutes after recovery showed still comparatively healthy sounds throughout the lungs.
The night following this exhibition of the gas the patient had no attack of dyspnoea ; no wheeze or rattle, and felt great relief in breathing, the first time in several weeks ; he was moreover able to lie down in bed, for the first time in an equally long period. The next day examination prior to inhalation showed greater area of true vesicular murmur, and certainly what appeared marked improvement in general respiratory condition.
Examination during inhalation showed a gradual clearing out as it were of air tubes with marked vesicular improvement, passing gradually into a condition similar to what has been described, viz., of evident congestion and occlusion of air cells ; well pronounced bronchial breathing, and at apex of left lung clearly transmitted heart sounds. After inhalation, which had been continued twelve minutes, patient spoke of the same sense of relief even while there remained still considerable occlusion of air cells.
The transmission of heart sounds, which singularly had occurred at seat of greatest emphysema, gradually ceased. Pulse and heart's action assumed a steady regularity during inhalation and became again irregular upon re- covery.1
Daily inhalations of about fifteen minutes were indulged in, but in no instance to complete anaesthesia, and from the date of the third inhalation no attack recurred for a month, and patient, who meanwhile had been using no other medication, was instructed to return home, and upon the first suspicion of threatened dyspnoea to resort to nitrous oxide ; accord- ingly, February 18, he presented himself, saying he had felt " wheezy, and found his breath somewhat shortened."
Daily inhalations as before, but for four days only ; removed every ves- tige of trouble, and an examination of the heart gave the following re- markable result : area of dulness diminished laterally one-half inch ; lon- gitudinally three-fourths of an inch ; apex beat one and one-fourth inches from its normal place.
Several weeks of immunity from all unpleasant symptoms have elapsed at the date of writing, and while one case proves nothing, however corrobo- rative it may seem of a preconceived theory, the suggestion afforded by the remarkable relief obtained may be of service to some sufferer similarly situ- ated.
Art. VIII. — On the Proper Use of the Obstetric Forceps. By Ellers- lie Wallace, M. D., Professor of Obstetrics and of the Diseases of Women and Children in Jefferson Medical College, Philadelphia.
Several practitioners from the western section of our country, who attended my lectures during the past session, stated to me what I had often
1 This feature, already before noted, occurred in many instances, and is suggestive of possible benefit to be derived also by sufferers from cardiac neurosis.
72 Wallace, Proper Use of the Obstetric Forceps. [July
previously been told, that there was a great popular prejudice in their neigh- bourhoods, which was fostered by the profession, against the use of the ob- stetric forceps, so that if any obstetrician were known to carry that instru- ment with him to a case of labour " it would ruin him — it would howl him out of practice." They, therefore, urged me to publish the views on^ the subject of the proper use of the forceps, which they had heard me incul- cate in my lectures, and requested that they should be published in the American Journal of the Medical Sciences, "for they were persuaded that such publication would tend to counteract the ignorance and prejudice which deterred practitioners from resorting to instrumental delivery in appropriate cases, and which thus often allowed the lives of mothers and children to be sacrificed."
A student from the west said to me, " There is not a pair of obstetric forceps in my county, and in the last year three women have died, unde- livered ; and when the two physicians in attendance were asked the cause of the deaths, they replied that the children could not be born, and so, of course, the women died !"
One gentleman told me, " There is but one pair of forceps in the county, and these I own. They are occasionally, but rarely, borrowed."
Another says, " I was called in consultation, just before leaving my home last fall, to see a woman who had been in labour for nearly two days ; she was seriously exhausted ; the breech of the child was presenting at the inferior strait ; with my blunt hook I drew the breech down, gently and patiently. The entire breech was devoid of cuticle, which had been pulled and rubbed off by the attempts made to deliver the buttocks, by the fingers, prior to my arrival. The child was dead ; the cord was flaccid and soft, and no pulsation in it. The head lodged in the vagina. The woman could not expel it. I said, ' Give me my forceps.' The answer was, ' No, sir, we both object to the use of the instrument ; give her fifty minutes and she will deliver herself.' I said, 4 1 will not give her fifty seconds.' I would not consent to be overruled ; I applied the forceps, and instantly removed the head, for which operation I was censured. The woman recovered perfectly."
