TRANSACTIONS 
OF THE 
b 
International Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
BY 
JOHN B. HAMILTON, M. D., 
Secretary-general. 
VOLUME V. 
WASHINGTON, D. C., U. S. A. 
1887. PUBLISHED BY AUTHORITY OF THE EXECUTIVE COMMITTEE. 
PUBLICATION COMMITTEE: 
JOHN B. HAMILTON, M. D., 
Secretary- General. 
A. Y. P. GARNETT, M. D.,* 
Chairman Local Committee of Arrangements. 
C. H. A. KLEINSCHMIDT, M.D., 
Librarian American Medical Association, 
* Deceased. 
WM. F. FELL & CO.. 
Electrotypers and Printers, 
PHILADELPHIA, PA. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
OFFICERS. 
President: ALBERT L. GHIOX, A. M., M. D„ U. S. N. 
VICE-PRESIDENTS. 
Dr. Victor Aud'houi, Paris, France. 
Henry M. Boone, m.d., Shanghai, China. 
Peter H. Bryce, m.a., m.d., Toronto, Canada. 
Dr. A. Chervin, Paris, France. 
Dr. Emilio R. Coni, Buenos Ayres, Argentine 
Republic. 
Roland G. Curtin, m.d., Philadelphia, Pa. 
Dr. Max. Durand-Fardel, Vichy, France. 
Prof. Eugenio Fazio, Naples, Italy. 
Prof. Thomas W. Kay, m.d., Beyrout, Turkey. 
Prof. Dr. E. H. Kisch, Prague, Austria. 
Joseph Körösi, Buda-Pesth, Hungary. 
Prof. Dr. H. C. Lombard, Geneva, Switzerland. 
John William Moore, m.d., m.ch.d., Dublin, 
Ireland. 
Le Marquis de Nadaillac, Cloyes, France. 
Dr. A. Oldendorff, Berlin, Germany. 
Dr. Prosper de Pietra Santa, Paris, France. 
Thomas C. Walton, m.d., U. S. N. 
C. Theodore Williams, m.a., m.d., oxon., Lon- 
don, England. 
George W. Woods, m.d., U. S. N. 
Theoron Woolverton, m.d., U. S. N. 
SECRETARIES. 
Prof. Charles Denison, a.m., m.d., Denver, Col. | IsambardOwen, m.d.,f.r.c.p., London, England. 
Dr. Agathon Wernich, Cöslin, Germany. 
COUNCIL. 
Charles L. Allen, m.d., Rutland, Vt. 
Thomas J. Allen, m.d., Shreveport, La. 
Henry B. Baker, m.d., Lansing, Mich. 
Samuel W. Battle, m.d.,P. A. Surgeon, U. S. N. 
Edgar P. Cook, m.d., Mendota, Ill. 
I#? F. Coomes, a.m., m.d., Louisville, Ky. 
Henry Z. Gill, m.d., Cleveland, Ohio. 
Thomas H. Helsby, m.d., Williamsport, Pa. 
Paul H. Kretzschmar, m.d., Brooklyn, N. V. 
J. Cheston Morris, M. d., Philadelphia, Pa. 
Richard J. Nunn, m. d., Savannah, Ga. 
W. Thornton Parker, m. d., Newport, R. I. 
Joseph Parrish, m. d., Burlington, N. J. 
Alexander M. Pollock, m. d., Pittsburgh, Pa. 
James T. Reeve, M. d., Appleton, Wis. 
P. C. Remondino, M. d., San Diego, Cal. 
George H. Rohé, M. D., Baltimore, Md. 
Melancthon L. Ruth, m. d., Surgeon, U. S. N. 
Edward W. Schauffler, m. d., Kansas City, Mo. 
Vol. V-1 
1 2 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met, as announced, at 3 P. M., in Grand Army Hall, the President 
in the Chair. 
The organization of the Section was effected, and the proposed programme sub- 
mitted and approved. Announcement was made that the morning hours would be 
occupied, as far as possible, with the discussion of papers read the previous after- 
noon. 
Yice-President, Dr. Bryce, of Canada, having taken the Chair, the following 
opening address was delivered by the President of the Section :- 
THE DOMAIN OF CLIMATOLOGY AND DEMOGRAPHY AS DEPEN- 
DENCIES OF MEDICINE. 
LE DOMAINE DE LA CLIMATOLOGIE ET DE LA DÉMOGRAPHIE COMME 
ACCESSOIRES DE LA MÉDECINE. 
DIE GEBIETE DER CLIMATOLOGIE UND DEMOGRAPHIE ALS ABTHEILUNGEN DER 
ALLGEMEINEN MEDICIN. 
BY ALBERT L. GIHON, A. M., M.D., 
Medical Director, United States Navy. 
The Rome that was built on the seven hills beside the Tiber was but the central 
sun of that great empire whose limits were co-extensive with human progress. So 
the medicine which rested on the foundations of the seven chairs of the schools of fifty 
years ago, was only the nucleus of that broad realm of science which to-day makes 
tributary every branch of human knowledge. 
There was a time when our ancients, wrapped in their togœ viriles, looked askance 
at that new-comer, Hygeia, who, in woman's garb, mounted the rostrum beside 
them. It was but yesterday that a throng of grandchildren, offspring of the second 
and third generations, gynecology, neurology, ophthalmology, otology, rhinology, 
laryngology, dermatology, claimed vacant stalls in the choir of professional dignita- 
ries; and as the dim aisles and gloomy nave of the grand old temple grow bright 
with the new lights flooded upon them, another throned seat in the sanctuary is 
seen, in which for the nonce, novice though I be in the priestly order, I find 
myself unworthily seated. Not to you, who are masters in the craft, are my words 
on this occasion really addressed, but to the outside world, to whom Medicine is yet 
only the mercenary art of healing, at so much apiece, the maimed and the halt and the 
blind of the human race. 
It is a matter of marvel when we look into the medical literature of the day and 
listen to the proceedings of medical bodies, that we find everywhere the dominating 
influence of a new philosophy in medicine. Time-honored tenets have been renounced SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
3 
and venerated authorities dethroned without violence, without protest, without 
surprise-insensibly as the darkness fades before the dawn. To the masses it is still 
an inscrutable mystery that the men who in their eyes are only tinkers of human 
mechanisms, whose sweet bells are jangled out of tune, can really be earnestly striving 
to prevent those very ills whose coming brings them profit; and, in fact, never priest- 
hood preached a purer gospel than this unselfish creed that the physician's first duty 
is to ward off those very diseases whose cure would have enriched him. 
The recognition of the subjection of the human organism to external influences, 
which sanitary considerations have induced, and of the dependence of healthy life 
upon ' ' the naturals ' ' of the old writers, has brought climatological questions into 
prominence as medical factors, not in the restricted therapeutic sense, which has 
been so long the only medium through which physicians were ever expected to look, but 
as active forces in man's economy, by which he lives and moves and has his being. 
The actinia fastened to the rock is not more swayed and tossed by the ambient waters 
than is man molded and moved and marked or marred by the powers of earth and air 
and sea, with whom he makes his home, and which together constitute what we call 
climate. 
In the scheme of subjects which I have outlined as a skeleton programme for 
this Section, the first, the importance of the study of Climatology and Demography 
in connection with the science of medicine, naturally falls to me as your presiding 
•officer, and the proposition being so self evident, my task is easy; but before the 
cursory reference I propose making to climatological inquiiy, it may be pertinent, at 
least for the English speaking members of the Section, with whom the word has not 
yet been acclimated, to say something in explanation of the term Demography, which 
forms part of the Section's title. 
When I was invested with the administration of this Section, it was entitled the 
4'Section on Climatology, Vital Statistics, Collective Investigation and Medical 
Nomenclature," a formidable array, which economy of time and convenience in writ- 
ing were reason enough for abridging, even if there were no natural coherence, as is 
the case, between the several classes of subjects assigned the Section. Accordingly, 
I suggested the substitution of the word Demography for the three final members of 
the title, a term which the familiar democracy should make especially grateful to 
American ears. Medical Demography, I therefore present as one of the legitimate 
offspring of the science of Medicine, a branch which concerns itself with the study of 
vital phenomena among masses of men rather than with the ills of individuals, 
treating of race viability, race fecundity, race morbility and mortality, as tending to 
density or sparseness of population, its rate of increase through marriage or ille- 
gitimacy, or its retardation by induced conjugal unfruitfulness, and the influence of 
•climate and of local conditions and customs in accomplishing ethnic modifications and 
changes. Hence, Collective Investigation is its logical first chapter, since it gathers 
the material for this study, and Statistics is the first fruit of this Col- 
lective Investigation, of which Medical Nomenclature is but the instrument ; and 
Demography, thus understood, the consideration of the effects of external agencies 
upon collective man, is naturally consequent to Climatology, which considers all the 
powers of nature, earthly, aqueous, atmospheric, imponderable, and the cosmic influ- 
ences beyond our globe, which constitute man's environment. The Section, there- 
fore, is not a medley of disjointed subjects, but a coherent department of science, of 
which Hygiene is the practical supplement, as Therapeutics is that of Physiology and 
Pathology. Thus, with widened office, Hygeia sits in her chair in the Faculty of 
medicine, side by side with Therapeia, who waits, with folded hands, to take up the 4 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
thread dropped through human folly, ignorance or weakness, or the inscrutable 
workings of a Providence which, perchance, ridicules all our speculations and defies 
all our conclusions. 
The place of Medical Climatology and Demography among the principia of 
Medicine thus assured, the error must not be made of regarding them as on the level 
of school-boy pursuits, as when Chemistry was reluctantly admitted into the teaching 
faculty of our profession. The woof of chemical coloring so interthreaded all Medicine 
that no system of professional instruction could omit it, but the crass ignorance of 
the mass of medical students led to the institution of elementary chemical instruction, 
which belonged to the academy or high school, instead of starting where they ended 
and entering at once upon the elucidation of the points where chemistry joins hands 
with the sisterhood of medical sciences. The chair of Climatology must not be a 
tutor's seat for first lessons in physical geography and geology or rudimental meteor- 
ology. The barometer, thermometer and hygrometer should already be his working 
tools when the medical student matriculates, as the first facts of botany and miner- 
alogy should be no new story to him who begins to read his materia medica. The 
medical college, the seat of the greatest of the sciences, the foster-mother of men 
aspiring to be considered doctissime eruditi, has no primary department for the 
unweaned sucklings of the seminary. It never had a place for him as a student, who 
four years after his travesty of graduation deliberately wrote, "The difference 
between galvanism and electricity is that one is the substance itself and the other its 
use." It has no time to waste teaching that oxygen is a gas and hydrogen another, 
and showing how this oxygen and this hydrogen combine to make water, and why 
this water runs down hill as a liquid and mounts skyward as vapor ; still less for 
explaining that foramen means hole and that sternum is not the classical equivalent 
for stern. Could there be a lower level of puerility in a medical curriculum, one 
would have to begin with the a-b-c's of orthography, of which, even in this day, 
many a student's note-book shows the actual necessity. 
Climatology comes to the front in medical teaching, not a suppliant willing to be 
taken in on any terms, even upon a primary school footing, but herself insisting upon 
that high degree of preliminary education which, in late years, has been shown to 
be indispensable to the comprehension of that teaching. To the knowledge of the 
etymology of Greek and Latin derivatives on which the anatomist and physiologist 
must insist, of botanical and mineralogical facts which the teacher of materia medica 
must require, of physical and chemical principles which are essential to the under- 
standing of medical chemistry and pharmacy, must now be added that of the phe- 
nomena of meteorology and physical geography, without which the intelligent 
acquaintance of the student of medicine with climatology is not possible. Professor 
Cooke, explaining the new requirements for admission to Harvard University, by 
which it is intended to raise scientific instruction to the level of literary, pertinently 
says, 11 we cannot reach a standard that will command general respect until we can 
secure real scientific training in the preparatory schools ; " and Professor Leyden, of 
Berlin, at the Congress of Physicians at Wiesbaden, over which he presided last April; 
"We all, as physicians, know how much the medicine of to-day has to thank natu- 
ral science-We know that she alone has rescued medicine from the pool of willful 
and unreasonable speculation and built it anew on a basis of well-grounded facts.- 
The physician must be a naturalist. He must learn to prove, observe, and sift the 
causes of disease with a knowledge of the natural sciences." 
If the study of the science of medicine has come to be a mightier task in this 
century, it is not that medicine has itself grown in dimensions, but that we have SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
5 
risen higher out of the slough of ignorance, and with clearer eyes and nearer vision 
can better discern her grand proportions. No new thing under the sun has been 
added to her domain, only we no longer see as through a glass darkly. The thera- 
peutic revolution which deposed King Leech and brought the dynasty of sanguinaria 
and other tyrants of the age of heroic dosing to an end, was attributed, for want of a better 
reason, to a change of type in disease, but the homunculus has the same life history 
to-day as when Buddha walked, and had to contend with the self-same microbiotic 
swarms. I recall with a shudder the gallons of narcotic tinctures and decoctions 
which I, an asthmatic boy, swallowed at the bidding in classic Latin of a most dis- 
tinguished practitioner. To-day the sufferer defies the same old enemy by running 
away into a more friendly atmosphere, or when he cannot do that, surrounds himself 
with an artificial one. Those of us who have lived through half a century, can 
remember when seven courses of lectures and as many text-books constituted the 
sum of the labors of a medical student, who, with honest effort and mind bewildered 
by unintelligible terms, waded through anatomy and practice, chemistry and obstet- 
rics, physiology and surgery, materia medica and the demonstration of an operation 
for stone or strangulated hernia, one after the other on the same day, and graduated 
with a glimmer of assurance that quinine cured chills, that mercury was the remedy 
for syphilis, copaiba and cubebs the twin antidotes for gonorrhoea, and calomel and 
jalap standbys for anything in the bowels except bloody flux and diarrhoea, for which 
ipecac and opium or catechu, kino and krameria were all sufficient. Has not the 
homoeopath, after all, with his long list of symptoms and his counter-list of lilliputian 
pellets, only parodied our own parade of dire diseases and dreadful drugs, which like 
checkers on a draught-board we played one against the other ? A century ago the 
doctor was summoned to pilot the frail bark only when disease was already at the 
helm, and drugs were the rocks and shoals that often left but one channel clear, and 
that to the harbor death. 
Within three years two eminent men have died who were foremost in the organi- 
zation of this International Congress-men whose lives stretched far back into the 
past, and bridged it over to the present-the one, the greatest American physician of 
our day, and the nominated President of this Congress at his death, Austin Flint, of 
New York-the other, Samuel D. Gross, of Philadelphia, father of American 
surgery, and peer of the whole world's greatest surgeons. By a significant coinci- 
dence, these two illustrious men have each left us, as their legacy, words uttered 
in the ripeness of their intellectual power, which, summing the professional wisdom 
of their long lives, the one as a practicing physician, and the other as an operative 
surgeon, and colored in no degree by association with special sanitary projects or 
interests, like prophets' voices make clear the way which those who follow should 
tread. 
Said Professor Flint, in his posthumous address on "The Medicine of the Future," 
prepared for the annual meeting of the British Medical Association, in 1886 : "The 
progress of medicine induces, slowly but surely, changes in popular ideas. The phy- 
sician of the future will, perhaps, not be better appreciated ; but there will be a 
truer estimate of medical knowledge and of the medical profession. It is a pleasant 
thought that hereafter the practice of medicine may not be so closely interwoven as 
hitherto, in the popular mind, with the use of drugs. The time may come when 
the visits of the physician will not as a matter of course involve the cooperation of 
the pharmacist ; when medical prescriptions will be divested of all mystery and have 
no force in the way of fortifying the confidence of the patient. The medical profession 6 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
will have reached a high ideal position when the physician, guided by his knowledge 
of diagnosis, the natural history of diseases and existing therapeutic resources, may, 
with neither self-distrust nor the distrust of others, treat an acute disease by hygienic 
measures without potent medication. When this time comes, a system of practice 
which assumes to substitute medicinal dynamics for the vis medicatrix natures will 
have been added to the list of by-gone medical delusions. ' ' 
This the testimony of Professor Gross, spoken at the dedication of the McDowell 
monument but a little while before his brilliant career was ended by death : " Young 
men of America, listen to the voice of one who has grown old in his profession, and 
who will probably never address you again, as he utters a parting word of advice. 
The great question of the day is not this operation or that-not ovariotomy, or 
lithotomy, or a hip-joint amputation, which have reflected so much glory upon 
American medicine-but preventive medicine ; the hygiene of our persons, our dwell- 
ings, our streets, in a word, our surroundings, whatever or wherever they may be, 
whether in city, town, hamlet or country. This is the great problem of the day- 
the question which you, as the representatives of the rising generation of physicians, 
should urge, in season and out of season, upon the attention of your fellow-citizens ; 
the question which, above and beyond all others, should engage your most serious 
thought and elicit your most earnest cooperation. When this great object shall be 
attained ; when man shall be able to prevent disease and to reach, with little or no 
suffering, his threescore years and ten so graphically described by the Psalmist, 
then, and not till then, will the world be a paradise." 
When men whose lives have been devoted to the benefit of humanity utter words 
like these for a testimony unto their professional inheritors, we must give good heed. 
The new era in Medicine, so long dawning, has become an historical fact. The 
dynasty of Preventive Medicine rules. Climatology and Hygiene have ceased to be 
mere adjuncts. The former is, moreover, a proper preface to clinical and curative 
medicine ; for while the knowledge of structure and function, and of remedies 
and appliances, can in no whit be abated, with them must be a thorough under- 
standing of the extrinsic influences which affect man, and of how nature's forces 
may be trained to serve his purpose. Twenty-five years ago Professor Oliver 
Wendell Holmes wrote, in his admirable discourse on "Border Lines of Knowledge 
in some provinces of Medical Science," "I cannot help believing that medical 
curative treatment will, by and by, resolve itself in great measure into modifica- 
tions of the food swallowed and breathed, and of the natural stimuli, and that 
less will be expected from specific and noxious disturbing agents, either alien 
or assimilable." Hence, the prime importance of the study of climatology in 
connection with the science of medicine ; and while the members of this Section, 
among whom I gladly recognize so many associates of the American Climatolog- 
ical Association, are fully aware of this, still I may be permitted to urge upon 
them, as well as upon you all, the necessity for a vigorous, earnest, public asser- 
tion of the fact. New departments have the disadvantage of appearing as tail- 
pieces to their predecessors, and are consequently assumed to be of minor importance ; 
but to the observant it is significant of the part in medicine which climatology 
naturally fills, and this in curative procedures as in preventive measures ; that the 
proceedings of medical societies and the pages of medical journals are now so 
often occupied with climatological questions ; and the time seems really to have 
come when the physician, turning from the introspect which has hitherto solely 
engaged him, looks about him upon the bright world in which he lives and through 
which only he has being-that world to him so great, but to the universe so small- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
7 
beside whose illimitable and eternal vastness hero or serf is but a monad, a blade of 
grass which in the evening is cut down and withereth, a dew-drop that when the 
sunrise comes slips into the shining sea. 
Like many other Greek words which form our scientific terminology, KA.ip.a has 
strayed from its original definition of certain imaginary parallel geographic zones or 
belts into which Ptolemy divided the supposed slope of the earth, from the Equator 
downward to the Arctic Circle, to become the expression of the ensemble of those 
physical circumstances proper to a particular locality, which produce an appreciable 
effect upon animal, and especially human life. These influences are atmospheric, 
telluric and cosmic, and comprehend the temperature, humidity, pressure, tran- 
quillity or disturbance of the circumambient air, the degree of electric tension and 
other meteorological phenomena, the altitude of the sun, the length and duration of 
season, amount of direct light, clearness or cloudiness of sky, quantity and continu- 
ance of rain-fall, the persistence of snow and ice, the vicinity or distance of seas or 
other great bodies of water, the proximity of mountains, the height above the sea- 
level, the nature of the soil, its moisture or dryness, its contained gases and the 
emanations from it, the character of vegetation or its absence and the coexistence of 
other forms of animal existence ; but none of these physical phenomena can be con- 
sidered determinate climatic characteristics except when grouped or associated 
according to certain definite laws, which Lombard specifies as those of periodicity, 
succession, intensity and variability. Latitude, altitude, distance from the ocean 
and prevailing winds are the chief elements of geographic climate. Irregular or 
accidental atmospheric mutations are simply incidents of weather of limited local 
influence. There is, however, no uniform understanding among physicians as to 
which are properly climatic characteristics or merely vicissitudinal occurrences. 
The slimy-surfaced frog pond which distributes its mists over some country neigh- 
borhood can hardly be said to have a climatic influence ; but is that shadowless, 
malign spirit of the Potomac marsh, which hovers like a filmy pall over this fair 
city of Washington, spite of the azure sky, whose scattered clouds are a purer white 
in contrast with the glorious blue, matchless upon this continent ; spite of the clear, 
crisp atmosphere through which the stars twinkle with brilliancy as nowhere else ; 
spite of the verdured avenues and parks and clean streets and pure water and air 
untained by man's befouling-is this a curse of climate like the parching sands of 
Sahara, the eternal summer of Manilla, or the ceaseless deluge of Darien, or is it 
only a local influence which engineers can combat better than physicians ? 
Some years ago an attempt was made, at my instance, to obtain statistical returns 
from medical officers of the navy based upon the ultimate causes of departures from 
health, and especially to determine which were local and which climatic ; but it was 
found that malarial cachexia, diarrhoeal and pulmonary affections appeared indiffer- 
ently under one or the other head. Paludal malarial infection being remediable by 
drainage is contested by some not to be a proper attribute of the climate of a locality, 
but until such an actual geographic reformation may be accomplished the effects of 
marsh miasma will be so persistent and endemic that it may appropriately be con- 
sidered a characteristic of climate. The genius of man-which has tunneled Mont 
Cenis and St. Gothard ; which has thrown a tiny strand of wire across three thou- 
sand miles of ocean ; which has, however unwisely, denuded vast forests and made 
whole regions rainless, and which now proposes to plant new forests and bring 
down rain again ; which has turned rivers from their courses and united transconti- 
nental seas, and which aims to make navigable waters where are now trackless des- 
erts ; which, like the coral-polyp in mid-ocean, has slowly piled brick upon brick, 8 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
stone upon stone, until great cities stand where were hundreds of hectares of green 
fields, till the vast red and white blotches can be seen by our neighbors in the Moon 
and Mars-can undoubtedly bring about this lesser change upon the face of nature, 
which will make the marsh no longer the home of the malarial germ. The trans- 
formation of the submerged environs of Savannah, of the Holland lowlands, the Tus- 
can Maremma and the Roman Campagna into fertile fields, where cattle graze and 
robust farmers till the soil, is evidence of what is possible. Although mortality 
returns alone are not exact indices of morbility, it is significant that the drying of the 
marshes of the Agro Romano has reduced the Italian military death rate due to 
malarial diseases from fifty per 100,000 in 1874 to seventeen in 1884. Nature's own 
undirected processes are not always beneficial to man. Weeds spring up instead of 
food-bearing plants, and when volcanic regions cease to be so, malarial diseases are 
said invariably to appear and the inhabitants soon exhibit the traits which distinguish 
dwellers of insalubrious localities. Some of nature's neglected by-places are so 
malefic that the belief in resident demons arose. Evil genii were assumed to kill, by 
invisible and insensible means, all who intruded upon their accursed domain, and 
this superstition was as prevalent among the negroes of the South and their Indian 
predecessors as among the ancient Chinese, whose semi-priestly, semi-medical skill 
was principally directed toward driving out the malign spirits. With better effect, 
these devils are exorcised in our day by drainage and disinfection, the burning sul- 
phur having a Hahnemannian suggestiveness of the Tartarus, whither they are 
adjured to return. 
The effects of climate are not to be looked for in the prevalence of specific 
diseases with well-defined geographic limits. Commerce, which fills the shop 
windows of Honolulu, Teheran and Tokio with the same wares as may be seen in 
London, Paris or New York, has helped to obliterate border lines between diseases, 
and the spread of civilization has carried its attendant pests where they were never 
before known. Cholera is engendered in the delta of the Ganges and the Hoogly, 
but it thrives in the temperate regions of the New World. Yellow fever sprang 
into life in the Gulf of Mexico and grew apace in Philadelphia. Syphilis and variola 
are no longer characteristic scourges of hot climates, nor do scurvy and scrofula 
linger only in the cold. Neither Greek nor Arab has monopoly of elephantiasis, and 
the bouton d' Alep is not peculiar to its Syrian habitat. The pellagra, which to-day 
numbers its victims in Northern Italy alone by the hundred thousand, and was first 
noticed more than a century ago in two circumscribed districts in the Asturias and in 
Lombardy on the same parallel of latitude, but separated by several meridians of 
longitude, now ranges from Spain to the Ionian Islands, but the scourge is not born 
of air, or earth, or water, but of bad food-damaged maize-which the cupidity of 
dealers in breadstuff's has foisted on the markets of southern Europe as a cheap pro- 
vender for the peasant class. Many other diseases attributed to climate have been 
due to local insanitary causes. A little station in the valley of the Rimae owes its 
name of Las Verrugas to the fatality of a disease, elsewhere benign, but as the site 
was an ancient burial place, man, not climate, first sowed its seeds. When the victori- 
ous Crotoniats turned the course of the river Crathis and inundated Sybaris, this 
seat of voluptuous delights, whose name lives as synonym for epicurean indulgence, 
became a desolate and pestilential swamp, the home to-day of a sparse and sickly 
population, whose ills are laid to the account of their insalubrious climate. 