I could multiply such records.
I have said to my class that " I deny the right of any man to attend a case of labour unless he carries his forceps with him ; and I consider that teaching to be erroneous, which says, go without your forceps, but send for them when you see the probable necessity of their use." Now, I ap- peal to the experience of obstetricians who have sent for their forceps under emergency. Have they not sometimes regretted that they had them not at hand, for instant use, in certain of these emergencies ?
Suppose, now, a case of puerperal convulsions occurring during labour, caused, as they often are, " by the pains of labour as the head is escaping
3 870. J Wallace, Proper Use of the Obstetric Forceps. 73
from the circle of the os uteri,"1 or " when it distends the perineum, and partially dilates the vulva."3 " It is then, especially, that a prompt ter- mination of the labour puts an end to the convulsive attack."3 Under these circumstances " the very best practice .... is to deliver the pa- tient There should be no hesitation in using the forceps."4 But
if your forceps should be at your home, perhaps miles away ? And we all have seen this awful malady suddenly set in, without more than a few minutes or 'a few seconds' warning. And so of other formidable conditions or accidents, such as placenta praevia, partial or complete ; accidental hemorrhage ; prolapse of the umbilical cord ; rupture of the vagina, or uterus, where an instant delivery — impossible without the forceps — may be indicated. Or in cases of hernia, of heart disease, of phthisis with hemorrhages on exertion, of exhaustion rapidly occurring, &c. ; cases in which prolonged labour is danger and death to the mother, and thence to the child, shall you send for your forceps, miles away ? or shall you — not possessing the instrument — seek to borrow a pair from some one and find that " there is not a pair of forceps in your county ?" Far better is it to take your forceps to a hundred cases in which they shall not be required, than to want them in a single case, and then to be without them.
I well know that some high authorities object to taking the forceps to every case of labour on the ground that we may be tempted to use them unnecessarily, and therefore improperly ! Shall a man not be trusted with the tools of his trade ?
The late Dr. Chas. D. Meigs used to tell his classes of a case of breech presentation, in which the head of the child lodged in the vagina. He pressed off the perineum, and admitted the air freely to its mouth and nos- trils. " The child cried from within the vagina, and I felt a hope that the forceps, which I now sent for, would arrive in time for its succor. In two minutes after I received the instruments they were applied, and the head withdrawn, but it was too late to resuscitate the child.'1'1 The case is re- corded in his Treatise on Obstetrics. If he had carried his forceps with him, a life would have been saved.
I was summoned some time ago to attend a young woman in her labour. Upon entering the house I learned that the child's entire body had been born some minutes. I ran up stairs, touched the umbilical cord and found it silent. I did not wait to warm or grease the forceps. I did not even remove my overcoat, but at once put the forceps on, and delivered the head. The child's heart-throb could not be heard nor felt. I inflated the lungs a few times, and then the heart sounded. I was obliged te continue arti- ficial respiration for more than twenty minutes before the child began to breathe. It revived and did well. Suppose I had lost time by sending for my forceps — two-thirds of a mile — to my house ! Many an obstet-
1 Colombat.
2 Tyler Smith.
3 Cazeaux.
* Bedford,
14 Wallace, Proper Use of the Obstetric Forceps. [July
rician has met with just such cases, and has dealt with them in the same way, and with like results.
Further, I have said to my class that the forceps are not used as often as they should be. I have taught that when the woman's powers begin to fail, when the pains are diminishing in force, frequency, and duration, and before exhaustion can set in, the instrument should be applied, if it be possible to apply it. I dissent from the doctrine which is laid down in some books, that the forceps must never be applied within the os uteri. Suppose the head will not enter the superior strait because of undue size of head, or of somewhat contracted pelvis, if we wait till the os uteri has risen above the head, we will wait till the vagina has been elongated to some ten inches or more — an anatomical impossibility. We occasionally meet with cases where the pains are waning out, or where, indeed, all labour pain has ceased, and where the os is yet not fully dilated, and is, possibly, somewhat tense, and the woman is more or less exhausted. We may give her good broth, or brandy punch, etc. — we ought to do so, to support her vital powers — but we must, in such cases, apply our forceps, and, by gentle traction, wedge open the os uteri, and gently and steadily deliver her, and so save her life and the life of the child.
Let us suppose that the child's head is jammed and locked in the pelvis ; — how long shall we leave it there ? How long shall we permit a well acting uterus to compress the placenta against the buttocks of the child, and to express from it the child's blood, to the risk of the child's life ? If the head do not advance under the influence of (say) six or eight good and strong pains, we should apply the forceps, and make it advance, first, to save the child, and second, to save the mother's tissues from injury by compression too long continued. Some authorities tell us to wait for four hours, and others say wait for six or eight hours, and let the head be moulded by these hours of pain, so that it may pass on without assistance. I consider such doctrine to be bad practice, and worse humanity.
Objectors to the forceps say that labour is a physiological process, and must not be interfered with, except in last extremity. Who has not heard this remark, or one somewhat like it ? Now I would insist that labour is not a physiological process, unless it be natural labour, where the woman can deliver herself safely, and with safety to her child. All other labours are preternatural.
If the head ceases to advance after having been subjected to six or eight good and strong pains, is that a natural condition ? Is it physiological ? Is it not rather a pathological state engrafted upon a physiological pro- cess ? Natural labour is, more or less, regularly progressive, both as to dilatation of the os uteri, and to descent of the child. Otherwise, the labour becomes preternatural. If six or eight pains, of good average power, cannot propel the head when it is in the pelvis, the labour is now preternatural—it is not progressing according to natural and physiologi-
1870.] Wood, Influence of Section of Cervical Pneuraogastrics. 75
cal laws — and so, by all allowance, aid is demanded at the hand of the ob- stetrician. I was called in consultation, some time ago, where a head had been impacted for only some four hours. Craniotomy was necessary. Bat the woman had a frightful slough of the vagina, and her recovery was tedious. The slough was caused by four hours of pressure.
We see cases of arrest of the head by a too resistant perineum, the pains diminishing in frequency, duration, and power. If the stronger pains, of greater length and of more frequent occurrence, have not propelled the child, shall these feebler, shorter, and more distant pains accomplish the delivery ?
Put on the forceps, make a little extension, and see how quickly and how easily the head will be born. (See Cazeaux, second American edition, pages 825-6.)
Dr. Andrew Nebinger, well known in our city as a practitioner of large experience, says : " I have never gone to a case of labour at night without my forceps, nor even by day, unless my patient was close by. I have, in a few cases, I believe, erred, but by omission, in not applying the forceps soon enough ; I certainly have not erred by commission, in applying them unnecessarily." Dr. Penrose, Professor of Obstetrics and Diseases of Women and Children in the University of Pennsylvania, tells me that he always carries his forceps with him to cases of labour, and has yet to re- gret having applied them too soon, or too often.
Of course, in making the above remarks, it is supposed that the practi- tioner thoroughly understands the forceps, the mode of application, and the nature of their action. There can be no doubt that this instrument, in the hands of the imprudent and unskilled, may be as potent for evil as, under proper circumstances, it is powerful for good.
I am well aware that to most of the readers of this Journal the doc- trines now inculcated have no novelty, and the expression of them may seem to be unnecessary, but we have been induced to publish them in com- pliance with the earnest request of many respectable practitioners who de- sire to be sustained in the performance of their duties, and protected against the slanders to which they have been exposed.
Art. IX. — On the Influence of Section of the1 Cervical Pneuraogastrics upon the Action of Emetics and Cathartics. By Horatio C. Wood, M.D., Jr., Professor of Botany in the University of Pennsylvania.
Last summer, whilst making the investigations upon the veratrum alka- loids, which were reported in the January number of this Journal, I had occasion to kill animals with veratria, after division of the pneumogastrics
76 Wood, Influence of Section of Cervical Pneumogastrics. [July
in the neck, and was surprised to find that neither vomiting nor purging were induced. At first the simple explanation of idiosyncrasies suggested itself, but when several experiments coincided, it was obvious that indivi- dual peculiarities could not account for habitual results — that there must be some connection between the pneumogastric nerves and gastro-intestinal secretion ; especially was this the case when the use of veratroidia was fol- lowed by similar absence of symptoms.
The experiments performed last summer were too few in number to lead to any conclusion whatever, but acted simply as an incentive to the present research, which was undertaken the more freely as tending to throw light upon the causes which, in various diseases, prevent purgatives from acting except in an increased dose.