What climate chiefly does is to establish constitutional tendencies, through 
molecular modifications, which become permanent and morbific if its warnings are 
disregarded or opposed, but are as often therapeutic and curative when intelligently SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
9 
conformed to and heeded. The British soldier marching in red coat and shako 
under an Indian inter-tropical sun-his civilian compatriot eating roast beef and 
drinking brandy and soda at Ceylon and Singapore, succumb to dysentery and blame 
the climate under which their Aryan progenitors attained ripe old age. Neglect of 
precautions observed by every native on the coast of Africa gives the casual resi- 
dent an attack of fever. With wiser providence, armies of invalids are migrating 
to the shores of the Bay of Fundy, to the elevated lands of Colorado, to the classic 
Riviera, to Egypt and the Pyrenees, where, laying aside pernicious habits that have 
ridden them like Sinbad's old man of the sea, they live regenerated lives. Apart 
from the thermal and saline springs, mud baths and sulphurous vapors, which are 
strictly medicinal, nature comes but half-way at the climatic curative resorts, and 
with the sunshine, pure air and crystal waters makes no compact with wrong-doing, 
but exacts a rational observance of natural modes of life as the condition of restored 
health. Even in that earthly paradise, the Valley of Orotava, where one may 
tranquilly glide past the patriarch's threescore and ten, with only part of a lung to 
breathe its balmy air, there is no tolerance of violated physical law. 
Lombard methodically classes the physical effects of climate, especially as mani- 
fested in the temperate zone, as hyperémie hivernale, pléthore printanière, hyp- 
émie estivale, and anémie automnale, which express only the general fact that the 
cold of winter causes internal congestions, which, in the spring, amount to plethoric 
fullness, while the heated summer induces relaxation and retarded circulation, which 
by autumn result in general debility and loss of vigor. In polar regions, where the 
winter lasts eight to ten months, the hyperæmia becomes, as it were, permanent, as 
in equatorial and inter-tropical localities the eternal summer entails lassitude of body 
and of mind. Thus, the coryza of a wintry day above the isotherm of -5° C., 
becomes endemic arctic influenza, while the scrofula and scurvy, which universal dirt 
and privation of food, air and light there make universal maladies, are seen elsewhere 
when dirt and cold and darkness and starvation play havoc with frail human bodies. 
" The thoughtful student," said President Gregory, "seesnothingabnormal in dis- 
ease. There is no disorder in cell processes-rather the perfection of order. Every 
cell-movement is direct, purposive, efficient. ' ' Our part is to be cautious of inter- 
ference-not to grope and strike wildly in the dark, like blind men, and if to help at 
all, to do so by holding back turbulent intruders, leaving the little workmen to their 
tasks, which will be well done if we do not overload them with unaccustomed burthens or 
force them into unnatural ways. Out of earth, air, fire, water and that fifth element 
called spirit, the ancient philosophers, working in their dimly lighted, narrow cells, 
made their man. Have we done much better with our creation from Adam's crooked 
rib ? Have we not looked upon our handiwork as something apart-forgetting that 
it has been built of the same few simples by which it is surrounded. Mongol, 
Hindoo and Greek, believing that thp air coursed through the vessels, were wiser 
than we who think we can live without concern of air, and pour into the crucible of 
our stomach, dross as well as metal, who act as though intellect were a lower motive 
than instinct, and end by worshiping the distorted thing called Fashion, of which we 
have made a very God. 
The effects of the several elements of climate must be sought and studied as gener- 
alizations. Animal life responds to the influences which surround it. Heat, light, 
electricity, magnetism, these latter in mysterious ways, and those other forms of 
energy of which we confess our ignorance, calling them psychic, ethereal and cosmic, 
make man athlete or invalid, according to the circumstances of his life, and the 
intelligent study of these external agencies in their influence upon man is the prov- 10 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ince of Climatology and its ally, Demography, which latter is but the expression in 
terms of the effects of climate and other conditions in modifying human develop- 
ment. 
It is not, of course, the fact that all the cachexiæ are attributable to climatic 
influences. Dr. Matthews, of the United States army, has shown that consumption 
increases among the American Indians under the influence of civilization, climatic 
conditions being, of course, unchanged and these being normal to them as aborigines. 
" It is the compulsory endeavor to accommodate them," he says, " to the food and 
habits of an alien and more advanced race, and that climate is no calculable factor in 
this increase." The Aryan of to-day returns to India, where his ethnic kin have not 
only thrived, but have absorbed the Semitic dwellers in the peninsula, while he 
succumbs to a climate to which he ought to be able to adapt himself as well as 
they, because he carries with him habits and customs of dress and diet that are 
unnatural. It is the over-feeding, over-stimulation, the attempted transplantation 
of the at all times ridiculous and abominable artificialities of our social life, rather 
than tropical hypæmia, which is fatal to the European. 
Hence, ethic as well as atmospheric and telluric influences are factors in demo- 
graphic changes and cannot be ignored in considering the question of acclimation. 
The red races of America are perishing in their own climatic home by reason of the 
vices of civilization, and their Indo-European successors are themselves only saved 
by fresh intermingling from the same fate, not through the influence of the alien 
cliuntte, but of the social evils sought to be ingrafted. A century of civilization, our 
colleague Dr. Woods, of the United States Navy, bears witness, in his paper 
on the demographic effects of introduced disease among the Hfcwaiians, has 
diminished a pure-blooded race, living under unchanged climatic conditions, four-fifths 
its number. The physical decline of the natives of Rapa-nui (Easter Island) began 
when French missionaries evolved out of nude, lascivious, dancing savages, timorous, 
weakly, clothed, pseudo-Christians, for with European religion were introduced 
European diseases. The Rome that conquered the world and the Rome which the 
Goths subjugated were the same geographically and climatically. The early settlers 
on the banks of the Delaware and Chesapeake waxed strong and were fruitful and 
multiplied, but how many among their descendants are feeble, weak-kneed men and 
sallow, flat-chested women, whose generative powers are exhausted on two or three 
sickly imitations of themselves! Their physical decadence is not all the direct effect 
of climate, although this is often remotely responsible for the ethnic customs that 
are themselves the immediate cause of impaired health. Reproduction is impeded 
in America, as in polygamous Turkey, the normal increase of the race in both being 
prevented by influences to which climate has only remote relation. The premature 
sexual development in warm climates leads to erotic indulgences, but sexual debility 
follows upon the constitutional anaemia, which is the effect of climate, and indulgence 
is restrained by inability. Northern races, in whose vessels the blood courses more 
briskly and whose virile powers are more pronounced, are those who, in both sexes, 
most transgress the restraints of moral law. Climate gives them vigor as climate 
makes the southern woman too indolent to resist, though too indifferent to desire, 
but it is the old Adam, who "forfeited and losed first in Eden," and not climate, 
which carries either into harmful excesses. 
The climate of the United States is commonly denounced, even by Americans, as 
pernicious, -when, in fact, the most heterogeneous race elements are here being welded 
on a vast scale, into intimate union, as nowhere else on earth. The mixture doubtless 
shows the influence of climate. Wheeler says, ' ' The reduction of volume, especially SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
11 
in chest sounds and the play of the nose in our language seem to be capable of but 
one explanation and that is that they are a tribute paid to the empire of climate." 
The seasonal changes which are considered most detrimental are actual elements of 
healthfulness. In climates where cold is long continued the hyperæmia becomes 
persistent, not being dissipated by the short summer, and in those where tropical 
heat prevails man loses that physical vigor on which mental effort and social pro- 
gress depend. The changes of season of the temperate zone have this advantage, 
that one season may be said to be remedial to its predecessor and prophylactic to that 
which follows. " Changer du climat, c'est naître à une nouvelle vie," says Michael 
Lèvy, and similarly, change of season is like travel over a new route to one wearied 
with following the beaten track. Fashion has given endorsement to the annual 
hegira to maritime, rural and mountain resorts, by which the jaded slaves of society 
in great cities seek to undo the evil of their winter follies, and the movement of 
hordes of invalids in Europe and America to mineral springs, elevated plateaus and 
sheltered seashores is assuming large proportions. Doubtless the climate often 
receives credit not its due, for the valetudinary, greedy to get the full effect of the 
healing influence of the place, lives out-doors and derives a benefit he could have had at 
home by an equal degree of judicious open air exposure. In most instances, undoubt- 
edly, the exercise in the air and sunlight are wonder-workers with persons who, living in 
great cities, see with indifference their own children condemned to a shorter allow- 
ance of fresh air and sunshine in their schools than the criminals of the State in their 
penitentiaries. 
The reciprocal influences of climate and custom are seen in the matter of popular 
diet. The food of a people largely determines its national characteristics, but climate 
determines the food. The Chinese of the northern provinces live on millet and wheat 
and vegetables, because these thrive best in the dry and dusty soil and severe winter, 
while the moist, hot climate of southern China produces rice, which with fish is the 
staple aliment of many millions of people. The lack of variety harmonizes with the 
conservatism of the race and has contributed to that spirit of contentment and 
domesticity which, as in Japan, are elements of real happiness not enjoyed by nations 
boasting a higher civilization. 
Man, better than any other animal, is able to adapt himself to climates unlike that 
of his native habitat, and the several races of men unequally, the Indo-European 
having the greatest resilience and adaptability. Nevertheless, it is alleged that the 
Scandinavian colonies in Greenland and Iceland have not thrived ; that Egypt is the 
tomb as well of Europeans as of Asiatics ; and that the Algerian sits hopefully 
waiting for time and climate to wipe out the Gallic intruders. ' ' Ah ! but the climate 
will kill them, ' ' was the thought of many a fair border-confederate sympathizer when 
she saw the stalwart regiments of the northwest marching to southern battle-fields. 
It is claimed that Arab and Turk only increase by intermarriage with their slaves, 
but manifestly climate has no part in this demographic result. With equal probability, 
the colonists of Greenland and Iceland would have thrived with the same regard to 
hygienic measures as the sailors and exploring parties who sustain the monotonous 
Arctic life without detriment. Rink positively attributes the striking decrease in 
numbers of the Moravian communities especially not to any accidental or climatic 
cause, but " merely to the prevailing mortality arising from the miserable condition 
of the natives belonging to the communities as regards their habitations, clothing 
and whole mode of life. ' ' More men are frozen to death in the United States than 
at that most frigid spot on earth, Veroynsk, in Siberia, where the thermometer 
falls to -86° F., and averages -50°. Like the naked natives of the Tierra del 12 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Fuego, they die from smallpox and scurvy, not from cold. The mortality among 
white settlers on the west coast of Africa, on the Isthmus of Darien, in the 
jungles of India and the swamps of Whampoa, is largely due to the failure to 
adapt dress and diet to exaggerated local malefic influences, for creoles of one or 
two generations are as tolerant of yellow fever and pernicious paludal fever as 
autochthones. Jew and Gypsy wander all over the earth, and their fruitfulness is 
evidence of their physical vigor. It is true that the negro cannot be acclimated in 
regions far north or south of his origin, which, with the fact of the infecundity of 
his mulatto progeny, indicates structural inferiority and inherent degenerative 
tendencies, but if black cannot bleach to white, there are abundant ethnic 
examples where the migrated white has exhibited every shade of discoloration, 
to the veriest Soudan ebony. The greater adaptability of the Aryan is, therefore, 
indicative of that higher place he holds in the great scheme of human existence, 
while the feebler Hamite is doomed to succumb and disappear when removed from 
those favorable conditions under which he lives at all, like plants, which respond so 
sensitively to transplantation that some will not grow and others lose their character- 
istic alkaloids and active principles when cultivated on other than their native soil. 
Climatology, therefore, is an indispensable chapter in the study of the natural 
history of man, whether our aim be to qualify ourselves to become ministers to the 
suffering, guardians of the well, or propagandists of that manly excellence to which 
we should all aspire, for, as Sir James Paget declares, " We want more ambition for 
renown in health. I should like to see a personal ambition for renown in health as 
keen as that for success in our athletic games and field sports. I wish there were 
such an ambition for the most perfect national health as there is for national renown 
in war, in art, or in commerce." Man's ailments are chiefly lesions of cell nutrition, 
and these are brought about by the perturbed surroundings. It is not difficult to 
imagine how marked the influence on human processes, when the mere befouling of 
the air reverses its polarity, or a change in altitude almost doubles the blood's capacity 
for absorbing oxygen, or a high atmospheric temperature increases the quantity of 
the nitrogenous elements of food assimilated. It has been said that if the winds of 
heaven were but made visible, their myriad movements would present a spectacle 
sublime beyond comparison. What would it be could we view the seemingly chaotic 
play of currents in that mysterious medium we term electric fluid, "a field of strains 
and stresses in something not the air yet in and with the air; of lines of forces with- 
out breadth and unending," penetrating, permeating, mingling with every created 
thing, inanimate or living ! If atoms, lifeless and dense as those of iron, are made to 
range end on end, or side by side, and vibrate in longer or shorter paths, so infinitesimal 
that only millions make their difference measurable by the microscope as this tenuous 
something sweeps among them, who can doubt that the living, sensitive molecules of 
blood and body and brain are also influenced by them for weal or woe. It may be 
that we have been scanning our pharmacopoeias too assiduously for strange plants 
and complex chemical compounds for healing means. Fortunately, perhaps, much 
of our vaunted medication has been inert, nature having shut her microscopic mouths 
to the coarse poisons we would have forced upon her-as when in the active stage of 
typhoid the suspension of the process of assimilation makes beef-tea and drugs alike 
innocuous-drags that we do not even know to be what they are, after they have ran 
the gauntlet of sophistication by the wholesale dealer, adulteration in the shop, dete- 
rioration, carelessness or ignorance in compounding, inaccuracy of weights and 
measures, and our own hap-hazard guess of dose. If the imputation of therapeutic 
fallibility imply ignorance, then, using Lawson Tait's comment upon some old-fash- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
13 
*oned terms sneered at by modern savants because they serve only to express our 
ignorance, " The reproach is true; we are ignorant, but it is better to be ignorant and 
to confess it, than to parade a lot of inaccurate conclusions in the name of science. ' ' 
This, at least, we ought to know, that the energy which can build up the wasted 
body, fire the sluggish blood, and animate the palsied brain, is not stored in gravime- 
tric dose in powder, pill or tincture, but in potential quantity in the great reservoirs 
of force by which we are surrounded. It would be too great a digression to dwell 
here upon the potency of nature's own therapeutic means, for which the climatolo- 
gist is apothecary. As a naval medical officer, I can testify, perhaps, better than 
my civil professional brethren, to the kingly tonic touch of earth upon the invalid 
who has looked for weeks only upon lifeless wooden decks. Side by side with the 
operating room where the chirurgeon lops off what he cannot mend, let there be the 
solarium, where ozone-laden air and vivifying sunshine and living plants and running 
water and the soothing melody of voiceful nature reproduce the conditions of health- 
ful out-door life. 
We can only hope to unravel the mystery of disease by seeking its first cause ; 
and though we know how large the share ignorance, sin and folly have had in weav- 
ing its meshes, we cannot yet say just where the tangled threads begin to inter- 
lock. Are we not fruitlessly piling up sand-hills to stay the torrent of disease, when 
we might better look far back among its sources for the tiny springs which have 
strayed from their course ? To hope for success we must, like hunters, surround the 
field at widely distant points, approaching the centre from all sides. We have to 
look to the results of patient Collective Investigation for data for our generalizations. 
Systematic inquiry has only recently been undertaken, and while coincident meteoro- 
logical, morbility and mortality records should be carefully accumulated, etiological 
research must be our objective point, and symptoms be tracked back to their causes, 
rather than be looked upon as prognostics of what may happen. It is especially 
important to determine the climatic causes, though it is hardly probable that the 
insidious effects of climate in modifying demographic conditions are susceptible of 
exact numerical expression. In the bulky volumes of Lombard, Foissac and Boudin, 
there is page after page of industriously computed millièmes, but it is questionable 
how many of them have been based upon exact data. The vital statistics of com- 
munities has, heretofore, been limited to records of births, deaths and marriages, 
and of these the latter have chiefly a sociological interest, while a numerical exhibit 
of deaths alone is an untrustworthy index of the vital condition of a people. The 
Italian military returns represent the mortality from paludal diseases, which are rife 
in that country, as only .17 per thousand ; but this, as well as the similarly small 
fraction which indicates the deaths per thousand in Washington from malaria, would 
be a very unequal measure of the miasmatic influence, which leaves its icteroid 
stamp upon the complexions of the entire community and subjects them to diseases 
they would have otherwise escaped. A still smaller decimal denotes the deaths 
recorded from syphilis, but it is easy to imagine myriads instead of millièmes, who, 
under more reputable designations, have died from venereal infection. 
Absolute records of prevailing disease are essential to any system of Vital Statistics 
of value to the science of medicine, and these cannot be obtained through volunteer 
effort. Personal rivalries, the disinclination to expose the real extent of a boasted 
clientèle, indifference and neglect, will always operate to make any work dependent 
upon individual contribution incomplete and inexact. To insure the accuracy which 
will give value to returns of diseases, they must be instituted and conducted by 
government, to which the profession and the public are both entitled to look for 14 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
information. The collective investigation as prosecuted by a few earnest, enthusiastic 
observers has an inestimable clinical value as far as it goes, but collective investiga- 
tion under the cognizance and by the authority of government, which shall record 
the precise kinds and number of cases of prevailing diseases, the absolute daily num- 
ber of men, women and children sick in a community (for sex and age should mark 
independent parallel lines of inquiry), as well as those born into it and those leaving 
it by death, is the only one from which it will be possible to tabulate precise results 
-the only one which will enable us to infer the exact degree of climatic and other 
influences and, after the lapse of years, determine the changes which these influences 
are accomplishing in the longevity, vigor, fecundity, morbility and other particulars 
of the economy of a people, on which depend their health, happiness and prosperity, 
the sanitary and sociological questions which underlie the science of medicine. The 
interest of a government in the health of its people, for whom that government is 
administered, ought to be as great as its concern for commerce, agriculture, education 
and labor, all of which are represented in the national organization by distinct bureaus. 
A minister, secretary, commissioner or director at the head of an organized depart- 
ment is so necessary a public functionary, that his absence from the high offices of state 
in every government is due only to that blindness to their real interests which makes 
the people acquiesce in the sacrifice of life and means for the defense of monarchical 
baubles and the maintenance of dynastic wars. Regretable differences hampered 
the efforts of the National Board of Health opportunely created in this country, but, 
despite political hindrances, the nucleus of a central controlling office remains for 
future development, when, in connection with the several State Boards of Health, 
we may hope to see obligatory collective investigations in the natural history of dis- 
ease instituted, which will give us accurate information of its remote causes, exhibit 
the respective share of climate and of personal neglect in its development and in the 
modification of 4emographic conditions, and indicate measures for its prevention, or 
its cure and relief when it cannot be prevented. The study of the natural history of 
pneumonia has resulted in placing its treatment on a rational basis, displacing one 
vaunted therapeutic specific after another, until so little has been left for the practi- 
tioner that ordinarily he has only to watch that nature have fair play. The studious 
investigation of the natural history of chronic interstitial nephritis, known as Bright's 
disease, which Fothergill declares to be especially the disease of the urban popula- 
tion, has shown that the renal changes begin with imperfect blood depuration. " The 
town dweller," he goes on to say, "works in ill-ventilated rooms, and his amuse- 
ments are in-door, in a vitiated atmosphere. With an insufficient liver, a meat 
dietary and insufficient oxidation, he is subject, more than all others, to the uric acid 
formation, with all its varied consequences. The effect of town life is to produce a 
distinct retrogression to a smaller, darker, precocious race, of less potentialities than 
the rustic population. Precocity is seen in early puberty' but reproduction is 
impaired, and Hayles, Walshe, McCantlie and others have shown that it is well- 
nigh impossible to find a true Cockney of the fourth generation." Thus, more 
familiarity with the causal relations of this disease develops, not specific lines of medi- 
cinal treatment, but definite preventive measures. No amount of clinical endeavor 
alone would have accomplished the results in restricting diphtheria which our fel- 
low councillor, Dr. Baker, reports in Michigan, where an average of sixteen cases, 
of which twenty per centum were fatal, occurring among 102 outbreaks of the dis- 
ease in that State during the past year, in which restrictive measures were neglected, 
was reduced, by their enforcement, to three cases, with a mortality of .2 per centum, 
a practical fruit of organized etiological inquiry by the State Board of Health. 15 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
How great the obligation of medicine to the late Dr. William Farr, Great 
Britain's distinguished statistician, has not yet been recognized. His services in 
directing inquiry in rational lines have made him an international benefactor-more 
worthy of a monument than any military hero, whose sole distinction is that he has 
led ignorant men to slaughter and added to human misery by filling the world with 
sorrowing women and children. What Farr began, this International Congress 
should insist upon continuing, and it will have accomplished no more important 
work if its influence can be successfully exerted in inducing national administrators 
to provide for resisting the approaches of those enemies which are common to all 
mankind, and this first by recognizing, classifying and numbering them. I submit, 
therefore, to the members of this Section the propriety of discussing and formulating 
an expression of its opinion, which the Secretary-General of the Congress may be 
requested to have transmitted to the various governments, to the effect that it is 
important there should be established in every country a national department, 
bureau or commission for the record of vital statistics upon a uniform basis, to 
include not only accurate returns of births and deaths, but the results of collective 
investigation, by governmental officials, of facts bearing upon the natural history of 
disease, as manifested among men, women and children, separately, especially with 
regard to the climatic and other discoverable causes of the several forms of disease, 
that necessary preventive measures may be determined and enforced for the preser- 
vation of the public health. Italy has already made commendable progress in this 
direction. The Minister of the Interior, in a circular dated January 9th, 1885, 
addressed to the Italian communes a series of questions drawn up by the Superior 
Council of Health in connection with the Superior Council of Statistics, the replies 
to which have been summarized and published under the supervision of Signor L. 
Bodio, Director General of Statistics, comprising information as to the topography, 
climatology and hydrography of each commune, the hygienic condition of dwellings, 
lavatories and cemeteries, the food supply and consumption of fresh meat and vege- 
table produce, movements of population, mortality, mortality, etc. 
A rational Medical Nomenclature becomes a matter of importance as the scaffold- 
ing upon which this collective investigation is to be built. Mortality returns are 
now customarily expressed in terms which give very little indication of the casus 
morin. The patient is recorded as having died from apoplexy or dropsy or paralysis, 
and the statistician sums up figures in one column, which may have had syphilis, 
alcohol or malaria as their true cause. While it is desirable to know, as pathological 
facts, through what gate the spirit quits its tenement, whether by the broken heart, 
the softened brain, the excavated lung, or the degenerated liver or kidney, it is far 
more important for the climatologist and demographer to know whether it is exposure, 
privation, neglect, cold, starvation or filth, marsh miasm or venereal lues, which is 
recruiting the armies of the sick. Mankind, generally, are averse to calling dis- 
agreeable things by their right names, so the effects of a debauch are labeled gas- 
tritis or dyspepsia, chancroid hides its origin as ulcus, and the syphiloderm is made 
reputable as eczema, but there is no reason why medical statisticians should falsify, 
since their records involve neither personal exposure nor violated confidence. Symp- 
tomatic nosology is useless for statistical purposes. It serves only for pretentious 
parade to report so many cases of albuminuria, dysuria, enuresis, hcematuria, or 
ischuria. So, palpitatio, constipatio, dyspepsia, insomnia, convulsio and odontalgia 
marshal columns of figures on which averages of third place decimals are based- 
of what possible utility ? What is the lesson to be learned from the fact that seven- 
teen individuals, or .068 per thousand, in a community have had runnings from their 16 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ears and nineteen, or .076 per thousand, runnings from their noses, that five have had 
earache and fifteen a pain in the belly? yet dignified as otorrhœa, catarrhus nasalis, 
otalgia and colica, these may be found displayed on statistical returns and elaborately 
calculated into per millages. I have known one case of surditas to figure under 
eleven different arithmetical guises in one report. The pallor of fever, the burning 
blush, or a fit of sneezing are just as truly pathological entities as the stitch in the 
side, which goes upon the record under an eleven letter Greek synonym. The 
Royal College of Physicians of London has wisely shown new nosological roads in 
its revised nomenclature, if it has not obliterated all the old by-paths. It deserves 
especial credit for having weeded out the one meaningless word adynamia, the very 
frequency of which in official returns shows what a cover it has been for diagnostic 
ignorance, having been made to include everything from the hebetude following a 
youth's debauch to the senile debility of his grandfather. Etiological explanations 
must go pari passu with the record of affected organs or perturbed functions, for 
preventive medicine can only be wisely applied when the facts of causation are 
indisputably established. Day by day we find that pathological lesions may be 
classified under fewer general heads. They are all modifications of molecular con- 
ditions-minute cell structure physiologically altered or degenerated. In gland or 
nerve or muscle or bone, the changes are similar. The new diseases which have 
sprung into existence like new plants, each ticketed with its discoverer's name-the 
morbus Smithii, the Brown's disease or Jones'-belong to old families, notwithstand- 
ing their new foster-fathers ; and though each microscopic bacterium or short or long 
bacillus or tiny coccus or amoeba may, like Tartar, Indian or Greek, preserve his 
identity as man's enemy, it will be found that the evil he does is after all determined 
by other circumstances than his own special malevolence-indeed, he is made an 
enemy only because a lair has been prepared for him and the food in store which he 
requires for his misshapen life. Disease approaches by many channels, which 
require all our vigilance to guard. We are surrounded by living hosts-our willing 
slaves, if we but let them do their appointed work-rapacious foes, if we turn them 
from their established way, which is only a less folly than to vainly seek safety in 
killing all. Morbid processes once set up are wonderfully alike in their history, and 
our therapeutic means may consequently be counted upon our fingers' ends. 
I have thus roughly plotted, as an artist would outline his intended work, the 
domain of Climatology and Demography as dependencies of medicine. These depart- 
ments have scarcely received that sharp definition and condensation which come 
from long collaboration and investigation. Systematic treatises on the subjects are 
comparatively few ; for, while their literature is not meagre, it has not been collated 
and bound together under distinct chapters as the older branches of medicine. The 
American Climatological Association has but yesterday taken its place among the 
national scientific bodies, though it has at once stepped into the foremost rank. In 
Europe an occasional Congress of Climatology and Hygiene has represented concerted 
inquiry in this direction, and three weeks hence an International Congress of Hygiene 
and Demography will assemble at Vienna, the programme embracing climatological 
subjects of great interest. 