The first question that arose in my mind in entering upon this investi- gation was as to the anatomical relations of the pneumogastrics and the intestines.
A prolonged search through English and French anatomical works re- sulted only in the confirmation of my previous idea, that the pneumogas- tric nerves do not descend in the abdomen below the upper end of the duo- denum.
Finally, however, my attention was directed to a beautifully illustrated prize essay published in the Zeitschrift fur Wissenschaftliche Zoologie, Band X., by Dr. J. Rollman. In this the author claims to have demon- strated that, whilst the anterior or left pneumogastric is distributed in the abdomen to the stomach and liver only, the posterior or right nerve, giv- ing off but few filaments to the former viscus, passes to the liver, the spleen, the kidneys, supra-renal capsules, and the whole of the small intes- tines.
There consequently seemed ground for believing that such anatomical relation exists between the par vagum and the intestinal canal as might account for a connection of function between them. In order to dis- cover the opinions of other observers as to the effect of section of the pneu- mogastrics upon secretion in the stomach and bowels, a search through all accessible French, English, and German authorities was instituted.
I believe it is now generally admitted that division of these nerves in the neck arrests secretion in the stomach, but I have not found more than two allusions to a similar influence upon intestinal secretion, one in a paper by Sir Benjamin Brodie, and the other in Dr. Reid's essays. These will be considered hereafter. As to the immediate cause of arrest of secretion in the stomach, there appears to be great diversity of opinion. This will also be commented on subsequently.
The series of experiments which will be first detailed was instituted to determine how far section of the par vagum interferes with vomiting. The latest published experiments bearing upon this point, as well as the fullest
1870.] Wood, Influence of Section of Cervical Pneumogastrics. tt
that I have met with, are those contained in the elaborate work of M. Schiff on digestion.
One set of his experiments would seem to prove that under certain cir- cumstances vomiting can occur after the pneumogastrics have been cut in the neck. In these experiments, after such division of the nerves, M. Schiff introduced a stomach tube through an artificial opening into the cervical oesophagus, and passed it into the stomach. He then pushed through this tube, by means of a flexible pistou, semi-solid food, of such a character as to be easily recognized. Out of 12 dogs subjected to this procedure, 1, after prolonged efforts, threw up a portion of the matters injected into the stomach.
M. Schiff does not appear to have tried whether, after section of the cervical pneumogastrics, it were possible to produce emesis by the action of ordinary emetics. He states, however, that when the nerves are cut below the diaphragm, tartar emetic causes efforts at vomiting as quickly as in healthy dogs, but that these efforts are rarely successful, or, if they be so, it is only after they have been very frequently repeated and long con- tinued. His explanation of this is, that the division of the nerves prevents the co-ordination of the dilating fibres of the cardia and the associated actious of vomiting. The cardiac sphincter occasionally relaxes, but it does so, apparently, spontaneously, and without relation to the contractions of the stomach. So that if the opening of the cardiac orifice occurs at the same time as the expulsive efforts it is simply by chance. Successful vomiting is, therefore, dependent upon the fortuitous consentaneousness of complicated acts — which can happen but rarely. The function of the par vagum in this regard, then, according to this authority, is simply to harmonize the numerous acts necessary to successful vomiting.
First Series of Experiments. Expt. 1. — Youngish mongrel hound. One hour after section of the pneu- mogastrics in the neck, the dog being strongly under the influence of sulphate of viridia, ^ gr. of the sulphate of veratria was given internally. Dog died in 30 minutes without vomiting or purging.
Expt. 2. — A good-sized Scotch terrier. One hour after section of the pneumogastrics in the neck, I gave hypodermically about -]th grain of sulphate of veratria. Thirty minutes afterwards I administered ^ grain in similar man- ner. The animal died one hour and twenty-five minutes afterwards without being purged or having made any efforts at vomiting.
Expt. 3. — I cut the pneumogastrics in the neck of a stout poodle dog, and some time after administered hypodermically one half of a gram of sulphate of veratria. Animal died in fifteen minutes without any vomiting or purging.
Expt. 4. — I cut the pneumogastrics in the neck of a small Scotch terrier, and a few minutes afterwards gave hypodermically one-half of a grain