A new star shines with growing light in the crowded galaxy of Science. In the 
words of our honored and distinguished confrère and titular Vice-President, Lombard, 
of Geneva, whose fourscore and four years have made the long and arduous travel 
impossible which would have brought him among us to-day: "Le moment est 
venu de réunir en un même faisçeau les disjecta membrana de cette vaste science que 
l'on appelle La Climatologie Médicale." SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
17 
THE METEOROLOGICAL ELEMENTS OF CLIMATE, AND THEIR 
EFFECTS UPON THE HUMAN ORGANISM. 
LES ÉLÉMENTS METEOROLOGIQUES DU CLIMAT ET LEURS EFFETS SUR L'OR- 
GANISME HUMAIN. 
DIE METEOROLOGISCHEN ELEMENTE DER KLIMATE UND IHRE WIRKUNGEN AUF DEN 
MENSCHLICHEN ORGANISMUS. 
BY GEORGE H. ROHÉ, M.D, 
Of Baltimore, Maryland. 
Medical climatology, although it has to deal with much more complex problems 
than physical climatology, must be based, like the latter, upon the recorded observa- 
tions of meteorological phenomena. In addition, however, certain other conditions 
must be taken into account. Among these the character of the soil takes an important 
rank. This is seen especially in studying the history of diseases of tropical climates, 
such as cholera, yellow fever and epidemic dysentery. Even in these most character- 
istic climatic diseases something besides the climatic influence must be assumed. This 
is the special virus or germ of the disease. A hot climate alone will not produce 
cholera. 
Many diseases, or perhaps it would be more correct to say, morbid conditions of the 
organism, are ascribed to varying meteorological conditions, to what may be termed 
transient climate. Thus accidental or seasonal changes of weather produce varying 
effects, sometimes of a sanatory, at others of a morbific character. Examples of both 
these classes of effects are the improvement in the condition of children suffering from 
cholera infantum which follow a fall of the external temperature, and the intensifica- 
tion of the disease produced by a higher temperature. 
Medical climatology must take account of pressure, temperature, humidity, direction 
and force of wind, precipitation, the proximity of large bodies of water, altitude, the 
character of the soil, and racial or social conditions of the inhabitants of a place. 
The experiments of Paul Bert, Pettenkofer, Friedländer and Herter, Fränkel and 
Geppert and of Speck, upon animals, as well as the observations of Lortet, Humboldt, 
Robert Schlagintweit, Glaisher, Gaston, Tissandier, Marcet and others, upon human 
subjects, have shown that great diminution of pressure may produce profound disturb- 
ances in health, and if the diminution is extreme, may even result in death. 
The minor disturbances of healthy function produced by diminished pressure 
(within the limits of 4000 metres altitude, or 460 millimetres barometric pressure) are 
an increase in the pulse and respiration rate. This is probably due to the struggle of 
the organism to take up the required quantity of oxygen, which is reduced in propor- 
tion by the rarefaction of the air. For example, the proportion of oxygen, at a pres- 
sure of 460 mm., would be equivalent to 12.6 per centum, at sea level, instead of the 
normal 20.9 per centum. Paul Bert has shown, by personal experiments in the pneumatic 
chamber, that the increase in pulse and respiration rate is not due to the merely mechan- 
ical diminution of pressure, but to the deficiency of oxygen in the respired air. Hence, 
the physiological effects of high altitudes upon circulation and respiration are not 
purely physical, due to diminished pressure, but more complex and dependent upon 
the change in chemical composition of the atmosphere. The simple diminution of 
oxygen without reduction of pressure will produce similar, though not identical effects 
upon the organism. 
Beyond an altitude of 4000 metres above sea level (below 460 mm. pressure) the 
nrofounder disturbances of function characterized as " mountain sickness " come on. 
Vol. V-2 18 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Different individuals react in varying degrees to the morbific influences, of greatly 
diminished atmospheric pressure (and coincident reduction of oxygen). Thus Glaisher 
reached an elevation of 11,000 metres (191.1 mm. pressure) and returned to the earth 
alive, while Crocé-Spinelli and Sivel perished at the considerably lower level of 8000 
metres (equivalent to a pressure of 260 mm., and 7.2 per centum of oxygen). 
The medical climatologist is most concerned about the effects of pressure of the 
atmosphere from 760 mm. down to 460 mm., or from sealevel to an altitude of 4000 
metres above. The climato-therapy of various diseases requires that the effects of 
pressure upon the organism between these limits should be carefully studied. The 
observations of Mermod and Jourdanet* have illustrated the common physiological 
effects of these circumscribed changes, while the experiences of therapeutists have 
established the fact very clearly that many cases of phthisis improve markedly in a 
rarefied atmosphere. Other observers have also shown that the effects of diminished 
pressure are not always beneficial, and Dr. Loomis has warned against sending patients 
with heart disease to high altitudes. Whether the lethal effects that have been recorded 
in such cases are due to the increased activity of the heart and heightened blood pres- 
sure from deficient oxygen, or to dilatation of the heart walls from diminution of exter- 
nal pressure is as yet unsettled.f • 
It is probable that the diurnal or accidental J oscillations of barometric pressure at 
sea level have no appreciable influence upon the organism. The statement is occasion- 
ally met in print that patients subjected to grave surgical operations during low atmos- 
pheric pressure offener do badly than when the pressure is high. Impressed by this 
statement some surgeons never operate if possible to avoid it, when the barometer is 
low or falling. An inquiry undertaken by the writer eleven years ago, in which the 
excellent records of the Massachusetts General Hospital and the observations of the 
Boston station of the United States Signal Service for a period of five years were used 
as a basis of comparison, resulted negatively. The deaths following operations done on 
days when the barometer was high or rising were exactly equal in number to those 
following operations done when the barometer was low or falling. Unfortunately, the 
investigation was never pursued to the extent of including other meteorological ele- 
ments, such as humidity, cloudiness, precipitation, etc. The numerous studies of the 
relations of variations of pressure to the progress of epidemics of infectious diseases 
have also failed to yield any fruits of value. Whether the nerve pains so frequently 
complained of, especially by elderly patients, during the advance of areas of low ba- 
rometer, are due to the influence of the diminished pressure, or to some other meteoro- 
logical factor, such as humidity or electrical condition, cannot yet be decisively stated. 
Attention may be directed to the masterly report of Dr. Weir Mitchell upon the case 
of Captain Catlin, as a model for such investigations. In this case, which is remarkable 
for the painstaking record kept by the patient of his sensations, it is shown that the 
progress of storms across the North American continent is always accompanied by more 
or less severe attacks of neuralgia in an old amputation-stump. The periods of maxi- 
mum pain coincide with a high but falling barometer and increasing absolute humidity. 
The maximum degree of pain during the attacks seems also to coincide with the 
maximum magnetic force as shown by the declinometer. 
* Jourdanet states that while the French and Belgian soldiers in Mexico had an accelerated 
pulse, the natives had a normal pulse. The pulse rate of the natives living at the highest inhab- 
ited places in the Andes and the Himalayas has not yet been studied with exactitude. In Mer- 
mod's observations the average frequency of the pulse at St. Croix (1106 metres above sea level), 
was nearly four beats greater than at Strassburg (142 metres elevation). 
f Dr. F. Donaldson, Jr., in Transaction» American Climatological Association, 1887. 
J Meaning the oscillations produced by storm waves. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
19 
The primary classification of climates into tropical, temperate and polar, indicates 
the influence ascribed to temperature in giving to climatic divisions their determinate 
character. Recently, however, other elements have been taken into consideration, one 
writer even regarding it as almost permissible to say that " climate is absolute humid- 
ity."* Notwithstanding these attempts to show the influence of other factors, the 
temperature must still be regarded as the proper index of climate, whether from a 
physical or medical standpoint. Certain morbific effects are plainly due to the state of 
temperature without regard to humidity, pressure, or other meteorological conditions. 
This is manifested in the local effects of extreme cold and heat and in insolation. The 
investigation of the sunstroke epidemic of Cincinnati in 1881,f by Dr. A. J. Miles, 
has shown that a high humidity had little if any influence in intensifying the morbific 
effects of the high temperature. In fact, a high temperature with dryness seemed to 
be more fatal than the opposite condition. 
Whether the low temperature alone is responsible for the causation of such diseases 
as pneumonia and bronchitis, whether these diseases are due to internal hyperæmia, 
consequent upon surface chilling and anaemia, or to a more complex condition, in which 
diminished absolute humidity with its effects upon transudation in the air vesicles and 
bronchi J is a factor, is not yet definitely known. 
Regarding the morbific effects of continued high temperatures, it is probable that 
an appropriate mode of life, diet and clothing would avert many of the bad consequences. 
Nevertheless, the fact remains that certain tropical or hot-weather diseases must be 
considered as primarily dependent upon high temperature, although the pathological 
effects may be due to an intermediate factor. It is not improbable that such inter- 
mediate factors will be found in microorganisms to explain yellow fever, cholera infantum 
and tropical dysentery, as has already been shown for cholera Asiatica. Here the high 
temperature is one of the associate, but none the less indispensable, factors in the pro- 
duction of the disease. 
Great importance has been attributed to moisture of the air as an element of climate. 
While the morbific effects of "dampness " in the atmosphere are acknowledged in the 
causation of rheumatism and neuralgia, a wide difference of opinion is still current in 
the profession regarding the remedial or morbific effects of a humid climate. There is 
good reason to believe that the insalubrity of a high humidity has been greatly exagger- 
ated. The testimony in favor of a marine or insular climate in the most varied diseases 
is too positive to admit of denial. It is extremely probable that the unfavorable influ- 
ence of low-lying districts, and demonstrably damp atmospheres, upon such affections 
as phthisis, is more dependent upon a wet and perhaps polluted soil than upon the mere 
excess of moisture in the air. So far as pulmonary diseases are concerned, too much 
influence has perhaps been ascribed to humidity, qua humidity, and too little to other 
surrounding conditions. It is also a question whether a broader study of the effects of 
climate in various diseases would not show that the lack of success in the climato- 
therapy of phthisis, for example, is less due to the presence or absence of any special 
climatic factor than to other remediable, insanitary conditions. Perhaps when more 
attention is paid to the sanitary outfitting of health resorts, and patients visiting such 
resorts are treated more in accordance with the recognized principles of medical art, 
better results will be obtained than heretofore. 
The agency of the wind as a factor in climate is too much ignored in medical 
climatology. The influence of air currents in promoting evaporation is fully appre- 
ciated as a physical phenomenon, but as to its effects upon the organism in health or 
disease the observations on record are scanty and vague. 
*C. Denison. "Moisture and Dryness," p. 3. f PuJZtc Health, Vol. vn, p. 293-304. 
J See H. B. Baker. "The Causation of Pneumonia." Michigan State Board of Health, 1887. 20 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Full credit is given by the laity to cold winds and draughts in producing catarrhs 
and rheumatic pains, but the effects, beneficial or otherwise, of prevailing currents have 
not been sufficiently studied. With the large number of accurate observations at com- 
mand in the records of the United States Signal Service, a careful and thorough study 
of this meteorological element should yield positive results. Furthermore, the pro- 
gression of certain infectious diseases, especially malaria, is popularly believed to stand 
in a definite relation with the direction of the wind. 
Sunshine and its opposite, cloudiness, are popularly credited with decided influence 
upon health, but inasmuch as these elements of weather are so closely related with other 
physical conditions of the atmosphere, no conclusions are at present permissible. The 
same may be said of precipitation in the form of rain or snow. While the records pub- 
lished by Boyden, Macpherson and others show that the advent of the rainy season in 
Calcutta arrests the spread of cholera, Lewis and Cunningham have pointed out that in 
the epidemic districts of India the rainy season causes an increase of cholera. This 
apparent discrepancy is explained by the different physical constitution of the soil in 
the different localities. Hence the great importance of a study of the sanitary relations 
of the soil before drawing conclusions respecting the influence of climate in the pro- 
duction of certain epidemic diseases. 
Of chemical changes in the atmosphere, none have had a greater interest to the 
climatologist than the variation in the proportion of ozone. But a few years ago ozone 
was regarded as a great sanitary agent, and extensive observations were planned, and 
in some cases carried out, to determine the influence of this substance in the causation 
of disease. Conclusions were drawn from insufficient data and many misleading state- 
ments were made. Recently, however, Schöne has called in question the existence of 
ozone in the atmosphere, and ascribed the reactions supposed to be due to it to hydrogen 
peroxide. The latter is now being studied by a number of observers, and great hygienic 
and sanitary virtues attributed to it. So far as ozone is concerned, the opinion of many 
sanitarians is tersely expressed by Renk : "Mit dem atmosphärischen Ozon in seiner 
grossen Verdünnung braucht sich die Hygiene nicht weiter zu befassen."* 
The question of the antiseptic action of hydrogen peroxide, and of certain volatile 
products of vegetation, as terebinthinate exhalations, has been recently studied by Dr. 
A. L. Loomis.t Dr. Loomis attributes the asserted good effects of pine forests as health 
resorts for phthisical patients to the antiseptic virtues of the volatile constituents, or of 
hydrogen peroxide in the air of such places. Whether the explanation is sufficient or 
not, there seems to be ample testimony in favor of the remedial powers of such air in 
phthisis. 
After having thus briefly reviewed the subject, the question may still be asked : 
What constitutes climate? The answer must in most cases be indefinite. While all 
meteorological elements must be taken into full consideration, and proper weight given 
to each, the subject must be studied in a broad manner, which renders it more complex 
and difficult. The medical climatologist must be more than a meteorologist. He must 
likewise be a student of medical geography and epidemiology, as well as climato- 
sanitation and climato-therapy. To this he must, add a knowledge of ethnology, for in 
many cases the comprehensive epigram of Sonderegger, " Der Mensch ist das Klima," 
seems to more than hint at a solution of the problem. 
* "Die Luft," in von Pettenkofer and Ziemssen's Handbuch f. Hygiene. 
f Transactions American Climatological Association, 1879. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY 
21 
THE IMPORTANCE OF THE STUDY OF CLIMATOLOGY IN CON- 
NECTION WITH THE SCIENCE OF MEDICINE. 
L'IMPORTANCE DE L'ÉTUDE DE LA CLIMATOLOGIE EN CONNEXITÉ AVEC LA 
SCIENCE DE LA MÉDECINE. 
DIE WICHTIGKEIT DES STUDIUMS DER CLIMATOLOGIE IN VERBINDUNG MIT DER 
MEDICINISCHEN WISSENSCHAFT. 
BY WM. THORNTON PARKER, M.D., 
Newport, R. I. 
Fifteen years ago students of medicine were taught comparatively little concerning 
the Science of Climatology. Certain locations were considered desirable for invalids, 
as, for example, Florida for American consumptives, or the shores of the Mediter- 
ranean for Europeans. Italy was then recommended as a desirable resort for tuber- 
culous patients of all nations. Physicians sent away their patients suffering from 
diseases of the lungs on long journeys to regions, and not to localities, but invariably 
to places where personal knowledge could have had little to do with the professional 
selection. The hasty and mistaken decision on the part of the medical adviser meant 
then, as it perhaps less frequently does to-day, untold suffering for patient and friends, 
enormous and useless expense, and even death. The great wrong perpetrated in the 
name of science never, perhaps, could be demonstrated. They advised to the best of 
their ability and according to general rules learned at the medical school or found by 
searching the short and unsatisfactory chapters devoted to "Climate." That was all 
the light they had to offer, and for their patients it proved capable only of rendering 
darkness visible. With the deep, imperishable hope ever present with this class of 
patients-for whom a good climate is imperative-they seized eagerly upon the advice 
of their trusted physicians, following the delusive " will-o'-the-wisp " into the swamps 
of death. 
If the Science of Climatology had been recognized earlier in the history of medicine 
as one of the most important studies, it would have kept pace with other departments 
of medicine, where most thorough and careful attention and investigation have been 
rewarded with brilliant, and oftentimes wonderful, success. It is only within very 
recent times that the study of health resorts for invalids has emerged from its darkened 
comer, where it had remained so long neglected and practically ignored. Therapeutics, 
Surgery, Ophthalmology, Gynaecology and many other departments are considered of 
practical importance, but the study of climate is too often thought to be only interest- 
ing for fashionable invalids, or as a " dernier ressort ' ' for patients who are hopelessly 
diseased. 
With all the light which patient research and brave exploration have yielded, medi- 
cal men still persist in recommending places of which they have very little knowledge, 
even theoretically, and generally absolutely no personal information. Patients are sent 
to Florida, California, Texas, Italy, etc. ; but the senders know little, if anything, of 
what will be the residence or surroundings of the unfortunates who, in the eager long- 
ing for health, leave home and friends in search of the climate cure. It would seem 
waste of time to repeat here the warnings so often given by faithful observers on this 
important subject. Briefly, they may be summed up as follows:- 
1. Know all that is possible to be known of the locality to which you will recom- 
mend your patients. With many invalids it is a desperate move, perhaps a last chance. 
If the climate does not prove beneficial, then they must die there; for many cannot 
possibly return. Perhaps all the means available for travel have been expended in 22 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
reaching the " health resort; " there is no money left for the return trip, and oftentimes 
the physical resources have been exhausted, as well as the money, by the long journey. 
Consider for a moment the situation: a tedious, expensive journey, during which the 
physical forces have been sustained and stimulated by the hope of a climate which will 
at least relieve; the patient arrives at some forlorn and poorly-managed house, where 
"home comforts" were never known. What is to be done? The very thought of a 
return trip is appalling. Money is gone; a small income-to be received at stated 
intervals-is nowall that is left; but even if one had money, to return would be certain 
death for many; and nothing remains but to face the dangers and miseries experienced 
by so many, and die. What a responsibility the physician has assumed ! and if he has 
sent his patient without due consideration and investigation, it must be well nigh a 
case of malpractice. 
2. In advising, the nature of the disease and the stage of the disorder must be 
thought of, the physical, mental and pecuniary resources taken into very careful con- 
sideration ; the season of the year, which may be nearly ready to assume unfavorable 
influences after the patient's arrival; the chances for really comfortable accommoda- 
tions. Crowding must be avoided, good food must be obtainable, reasonable amuse- 
ments must be provided, and a certain amount of useful occupation, to divert the mind, 
is always needed. 
I have heard physicians speak of sending patients, for hunting and fishing, to locali- 
ties where for years none had existed except in the rosy-hued advertisements of railroad 
companies. Out of twelve patients sent from all parts of the country, by physicians, to 
Colorado, in May, 1878, by August 19th following only one remained alive. Some 
interesting statements in this connection will be found in Harper's Magazine, March, 
1879. This is not mentioned to demonstrate that the climate of Colorado is often over- 
estimated, but to prove how recklessly medical men of good standing, and otherwise ex- 
cellent j udgment, will advise or permit patients to go West on long journeys, when every 
vestige of hope for recovery must have ceased to exist. A statement has been made 
that only one patient in fifteen makes a recovery in Colorado ! The question may be 
asked, Why is it, then, that Colorado has such a reputation for restoring consumptives 
to health, and why do you continue to advise that section for tuberculous patients ? 
The answer is found in the fact that, twenty years ago, invalids seeking Colorado for its 
climate cure approached in wagons, ambulances and stages, slowly. They spent weeks 
in the journey, where now only two or three days are necessary. They began the great 
rise to the Rockies very deliberately, and spent the time in the open air, and slept under 
the most favorable chances for restoration to health-in a tent. How all this has changed ! 
-the close carriage to the train, the overheated and badly-ventilated sleeper, the express 
rate of speed, the hasty meal, the tiresome noise of the journey-all these things, and 
many more, exhaust the invalid patient. In a comparatively short time after leaving 
his home, at sea level, he finds himself struggling for breath, thousands of feet above 
it. Unprepared for the change, the pulmonary hemorrhage, so likely to result, 
draws forth the last of physical resources, and the patient dies in sight of what might 
have been his triumph in health, if the journey had been undertaken with more cau- 
tion. For invalid men in the earlier stages of phthisis, the trip across the great plains 
is a most excellent means of regaining health and strength. A large wagon, with horses, 
can be purchased at Leavenworth, Kansas. One or two men can be employed by the 
month to act as cook, driver and for general service in looking after the camp. For the 
outfit two United States regulation wall tents, a camp mess chest, camp cots, blankets, 
etc., also a good shot-gun and a well-trained hunting dog, will add to both health and 
pleasure. The best time to start from Leavenworth is the second week in May, not 
earlier. The daily journey can average eighteen or twenty miles. A little painstaking SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
23 
in Leavenworth will enable one to secure the services of a frontiersman of experience, 
who will understand the route, and the old Santa Fé trail is the best for camping 
parties. 
When the writer crossed the great plains in 1867, it was then known as a hostile 
country, and only well-protected expeditions could undertake such a journey with 
safety; but now all this is changed. Prosperous villages are found in every direction, 
and a safe and pleasant journey can be enjoyed. Following the old Santa Fé trail will 
afford comfortable camping grounds and an abundance of food and good water. This 
plan may seem to suggest the methods of the gypsies, and may be considered out of 
place in a paper for medical men, but, if faithfully carried out, will prove of the greatest 
value in restoring a large class of invalids to health. For those who can ride on horse- 
back the journey would be more delightful. This plan is mentioned because all med- 
ical writers of experience in the climate of Colorado can bear witness to the injurious 
effects of the sudden and great change experienced by all classes in rushing west. In 
carrying out such a journey as I have suggested the invalid gradually approaches the 
high altitudes of the Rockies, and under the most favorable auspices. 
This plan also illustrates the importance of attention to details in the study of 
Climatology. The mere statement, "Go to Colorado," may be disastrous if immedi- 
ately and hastily carried out; but when the question, "How shall I go to Colorado?" is 
carefully answered, then an opportunity for restoration to health is presented which 
can be found in few sections of this country, if, indeed, elsewhere in the world. Many 
nights have I spent sleeping on the ground, the clear skies, star-filled, for a canopy, and 
the delicious atmosphere refreshing and invigorating the body. Little dew falls, and 
one wakes in the morning, after such a wholesome rest, with a good appetite and in a 
condition well suited for a twenty-mile ride before the next camp. 
Occupation is a valuable remedy in connection with climate cure. Idleness will 
defeat the good results to be obtained from any climate. For restoration to health, the 
body and the mind must be actively employed. The expansion of the chest, and the 
reception of the pure, health-giving atmosphere, destroy the efforts of the deadly bacilli, 
and new life is added daily by the favoring journey. 
Considering the evidence offered us in recent medical literature, we must admit 
that, in general, dryness, either cold or mild, is the most desirable condition sought for 
-other things being equal-in the treatment of pulmonary diseases. With this dryness 
we must have more or less elevation associated, to obtain the best results-certainly 
nothing under 1000 feet above sea level, or over 6000. While the careful study and 
investigation of Climatology will undoubtedly discover many regions and localities in 
Europe, Africa, South America and North America suitable for the relief, and often- 
times for the cure, of pulmonary diseases, the accumulated evidence offered by our 
best and most thorough climatologists demonstrate without doubt that the climate for 
which we have been seeking to cure our phthisical patients is to be found in what I 
have described in an article in the Philadelphia Medical Times, Feb. 7th, 1885, as the 
"Western Health Section. " 
Probably nowhere else in the world is such a healing zone to be found. This section 
comprises Western Kansas, the western portion of Indian Territory, the Texan Pan- 
handle, New Mexico, and the southeastern and eastern slope of Colorado. The state- 
ment that American phthisical patients should be sent "west of the Mississippi " is very 
true, but the results would prove unsatisfactory unless "far west" were the orders 
given. In my experience and that of other investigators the Pacific slope is not desirable, 
but is, in many cases, very injurious. California, and especially southern California, is 
objectionable on account of the moist, warm climate and the fogs which prevail. For 
the same reason Florida has not of late been considered a healing climate for diseased 
lungs. When we search our libraries and the columns of the medical journals of this 24 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and other countries, we find that the health resorts of real value are not very numerous, 
but in spite of the fact that the American climate is, generally speaking, a severe one 
for invalids, we have many regions suitable for winter resorts for pulmonary invalids 
unsurpassed in any quarter of the globe. For summer in the east, the sea coasts of 
Maine, New Hampshire, Massachusetts and Rhode Island. In the latter State, the 
climate of Newport, and more especially to be recommended, that of Jamestown, on 
Conanicut Island, and indeed the whole island, is a most valuable seaside resort for a 
large class of pulmonary invalids. The writings of Prof. Horatio R. Storer have fully 
demonstrated that this climate more nearly resembles that of the famous English South 
Coast or climate of Ventnor, Isle of Wight, than any other in America. 
The atmosphere certainly possesses very remarkable qualities, both as tonic and, better 
still, as a real healer of diseased tissues. The coasts of Connecticut and New Jersey are 
not so desirable. The mountains of the Adirondack region, and certain sections of the 
White and Green Mountain ranges, the forests of Maine and the Adirondack region, the 
lakes of the St. Lawrence, portions of Virginia and North Carolina and Tennessee, 
west of the Mississippi, the Rocky Mountain region and the " Western Health Section " 
already referred to. 
This list is not a large one, and yet, while I am free to confess that many other places 
might with justice be mentioned as health resorts, these which we have mentioned are 
the most important and the most promising. 
If the profession of medicine is threatened with serious and lasting injury from the 
great number of specialists who now appear even in our smaller towns, it is equally 
true that the specialist devoting his time to the science of climatology has a right to 
exist, and will prove a valuable member of the body medical. At present we expect our 
specialists in diseases of the air passages to be experts in climatology. We cannot 
hope, at the present age of learning, to understand all the different branches of medicine, 
and for most men one specialty is quite enough, and certainly climatology is worthy of 
the most patient study and investigation. While farmers, mariners, etc., are especially 
benefited by Government reports and the collection of news concerning the weather, it 
might be well to have a bureau of Climatology, to aid the medical profession of the 
United States in collecting reports concerning climate from every State and territory on 
this continent. 
Success in the study of climatology must depend largely upon attention to what may 
seem to be minor and unimportant details. As life is made up of little things, so we must 
consider minutiæ in the study of climatology. In sending a patient to any given place, 
we must know beforehand what he will find when he arrives, to insure his comfort and 
protection. I do not think that the plan of roughing it is always a practical one for 
invalids, or for those inexperienced in camping out. There is often too much danger 
and hardship for men to desire it very much, but I certainly do believe that to get well 
camping is the very best way for health's sake. Nothing can be better in summer than 
the canvas house, well built and well arranged, and equipped with that indispensable 
adjunct-the most important member of the party-a really good cook. Plenty of 
nutritious food must follow the abundant exercise and exposure in the fresh air. 
The pleasant side of the picture of camp life in the west is the constant bright sun- 
shine, of clear skies and glorious mornings and evenings. For the investigation of cli- 
matology a great deal of actual travel is necessary and the outlay of thousands of dollars, 
that is for practical and really valuable information. To study climatology7 without 
traveling is like studying anatomy without dissecting, and he who recommends resorts 
which he has not seen and examined may be the means of making much unhappiness. 
It is on this account that we have considered the importance of the study of climatology 
in connection with the science of medicine. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
25 
SECOND DAY. 
The Section met at 11.30 A.M., and was occupied with the discussion of the 
papers read and the consideration of the resolution submitted in the address of the 
President. 
DISCUSSION. 
Dr. J. Cheston Morris, of Philadelphia, Pennsylvania, said that he desired to 
return thanks to the President of the Section for the able manner in which he had 
outlined the province of Medical Climatology and Demography, showing them to be, 
in fact, Institutes of Medicine in the very highest sense. ' ' Das Klima ist der Mensch. ' ' 
The proper, and for us necessary, study of mankind is man-his food, labor, social 
surroundings, race tendencies and material environment. We of the United States 
have a climate said to be enfeebling and exhausting. European races are claimed 
not to thrive here as regards longevity and vital power. This is not the fact, and 
the proof can readily be found in the medical history of the late civil war, derived 
from the reports of our army and navy hospitals and posts and those of the Census 
Bureau. We have now accumulated a mass of material which could be and should 
be utilized by the government for the benefit of the people. The opportunity here 
exists for an investigation into the circumstances and conditions of each of the 
numerous races which aid to form our composite nation, to demonstrate which will 
thrive and flourish and which tend to be diminished or extinguished. Changes of 
food, for instance, as shown by the experience of the late Dr. Shippen, of Philadel- 
phia, in the management of the dietary of the House of Refuge of that city, may 
lessen remarkably the mortality from scrofulo-tuberculous disease. The negro chil- 
dren in that institution suffered more than the white from these diseases until their 
dietary was changed, so as to include corn-meal instead of wheat-flour. Such is only 
one of the many instances where study of racial peculiarities, which Medical Demog- 
raphy inculcates, becomes of great importance. 
Dr. Richard J. Nunn, of Savannah, Georgia, suggested that race, and occupa- 
tion as matters of record should be inserted in the resolution proposed by the 
President. The difference in the vital statistics of different races is well illustrated 
by recorded observations of facts relating to the life history of the Hebrews as con- 
trasted with that of some of the Aryan races. The negro will also present striking 
differences in his vital statistics since his emancipation, as instanced by his present 
susceptibility to yellow fever, insanity, phthisis, etc. The wide prevalence of specific 
disease among this people is a most important subject of inquiry. 
Dr. Paul H. Kretzschmar, of Brooklyn, New York, indorsed the proposal to 
make race investigations a matter of special record in any system of vital statistics. 
He referred to the peculiar condition of the Jewish race and to the want of definite 
information as to many matters concerning them. The former immunity of negroes 
from phthisis seems to be in direct opposition to their present condition. He hoped 26 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the resolution submitted by the President would be adopted, and he further suggested 
that the Section on Public and International Hygiene should be asked to indorse the 
same, and lie would later move that the Secretary be instructed to transmit a copy 
of the resolution to that Section for this purpose. 
Dr. J.E. Kelly,of New York City,had much pleasure in secondingthis proposition, 
having prepared a paper on the practical aspects of vital statistics, which must lie 
regarded as the only medium of demonstrating the results of habits, climatic influences 
and treatment. The influence of climate must be considered in conjunction with racial 
tendency and habits, whether national or acquired. In every other country the people 
develop in the course of generations some habits which are agreeable and perhaps more 
or less injurious, and others which are not pleasant, but may be corrective. It is natural 
for men to tend most toward the former or luxurious habits. The United States are 
peopled from many different countries and by widely divergent races, who bring with 
them their respective traits and habits, which become incorporated and amalgamated 
with those of the others. From the mpdley of habits, the masses naturally select the 
agreeable of other nationalities and renounce those which are corrective and tend to 
suppress or prevent diseased conditions. The speaker referred to the changes taking 
place in the Irish race in America. 
Prof. Denison, of Denver, Colorado, said that the resolution of the President of 
this Section had his hearty endorsement. It is not until governments appreciate 
their responsibility to the individual that the full knowledge will be obtained or dis- 
seminated which will place our department of Climate and Vital Statistics, in these 
medical gatherings, in its appropriate, important relation to medical science. We 
cannot over-estimate the good which may accrue through information imparted by the 
general collective investigation of disease and the tabulation of climatic data repre- 
senting broad areas. This is what the individual cannot do, and because of his 
inability, and because of the character of the work, that it should be general, 
impartial and carried out on a continuous and uniform basis, it must be performed 
by the general government. There is no question about this conclusion. The only 
regret he would express about the resolution is that it is necessarily so general in its 
terms. There is great need, in the speaker's opinion, of special influence to be 
brought upon the officials of our own government for the accomplishment, first, of 
specific work, the wide-spread dissemination of climatic data. Look at the annual 
report of the Signal Service Bureau. It is a voluminous collection or conglomeration 
of specific data, of local and temporal interest to a very few individuals. It finds a 
place on the book-shelves of a few physicians' libraries, where, unused, it gathers the 
dust of years. The same machinery of the Government, with small, if any, extra 
expense, could average these statistics by the season and the year, and regularly send 
them in graphic and condensed form to journals, societies, physicians and scientists 
all over this country and other countries, who would apply for them. Secondly, 
besides the graphic illustration of mortality statistics, he wished that our government 
would prepare and issue a soil-map of the United States for similar use, graphically 
illustrating the distribution of different soils with special reference to their absorbent 
and moisture-retaining characters. Information is constantly gathering which makes 
this subject most important, and in this connection reference is made to Inspector- 
General Macdonald's paper, to be presented to this Section, on ground air in its hygi- 
enic relations, and to the works of others, as well as to the valuable comparisons 
which could, with such a map before us, be instituted between climatic statistics and 
diseases which prevail over our broad areas, and also the correspondences which will SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
27 
be found to exist between soil conditions and atmospheric humidities when the whole 
countries or independent localities are considered. 
Dr. Bryce, of Toronto, Canada, said that he was glad of the opportunity to 
support the motion, inasmuch as the remarks already made by Drs. Morris, Nunn 
and Kelly show the diversity of opinion on the various subjects on which infor- 
mation is desired. From the statements made regarding the immunity from 
diphtheria, yellow fever and pulmonary consumption, of the negro race before 
emancipation, and those of Dr. Kelly regarding the deterioration of the Irish race in 
America, it is quite evident that there are causes at work which are inducing serious 
changes among the people of this continent. Living to the north, where house life 
during five months of the year is largely a necessity, he was naturally inclined to look 
to the condition of house life as a very important element in this deteriorating 
influence. It is manifest, then, that statistical information on the points suggested is 
of the greatest necessity, and he was very glad that the resolution had been introduced 
and that he has had an opportunity of supporting it, and he will deem it both a 
pleasure and his duty to advocate it in his own country, with all the influence he can 
bring to bear upon the authorities. 
Professor Rohé, of Baltimore, Md., stated that racial, social, and what may be 
termed economic conditions had undoubtedly a profound influence upon mortality and 
mortality. Thus, the changed condition of living of the Indians since they had been 
brought under the dominion of the white race would largely account for the physical 
degeneration so wide-spread among them. So, likewise, to the changed social and 
industrial relations of the negroes since their emancipation may be to a great degree 
ascribed the largely increased mortality and morbility of that race. 
But aside from these social and economic conditions, the ethnological problem, as 
pointed out by Dr. Cheston Morris, must not be overlooked. Negroes are more 
liable than whites to certain diseases, and almost exempt from others which are 
veritable scourges to their Caucasian brethren. Thus, it is a common observation that 
scrofula, tuberculosis, rachitis and similar diathetic diseases are more frequent in the 
colored race. From cancer or other epithelial hyperplasias they are almost entirely 
free. Although the speaker was not able to refer to statistics, and hence could only 
offer testimony open to the criticism of want of exactness, he could not recollect a 
single case of psoriasis or diphtheria in a negro, notwithstanding that his practice 
among individuals of that race had been rather extensive. Another curious fact was 
the rarity of ectasia of vessels in negroes. In a considerable number of examinations 
of military recruits, in which careful observations were made and exact records kept, 
the rejections for hemorrhoids and varicose veins were extremely few in comparison 
to those among the white applicants of various nationalities. 
In a large general hospital in which he had charge of the medical wards during 
part of the year, the beds for colored patients are nearly all occupied by tuberculous 
and paralytic cases. In the surgical wards of the same hospital, strumous diseases of 
the glands, tuberculous and rachitic bone affections, and venereal disorders furnish 
the bulk of the cases. Among the whites these classes of cases do not bear the same 
relation to the total. 
Prof. Rohé does not think the differences are explained solely by the differing 
social conditions of the patients of the two races. He believes that the racial influ- 
ence is an important one, which has been too little appreciated. He fully endorses 
the resolutions offered by the President of the Section, and hopes they will be 
unanimously adopted. 28 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Parker, of Newport, Rhode Island, referred to the asserted increase of 
mortality among the Indian, negro and Irish races. Undoubtedly, in the case of the 
Indian this is attributable to the change from the free, open-air life of hunting, and a 
diet of fresh meat, to the close, unhealthy cabins of the reservations, overheated by 
iron stoves, and to the salt meat and doughy bread with which they are there fed. 
Undoubtedly better information on these pointswill lead to an improved hygiene, and 
consequent diminished mortality. 
After further remarks, the resolutions were amended as follows and unanimously 
adopted :- 
Resolved, That in the opinion of the Section on Medical Climatology and Demog- 
raphy of the Ninth International Medical Congress, assembled in the city of 
Washington, September 5-10, 1887, it is important there should be established in 
every country a national department, bureau or commission for the record of Vital 
Statistics upon a uniform basis, to include not only accurate returns of births and 
deaths, but the results of collective investigation by government officials of facts 
bearing upon the natural history of disease as manifested among men, women and 
children separately, especially with regard to climatic and other discoverable causes 
of the several forms of disease-race, residence and occupation being also made 
matters of record-that necessary preventive measures may be determined and 
enforced for the preservation of the public health. 
Resolved, That the Secretary General of the Congress be requested to have this 
expression of opinion communicated to the several governments. 
On motion of Dr. Kretzschmar, seconded by Dr. Kelly, it was further unani- 
mously 
Resolved, That a copy of these resolutions be laid before the Section on Public 
and International Hygiene and the cooperation of that Section in their objects be 
invited. 
THE PREFERABLE CLIMATE FOR PHTHISIS ; OR THE COMPARA- 
TIVE IMPORTANCE OF DIFFERENT CLIMATIC ATTRIBUTES 
IN THE ARREST OF CHRONIC PULMONARY DISEASES. 
LE CLIMAT PRÉFÉRABLE POUR LA PHTHISIE; OU L'IMPORTANCE COMPARA- 
TIVE DES DIFFERENTS ATTRIBUTS CLIMATERIQUES DANS L'ARRÊT 
DES MALADIES PULMONAIRES. 
DAS BEIDER BEHANDLUNG DER PHTHISIS PULMONALIS VORZUZIEHENDE KLIMA ; ODER 
DIE RELATIVE WICHTIGKEIT DER VERSCHIEDENEN KLIMATISCHEN EIGENSCHAFTEN, 
WELCHE EINEN STILLSTAND CHRONISCHER LUNGENKRANKHEITEN BEWIRKEN. 
BY CHARLES DENISON, A.M., M.D., 
Of Denver, Colorado. 
With a proper elimination of negative conditions, the writer takes the affirmative 
side of the following divisions of the discussion. He illustrates his argument by the 
climatic or physical causes of "purity of atmosphere," as well as by evidences of 
experience. 
The order in which the first five subjects are arranged is intended to indicate the 
relative importance of the attributes considered, the last five being added as confirma- 
tive of these main propositions :- SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
29 
SYNOPSIS OF THE DISCUSSION. 
1. Dryness as opposed to moisture. 
2. Coolness or cold preferable to warmth or heat. 
3. Rarefaction as opposed to sea-level pressure. 
4. Sunshine as opposed to cloudiness. 
5. Variability of temperature as opposed to equability. 
CONFIRMATORY PROPOSITIONS. 
6. Marked diathermancy of the air to be preferred to the smoky atmosphere of cities or 
the dense air strata of moist currents. 
7. Radiation and absorption of heat by rocks and sandy loams better than latent absorp- 
tion by water and damp clay soils. 
8. Mountainous configuration of country (quick drainage) contrasted with the flatness, 
etc., of level sections. 
9. Frequent electrical changes of atmosphere, also moderate winds (except in quite 
cold weather) preferable to continuous stillness of the air. 
10. Inland altitudes contrasted with sea air (total absence of land influence); but in 
certain cases sea voyages and island resorts to be preferred as compromise substitutes for 
high altitudes. 
INTRODUCTION. 
The discussion of this most important question of "Climatic Influence in Phthisis," 
to be fair, must be general, with no unworthy prominence given to any one of its many 
elements. The subject is necessarily complex, and in order to reach right conclusions 
must be candidly considered, without reference to the convenience of the medical adviser 
or of the patient. 
Hitherto, * the chief obstacles in the way of right conclusions have been :- 
1. Ignorance of the exact nature and progress of the disease, and 
2. A lack of appreciation of the relative importance of different climatic attributes 
in its arrest. 
With reference to the first obstacle, the writer accepts with confidence the germ 
theory of Koch, i. e., that the bacillus of tubercle is the essential principle in all tuber- 
cular lesions. 
The discussion of this theory is foreign to our present purpose, yet its acceptance 
helps to explain the confidence the writer has in his classification of climatic attributes. 
To him the harmony is most evident which is found to exist between our limited knowl- 
edge of the life conditions of the bacillus tuberculosis and our experience in the arrest 
of phthisis in the dry, cool, rarefied, sunny and stimulating atmosphere of high altitude 
climates. 
As to the second obstacle mentioned, the medical profession did not start out right, 
and so of necessity has to go through the process of getting righted. It was a clear case 
of theory not being supported by experience. The sanguine anticipations of benefit 
from warm, equable, low altitude climates were not realized. There may have been 
gain in flesh, strength, appetite and sensations, or the scanty building up of the system 
may have been wholly neutralized by the fostering and feeding of the sources of its 
consumption. The trouble was, there was always a deficiency of elimination. So 
when the fact of something to be eliminated dawned on the medical mind, then those 
climatic attributes which were able and suited to eliminate began to be appreciated. 
There is nothing equal to facts and experience in correcting the errors of mere theory. 
The medical profession has come to insist upon the largest possible collection of facts, 
supported by an ample array of experience, before the superior utility of any theoretical 
cure will be accepted as established- Especially is this the case with reference to the 
climatic treatment of consumption ; and the teacher of therapeutics who has not the 30 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
time nor inclination to investigate an extended array of climatic data, which constitutes 
the basis of a given discussion, cannot of necessity speak with any authority against the 
evidence of those facts. 
The value of comparisons and conclusions as to climatic data largely depends upon 
the time involved and the area represented, presupposing, of course, an impartial and 
universal method of collecting such data. 
It was the value of the records of the United States Signal Service Bureau, and the 
importance to the medical profession of condensing the averages of all climatic attributes 
in a convenient and graphic form, that led the writer to compile some eight million sepa- 
rate signal service observations into the annual and seasonal climatic maps of the United 
States, which are the authorities for many of the conclusions reached in this paper.* 
The preliminary synopsis of this paper is sufficient evidence that no particular attri- 
bute is held to be the only cause or the only cure of phthisis. 
The proper sequence of these attributes, and the validity of their defense, are what 
need to be proved. 
I. DRYNESS VS. MOISTURE. 
At the outset we should have a line of deinarkation between these two opposing 
qualities of the atmosphere; a subdivision that would be fair and acceptable to all, so 
that there could be no confusion in the use of the terms dryness and moisture. It seems 
to the writer that the average of the combined hygrometric conditions of the atmosphere, 
for the whole inhabited portion of the country, is a fair division line between these two 
opposite conditions. 
If you please, we will accept this as the line of definition. 
Of course, temperature must be accounted for, as the capacity of the air to hold mois- 
ture varies so greatly according to this record, the variation being from about half a grain 
to the cubic foot at zero to nearly twenty grains at 100° F. when the air is saturated. 
This was the basis of the writer's ' ' Rule for the Determination of Moisture and Dryness. "f 
This rule was based upon the calculation of a table representing the average of the 
combined humidities of the air (cloudiness, absolute and relative humidity) for the 
whole United States and for every degree of temperature. The averages of these three 
evidences of humidity were found to be 44j per cent, of the time for cloudiness, 67 per 
cent, for relative humidity, and, consequently, 67 per cent, of saturation for absolute 
humidity. These means ■were accepted by the late chief signal service officer (General 
Hazen) to be as nearly correct as could be determined. A rating table of means of 
these three attributes having been constructed for every degree of temperature (see table 
on map for spring, on climatic charts, previously referred to), the following rule was 
formulated :- 
First find for the given time and place the per centum of relative humidity and cloudi- 
ness and the absolute humidity in tenths of a grain of vapor to the cubic foot of air. 
Then compute the difference between one-third of these three and the standard number 
(the mean) given opposite the proper temperature in the rating table, and the result, 
plus or minus, will show the relation of the given climate to the average for the United 
States. An excess of six locates a place in moderate moisture and over six in extreme 
moisture, while a deficiency of six belongs to moderate dryness and of more than six to 
extreme dryness. 
The graphic illustration of this rule, compared with mortality statistics, shows that 
the arrest of phthisis is far more surely to be accomplished as you go toward the extreme 
-s «The Annual and Seasonal Climatic Maps of the United States." Rand, McNally & Co., 
publishers, Chicago, Ill. 
f "Moisture and Dryness." Report made to the American Climatological Association, 1884. 
Rand, McNally & Co., Chicago, Ill. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
31 
of dryness from the mean, than as you go in the opposite direction from the mean 
toward the extreme of moisture. Indeed, it is the very moist climates which furnish 
most of the cases to be arrested in the very dry sections. 
However, in the writer's opinion, the chief argument in favor of atmospheric dry- 
ness is based upon the increased transpiration of aqueous vapor from the lungs, in a 
degree according to the dryness of the air breathed. 
The germs of disease need warmth and moisture in which to live and flourish, a 
climate tempered and constituted according to the requirements of their peculiar exist- 
ence. It is reasonable to infer that the preference shown by the bacilli of tubercle for 
a locus hdbitandi in pulmonary tissue, is in no small degree governed by the catarrhal 
or other products of inflammatory change, which clog or close the alveoli and connecting 
bronchioles. Well, then, if these secretions or morbid products could be removed, and 
at the same time the bacilli which inhabit them thrown off, the result would certainly 
be salutary. These could be so expelled if they could be reached by the inhaled air, 
and this in turn had the requisite absorbent power. 
This absorbent power is just what the inhaled air possesses through its quality of 
dryness, and in proportion thereto. Absorption takes place through the difference in 
percentage of saturation (relative humidity) between the inspired and expired air, and 
also much more through the difference in weight (relative humidity) between the 
moisture inhaled and that expelled. This especially takes place if cold air is inhaled, 
which is then raised to the temperature of the body. 
Valentin, Sanctorius, Lavoisier, Seguin, Dalton and others have investigated the 
subject of transpiration, but not to differentiate between persons at different altitudes 
and temperatures. In the analysis of humidities already referred to * the writer made 
an attempt to compute this difference in transpiration. 
He took Draper's statement as the basis of his calculations, namely, that the dew- 
point of the expired breath is 94°. f 
Two divisions of the calculation were made. 
1. Difference in vapor transpiration between a warm, moist (Jacksonville, Florida), 
and a warm, dry climate (Yuma, Arizona). These two signal stations were chosen, 
and for the autumn of 1883, because their temperatures were the same, i.e., 71.3°. An 
ordinary-sized man was assumed to breathe eighteen times in a minute (Quintelet), 
and to expire when at rest twenty cubic inches at each breath (Hutchinson, Flint, Jr., 
and others), and that the loss of breathing-ï.e., the used-up atmosphere-from to 
in volume (Davy and Currier), is made up by the expansion of the air in the lungs, 
through its being raised from 71.3° to the heat of the body. 
The calculation resulted in the following table :- 
TABLE I. 
Jacksonville. 
AUTUMN, 1883. 
Yuma. 
Mean temperature 
Grains of vapor in saturated air per cubic foot at given tem- 
71.3° 
71.3° 
perature (Glaisher) 
8.33 
8.33 
Mean relative humidity 
.428 
.774 
Cubic feet of air breathed in 24 hours .. 
300. 
300. 
Grains of vapor inhaled 
1070. 
1934. 
Grains of vapor exhaled with dew point at 94° 
5007. 
5007. 
Vapor exhaled more than inhaled 
3937. 
3073. 
* " Moisture and Dryness," pages 27 to 29. 
•f Candor compels expression of the suspicion-chiefly based upon the increased thirst and aug- 
mented respiratory activity in those who live in elevated and very dry sections-that the dew point 
given may be too high for such dry regions. However, this is less than Dalton's estimate, who 
says the expired air is in a state of saturation. So we will call it that the expired breath is satu- 
rated at 94° F. 32 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Excess of Yuma over Jacksonville 864 grains a day. 
This is the moisture thrown off from the lungs in a given dry climate in excess of that 
in the rather moist one of the same temperature and no exercise taken. When one 
makes an allowance for the increased respiratory activity due to exercise he is en- 
abled to realize the still greater difference in transpiration, as shown by Dr. Edward 
Smith's calculation that "one at sea-level, walking at the rate of three miles an hour, 
consumes three times as much air as when at rest." Ordinary every-day exercise of a 
man would make this difference in transpiration, under the given conditions, equal to 
about a gill in twenty-four hours. 
2. It is when we make this calculation for places of different temperatures and eleva- 
tion, that the argument becomes still more conclusive, for cold is probably the most 
important factor in the production of dryness, and elevation is not far inferior, because 
it in turn produces cold as well as expansion in the volume of the air. It is just to 
allow for elevation an equivalent to the proportionate rarefaction of the air, i. e., if the 
pressure is one-fifth less (12 pounds to the square inch) at Denver than at Jacksonville, 
then one-fifth more air will be breathed at the former station. In this calculation we 
will assume a good-sized man, thirty years old, as breathing, in both Denver and 
Jacksonville, twenty breaths a minute and thirty cubic inches per breath (Dr. Grehant), 
ordinary exercise included, and for the same season as that used before. The result is 
as follows :- 
TABLE II. 
AUTUMN, 1883. 
Denver. 
Jacksonville. 
Mean temperature Fahr 
50.4° 
71.3° 
Grains of vapor per cubic foot, at saturation, for 
given temperatures 
4.44 
8.33 
Mean relative humidity 
.501 
.774 
Quantity of air breathed in 24 hours, cubic inches, or 
1,062,800. 
884,000. 
cubic feet 
615. 
492. 
Amount of vapor inhaled at the given humidity and 
temperature, grains 
1,364. 
3,172. 
Vapor exhaled at dew point (94°), saturation being 
16.69 grains per cubic foot (Glaisher), grains 
10,264. 
8,111. 
Vapor exhaled above that inhaled in 24 hours, grains 
8,900. 
4,939. 
Excess of transpiration in favor of Denver 3961 grains, or over eight ounces, or two 
gills, in twenty-four hours. 
There are two important considerations which would further add to this difference 
in evaporation of moisture from the lungs in favor of the high-altitude station. 
1. The expansion of the air in being raised in the respiratory tract from the lower 
temperature of the atmosphere to the higher temperature of the body. 
2. The increased amount of exercise naturally indulged in at the higher station, 
due to the stimulation of cold, electrical influence, etc., and the augmented effect of 
exercise upon the respiratory functions. 
For the purpose of still further comparison it is instructive to take a cold dry place 
in winter (Cheyenne, Wyoming) and a warm, moist one in summer (Charleston, South 
Carolina) on the same basis (though Cheyenne is a little more elevated than Denver). 
The calculation is as follows :- 
TABLE III. 
C 
heyenne, Wyo. 
Winter, 1883. 
Charleston, S. C., 
Summer, 1883. 
Mean temperature, Fahr 
23.2° 
81.2° 
Weight of vapor at saturation for given tempera- 
ture, grains 
1.30 
11.38 
Mean relative humidity 
.478 
.803 
Amount of air breathed in 24 hours, cubic feet 
615. 
492. 
Weight of vapor inhaled, grains 
383. 
4496. 
Weight of vapor exhaled, dew point 94°, saturation 
being 16.69 grains per cubic foot, grains 
10,264. 
8111. 
Vapor exhaled above that inhaled in 24 hours, grains 
9,881. 
3615. 33 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
Excess of respiratory evaporation in favor of Cheyenne in winter, over Charleston 
in summer, 6266 grains, or 13 ounces. 
If the two modifying effects previously mentioned were to he taken into considera- 
tion, together with the usually increased activity of the respiratory organs, in such 
cold as compared with such warm atmospheres, the result would show for Cheyenne in 
winter a daily passing off of vapor from the lungs of at least a pint more than for 
Charleston in summer. This calculation accords with the sensations and the greatly 
increased thirst experienced in cold dry climates, especially when exercising.* 
This is the argument of the increased pulmonary evaporation due to the coldness 
and dryness of the air. It cannot be ignored, though the stated records of pulmonary 
transpiration may be modified by different allowances for elevation and the dew point 
of expired air. 
It is not claimed that dryness itself is an independent feature. On the contrary, it 
will be seen as we proceed how every successful climatic constituent really favors or 
produces this one which we have placed at the head of the list, f 
II. COOLNESS OK COLD PREFERABLE TO WARMTH OR HEAT. 
The importance of cold, in the composition of the curative atmosphere we seek, is 
hardly less than that of dryness. In fact, the two are so interdependent and neces- 
sarily associated, they cannot be easily separated. 
1. How much atmospheric humidity is influenced by the element of temperature is 
shown by the sensational effect of cold. It is through conduction chiefly that the body 
parts with its heat. Evaporation and radiation together do not equal this agency of 
conduction, which the circumambient atmosphere, in common with everything that 
touches the body, possesses in no small degree. Now the conductibility of the air 
depends greatly upon its moisture. It is with the air as it is with solid substances. A 
bar of iron feels very much colder than the same shaped piece of dry pine, though they 
both be of the same temperature. The iron is by far the better conductor, the same as 
is moist cold compared with dry cold air. To those who have never previously experi- 
enced a dry, cold and sunny morning on the eastern slope of the Rocky mountains, 
there is a deception in the sensation of cold, which is equivalent to fifteen to twenty- 
five degrees. One seems to be in a much warmer atmosphere than that in which he 
really is. Temperature, then, is a relative attribute and cannot be considered as inde- 
pendent of humidity. 
Aside from the drying effect of cold upon the atmosphere already alluded to, low 
temperature has several remarkable as well as useful effects in the arrest of phthisis. 
2. Heat expands the air so that the contrast between the temperature of the atmos- 
phere and that of the body indicates the swelling effect cold air produces when full 
breaths are taken. Any doubt about this cau be dispelled by trying the simple experi- 
* How much the activity of the skin is relieved by this increasing pulmonary evaporation 
would be a very interesting problem to work out, if it could be done. 
f Aside from exceptional effects merely upon sensations, the only consideration which seems to 
be arrayed against atmospheric dryness is the announcement of Lehman that "the exhalation of 
carbonic acid is greater in moist than in dry atmosphere, temperature remaining the same." 
(Lehmann. " Physiological Chemistry," Philadelphia, 1885, vol. in, p. 414.) Per contra Crawford's 
experiments prove that the pulmonary exhalation of moisture is much greater in low than in high 
temperatures. While Draper says twice as much carbonic acid is liberated with a temperature of 
68° as at 106°. Well, then, a slightly lower average of temperature compensates for the little 
difference mentioned by Lehmann. Besides, we are in favor of the cooler temperature for other 
reasons than because of the remarkable power cold has in drying the atmosphere. As Dr. Lom- 
bard has expressed it : " In the altitudes the digestion, the muscular exercise and the lowering of 
the temperature increase and accelerate the exhalation of carbonic acid." 
Vol. V-3 NINTH INTERNATIONAL MEDICAL CONGRESS. 
34 
ment of breathing one's utmost into a spirometer in a heated room, when the air is 
frozen out doors. Then step to the door, take a full breath and try again ; the differ- 
ence should in part indicate the expanding force heat imparts to the inhaled air. This 
lung stretching capacity of inhaled cold air is especially appreciated by those of us who 
hold that it is most often the lack of use which paves the way to infiltrations or tuber- 
cular deposits in the apices or other portions of the lung periphery. It is to these out- 
of-the-way places the expanding air carries the evaporating influence of dryness. 
3. Cold stimulates and heat depresses. This is a generally accepted proposition 
which needs no extended elaboration. The sensations themselves are a good guide, and 
the colder the air the more stimulating it is. As Dr. Wise expresses it, when intro- 
ducing the winter climate of the snow-covered region of the Alps, ' ' A bright sun and 
blue sky overhead, a clear and quiet atmosphere, distant sounds transmitted to the ear 
through the still air, combine with the charms of the scenery to produce such a buoy- 
ancy of spirits that a man is braced and invigorated for almost any exertion."* 
It is in harmony with this stimulating effect of cold that the respiratory function 
should be diminished in activity in hot climates, and an increased amount of blood be 
found in the lungs of those who live in cold countries, as is shown by Parkes, Rattray 
and Dr. Francis of the Bengal army. The last of these found, from a large number of 
observations, that the lungs are lighter in Europeans in India than the European 
standard. 
The increased quantity of blood circulating through the lungs, of course, means 
increased oxidation of the blood and renewal of tissue. The pulmonary lymphatics 
join in the increased acti vity, the nervous system is exhilarated and the whole nutrition 
is improved. 
4. Cold is not only stimulating and encourages needed exercise, but under certain 
conditions it may result in a desirable sedative effect. The sleep which comes at night 
after the day's exhilaration and excitement induced by cold, is the most refreshing of 
all rest. Dr. Wise refers to the analogous somniferous effect of cold upon animals 
which hibernate. Dr. George Bodington, one of the first to appreciate the diy, cold- 
air treatment of consumption, wrote, in 1840 : " The application of cold, pure air to the 
interior surface of the lungs is the most sedative, and does more to promote the healing 
and closing of cavities and ulcers of the lungs than any other means that can be 
applied, f 
5. The effect of cold in destroying or impeding germ life, especially the life of the 
bacillus of tubercle, is a most important consideration. 
This is diametrically opposed to the fostering of nearly all germ life, which is the 
effect of moisture and mild heat. If one has ever camped out on the top of a Rocky 
mountain pass, as on a given occasion did the writer, he will never forget the noiseless- 
ness of that insectless and germless locality. The only sound heard was that of a sol- 
itary cricket, and as for bugs or flies, it would have been a paradise for some tormented 
housewife whose life is made a burden by these evidences of atmospheric vitality. The 
nightly freezing of the air, together with its dilution through lessened atmospheric 
pressure, are enough to render germ life impossible. But the best evidence is that 
which has reference to the climate and natural life conditions of the bacillus, limited 
as they are to a narrow range of temperature. This most interesting information is 
given us by Dr. Hermann Weber in his excellent "Croonian lectures on chronic pul- 
monary phthisis." " The air which we inhale perhaps does not so often contain the 
fully-developed bacillus as is supposed by many people, for this microbe does not 
thrive in the air at the usual temperature, but requires, according to Koch, a tempera- 
* " Wiesen as a Health Resort," by Dr. A. Tucker Wise. 
f Essay on "The Treatment and Cure of Pulmonary Consumption." SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
35 
ture approaching that of the human body. Its growth entirely ceases below about 82° 
F., and above 107°, and it thrives best at about 98 to 100°, while other pathogenic 
microbes have a much wider field, for instance, the anthrax bacillus, which grows luxu- 
riantly between 67 and 74° and up to 110°.* 
This evidence should be borne in mind by the defenders of Italian and Florida heat 
or Pacific coast dampness, f 
6. The investigation of seasonal effects in phthisis shows the salutary influence of 
cold. This may appear strange to those people of the north Atlantic, Middle and Lake 
States who flee to the South in terror of the winter weather. Admitted, but do not 
thousands yearly leave moist England for a winter stay in the frozen uplands of Swit- 
zerland ? The force of this consideration is not appreciated except through a recognition 
of the importance of dryness. Notice on a winter seasonal map the prevailing north- 
west, west, and southwest winds, some one of them everywhere moving toward the 
great interior lake region of the United States. The cooling of the air currents causing 
condensation of vapor, with the addition of moisture already existing, is enough to 
produce cloudiness in this section six to eight-tenths of the winter season. The effect 
of cold moisture (already referred to) renders this a climate to be avoided by enfeebled 
lungs. When, however, the other attributes, dryness, elevation and sunshine, are 
favorable, the winter is the best time of year for most consumptives. In cases suitable 
for positive treatment these favorable climatic conditions, by means of this cooler tem- 
perature, can be increased to a climax, so to speak, of success not otherwise attainable. 
The experience of invalids in Colorado bears out this conclusion. It is to secure the 
cooler temperature in summer time that some of the phthisical patients from the plains 
are sent higher up to the parks and divides of the Rocky mountains. The effect of the 
change is very generally good ; and a tubercular fire, which had been rekindled in Den- 
* A further point against the spread of the tubercle bacillus out of the human body is that it 
does not form spores in the air, while the anthrax bacillus does. , Another peculiarity in the life 
of the former is that it grows slowly, that it requires as many days for its development as the 
anthrax bacillus requires hours. This circumstance seems to diminish our danger considerably, 
for we may presume that the bronchial mucous membrane, when healthy, materially assists the 
expelling act of expiration, by its ciliary functions. We are, however, less secure when by 
catarrhal or inflammatory conditions the mucous membrane of the bronchi, and especially of the 
smallest divisions, is deprived of its protecting surface, and when the respiratory acts are imper- 
fectly performed, especially the expiratory, thus allowing the stagnation of impure air in the 
alveolar spaces and permitting the bacilli and their spores to develop under circumstances most 
favorable to them. " Chronic Pulmonary Phthisis," by Hermann Weber, m. d., London. 
f Here it is that the writer ventures the inquiry : what relation have the chills and low tem- 
perature of tuberculosis, regularly succeeded by the intense fever, to the limited range of tempera- 
ture which bounds the existence of tubercle bacillus ? Does nature appreciate the presence of 
this myriad enemy and, worked up to a given point of resistance, try to freeze and then heat it 
out? 
Is the life principle carrying on single handed this unequal fight with millions of germs, 
only in the end to be worn out and to succumb ? Do we know enough of this bacillus of tubercle 
-this microscopic enemy of the human race-to exterminate it ? The relation of this germ to 
that of " malaria " is another difficult problem. Is there a bond of brotherly love, or a cousinship 
only, between the malarial germ and the tubercular, or do their climates and like conditions in no 
way harmonize ? The writer sought to have this question answered for this Congress by Professor 
W. H. Walche, of London. In regretting his inability to be present, he says: "Ah, malaria! 
That is a subject for an emperor of pathology, climatology and various other ologies. How curious 
it is; one fancied, in the boyhood of one's medical career, that the whole affair was clear enough. 
Now, in the evening of one's days, one knows that the whole subject remains to be re-worked, on 
absolutely new lines." 36 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ver on the approach of warm weather, had been rearrested, as appearances indicated, 
by a sojourn in a cool park 8000 feet above the sea. The following case illustrates in a 
striking manner this favorable influence of cold. Being that of a careful and observing 
physician, the evidence is thereby strengthened. 
Dr. W. H. R., of Kansas City, examined, July 12th, 1887, at Denver ; age 29, gradu- 
ate of Bellevue, '83; single; no especial inheritance; well until spring of 1884; then 
had a cough, and in summer lost more flesh than usual. Cough and expectoration 
stopped each fall and during winters. Each spring they returned and he lost more 
weight each summer. Since May, 1886, cough has been continuous. In May and June, 
1886, had drenching night sweats. Over one-half pint each night of gangrenous and 
purulent-looking expectoration which continued more or less after arriving in Colo- 
rado. This was July 5th, 1886. Felt elevation only slightly and went to Cassells, 
west of Denver, 8050 feet above sea level. Elevation not too high, and in two weeks 
went up to " timber line" (11,000 feet), a course to be repeated very cautiously, if at 
all, by any other like affected invalid. Night sweats ceased two weeks after arrival 
and temperature fell from 103° to 100°, F., and then to 99|°. The morning tempera- 
ture was normal instead of sub-normal, as before arrival. There was decided arrest by 
the last of August, when he returned to Kansas City. In two weeks after return, even- 
ing temperature back to 102°. Night sweats returned and had two hemorrhages, the 
first in his case. The fall was dry and favorable, and after frost he gained rapidly. By 
January 1st was back to his normal weight and ceased to have night sweats. Temper- 
ature about 99j°. February 1st returned to Denver, fearing the approach of warm 
weather, and April 1st went up to Cassells and remained until July 10th. Always 
better in dry weather, the altitude not unpleasant. Weight 134 pounds; in health, 
145 to 150 ; on arrival a year ago 125. Pulse 92 ; respiration 20 ; temperature, 10 A.M., 
99 j°; height five feet seven inches; spirometrical record 167 cubic inches; chest expan- 
sion 311 and 33 inches. Chest well preserved in form; movement decided on right and 
restricted on left. Dullness more or less over most of the left, especially marked at 
apex front; tympanitic in character in left infraclavicular region; "cracked metal" 
sound on stethoscopic percussion below and along inner two-thirds of clavicle and to the 
left of the upper third of sternum; with moist râles crackling and high pitched and 
cavernous voice and whispered sounds. In left interspinatus region, leathery, squeaky 
râles at end of forced inspiration. Diagnosis: tolerated third stage fibro-tuberculosis, 
now in arrest. 
III. RAREFACTION VS. SEA-LEVEL PRESSURE. 
That altitude is not made to precede dryness, and coldness may need to be explained, 
in view of the great prominence given to elevation by Jaccoud in his excellent work on 
pulmonary phthisis, which, by the way, contains a better appreciation of the benefits 
of climatic treatment than any other similar book extant. The difference is this: In 
the present classification the qualities which altitude produces are given their due prom- 
inence without special reference to their causes, while rarefaction is considered as an 
individual quality, with special reference to its mechanical effect upon the respiratory 
function. 
The consideration of elevation is divided into:- 
1. The effect upon other climatic attributes. 
2. The physical influence upon man in health. 
3. Its effects in disease, and the experience of invalids. 
4. The evidence of immunity from phthisis. 
First. We have already adverted to the influence of rarefaction in producing dryness 
and coolness. Its effect upon sunshine, diathermancy, variability of temperature, wind 
movements, radiation, quick drainage, etc., will appear as we proceed. 
The expansion of the air is equivalent in degree to any given elevation. The extra SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
37 
space occupied carries with it its due proportion of atmospheric moisture. In favorable 
localities for health resorts this deprivation usually more than counterbalances the con- 
densation of vapor which is due to cold. The result is a total decrease of moisture, 
which is shown by the small percentage of cloudiness, low relative humidity and also a 
small absolute humidity for all such favorable localities. (See Seasonal Charts already 
referred to. ) Then through its expansive effect on the air, as well as by its influence 
upon other producers of dryness, elevation is a powerful agent in controlling atmos- 
pheric humidity.* 
2. As to the physical effect of rarefaction upon human beings the evidence is not 
insignificant, or to be lightly called in question by those who have had no experience 
with high altitude resorts. Jordanet f gave us a most complete and elaborate exposition 
of the physiological effects of diminished air pressure, and, not content with this ana- 
lytical investigation, he induced Paul Bert, J to work out by experimentation, chiefly on 
the life of birds, the effects of the equivalents of various elevations, even up to starva- 
tion limits, as to the supply of oxygen. These and many other investigations could be 
elaborated if space permitted. Ignoring their trivial differences we will state only 
settled conclusions. 
Lessened atmospheric pressure leads to an equivalent loss of oxygen, which deficiency 
Parkes, in his " Practical Hygiene," says is not felt by animals till a rarefaction equal 
to 14 per centum is reached. This loss is about equal to an elevation of 10,000 feet, and 
many animals-cats for instance-do begin to live an abbreviated existence at this height. 
But there are previous effects which man can appreciate, all the way from 3000 to 6000 
feet, at which latter limit the air is one-fifth rarefied, and this appreciation is from 
nothing to considerable, in a state of rest, according to the sensitiveness of both the 
heart and lungs or one of them. 
There is an adaptability of these organs in perfect health, which more than compen- 
sates for a rarefaction of one-fifth, so that only a pleasant exhilaration is felt, even with 
moderate exercise. Much exertion strains this adaptability and a degree of breathless- 
ness may be reached, which indicates a decided deficiency of oxygen, compared with 
the immediate requirements. However, it is not the point of injury or danger that is 
intended to be recommended, but the altitudes which produce healthful and well-born 
respiratory activity in states of rest and moderate exercise. The effect of altitude 
varies according to the pulmonary or cardiac susceptibility of the individual. We divide 
the effects into (one) first effects and (two) permanent effects, or acclimatization. 
On arrival of a healthy individual in a high altitude, there is first an increase, both 
in frequency and in the depth of respiration. When adjustment to the new conditions 
has taken place, which requires a variable period, according to the altitude and the 
individual, the respirations are not nearly so much increased in frequency during rest, 
but the depth of breathing becomes habitually greater. This is shown by the large 
spirometrical records of those who live at great elevations and the increased size of the 
chest in children and in resident adults. This is further shown by the necessity of the 
* Upon temperature elevation has a constant effect in the production of cold. It is differently 
estimated by those who make accurate calculations, but does not vary greatly from about three 
degrees for each 1000 feet rise. In some favorable localities, as the eastern slope or base of the 
Rocky mountains, this lowering temperature is neutralized by local conditions, such as the pre- 
ponderance of sunshine, the character of the soil-being dry and sandy-and the protection of 
mountain ranges which drain western humid air currents of their moisture, so that the isotherms, 
as a given elevation is reached, continue on a western course till the high mountains turn them 
southward. f " Le Mexique et l'Amérique Tropicale." 
J " La Pressure Barométrique, Recherches de Physiologie Expérimentale," Paul Bert, Paris, 
1878. 38 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
climatic change to supply the usual, if not augmented, demand for oxygen, which is to 
meet an increased combustion or change of tissues. The increased exhalation of car- 
bonic acid, due to the chest expansion and lower air temperature, as well as the increased 
chest measurements in those invalids who are not so far advanced in disease but that 
the affected lung tissue can be returned to use (an effect noted in the writer's cases, as 
well as in those of C. T. Williams, Weber and others), are in perfect accord with the 
habitual use of more air for all the purposes of living in high altitudes. 
The heart and lungs having a reciprocal relation to each other are both proportion- 
ately more active. In imperfect respiratory states, or incipient phthisis, the impeded 
circulation feels the "boom," so to speak, especially in those portions of the body 
which were the least active before, namely, in the lung periphery and capillary system 
generally. The result is a more perfect circulation of the blood and oxygenation of 
healthy tissues, as well as of carbonaceous and effete materials. The supply and waste 
are more completely attended to, and the sewer work of the respiratory system, espe- 
cially, is a cleaner and more finished process. Not only this much, but there is a 
change in the relative density of the air in the lungs, due to this increased activity and 
to the fact that the air breathed is rarefied. There is a "pneumatic differentiation," as 
the inventors call it, going on all the time, and this is better than any spasmodic or 
artificial effect. 
There exists an alternate greater pressure or density with expiration, and less pres- 
sure or rarefaction, during inspiration, with each respiratory act, i. e., compared with 
the air pressure outside the body, and also compared with the usual change of density 
of the air in the lungs during respiration. This increased outward pressure within the 
lungs is especially salutary in chftmic hypertrophies, etc., of bronchial and alveolar 
lining membranes, and it has a tendency to open up passages closed to the entrance 
of pure dry air. Some of the worst cases of phthisis are those where the air cannot 
reach the microbes or morbid products. 
3. It is this question of increased and lessened air pressure, the augmented respiratory 
activity and the rush of blood into and through the pulmonary capillaries, which seem 
to disturb the judgment of many physicians with reference to the liability to the occur- 
rence of pneumonia or pulmonary hemorrhage in high altitudes. 
The writer has always maintained, and still holds, that there is no cause for fear if 
proper precautions are taken as to extreme elevations, and the character and stage of 
the disease existing in the lungs, i. e., that there should be no spots of softened lung 
tissue (especially near the root of the lungs) which are insufficiently protected by 
natures's great conservative process-the deposition of fibrous tissue. Only those cases 
should be sent who can bear the expansion.and augmented circulation without rupture 
of blood vessels. In portions of lungs where there is no softening this increased pres- 
sure acts on the distended vessels as does a properly adjusted bandage to a swollen limb. 
The alternate crowding of the dry air against hypertrophied or diseased alveolar walls 
and the suction directly applied through the push given to the circulation, tend to 
relieve congestion and clean out the products of morbid processes. 
There is, as mentioned by Dr. C. T. Williams, " first, hypertrophy or more com- 
plete development of certain portions of healthy lung tissue ; second, emphysema of 
other portions, specially of those in the neighborhood of the consolidations and cavi- 
ties. ' '* 
This increased action and the dilatation help to isolate caseous or tubercular por- 
tions, prevent the spread of infection, and promote the cicatrization or fibrination of 
these affected parts. 
* " The Treatment of Phthisis by Residence in High Altitudes." SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
39 
Of course, in very acute conditions we are " on the other side of the fence," and it 
is rest which is needed.* 
As to pneumonic and hemorrhagic cases the writer's later experience, and it has 
been considerable, tallies well with that tabulated in his report to the International 
Medical Congress of 1876, when records w ere presented of 202 consumptives who had 
spent a total of 350 years in Colorado. The pneumonic cases and the hemorrhagic 
(without càvity) were by far the best influenced of all varieties, f 
4. The question of an altitude of immunity from phthisis is important, because 
there is strong presumptive proof that those climatic conditions which prevail where 
phthisis seldom or never originates, are best suited to arrest the disease when it has 
commenced elsewhere. 
Reference must be briefly made to the considerable evidence of medical writers in 
favor of an altitude of approximate immunity from phthisis, which, with us in America, 
ranges not far from 8000 feet in the southwestern part of the United States to about 
4000 on our northern boundary. J 
As to the quality of the climate which affords this immunity, Jaccoud says : " Alti- 
tude is the most important element. . . . Climates with a high altitude, having 
tonic and stimulant effects, can alone confer on the inhabitants absolute or relative 
immunity from pulmonary phthisis." 
While altitude is the governing element, all the associated favorable conditions of 
the atmosphere, somewhat in the order in which we have named them, seem to go hand 
in hand, until they reach the climax of success in conferring a more or less complete 
immunity from consumption among the residents at the given altitude. 
In illustration of this influence, the records of the mortality from phthisis in the 
city of Denver during the last year might be cited. The Health Commissioner's report 
gives the total number as 195 deaths, of which only five originated in Colorado. $ 
If the much better results were obtainable from the country, instead of from the 
city, and from a little greater elevation, say at or above 6000 feet, the immunity would 
most likely be more apparent. 
IV. SUNSHINE AS OPPOSED TO CLOUDINESS. 
There is little necessity of advocating the utility of the sunshine. Proof is suffi- 
cient, but it is necessarily combined wfith that of other climatic attributes. Everybody 
acknowledges the goodness of sunshine, though in summer time they may have a per- 
sonal preference for shade. 
Undoubtedly the effect of light upon man's physical and moral well-being is analo- 
gous to the fructifying influence of the sun's rays upon the vegetable kingdom. All 
life depends upon sunshine and, for successful existence, must have it. 
* Therefore, experience in high altitudes naturally leads to the appreciation of using restraint 
to chest movements in pneumonia. The cotton jacket, with pressure to the limit of comfort, is 
the writer's custom in catarrhal or bronchial pneumonias of children, which are more apt to occur 
during extremely cold weather in high altitudes. 
f It was the writer's intention to give cases illustrating e.Tects mentioned in dilferent parts of 
this paper, but lack of time compels their omission. 
J Jourdanet's " Le Mexique et l'Amérique Tropicale." Dr. Hermann Weber's " Climate of 
the Swiss Alps." Dr. S. Jaccoud on " The Curability and Treatment of Pulmonary Phthisis," 
pp. 286-295. The writer's " Rocky Mountain Health Resorts," p. 94. Among other authors who 
have furnished proofs of an altitude of immunity the following should be included : Drs. H. C. 
Lombard, C. T. Williams, Küchenmeister, Bremer, Archibald Smith, Fuchs, Nubry, Spengler, 
Kirsch and Guilbert. 
$ It is unnecessary here to refer to the effect such imported deaths from phthisis have upon the 
mortality statistics of a given locality. 40 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The proportion of sunshine to cloudiness depends on the length of day, the exposure 
of a given place, whether or not concealed in a valley, and on the cloudiness of the sky. 
The distribution of clouds in the United States is computed by the Signal Service 
Bureau in tenths of obscuration of the sky, and from these observations the percentage 
of cloudiness, and conversely of approximate sunshine, can be noted for the whole 
country. > 
To illustrate this distribution of cloudiness, the writer has drawn the lines repre- 
senting all these records of the United States Signal Service Bureau up to January, 
1886. (See accompanying Chart. ) 
The variations for cloudiness range from above sixty per cent, of the time over the 
interior lake region, down to less than thirty per cent, in the southwestern portion (New 
Mexico and Arizona). 
Taking so broad a field into calculation, a striking harmony is noted between cloud- 
lessness or sunshine and the other favorable attributes. They all go together. 
A preponderance of sunshine should be mentioned as favoring the possibility of 
much-to-be-desired out-door life, and also of the camping out idea in summer time. 
Many excellent illustrations resulting therefrom could be cited if time permitted. 
V. VARIABILITY VS. EQUABILITY. 
How uniformly variability goes with dryness and equability with moisture can be 
illustrated by the daily and monthly ranges of temperature at places which represent 
dry and moist climates. 
Chosen without reference to this particular evidence, twenty-five dry and twenty- 
five moist prominent stations and health resorts in the United States give the following 
means :- 
First-Extreme dryness 
TABLE IV. 
Means of Daily 
Ranges. 
36.51° 
Means of Monthly 
Ranges. 
53.65° 
Second-Moderate dryness 
20.63° 
49.38° 
Third-Moderate moisture 
17.09° 
45.48° 
Fourth-Extreme moisture.... 
13.61° 
41.55° 
Again, taking the fifteen most and the fifteen least variable signal stations in the 
United States for 1883, (out of the 136 stations) we have the following daily ranges 
averaged by seasons and for the year :- 
TABLE V. 
Fifteen Stations. 
Spring. 
Summer. 
Autumn. 
Winter. 
Year. 
Most variable 
30.7° 
29.1° 
28.4° 
26.5° 
28.7° 
Least variable 
12.1° 
12.9° 
10.8° 
12° 
11.9° 
The first are extremely dry and the second fifteen decidedly moist localities.* 
Seasonal ranges of temperature likewise show the inseparability of equability from 
atmospheric moisture and of variability from dryness. Compare the winter and summer 
temperature lines on seasonal charts. The sea is the great equalizing influence, and the 
colder land in winter turns these isotherms to the south for a considerable distance in 
the United States, viz., about parallel with the Pacific coast. In the summer, however, 
when they leave the ocean, these lines are turned nearly as much to the north as the 
winter ones are to the south. The further we get away from humid influences the 
greater is the variability of temperature. 
It is not claimed that extreme variability should always be sought for, nor that of 
* The highest average variability for the winter of that year was La Mesilla, N. M., (34.6°) 
and the lowest both San Francisco, Cal., and Key West, Fla. (8.8°). \ MEAN CLOUDINESS 
' IN HUNDREDTHS - 
COMPUTED FROM THE COMMENCEMENT OF 
OBSERVATIONS BY THE U.S. SIGNAL SERVICE 
TO DEC. 1885-AN AVERAGE FOR OVER TEN YEARS. 
I 
T. SINCLAIR & SON. PHILA . 41 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
two places, with all other advantages the same, the more variable one is the better ; on 
the contrary, the less variable would certainly be preferred in cold weather. It is 
claimed, however, that variability is quite a uniform constituent of dry, high climates, 
and that as the dryness predominates, the marked variability is less felt, and is less, if 
at all, objectionable. On the other hand, marked atmospheric equability, wherever 
found, is prima facie evidence of excessive humidity. 
The worst that can be said against combining variability with the favorable attributes 
of climate for phthisis is that its defense is necessary, because it is a sine qua non of the 
preferable combination. Very well, but there would be no excuse for advocating a false 
theory of climate, even if this one element were unfavorable. There is a prevalent 
exaggeration of the effect of temperature changes. The change gets the blame which 
rightly belongs to the element of humidity, which constituent is always excessive when 
a given change is injurious. For instance, a change of 20° from a warmer to a colder 
temperature, with relative humidity .50 per centum, does not equal, in sensation or shock 
to the system, a change of 8° with relative humidity at .80. The former change does 
not produce saturation, but the latter does ; so does a change of 5° with humidity at 
.90, and even 2° with humidity at .95. (See Glaisher's table.) Therefore it is the 
humidity of the air which, through conduction of heat from the body, makes a slight 
temperature change, with air near saturation, equivalent to a much greater change with 
the air dry. 
It is toadyism to the mistakes of medical antiquity for equability to be any longer 
insisted on as a constituent of the best climate for phthisis. It is all right and essential 
for humid climates, but for dry, cool and elevated resorts it is out of the question. 
There is something wrong with the reasoning powers of an author who j umbles together 
climatic attributes so that his "ideal climate" has no real counterpart among the 
known climates of the world ! The trouble is chiefly with the vague use of the words 
equability and variability. There has been no accepted line of definition between these 
two terms. If the mean of variability for the whole country were taken as a just 
division, and the daily and monthly ranges of temperature were the criterion to decide 
by, we would then have a division line approximately represented by 18° to 20° for the 
daily, and 46° to 48° for the monthly range, the same being in harmony with the 
dividing line between moisture and dryness. 
Besides the quality of stimulation, which is associated with variability, there is an 
important consideration in the purifying of the atmosphere which variability indicates. 
This happens through the alternate expansion by heat and contraction of the air by cold, 
together with the nightly chilling and sometimes freezing, which regularly renders it 
inimical to germ life. 
The purity of atmosphere which is represented by warm, moist and equable climates, 
is not to be compared with that purity which is represented by the opposite attributes. 
The first is where the temperature so continuously hovers within the limits of the 
microbe's needs, where sound as well as heat is smothered within a short distance, and 
the sun's rays give a dusky-red glow. The second, indicating a comparative absence of 
germs-is where exposed meat can cure and not spoil, where far-distant objects appear 
near, and the unobstructed rays of the sun give nearly as white a light as does an 
electric lamp. 
VI. DIATHERMANCY VS. DENSE, MOIST OR SMOKY ATMOSPHERES. 
The clearness or transparency of the air is a decided indication of its purity. It is 
with the atmosphere as with water. The larger the lake, with perfectly clear water, 
through which one can see to a great depth, the better is the evidence of purity. So a 
large area, having throughout a similar atmosphere, through which one can see most 
remarkable distances, and besides, probably, be deceived as regards the same, must 42 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
indicate, as does its coldness, rarefaction and dryness, that the purity is approaching 
the absolute. 
This increasing purity of atmosphere-that is, the absence of dust or smoke, or of 
moisture with its attendant infusoria-is a decided feature of elevation, because with 
each rise of 1000 feet an equivalent stratum of air has been left down below, and, accord- 
ing to Prof. Tyndall, each successive stratum contains less and less of infusoria. 
Prof. Miquel, of the Observatoire de Montsouris, near Paris, has achieved a result 
in the analysis of the air, which, as mentioned by Dr. Poore in his Cantor lectures, is 
very interesting in this connection.* 
Miquel found the following numbers of bacteria in ten cubic metres of air taken as 
nearly as possible at the same time, in July, 1883, at the respective places :- 
TABLE V. 
At an elevation of from 2000 to 4000 metres None 
On the lake of Thun (560 metres) 8 
Near the Hotel Bellevue, Thun 25 
In a room of Hotel Bellevue, Thun 600 
In the park of Montsouris (near Paris) 7,600 
In Paris itself (Rue de Rivoli) 55,000 
These figures, whatever way they are studied, are certainly suggestive of the fact 
that atmospheric purity, in so far as its aseptic nature is concerned, keeps pace with 
diathermancy. 
A rule for the average change in diathermancy,'for each rise in elevation, was devised 
by the writer in 1876, from consecutive observations of the sun temperature at two P.M., 
and at different elevations.f It is as follows:- 
For each rise of about 235 feet there is one degree greater difference in temperature 
between sun and shade at 2 P.M., as shown by metallic thermometers. J 
Vii. An attempt by the writer to graphically illustrate the distribution of soils in 
the United States, on the basis of their absorbent or moisture-retaining proclivity, was 
met by many obstacles. Such work pertains rather to the duties and obligations of the 
Government. This much, however, is evident, that the distribution of atmospheric 
moisture closely coincides with that of soils. The dry soils, the rocky and sandy por- 
tions of mountainous configuration, and the dry, sandy loams, with rapid absorption of 
air, vapor, and radiation of heat, nearly represent the dry sections, atmospherically 
speaking. Per contra, the clay soil and marshes of level sections, with their moist cold 
and the easy solution of organic emanations, are closely associated with the moistest 
atmospheres, excepting where there are humid currents from over large bodies of water 
or extensive marshes. This correspondence with reference to broad areas becomes a 
strong proof of the utility of our preferable combination of climatic attributes. 
Vin. A mountainous configuration of country, aside from the benefit of elevation 
above the sea, has many advantages over a level region. Chief among these are the 
quick drainage, which allows of no detention of stagnant water; the greater surface of 
the earth exposed to absorb atmospheric moisture; the many faces of rocks, etc., favor- 
ing radiation of heat and reflection of light; the element of stimulation, both atmo- 
spheric and electric; the controlling of severe winds; the variations of scenery, tem- 
perature and exposure afforded, and the facility with which one can indulge in the 
useful "climbing treatment" and pleasurable out-door activities. When these advan- 
tages are compared with the moisture retaining properties, the sameness, the " siroccos," 
* "Chronic Pulmonary Phthisis," by Hermann Weber. 
f " Rocky Mountain Health Resorts." 
J At great heights the protection of thermometers from extraordinary radiation must be secured, 
to get a fair test. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
43 
the trade winds and the ' • northers ' ' of level regions, there is not much difficulty in 
choosing between them. 
IX. The changes in the atmosphere, in consonance with the variability of tempera- 
ture of high climates, are in no small degree electrical. There is an increase of elec- 
trical tension and an easier and more frequent interchange between the positive electricity 
of the dry air and the negative quality of the ground and of clouds, so that the condi- 
tion is decidedly stimulating. This quality, in mountainous sections, is associated with 
light showers, especially iu summer time, when most needed to clean the atmosphere. 
The simultaneous whirl of a light or rapid wind, often seen in high altitudes, purifies 
by its substitution of an unused and fresh supply of air for that which is contaminated. 
Where people crowd together in large numbers, the daily freezing of the air is the 
only sufficient substitute for the movement which is caused by a mild wind; we thus 
arrive at the conclusion that, in densely settled sections, continuous stillness of the 
atmosphere is only to be preferred in the freezing weather of winter. In other words, 
the warmer the atmosphere, the more is air movement desirable. 
x. It is where there is a total absence of land influence, as in sea voyages and on 
islands far out at sea, or on dry, sandy coasts, with favorable sea winds prevailing, that 
low climates may, if necessary, be substituted for high ones. The malarial and organic 
emanations from the soil, which are a fruitful source of increased mortality from 
phthisis (Buchanan and Bowditch), are thus excluded from the climatic calculation. 
The aseptic condition of the atmosphere (Miquel), with its quality of stimulation, 
and the tonic effect of the change, with the invigoration of all the bodily functions- 
including the improvement of appetite and digestion-are all akin to the best effects of 
high climates, though the bacillus of tubercle is not so decidedly eliminated. 
There is nothing more evident about this discussion than that the element of altitude 
is inseparable from the best climate for phthisis. A natural question then follows. 
What is the limit up to which this combination of qualities can be carried, that 
the best results may be obtained ? The answer is, It is a question of individual 
adaptability. 
The best method of conclusion is to determine what conditions or disease are suit- 
able for the extreme of the preferable combination of attributes, and then arrive at 
modifications or rejections of the high climate cure by a system of exclusion. This is 
the position always held by the writer,* and he is pleased to see the confirmation of it 
by the extended experience of Jaccoud, as given in his late work on "The Treatment 
of Phthisis." Jaccoud's conclusions are in the main correct, but it must be borne in 
mind that they pertain to a more northern latitude than we reason about in the United 
States; that the gradual rise, distance and the peculiar protection of our interior alti- 
tudes make the change from low levels less severe here. Also, that we in America have 
an immense advantage over most European high climates, in that we keep up the curative 
effect by suitable increase of altitude in summer. Instead, they are compelled, as at 
Davos, St. Moritz, etc., to give up the chosen climatic treatment during the warm 
weather. 
The plan of deciding if the preferable climate can be utilized in a given case, by 
exclusion because of negative conditions, will not be readily accepted by the advocates 
of the low climates. This is because, generally speaking, the more reasons there are 
* " Lessened barometric pressure, twenty-five to twenty-four inches, being an important condi- 
tion of successful climatic treatment, a resort to a well-chosen elevated climate should constitute à 
part of the physician's advice to every consumptive who can follow it, and for whom the eleva- 
tion is not specially contraindicated."-Rocky Mountain Health Resorts. 44 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
for exclusion from the better climate the less likelihood is there of an ultimate recovery, 
and no set of physicians want to take only unfavorable cases. 
Sometimes it is not an easy matter to decide what change of climate a given patient 
shall have, because of the many varying considerations to be weighed, both as to 
patient and climate. 
This already too protracted essay cannot allow of elaboration. We may only sum- 
marize by saying, the preferable climate for the great majority of consumptives in the 
United States varies, according to the case, from 1500 feet elevation in the North in 
winter, to 10,000 feet as a possible extreme, in the Southern portion in summer. As to 
patients, not omitting social and economic bearings, it varies all the way from hopeless 
cases, with almost no discernible lung lesion, to probably successful ones, with marked 
pulmonary destructions; as well as from the usual mild remediable cases (simple chronic 
inflammations) to severe incurable ones. 
Of course, then, any rule of procedure must be susceptible of much variation, and 
the physician who takes the most factors into account, and weighs them best, will be 
most successful in the management of each individual case. With this broad proviso 
we state some general contraindications to an otherwise preferable high climate :- 
1. The coldest season of the year, intensifying the effect of altitude. 
2. Advanced age of the individual, rendering acclimatization difficult. 
3. An excitable, nervous temperament, aggravating the stimulation of climate, 
producing irritability and sometimes wakefulness. 
4. Women, for a like susceptibility, and less adaptability to the change and to out- 
door life than men. 
5. Valvular lesions with rapid action of the heart, especially with the previous 
exceptions. 
6. Marked and extensive emphysema, pneumothorax and hydro-pneumothorax. 
7. Active pneumonia or existing haemoptysis. If these are recent the contraindica- 
tions are much less than if they are present ; if remote, and without other objections, 
these diseases are most favorably influenced by the change. If there is reason for some 
doubt, in any such otherwise favorable case, a gradual rise in elevation should be 
chosen. 
8. High bodily temperature, whether it be rather constant, as in some inflammatory 
states, or in catarrhal extension beyond a tubercular zone, or whether it be regularly 
vacillating, as in tubercular infection, i. e., daily low or subnormal in morning and up to 
103° or more later in the day, especially with suspicious laryngeal complication. 
9. Extensive involvement of lung tissue in diseased action, i. e., so that the healthy 
spirometrical record is more than one-half abridged. Of course advanced stage of dis- 
ease renders this contraindication much stronger. 
10. The stage of softening, if accompanied by marked pyrexia, or in one of decided 
hemorrhagic diathesis. 
Allowing patients to go to Colorado, which many physicians have done, as a dernier 
ressort, when they have not a five per centum chance of living more than six months 
anywhere, needs our strong condemnation. 
It must always be remembered that every rule has its exceptions, and that contra- 
indications may be neutralized by favorable circumstances, such as the best time of year 
for the change, previous experience of the individual in high climates, and the associa- 
tion of opposite conditions in the same patient. For instance, the writer has in mind 
an excitable lady with aortic insufficiency, neurasthenia, and some fibroid lung, who 
has done excellently well in Colorado. 
Another case of asthma and enlargement of the heart, with mitral regurgitation, 
was free from asthma while he remained, and was very little troubled with his valvu- 
lar lesion. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
45 
Other and finer distinctions or indications are necessarily omitted for lack of time to 
consider them. Enough, however, has been here presented to indicate the way to a 
desirable harmony between the adaptability of an affected person to the preferable climate 
for phthisis, which in most cases is in the dry, cool, rarefied, sunny, clear and pure, 
though variable, atmosphere of a well-chosen high altitude. 
Vice-President, Dr. Walton, U. S. Navy, in the Chair. 
THE SEASONAL PREVALENCE OF PNEUMONIC FEVER. 
LA PRÉDOMINANCE DE LA FIEVRE PNEUMONIQUE DANS LES SAISONS DE 
L'ANNÉE. 
ÜBER DAS VORHERRSCHEN DER PNEUMONIEN IN GEWISSEN JAHRESZEITEN. 
JOHN WILLIAM MOORE, B.A., M.D. UNIV. DUB., 
In April, 1875, Dr. T. W. Grimshaw, now Registrar-General for Ireland, and I read 
before the Medical Society of the King and Queen's College of Physicians a paper on 
what we ventured to call " Pythogenic Pneumonia." This paper, which was pub- 
lished in the number of the Dublin Journal of Medical Science for May, 1875,* was 
based upon observations of pneumonia in Steevens' and Cork street Hospitals, Dublin, 
during the summer of 1874, when an epidemic of the disease prevailed in the Irish 
capital; as well as upon an analysis of the statistics of death from bronchitis and pneu- 
monia registered in Dublin during nine years ending with 1873. In the same commu- 
nication, the meteorological and epidemic conditions of 1874 were discussed, and our 
researches seemed to warrant us in drawing the following conclusions:- 
1. That the bibliography of pneumonia indicates the existence of a form of the 
disease which arises under miasmatic influences, and is contagious. 
2. That this view is supported by the relations which exist between this form of 
pneumonia and certain zymotic affections-notably, enteric fever and cholera-and by 
the resemblance between it and epizootic pleuro-pneumonia. 
3. That its aetiology justifies us in regarding the disease as a zymotic affection and 
in naming it "pythogenic pneumonia." 
4. That pythogenic pneumonia presents peculiar clinical features which enable us 
to distinguish it from ordinary pneumonia. 
5. That much of the pneumonia which prevailed in Dublin during 1874 was of this 
pythogenic character. 
6. That, whereas ordinary pneumonia is specially prevalent during a continuance 
of cold, dry weather, with high winds and extreme variations in temperature, pytho- 
genic pneumonia reaches its maximum during tolerably warm weather, accompanied 
with a dry air, deficient rainfall, hot sun and rapid evaporation. 
The twelve years which have elapsed since the publication of this paper on " Pytho- 
genic Pneumonia " have been fruitful in the literature of the subject to an unprece- 
dented degree. Among the many monographs on pneumonia which have of late 
appeared, perhaps the most valuable are that by Dr. August Hirsch, Professor of Medi- 
cine in the University of Berlin, on the Geographical and Historical Pathology of the 
Of Dublin, Ireland. 
* Vol. Lix, No. 41. Third Series. Page 399. 46 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Disease,* and that by the late Dr. C. Friedländer, of Berlin, on the " Micrococci of Pneu- 
monia. ''f 
Hirsch, after pointing out that pneumonia, even in its narrowest acceptation of 
fibrinous or so-called croupous pneumonia, is an anatomical term that includes several 
inflammatory processes differing from one another in their aetiology, goes on to observe 
that the prevalence of the malady depends very decidedly upon certain influences of 
season and weather. He gives an elaborate table of percentages of pneumonic preva- 
lence in the several months at a large number of places in Europe and America. 
According to this table, the largest number of cases falls in the months from February 
to May; the smallest number in the period from July to September. Taking the 
average for all the places mentioned in the table, it appears that 34.7 per centum of the 
patients were attacked in spring (March to May, inclusive); 29.0 in winter (December 
to February); 18.3 in autumn (September to November); and 18.0 in summer (June to 
August). The combined percentage for winter and spring is 63.7; that for summer and 
autumn is 36.3. If the number of cases in summer be taken as 1, then autumn has 
1.02, winter 1.6 and spring 1.9. Nearly all the recorded epidemics of pneumonia have 
occurred in winter and spring. From the foregoing considerations, Hirsch confidently 
concludes that the origin of the malady is dependent on weather influences proper to 
winter and spring, and more particularly on sudden changes of temperature and consider- 
able fluctuations in the proportion of moisture in the air. He holds that any exceptionally 
large number of cases of "inflammation of the lungs" at other seasons, more espe- 
cially in summer, has coincided with the prevalence of the same meteorological condi- 
tions phenomenally at that season. 
"But that conclusion," he goes on to say, "is still further borne out by the fact 
that in those northern regions (Russia, Sweden, Denmark, Germany, England, North 
of France, and Northern States of the American Union) where the most sudden and 
severe changes of temperature fall in spring, the largest number of cases is met with in 
spring, also; while in the warmer and sub-tropical countries (Italy, islands of the 
Mediterranean, Spain and Portugal, Greece, Algiers, Southern States of the Union, 
Chili and Peru), which are subject to those meteorological influences, for the most part, 
in winter, it is winter that represents the proper season of pneumonia. And that 
applies not merely to sporadic cases, but, in part, at least, to epidemic outbreaks of the 
malady as well. One other fact deserves to be noticed here, namely, that those tracts 
of country, especially in the tropics, which are highly favored in their climate or in the 
steadiness of the temperature from day to day (Egypt, many parts of India, including 
Bengal and the plain of Burmah, California, etc.), are subject to pneumonia to a com- 
paratively slight extent. ' ' 
In the paper on "Pythogenic Pneumonia," by Dr. Grimshaw and myself, will be 
found a table, compiled from the returns of the Registrar-General for Ireland, which 
shows the number of deaths from bronchitis and pneumonia registered in the Dublin 
Registration District in each quarter of the nine years, 1865-1873, inclusive. Accord- 
ing to that table, of every 100 deaths from bronchitis, 44 on the average occurred in 
the first quarter of the year, 22 in the second, only 10 in the third, and 24 in the fourth 
quarter. Thus, the mortality from bronchitis was twice as great in the first as it was 
in the second quarter, and more than four times greater in the first than in the third 
quarter. 
* " Handbook of Geographical and Historical Pathology." Vol. in. Translated from the 
Second German Edition, by Charles Creighton, m.d. London: The New Sydenham Society, 
1886. 
f Fortschritte der Meditin. Band I, Heft 22, Nov. 22d, 1883. Translated for the New 
Sydenham Society. By Edgar Thurston, 1886. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
47 
Very different were the facts as to pneumonia-of every 100 deaths from this 
disease, 32 on the average occurred in the first quarter, 27 in the second, 16 in the 
third and 25 in the fourth quarter. The mortality from pneumonia was only one-fifth 
greater in the first than in the second quarter, and only twice as great in the first as in 
the third quarter. The extreme winter fatality of bronchitis and its low summer fatal- 
ity were equally wanting in the case of pneumonia. 
A careful analysis of the weekly returns of the Registrars-General of England and 
Ireland for ten years ending with 1885 and of the same returns for the year 1886, 
brings out a similar remarkable contrast between bronchitis and pneumonia, as to the 
time of year when these diseases are respectively most prevalent and fatal in London 
and Dublin. 
Table I contains the figures relating to bronchitis; Table II, those relating to pneu- 
monia. Each table sets forth the weekly average number of deaths in London and in 
Dublin from bronchitis and pneumonia, respectively, in the ten years, 1876-85, as well 
as the actual weekly number of deaths from these diseases in the year 1886. 
In Tables III and IV these numerical results are thrown into curves. 
It will be observed that the statistics for London and for Dublin agree to a remark- 
able extent. In both cities bronchitis falls to a very low ebb in the third, or summer, 
quarter of the year (July to September, inclusive), when only 12 per centum of the 
deaths annually caused by this disease take place in Dublin, and only 11 per centum in 
London. In the last, or fourth, quarter (October to December, inclusive), the percentage 
of deaths from bronchitis rises to 27 in Dublin and to 30 in London. The maximal 
mortality occurs in the first quarter (January to March, inclusive), when it is 38 per 
centum in both London and Dublin. In the second, or spring, quarter (April to June, 
inclusive), the deaths from bronchitis declined to 23 per centum in Dublin and to 21 per 
centum in London. 
The mortality from "pneumonic fever" is very differently distributed throughout 
the year. In the summer quarter more than 14 per centum of the deaths yearly referable 
to this disease are recorded in Dublin, and more than 15 per centum in London. In the 
first quarter, the figures are: Dublin, 31 per centum ; London, 31 per centum; in the second 
quarter they are : Dublin, 30 per centum; London, 26 per centum; in the fourth quarter 
they are: Dublin, 24 per centum; London, 28 per centum. 
From these numerical results it therefore appears that the fatality and (indi- 
rectly) the prevalence of pneumonic fever from season to season do not correspond with 
the seasonal prevalence and fatality of bronchitis. The latter disease-be it of pri- 
mary or secondary origin-increases and kills in direct relation to the setting in of cold 
weather, with excessive relative humidity and increased and frequent precipitation in 
the.form of rain, snow or sleet, and hail. It subsides in prevalence and fatality with 
the advance of spring and the advent of summer. 
Pneumonic fever, on the other hand, increases less quickly in winter and remains 
more prevalent and fatal in spring and summer than bronchitis; its maximal incidence 
coincides with the season of dry, harsh winds and hot sunshine in spring, when also the 
relative humidity is low, precipitation is scanty, while the diurnal range of temperature 
is extreme. 
A closer study of Tables III and iv yields some interesting results. In the first place, 
we observe that the London curves of deaths both from bronchitis and from pneumonia 
vary less from week to week than the corresponding curves for Dublin, which are much 
less regular and, as it were, more serrated. The reason for this evidently is, that in 
the case of London we have to deal with a population which is now some twelve times 
greater than that of Dublin, hence the law of periodicity fulfills itself with greater 
exactness in the vast population of London than in the comparatively small population 
of Dublin. The death curves of the larger city are, as it were, seen through a magnify- 48 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ingglass of ten diameters, in the corresponding death curves of Dublin,the variation from 
week to week being magnified or multiplied tenfold. In the second place, it will be 
noticed that bronchitis is uniformly throughout the year less fatal in proportion to the 
population in London than it is in Dublin, while the converse is true of pneumonia. 
According to the census of 1881, the middle year of the decade with which we are at 
present concerned, the population of the London Registration District was 3,893,272; 
that of the Dublin Registration District was 348,293. The average quarterly numbers 
of deaths from bronchitis in the ten years-1876-85 were these :- 
First quarter, Dublin, 566.9; London, 4358.5. 
Second quarter, Dublin, 338.2; London, 2397.1. 
Third quarter, Dublin, 172.7; London, 1253.8. 
Fourth quarter, Dublin, 395.4; London, 3413.2. 
On the other hand, the average quarterly numbers of deaths from pneumonia in the 
same ten years were :- 
First quarter, Dublin, 112.2; London, 1467.2. 
Second quarter, Dublin, 108.8; London, 1222.5. 
Third quarter, Dublin, 51.4; London, 734.8. 
Fourth quarter, Dublin, 85.9; London, 1350.2. 
The third point of interest in Tables III and iv is the dip in the death curve from 
bronchitis, both in London and in Dublin, from the seventh to the tenth week of the year. 
This would seem to depend on several causes-first, the removal by death at the begin- 
ning of the year of those individuals who were most susceptible to bronchitis; secondly, 
the acclimatization of the surviving population to the continued cold of winter ; and 
thirdly, the prevalence of southwest winds and open weather toward the close of January 
and early in February. With the setting in of the searching east winds of early spring 
the death curve again rises at the beginning of March, when also there is a marked rise 
in the death-toll exacted by pneumonia, more especially in London. 
Another curious point is, that the changes in the contour of the death curves appa- 
rently occur a week earlier in London than they do in Dublin. Delay in registration 
in the latter city seems to be the explanation of this otherwise puzzling circumstance. 
It will be observed that in the foregoing analysis only statistics of deaths are con- 
sidered, and these, unfortunately, are of minor value compared with statistics of the 
prevalence of bronchitis and of pneumonia respectively, were such available. Let 
us hope that the day is not far distant when registration of disease will be compulsory, 
as registration of the cause of death is at present. Until this much-needed reform 
is carried into effect, statistical inquiries into the prevalence of disease in localities and 
in seasons will want much of that precision which alone can give them scientific value. 
How are we to explain the continued frequency of pneumonic fever in sumpier 
and autumn? In my opinion the solution of this paradox is to be sought in the con- 
sideration of the pythogenic origin of the disease in many instances, and particularly in 
the warm season of the year. In a word, I would regard exposure to cold, extremes 
of temperature, harsh, drying winds, and other personal or climatological conditions as 
merely so many predisposing causes of the disease, while I would reserve for the intro- 
duction into the system of a specific virus or contagium the rôle of an exciting cause- 
perhaps the sole exciting cause of pneumonic fever. As to the exact nature of that virus 
or contagium, we are as yet practically ignorant, but the researches and discoveries of 
Klebs, Eberth, Koch, and Friedländer in connection with the micrococci of pneumonia- 
the pneumococcus (Pneumonic-kokken) of Friedländer, are full of promise. We stand on 
the threshold of a new Science of Medicine, and before long a flood of light will doubt- 
less be shed upon the intimate nature and pathology of pneumonia as well as of other 
blood diseases. 
In the " Medical Report of Cork Street Fever Hospital and House of Recovery, SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
49 
Dublin," for the year 1884, I ventured to assert that the claims of pneumonia to be 
considered a specific fever rested principally upon- 
1. Its not infrequent epidemic prevalence, which the bibliography of the disease 
places beyond dispute. 
2. Its proved infectiousness in some instances, as, for example, those observed at 
Dalton in the spring months of 1883, by Dr. E. Slade King and Mr. Sloane Michell, 
M.R.C.S., England.* 
3. Its occasional pythogenic origin, and the remarkable correlation which appears to 
exist between it and enteric fever. 
4. Its mode of onset, or " invasion," which exactly resembles that of the recognized 
specific fevers. ' 
5. The appearance of constitutional symptoms before the development of local signs, 
or even local symptoms in many instances; in other words, the existence of a true 
"period of invasion." 
6. The critical termination of the febrile movement in all uncomplicated cases. 
7. The presence of local epi-phenomena in connection with the skin, such, for example, 
as eruptions of herpes, the appearance of taches bleuâtres, and the occurrence of 
desquamation. 
8. The development of sequelæ in some cases, such as an attack of nephritis, followed 
by renal dropsy, ataxia like that observed after typhus or diphtheria, and so on. 
. 9. The discovery of a bacterium in pneumonic exudation, to which analogy, at all 
events, points as pathognomonic. 
In my hospital and private practice I have acquired the habit of expressing the 
relation of the local lesion in pneumonia, or pneumonic fever, to the essential disorder, 
in terms of the intestinal lesion in enteric fever to that disease. Just as physicians and 
pathologists have long since come to avoid the dangerous error-I would even say 
heresy-of Broussais and his school, who held that the pyrexia or feverishness in enteric 
fever was symptomatic of and secondary to a local inflammation of the glands of the 
small intestine, so we shall come in time to avoid the similar and not less dangerous 
but more widely disseminated error, of regarding the pyrexia in pneumonia as symp- 
tomatic of and secondary to a local inflammation of the lungs. The day iß seemingly 
not far distant when we shall speak of "pneumonic fever" in precisely the same way 
as we use the term "enteric fever " at present-that is, to signify a zymotic or specific 
blood disease, manifesting itself after the lapse of a certain time- the period of incuba- 
tion-by physical phenomena-objective and subjective-connected, in this instance, 
with the lungs. 
* Cf. The Practitioner, April, 1884. 
Vol. V-4 50 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
TABLE I. 
SHOWING THE DEATHS FROM BRONCHITIS, BY WEEKS AND QUARTERS, IN DUBLIN AND 
LONDON, IN THE TEN YEARS 1876-1885 INCLUSIVE, AND IN THE YEAR 1886. 
Week. 
Dublin Registration District. 
London Registration District. 
First 
Quarter. 
Second 
Quarter. 
Third 
Quarter. 
Fourth 
Quarter. 
First 
Quarter. 
Second 
Quarter. 
Third 
Quarter. 
Fourth 
Quarter. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
QO 
1886. 
1876-85. 
1886. 
1876-85. 
00 
1876-85. 
1876-85. 
1886. 
1 
43 4 
26 
38.0 
30 
13.0 
11 
18.9 
7 
314.7 
338 
309.0 
218 
106.8 
93 
135.9 
124 
2 
42 3 
21 
31.6 
20 
15.9 
8 
19.8 
11 
311.8 
351 
277.5 
213 
102.8 
88 
166.1 
122 
3 
44.5 
32 
36.0 
27 
12.6 
13 
18.9 
12 
350.2 
308 
239.8 
179 
97.2 
71 
195.9 
160 
4 
49.7 
29 
29.0 
30 
13.2 
10 
22.6 
13 
368.2 
330 
222.7 
175 
92.8 
84 
221.6 
189 
5 
48.3 
38 
26.4 
22 
12.4 
4 
24.3 
11 
435.6 
304 
193.0 
179 
95.7 
82 
237.5 
176 
6 
54.3 
40 
26.9 
16 
11.7 
16 
26.5 
22 
405.2 
394 
189 8 
166 
90.5 
76 
266.1 
186 
7 
50.2 
52 
21.5 
13 
13.0 
7 
29.7 
24 
340.7 
452 
172.1 
137 
91.6 
74 
272.1 
216 
8 
43.4 
47 
24 2 
17 
11.2 
10 
34.1 
16 
290.9 
439 
157.3 
108 
83.7 
89 
289.5 
273 
9 
38.6 
28 
23.2 
24 
13.0 
13 
32.8 
23 
289.9 
526 
146.0 
91 
86.6 
63 
297.5 
278 
10 
37.3 
55 
22.8 
11 
12.5 
9 
39.4 
33 
295 2 
566 
143.2 
96 
82.5 
59 
294.4 
327 
11 
35.0 
41 
20.2 
11 
14.5 
17 
42.1 
33 
304.4 
646 
124.4 
90 
95.5 
85 
345.3 
260 
12 
41.4 
38 
19.0 
15 
14.1 
14 
43.3 
30 
318.9 
474 
114.2 
82 
109.7 
71 
342.2 
276 
13 
38.5 
28 
19.4 
8 
15.6 
6 
43.0 
35 
332.8 
330 
108.1 
98 
118.4 
102 
347.1 
370 
Totals. 
566.9 
475 
338.2 
244 
172.7 
138 
395.4 
270 
4358.5 
5458 
2397.1 
1832 
1253.8 
1037 
3413.2 
2957 
Per Cent. 
38.5 
42.1 
23.0 
21.7 
11 7 
12.2 
26 8 
2.40 
38.2 
48.4 
21.0 
16.2 
11.0 
9.2 
29.8 
26.2 
Total Deaths from Bronchitis : 
Dublin, 
Total Deaths from Bronchitis : London, 
1876-85 (Average), 1473.2 
; 1886, 1127. 
1876-85 (Average), 11,422.6; 
1886, 
11,284. 
TABLE II. 
SHOWING THE DEATHS FROM PNEUMONIA, BY WEEKS AND QUARTERS, IN DUBLIN AND 
LONDON, IN THE TEN YEARS 1876-1885, INCLUSIVE, AND IN THE YEAR 1886. 
Week. 
Dublin Registration District. 
London Registration District. 
First 
Quarter. 
Second 
Quarter. 
Third 
Quarter. 
Fourth 
Quarter. 
First 
Quarter. 
Second 
Quarter. 
Third 
Quarter. 
Fourth 
Quarter. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1876-85. 
1886. 
1 
8.6 
7 
9.5 
7 
5.1 
10 
3.5 
5 
107.0 
117 
127.3 
84 
63.7 
64 
73.1 
56 
2 
9.0 
10 
8.9 
8 
4.9 
1 
4.5 
2 
106.4 
113 
124.7 
95 
62 0 
56 
75 8 
75 
3 
6.7 
4 
8.9 
11 
3.0 
0 
5.7 
5 
111.1 
109 
1118 
100 
56.2 
56 
86.3 
83 
4 
9.8 
7 
9.5 
4 
3 9 
1 
5.6 
6 
110.1 
90 
109.1 
73 
58.3 
53 
101.6 
59 
5 
9.1 
9 
9.5 
9 
3.7 
4 
5.2 
5 
125.6 
114 
101.6 
93 
60.2 
42 
103.4 
80 
6 
7.0 
7 
9.6 
9 
4.8 
7 
6.9 
1 
123.5 
122 
97.4 
95 
57 9 
46 
114.8 
90 
7 
10.5 
11 
7.2 
5 
2.9 
2 
6 7 
4 
121.5 
128 
90.0 
107 
51.9 
51 
112.3 
91 
8 
7.7 
7 
8.5 
10 
4.5 
1 
7.8 
5 
104.9 
139 
87.6 
80 
53.9 
45 
120.8 
95 
9 
9.5 
5 
8.2 
5 
4.3 
1 
7.9 
5 
93.7 
146 
83.9 
58 
49.4 
48 
116.4 
121 
10 
10.2 
9 
8.8 
6 
3.7 
2 
7.9 
9 
104.5 
206 
76.3 
83 
50.9 
34 
106.6 
no 
11 
7.8 
17 
8.0 
6 
3.2 
1 
7.8 
7 
109.8 
182 
74.6 
60 
51.3 
54 
111 8 
101 
12 
7.9 
11 
5.4 
9 
4.1 
1 
6.6 
2 
120.1 
165 
66.2 
72 
58.1 
48 
115.4 
112 
13 
8.4 
11 
6.8 
4 
3.3 
1 
9.8 
9 
129.0 
125 
72.0 
64 
61.0 
43 
111.9 
127 
Totals. 
112.2 
115 
108.8 
93 
51.4 
32 
85.9 
65 
1467.2 
1756 
1222.5 
1064 
734.8 
640 
1350.2 
1200 
Per Cent. 
31.3 
37.7 
30.4 
30.5 
14.4 
10.5 
23.9 
21.3 
30.7 
37.7 
25.6 
22.8 
15.4 
13.7 
28.3 
25.8 
Total Deaths from Pneumonia : 
1876-85 (Average), 358.3; 1886 
Dublin, 
, 305. 
Total Deaths from Pneumonia: London, 
1876-85 (Average), 4774.7 ; 1886, 4660. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
51 
Talk TIT Showing Hu average weekly em ml er of Deaths from 
D/'onctuùs and front D/ieuinuiuw in die Decade /ore-es 8 s' ia 
7/tf Jdatdcii rtcfilial ion Jdisfrici. 
First tjnarliryS'ccoad Quader I TH rd Qeiarkr I fourth Quarter 
Tal?« ZV SJiceorny the ayera/t weekly reuntler ef 
/Drath s front JBroncfyifc's, and frotte DnriLiitoiiia, 
de /fie /Deceide /87c -JS8S - in -London. 
Iferji Quarter <Stevud Qua/Jrr Third Quarter I Taurtli Quaflîï\. 52 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
RELATIONS OF CERTAIN METEOROLOGICAL CONDITIONS TO 
DISEASES OF THE LUNGS AND AIR PASSAGES, AS SHOWN 
BY STATISTICAL AND OTHER EVIDENCE. 
CONNEXITÉ DE CERTAINES CONDITIONS METEOROLOGIQUES AVEC LES MALA- 
DIES DES POUMONS ET DES VOIES RESPIRATOIRES COMME LE 
DÉMONTRENT LA STATISTIQUE ET D'AUTRES ÉVIDENCES. 
ÜBER DIE BEZIEHUNGEN GEWISSER METEOROLOGISCHER ZUSTÄNDE ZU DEN KRANK- 
HEITEN DER LUNGE UND LUFTWEGE, WIE SIE DURCH STATISTISCHE 
UND SONSTIGE BELEGE ERWIESEN. 
BY HENRY B. BAKER, A.M., M.D., 
Of Lansing, Michigan. 
One of the reasons for the presentation of this paper is the possibility of bringing 
forward a kind of evidence not usually obtainable, namely, statistics of sickness over 
wide areas, and the comparison of those statistics with statistics of the principal meteor- 
ological conditions antecedent to and coincident with the sickness. Another reason is 
the belief of the writer that he has learned some of the reasons why the rise and fall 
of diseases of the lungs and air passages are, ordinarily, controlled by the temperature 
and other conditions of the atmosphere. Before stating the reasons why, however, it 
may be best to make sure that the fact is established that the rise and fall of certain 
diseases are ordinarily controlled by meteorological conditions. For this purpose I 
present several diagrams, accurately drawn to scale and based upon statistics carefully 
and conscientiously compiled; and I ask attention especially to a diagram (No. 4) 
showing a comparison of over 30,000 weekly reports of sickness, during the eight years 
1877-84, with over 150,000 coincident observations of the atmospheric temperature- 
from which it may be seen that the rise and fall of the sickness from pneumonia in 
Michigan follow absolutely the fall and rise of the atmospheric temperature. The 
sickness is reported each week so long as it continues. I believe that is one reason why 
the line representing sickness from pneumonia follows uniformly later than the line 
representing temperature. It should, on that account, follow later by a time equal to 
the average duration of the disease. But if caused in the way I point out, it should 
follow later, also because the condition which permits the exudation of the albuminous 
constituents of the blood into the air celts requires, for its production, the continuance 
of the effects of the inhalation of cold air. 
That pneumonia may sometimes result from a sudden and short exposure to cold is 
not here denied, but it is affirmed that, as a rule, the previous exposure to the inhala- 
tion of cold air for a considerable time had prepared the lungs to be thus affected. 
(This may be more apparent further on.) 
The fact that the curves for influenza, tonsillitis, bronchitis and pneumonia are, in 
general outlines, all practically the same, seems to me strong proof that the controlling 
cause is one and the same for all these diseases. They are diseases of the air passages, 
and may be supposed to be influenced or controlled by the atmosphere. The atmo- 
spheric conditions which I have found to stand in such relation to all of them as to 
make it possible that they have causal relation, are the temperature, the absolute 
humidity, the daily range of pressure and the ozone. Of these conditions the temper- 
ature of the atmosphere seems to me to be probably the most important causal condi- 
tion controlling these diseases. I believe that a large share of its control is through 
its control of the humidity of the air, and this point I hope to make plain. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
53 
ORDER OF SUCCESSION OF SOME OF THE COLD-WEATHER DISEASES. 
I have proved that in Michigan the rise and fall of sickness from, pneumonia follow 
quantitatively the fall and rise of the atmospheric temperature. This is apparent from 
a diagram (No. 4) which I present. I have shown by diagram (No. 3) that the rise 
and fall in the sickness from bronchitis, in Michigan, follow the fall and rise of the 
atmospheric temperature, although not so precisely quantitatively as is the case with 
pneumonia. By examining the evidence in these two diagrams, it may be seen that 
throughout the year an average of about forty per centum of the weekly reports stated 
that pneumonia was under observation, while an average of about sixty per centum of 
the reports stated that bronchitis was observed. It follows that among persons through- 
out the State exposed to the same atmospheric temperature, many more are taken sick 
with bronchitis than with pneumonia. It may also be seen that, as the cold weather 
approaches in the autumn, bronchitis increases more rapidly than pneumonia, also that 
it lingers longer in the spring months than does pneumonia. All these facts harmonize 
if we suppose that a less exposure to low temperature is ordinarily required to produce 
bronchitis than to produce pneumonia. 
In Michigan the sickness from influenza, tonsillitis, croup, diphtheria and scarlet 
fever, follows more or less closely the fluctuations of atmospheric temperature. It seems 
necessary to explain how it is possible for a cold atmosphere to cause in one person 
influenza, in another tonsillitis, in another croup, while in others it favors the contrac- 
tion of a contagious disease like scarlet fever.* It is probable, however, that the 
explanation would have been easy long ago except for a misapprehension of one of the 
principal facts. It has generally been stated that when these diseases were favored by 
a cold atmosphere, the air was not only cold but damp; and just how cold alone could 
do so much, or how dampness could favor the production of one of these diseases, has 
never been explained, notwithstanding the fact that dampness renders the cold more 
apparent and perhaps more effective. But the fact which has been lost sight of is that 
cold air is always dry air, absolutely; it is only the relative humidity or percentage of 
saturation of the air that is great when the air is cold. This is made plain by the study 
of any table of the absolute humidity showing saturation of air at different tempera- 
tures; thus a cubic foot of air at zero Fahrenheit cannot contain more than one-half 
grain of vapor of water; at 32° F. it cannot contain more than two grains; while at 
70° it may contain eight grains, and at 98° F., which is near the temperature of 
the air passages, each cubic foot of air may contain 18.69 grains of vapor. The influ- 
ence of cold dry air in the production of " chapped " hands has probably been noticed 
by most persons, and the stopping up of the nose by drying must have been often 
observed early in the occurrence of common colds, as also the dry cough which so com- 
monly calls for some medicine to ' ' loosen the cough. ' ' But the drying effects of the 
inhalation of cold air can best be understood by reflecting that each cubic foot of air 
inhaled at zero F. can contain only one-half a grain of vapor, while when exhaled it is 
nearly saturated at a temperature of about 98° F., and therefore contains about 18.69 
grains of water, about 18 grains of which has been abstracted from the air passages. 
Coryza.-Thus, cold air falling upon susceptible nasal surfaces tends to produce an 
abnormal dryness, which may go so far as to cause the "stopping up" of the nose, 
which may be followed by suppuration. In my opinion a common cold or coryza may 
thus be caused. 
Influenza.-In some persons, under some circumstances, the nasal surfaces may not 
be susceptible to drying, that is to say, fluids may be supplied in increased quantity to 
* In a paper entitled " Some of the Cold-weather Communicable Diseases," published in the 
Transactions of the Michigan State Medical Society for 1887, I have shown that the curves for 
scarlet fever, diphtheria and smallpox follow the curve for temperature. 54 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
meet the increased demand by the cold dry air, in which case the constant evaporation 
of the fluids will lead to an abnormal local accumulation of the non-volatile salts of the 
blood, such as sodium chloride, which is an irritant; and what is termed influenza may 
then arise. The close relations of influenza and atmospheric temperature are shown in 
the diagram (No. 1) which I submit herewith. It may be seen that influenza increases 
promptly in the summer and autumn, as soon as cold weather begins-more promptly 
than bronchitis or pneumonia does. This order of succession might be expected if these 
diseases are all caused in the manner pointed out in this paper; but it may, in part at 
least, be due to the shorter average duration of influenza. 
Bronchitis.-The effects which the inhalation of cold dry air have upon the bron- 
chial surfaces will depend greatly upon how the upper air passages respond to the 
increased demand for fluids; because if they do not supply the moisture the bronchial 
surfaces will certainly have to sustain an increased demand, in which case, as the 
phrase is among the common people, a " cold in the head " may then " settle on the 
lungs," and the person may have bronchitis. The bronchitis which results from the 
inhalation of cold dry air may be of that sort (like a cold in the head) characterized by 
an abnormal deficiency of the fluids, at least in the beginning of the disease, or it may 
be of that sort (like influenza) which is characterized by an excess of fluids, in which 
case, if the exposure is continued, the evaporation which results from the inhalation of 
air unusually cold and dry necessarily leads to the abnormal increase in that fluid of 
the non-volatile salts of the blood. 
Pneumonia.-Bronchitis not infrequently precedes pneumonia. The most distinctive 
feature of lobar pneumonia is the exudation. Certainly the causation of pneumonia 
is not explained until the manner in which the exudation is caused has been made 
plain. In papers on the causation of pneumonia I have elsewhere pointed out how 
such an exudation should be expected to result, in accordance with known laws of 
osmosis, from long-continued exposure to the inhalation of cold dry air. Since 1850, 
when Dr. Redtenbacher published his observations, * it has been known that during the 
onward progress of pneumonia chloride of sodium is absent from the urine ; and since 
1852 it has been known, through the researches of Lionel Smith Beale, f of London, 
England, that the chloride of sodium which then disappears from the urine of a 
pneumonia patient, may be found in the sputa and in the solidified lung. I have 
shown J that during the inhalation of cold dry air the quantity of fluid which passes 
out from the blood vessels into the air cells must be increased in order to meet the 
increased demand, and that through the increased evaporation an increasing quantity 
of the non-volatile salts of the blood may accumulate in the air cells. In connection 
with the foregoing I have also pointed out that as soon as the proportion of sodium 
chloride reaches about three or four per centum of the fluid in the air cells, the albumi- 
nous constituents of the blood should begin to pass out into the air cells. § And thus 
the chain of explanation of how the exudation which occurs in croupous pneumonia is 
caused, seems to have been completed. 
* Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien, Aug. 1850. 
f Vol. xxxv, Medico-Chirurgical Transactions, published by the Royal Medical and Chirur- 
gical Society, London. 
J Transactions of the American Climatological Association, May 10, 11, 1886, pp. 226-233. 
Also, Proceedings of Michigan State Board of Health, Oct. 1886, pp. 7-11. 
§ "But a substance like albumen, which will not pass out by exosmosis toward pure water, 
may traverse a membrane which is in contact with a solution of salt. This has been shown to be 
the case with the shell membrane of the fowl's egg, which, if immersed in a watery solution con- 
taining from three to four per centum of sodium chloride, will allow the escape of a small proportion 
of albumen. Furthermore, if a mixed solution of albumen and salt be placed in a dialysing SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
55 
The law of osmosis, in accordance with which albuminous exudations occur when- 
ever the fluid exterior to the blood vessels contains about four per centum of sodium 
chloride, probably applies, as a rule, to exudations throughout the air passages, and so 
I will not repeat it in connection with coryza, influenza, tonsillitis, croup and bronchitis. 
Indeed, the law probably applies in all diseases and throughout the human body ; but 
it seems probable that there are other conditions which favor the exudation of the 
albuminous constituents of the blood, such conditions, for instance, as cause a breaking 
down or change in the albuminous constituents themselves, variation in the blood 
pressure through variations in the atmospheric pressure ; and it is not difficult to see 
that blood pressure may be increased locally, as, for instance, through disturbed action 
of the heart, and, finally, an important factor in the causation of pneumonia and of 
exudation throughout the air passages, is undoubtedly the more or less complete 
paralysis of parts directly exposed to unusual cold, which may subsequently occur on 
their being subjected to warmth. 
Bearing upon the subject of the influence of atmospheric pressure in favoring pneu- 
monia, I submit a diagram (No. 7), which shows that in Michigan the curve for the 
average daily range of atmospheric pressure coincides very nearly with the reversed 
curve for the temperature, and that the sickness from pneumonia follows it somewhat 
closely, but not as closely as it does the temperature, perhaps, however, because the 
statistics relative to pressure do not cover sufficient time to obtain a correct average. 
My researches appear to prove that pneumonia, whether croupous or catarrhal, 
seems to be controlled by the atmospheric temperature. It, therefore, seems true, as 
many have long believed, that for both forms the causation is similar. From my stand- 
point it seems possible that in the catarrhal form the sodium chloride in the fluid 
which moistens the air cells, does not reach or much exceed the three or four per centum, 
which is required in order that the ordinary albuminous constituents of the blood should 
begin to pass out into the air cells, as it does in croupous pneumonia. It also seems 
possible that lobar pneumonia may require for its production that partial paralysis 
which results from the experience of a warm atmosphere immediately following expo- 
sure to cold (such an effect as is seen in the flushed cheek of a person brought into a 
warm room from extreme cold outer air), in which case the exudation should occur in 
just that part of the lungs supplied by the nerve influenced by the cold, because the 
walls of the blood vessels of just that part should be relaxed. The chill may result 
from such a disturbance of the nervous equilibrium, and be in the nature of an attempt 
to regain control of the relaxed blood vessels. 
Elsewhere * I have shown-and it may be seen by diagrams 8 and 9-that a few 
communicable diseases, which, as a rule, gain access to the body through the air pas- 
sages, are quantitatively related to the atmospheric temperature, almost invariably 
rising after the temperature falls, and falling after the temperature rises. The expla- 
nation has seemed to me to be that those exudations which result from the inhalation 
of air colder than usual supply a nidus for the reception and reproduction of the spe- 
cific contagia of scarlet fever, smallpox, etc. 
Inasmuch as diseases known to be contagious follow so exactly the fluctuations of 
atmospheric temperature that pneumonia is also controlled by the temperature, is no 
proof of the non-contagiousness of pneumonia ; but all, or nearly all, of the phenomena 
apparatus, the salt alone will at first pass outward, leaving the albumen ; but after the exterior 
liquid has become perceptibly saline, the albumen also begins to pass in an appreciable quantity." 
John C. Dalton, "Treatise on Human Physiology for use of Students and Practitioners," etc., 
Philadelphia, 1875, p. 363. 
* "Some of the Cold-weather Communicable Diseases," in Transactions of the Michigan State 
Medical Society, 1887. 56 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of pneumonia are now accounted for without reference to a special coutagium, and the 
same can be said of bronchitis, influenza and the other diseases of the upper air passages. 
BEARING UPON DIET AND TREATMENT. 
If, as I believe, nearly all of the diseases of the air passages, and some contagious 
diseases which gain entrance to the body through the air passages, are associated with 
unusual evaporation of fluids from their surfaces, and the accumulation there of the 
non-volatile salts of the blood which act as irritants, and which, when in sufficient 
quantity, cause the exudation of the albuminous constituents of the blood, these facts 
have an important bearing upon the subject of diet best adapted to freedom from these 
two classes of diseases ; for it is obvious that in a person whose blood is strongly satu- 
rated with sodium chloride or other fixed salt, the exudations may be quite different 
from those in a person whose blood is only scantily supplied with fixed salts. 
If these views are found to be correct-namely, that trouble comes from the accumu- 
lation of the non-volatile salts in the air passages-they may help to explain why in 
practice a volatile salt, like ammonia, has sometimes been preferred to a salt of a fixed 
alkali, and why such a volatile substance as carbonate of ammonia has been preferred 
by some as even more satisfactory than the chloride of ammonium in the treatment of 
certain acute affections of the air passages. 
The importance of ascertaining the controlling causes of this large class of diseases 
seems to warrant analyses of the fluids transuded in influenza and in bronchitis, and 
such other experiments by those who have opportunity as shall prove or disprove the 
views here set forth. 
PREDISPOSING CAUSES-HYPERINOSIS AND PNEUMONIA. 
Chemically, fibrin is oxidized albumen. It should not, therefore, be difficult to 
infer the direction in which we must search for the causation of hyperiuosis, namely, 
in the direction of the causation of abnormal oxidation of the blood. This condition of 
the blood occurs in pneumonia, in rheumatism and in certain other diseases, and is 
believed by some to constitute an inflammatory condition of the blood-a tendency 
toward inflammation. Thus, in Aitken's " Science and Practice of Medicine," Vol. n, 
p. 508, Dr. Parkes is quoted as saying: " That hyperiuosis is really anterior in pneu- 
monia as in rheumatism, must, in spite of the opinion of Virchow, be considered likely 
from experiments, among others, of Prof. Naumann, of Bonn." It is conceivable that 
abnormal oxidation of the blood serum may result from an abnormal proportion or 
activity of the red blood corpuscles. In the same paragraph quotation from Dr. Parkes 
it is said : " It is well known how frequently the liver is affected in pneumonia, so that 
some amount of jaundice is not at all uncommon, and sometimes bile pigment appears 
in the pneumonic sputa. I have also found in some cases evidence of liver affection for 
some time before the lung disease, especially the so called torpor with deficient biliary 
flow." * Whenever the production of red corpuscles continues at the normal rate, and 
they are not destroyed in the liver as fast as they normally are, it would seem that their 
accumulation may favor excessive oxidation of the albuminous constituents of the blood 
serum, in a condition described by the word hyperinosis. But it is still more conceiv- 
able that abnormal oxidation of the blood serum may result from the inhalation of 
oxygen in greater than normal amount, or in a condition of unusual activity, and ozone 
is oxygen in such an active condition. Furthermore, the curve for the rise and fall of 
atmospheric ozone is, in Michigan at least, almost precisely the curve for the rise and 
fall of pneumonia. (It is probable, however, that the quantity of residual atmospheric 
ozone is controlled by the atmospheric temperature.) It may be added, also, that the 
* Aitken's " Practice," Vol. II, p. 508. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
57 
late Dr. Henry Day, of London, England, claimed that his experiments with dogs 
proved that the inhalation of ozone caused bronchitis, and in larger quantities, pneu- 
monia. 
While, therefore, I do not claim that atmospheric ozone is the sole cause of pneu- 
monia, it seems quite probable that it may be a cause of hyperinosis, which is appar- 
ently a predisposing cause of pneumonia and of other diseases. It seems reasonable to 
believe also that an exudate, which under other conditions would be readily reabsorbed 
or taken away by the lymphatics as rapidly as formed may, under the influence of the 
abnormal oxidizing action of ozone, become too insoluble to be thus disposed of, and 
consequently accumulate as the fibrinous exudate in pneumonia, in pleuritis, in croup, 
etc., and also serve as a nidus for any contagium inhaled. 
In Michigan the curves for sickness and for deaths from pulmonary consumption 
seem to follow irregularly the inverted temperature curve, about one to three months 
later in time. Consumption thus seems to be influenced by the same meteorological 
conditions as is pneumonia. In this connection and in connection with what has been 
said as to the difficult removal of oxidized exudates, it is worthy of notice that Dr. H. 
F. Formad, of Philadelphia, has claimed that a structural condition predisposing to 
consumption is abnormally few and narrow lymph spaces in the connective tissues.* 
All of these alleged facts seem to be in harmony with what I have suggested as to the 
fibrinous nidus being the controlling cause of certain communicable diseases which 
enter through the air passages. 
Pulmonary Consumption. -But with a contagium which enters the body, but not 
through the air passages, if it is capable of entering the general circulation it is prob- 
ably capable of passing from the circulation to any exudate; so the formation and espe- 
cially the retention of such an exudate in the lungs and air passages would be expected 
to supply the conditions for the rapid multiplication of any such contagium. In this 
connection I submit a diagram (No. 11) showing that in Michigan the sickness reported 
from pulmonary consumption follows the inverted temperature curve with consider- 
able regularity, except that in the summer and autumn months it is separated from the 
temperature by a shorter period of time than it is in the winter and spring. The sick- 
ness under observation (which includes old cases) will be lessened by the deaths, and 
this should be especially noticed when the conditions favoring deaths do not also 
equally favor the production of new cases, as may be the fact on the approach of warm 
weather. However it may be, the curves for deaths need to be studied. I regret that 
the deaths in Michigan are not all reported, and the omissions are greater in the earlier 
months of each year; but in a diagram which I have prepared it may be seen that after 
making a correction for the omissions (estimated by comparison with census statistics) 
the curve for deaths is somewhat similar to the curve representing sickness. Relative 
to deaths, however, more satisfactory evidence is presented to you in the diagram (No. 
10) representing the relation of the deaths from phthisis in London, England, during 
thirty years, from which it is plain that the curve for deaths from phthisis follows the 
inverted temperature curve with great regularity. 
Returning now to the curve for sickness from consumption in Michigan (Diagram 
11) If in the summer months the reduction of the sickness by reason of the deaths 
is as great as the reduction by reason of the warmer weather, the curve for sickness 
should show, as it does, a more than average decrease, in fact, a double decrease after 
«"Tuberculosis usually ensues when a simple inflammation is set up by any kind of injury, in 
animals with the structural peculiarities that I have described ; but tuberculosis cannot be pro- 
duced in animals which do not have this structural peculiarity, so far as my experiments show, 
unless the injury is inflicted upon serous membranes."-Journal of American Medical Associa- 
tion, Vol. ii, p. 148. 58 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the great death rate, which culminates in April; hut this double decrease will soon 
change to less than average decrease, and then, as soon as there is an increase in sick- 
ness to more than average increase, culminating at the time of least deaths-which, 
in Michigan, seems to be in October, but in London is unmistakably in September 
-then, as the deaths increase, the sickness under observation (old cases and new 
cases) should not increase as fast as it otherwise would. This may serve to explain 
why the curve for sickness drops from its maximum in April to its minimum in August, 
in four months, while it occupies double that number of months in going from its min- 
imum to its maximum, which it does not reach until April, but which it might reach 
in March if the great number of deaths then did not keep it down. 
WHAT IS PROVED? 
It is useful to " take account of stock," as the merchants do at the close of the year, 
and ascertain just what is the state of our knowledge. In science I understand that a 
proposed mode of causation is considered proved when (1) it is demonstrated that the 
cause assigned is a ver a causa-a true cause, capable of causing the phenomena ascribed 
to it; (2) that the cause assigned is present and acting, and (3) that no other known 
cause capable of causing the phenomena is present and acting. That chloride of sodium 
in strong solution is an irritant and a poison is a well-known fact, and the mode of 
death of animals poisoned therewith has been made the subject of experimental study.* 
That whenever a fluid containing a non-volatile salt is evaporated there is left a residue 
of salt, is now a part of our most common knowledge, that is implied by the term 
" non-volatile." That the blood serum and the fluids of the human body contain non- 
volatile salts has been demonstrated by many analyses. That the quantity of vapor of 
water which air can contain is dependent upon the temperature is one of the most well- 
known facts in meteorology, and that raising the temperature of air increases its capacity 
for moisture is equally well known. When cold air, which can contain only a small 
quantity of vapor of water, enters the air passages, and before it is exhaled is warmed, 
so that it can contain a large quantity, and is constantly in contact with moist mem- 
branes, from which it can take vapor of water-that it should take the moisture, and 
leave a residue of non-volatile salts, is in accordance with all our knowledge and experi- 
ence on this subject. Finally, in pneumonia the increased non-volatile residue has 
actually been found, by analyses, in the sputa and in the solidified lung.f 
It seems to be demonstrated that the alleged evaporation of fluids containing non- 
volatile salts takes place, and that the salt is ' ' present and acting ' ' in the air passages. 
(It does not change this fact if we admit that, normally, the residue left by evapora- 
tion is constantly reabsorbed or removed through the lymph channels; because it is 
possible that, when formed faster than normal, the lymph channels are not capable of 
removing the residue, or, if removed through them, the irritation may cause oedema 
sufficient to close those channels. J) 
Considering that the temperature of the air exhaled from the air passages is always 
nearly the same, it would appear that the residue of non-volatile salts in the air pas- 
sages should be quantitatively related to the temperature of the air inhaled-that is, to 
* By B. J. Stokvis. 
f By Lionel Smith Beale. Transactions Royal Medical and Chirurgical Society, London, 
England, 1852, Vol xxxv, pages 325-375. 
J Interesting in this connection are the researches of Dr. II. F. Formad, of Philadelphia, 
which, he claims, prove that few and narrow lymph spaces in the connective tissue constitute a 
structural predisposition to tuberculosis.-Journal of American Medical Association, Vol II, page 
148. In Archives für Experimentelle Physiologie und Pathologie Dr. Stokvis has shown that 
animals fatally poisoned by sodium chloride invariably have oedema of the lungs. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
59 
the temperature of the atmosphere. That the sickness from several diseases of the air 
passages is quantitatively related to the temperature of the atmosphere is demonstrated 
by the statistics which I have presented. I know of no cause, other than the one I 
assign, capable of causing the irritation of the air passages, so as to control the rise 
and fall of coryza, influenza, tonsillitis, croup, bronchitis, pneumonia, and apparently 
also pulmonary consumption. For myself, therefore, it is proved (1) that the cause 
assigned is a true cause; (2) that it is present and acting when these diseases are caused, 
and that it is not only qualitatively but quantitatively related to these diseases; (3) 
that no other known cause is present and acting, even if we refer to each disease singly, 
and much less is there present any other known or alleged cause capable of inducing 
all of these diseases. 
It has been objected that it has not been proved that evaporation from the air pas- 
sages extends to " parts so remote from the outer air as the pulmonary alveoli."* While 
it may be difficult to demonstrate this experimentally, I submit that it is susceptible 
of proof, as follows: Pneumonia rises and falls in relation to the atmospheric tempera- 
ture in ways similar to those of the diseases of the upper air passages ; if the diseases 
of the upper air passages are due to a non-volatile residue left by excessive evaporation, 
there is no other known cause "present and acting" to account for the pneumonia 
which is coincident therewith. Furthermore, the increased non-volatile residue having 
actually been found, by analyses, in the sputa and in the solidified lung of the person 
dead from pneumonia, f this alone amounts to nearly complete proof that the evapora- 
tion occurred, because (1) the evaporation of the fluid containing it is known to leave 
such a residue, and (2) there is no other known cause of the abnormal accumulation 
there of such a residue as the chloride of sodium. Finally, to assume that evaporation 
of moisture does not extend to the pulmonary alveoli is to assume that the air inhaled 
reaches its highest temperature before it reaches the alveoli, and that it is fully satur- 
ated with moisture at that highest temperature before it reaches the alveoli, neither of 
which assumptions is probably true, because the air comes most nearly in contact with 
the warm and fluid blood in the alveoli themselves. 
There may be no necessity for any further attempt to account for the fibrinous or 
albuminous exudations which occur in some or all of these diseases; the irritation of 
an abnormal proportion of non-volatile salts may be sufficient ; but the fact that albu- 
men will pass to a four per centum solution of sodium chloride may well be kept in mind 
in connection with this subject. 
I consider it proved, then, that the rise and fall of the diseases of the air passages are 
controlled by the atmospheric temperature, and that this is accomplished mainly 
through the quantity of vapor of water abstracted from the air passages. At the same 
time the mere evaporation of the water is probably harmless except it leaves an abnor- 
mal residue of non-volatile salts, which probably it may most readily do in persons 
whose blood is abnormally saturated with such non-volatile salts as usually pass out by 
way of the kidneys, and of which sodium chloride may be named as an example. 
THE BEADING OF THE DIAGRAMS. 
For the convenience of those who use the following diagrams, it may be stated that 
they are to be read with reference to the figures in the right- and left-hand margins, the 
numbers indicating the temperature being on the right and those representing the 
sickness or deaths, as the case may be, on the left. Thus, in Diagram No. 1 it will be 
seen that in the month of January, the average atmospheric temperature for ten years 
* New York Medical Journal, Aug. 13, 1887, page 186. 
f By Lionel Smith Beale. Transactions Royal Med. and Chirurg. Soc., London, England, 1852, 
Vol. xxxv, pages 325-375. 60 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
was 20.56°, and in the same month the average percentage of reports which stated the 
presence of influenza was 55. In February the average atmospheric temperature was 
23.62°, the percentage of reports stating the presence of influenza was 61. In August, 
when the curves for atmospheric temperature and sickness both reached their lowest 
point (the curve for temperature being reversed), the percentage of reports stating pres- 
ence of influenza was 21, while the average atmospheric temperature was 68.14°. 
As an illustration, the table giving by months the average atmospheric temperature 
and the influenza (from which Diagram No. 1 is constructed) is given herewith :- 
TABLE. 
STATING, BY MONTHS, FOR THE TEN YEARS, 1877-86, THE AVERAGE PERCENTAGE 
OF REPORTS STATING THE PRESENCE OF INFLUENZA IN MICHIGAN, ALSO 
THE AVERAGE ATMOSPHERIC TEMPERATURE FOR THE SAME PERIOD. 
Jan. 
Feb. 
c3 
Apr. 
C? 
s 
d 
a 
5 
8 
Aug. 
i 
Oct. 
Nov. 
Q 
S 
P 
Percentage of weekly reports stating 
presence of Influenza 
55. 
61. 
59. 
52. 
38. 
28. 
65.10 
20. 
21. 
33. 
41. 
36.04 
48 
Av. atmos. temp., degrees Fahr 
20.56 
23.62 
29.80 
44.33 
56.08 
70.52 
68.14 
61.67 
50.83 
26.60 
For an exact reading of the figures, the tables which accompany the paper should 
be studied ; but the relations of the temperature in one month to the sickness in that 
month or in a succeeding month can best be seen from the diagrams. In these diagrams, 
in which the unit of time is one month, and the curve representing sickness is made 
from reports of all cases under observation, old cases as well as new cases, the sickness 
curve should coincide with a curve representing a controlling cause of that sickness if 
the duration of the disease is less than one-half month, and the disease has no period 
of incubation, otherwise the curves may be separated by an interval corresponding, as 
nearly as the long unit of time will permit, to the average duration of the incubation 
and the sickness. NO. 1.-TEMPERATURE, AND SICKNESS FROM INFLUENZA IN MICHIGAN. 
Tei* Cent of- 
mordhs for a fieri od of /O years? /%7f- Ÿ6> ffie 
retafi on between Jicfcness in JW>ieb(gcoz from fnftuenxcL 
ccnd the dverage mosfiberîe Je mfier attire. f<77?e temfier- 
ctfure Curue ts the ate in erect ses c/ou/rtu/arete.) 
Degrees 
Fahr*. 
Jnjizcenzcv 
'ßue.'rccge 
61 NO. 2.-TEMPERATVBE, AND SICKNESS FROM TONSILLITIS IN MICHIGAN. 
By months for a period of F years, /87frlf6, fàe 
relation he I laeen. die Xn ess in .Michigan from Jonsilitis 
and the Peerage dfrm os ft I eric dem ft er glare. (She 
er glare Clerne is reversed, - die scale Inereas es doucncuardsi) 
JonSilitis _ 
Average Jemfierature 
62 Per etnr 
of fl f fiords * 
By m on/Jia for fMe ffyecw, Xf, Me -re7afion\ 
of- c£tcfinejs in M'iicMifan from BruncJt fiJ., do Me Ma~ 
er age Ji/moafJieTcc JJemf erasure. de mferasure 
Ctcrue is rev er$e cft dfae aeale increàoetr Jou/n loctrtJô. 
NO. 3.-TEMPERATURE, AND SICKNESS FROM BRONCHITIS IN MICHIGAN. 
Deg re e J 
MaM r. 
Jan, 
Je'h 
Mar 
Mfr 
May 
Jur\. 
Jul 
May. 
Sr/J 
Oaf 
Joe. 
Dec., 
27?» o n c h i . I . ve. r a ge ret fare - -- - * 
K tÿndlea fang u/hctdfer oen/ of all refer fa received, J1fa fad 
fate freoence of Uronchiffa fa/iett uuden jfie ofaervafaontf fae 
forcing. 
Over 3S;000 ref or fa of and abouf/fj, 0OO oi 
of fae afawsfheric, ùm far a fare are iju 
fafa cfaayra7K/. 
63 By rrtonths for a feriocl of years, /X77-th e re- 
Icctiiorc betiiveen Ji c bn ess in /Michigan from Pneu- 
m oxi a, and the djuergqe few/eralure of tihetMtimod- 
fhere (Jem/eralure Curve reversed, Je aie increases down isards) 
NO. 4. -TEMPERATUBE, AND SICKNESS FBOM PNEUMONIA IN MICHIGAN. 
Pe r Cent <f 
P C fo r/s. %■ 
F«Tir*. 
? Jan. 
>Fcl. 
-Mar 
_ Ji/>r 
-May. 
- Jan. 
- Joel. 
- Sef. 
- Octi 
-Mod 
- Hee. 
ôtesness from Pneumonia.. diver a ge Jemfercicure- - . 
octimg u/hati Cent of all reports recet v col, stateci 
the fires exce of fi>t e urn one a- then under f/te observa/ton, 
of the fihysiciaxs re/> ortiirerj • 
Oder J 0,000 vueeftiy refiortis of siefuejs,anc/ ever J<56), 000 
observations cf /be a/mosfikerie te~mfi>eratiure are reftre- 
resentecl irt /Jr<s diaqrcm , 
64 éases of PTL ea- 
rn onia tri /0,0OO 
cTo l c{ ïefS • 
NO. 5.-TEMPERATURE AND SICKNESS FROM PNEUMONIA IN U. S. ARMIES. 
Uy »tonlAs for /he <3 years /ï/% - 6¥, /he re ta/ion of 
. <Sicftness from Pneumonia. in /he 'lù.J. d/rm i es, /o /he 
> Jl/mosbh crée Jem/e r a /ur e . J/te /erriferature 
i Ciarue is L*e /he Scale lucre aS es cZüu/n.a/ a r d 
f- - - ----- - 
iïèyrees 7ô/ir. 
JicXness front Pneumonia • Jiverage Jémfera/ure 
JTie temperature curve is niacle from normals at 
six stations representing tne 
ties occupied tfie armies of the "Icnite<f cf/a/es. 
Vol. V-5. 
65 NO. 6.-TEMPERATURE AND DEATHS FROM PNEUMONIA IN LONDON. 
fa er 
u/e v fa/rom 
fanau mon < a. 
By mantis for aferiod <f 30 years,Ile re- 
lotion of dluerage Bealls f>er uieel, in Bon a on, .Eng- 
land from ireumoma, toile 
yifhetemperature cureThreversedti/iescole dou/nu/Ords.) 
Dry i* e e*f 
Jal r. 
' „ . .Jneumovia -, .JJuerageCTéTnfienatare 
* JPerhafoö a greater proportion' of Jeat/fj are 
returned for the later than for the earlier months 
in each, year ? 
66 NO. 7.-DAILY RANGE OF BAROMETER, AND SICKNESS FROM PNEUMONIA. 
Ter cent of 
fie ports. K- 
Jty months Jor a period of t/-years,JK%'2,-26', the 
re tat ion. of diciness in Michigan from fneumcnicc 
to the Maerage Jtaiiy Tange of ditrnosftherio 
pressure . 
Inches of 
Mercury. 
die knees JrûYrt "pneumonia - daily ronge of Ha remet er - 
* Which slated ihcd Pneumonia u/as ancien the observa I/'on 
ofthe jbhysie i ans vu ko 'macle 
67 NO. 8.-TEMPERATURE, AND SICKNESS FROM SCARLATINA IN MICHIGAN. 
Per ein i of 
71 e forts.*' 
By months Jor afieri od of JO ye ars, Jjïff-Ÿi, the rela- 
tion/ of çk n ess in Jtichig an from fear le t Jei/er to 
the Jli/eraqe Jlfmosfheric iJemforaiure .ÇTke fern fera,- 
iure Curve is re Versed,-the scale increases downivardt.) 
Degrees fahr. 
Scarlet Jeuer .... Juerage Sémfera/ur e - -„ _ . ■ - . 
*Wkich s/atecl ihai Scarlet dFeuer utas under the obser- 
vation, of ike ftkysi eians u/ko made reports - 
Over forty-one thousand u/ee'kly reports of sickness and 
over /<} 0,000 observations of the effort OS fiberib Jèmfier aiztre 
are represented in this diagram/. 
68 NO. 9.-TEMPERATURE, AND DEATHS FROM SMALLPOX IN LONDON. 
Up a t hsfrom omalf- 
fox, )heetly. 
Uy months, for a period of 30years, UMS'-/#, ffre rela- 
tion betu/een the -duerage from J mall-for in- 
io nd on, £ ng I an d, and the \Pc/erage c 
\Jentf> e rahi re. Cd he Jem fera tare curve is 
the Scale increases doujnu/ards.) Hecords of thirty 
thousand deaths are in elu.de d, in this eft a grams. 
Degrees Jahr. 
tSrnall-fto?c -» . Jfi/erage Jemfterature 
refit in. a Jeus ntonikj the JTnall-ftor. Joli o uus teuso 
Itlonths later than, the iemfier alar e Chang es. 
Jhe line re fibres eivling dmall-fi>oy, shouldJollobu as long a. 
time later than a line representing its. controlling condition, 
as is the average duration, <J Ihejcdat casesfilas lhefieriod 
ofi incut all on I 
69  OJX& g c/gci. 
/j er 
jffyn/cn/faJcr aféfatl èf Sû yttarj, /f^(J-'/&, tâe' 
seta/tesc cf M j7ttZi /s/na//, in 
JtJnyJcMcZ frv/n /Vti/i/sjs, 7c 
£& Tê^-i/tZ/xé ( 77/& Z&n2>era faste' xs 
rt>&ej7ÿscS,- 'Me scatty jns.reales ) 
/Jcyrsej fa fis 
/Ào/Z/cS yJl e r jZo 7/^)07'0/71/7T 
jiïfrçuf £31.000 dcci/As'£ron? JT/iOTiisis erre 
O/lis. c/jOtc/mscc cZcz/zt/rr~ u/Zc/i c/rtfreen .7e cl tSccOtish 
tSlc., yKs JtLW, JZT7 XLVJ., 77Oi7 ÿ63. 
70 '7esnpera/lcr&'' and' fynsaftifövndnJtficdnyGtrt. 
£t/ m&nTÀsfûr a- /j&/~t6>fZ c/ f 
rclaJlciclclic&ea' tSi'(>fyn'€-&S' 
JlfyititanPficn a?xlZ/x/l/x/zzz/c o 
C temfêrwifa?#'' ctt7'Z/& 4T 
f/zés <$calez z zi crta scs r/c't/ 'ZZit/fzzuS', ) 
DejretsT&in 
/XC C&nl cf 
71 J2 . asfd Aeeriifij ?# LmA/p, 
f/lÏ7C/CS7 ZZcCr///!) 
jy</ mc/itâsfc/ a- /jcscccf cf «ff Z/eccca, ffffZ- ff 
fefzZ/tw cf ffi/escx//// fcfc/c&f i/i 
■ fnm f/s, f/jecy^/e^rf^e'yf//7zawz- 
71/kfewZas?'' ( c//7/z'/y 
<C Z/x _ /fo öCSlZec 1rt£/'/(c'>/3 c/cU777CC a/rfs.) 
--- 
AfäotA ctor tâ s ZJ/cnc/? i/ri c^îr ' /Y/>/r^, 
in t/us ch'agrriarTt' (Ari/rr s-ri/ri Jeur A iScc/f/sft A/riAiçï 
/Yen, .Ari. JX&lf XIJV.JiLV, JZZtt.. />c/y<\S 
72 cfoJp 7eruJ)ercfur#tund Sick/iess frouft injfächigan. 
cent <f~ 
-By uwn lb for opfer/et# f fb yrpvrif,/JfZ-tffî, tb# 
reloil ion, iotureeris uStcbrioss in<.ABr/r iyoonfronu 
"Memb, rd/ncus Brcuu and tbes -dofy/ft/wo 
jf/ior/o' PTr/fperafuro''. (The lompora/ufor cuît/cs 
is yT'oi/rrsul,- t/sr scct/o/ ooicre oosos obudo wco 
r: r r? r; rr rv -r; rr- 
JdcMbrctMcco'} (Jroup 
73 <=yfv ff f7E?rtfseTf/f//y;rssrf SirfrfEjj 'fas/Hra/yyzfaeasEX wJjwfi'de- 
fines 
MM Jc/tZâï 
ffy -mtmMs fer et />er&e£ ef Jyears. Me refeety? 
ef âf <ste. fyss fem' 'yer/ferefey ''ez/wezy /fe 
tr/>S f/t fs/r/fs /c ffE f//£/ef/f£ r///yf s/jf - 
c/ff 77rrff/es/M/rfïfr fsrtfErœfrrff re- 
rerj-Eff f fïr sca/e £/s crerfsey fff<x rue arr/f.) 
1 Ssf/j? 
-/h/erag cases of secfness ditraye Tevfrrafarr-...- 
.jRre/MirecZ/rem c/a/ar/ouncl m 2v, 2if *cteic/ 22n 
ï/i&Saeûfary /fommissicner av/ft //ve 
74 75 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
Table 1.-Exhibiting, by months, for the ten years, 1877-1886, the average per- 
centage of reports stating the presence of sickness from Influenza in Michigan, also 
the average temperature at stations in Michigan for the same period of time. 
10 years, 1877-1886. 
Jan. 
Mar. 
a 
◄ 
June. 
B 
Aug. 1 
32 
O 
Nov. 
6 
Average percentage of reports of 
sickness 
55 
61 
59 
52 
38 
28 
20 
21 
29 
33 
41 
48 
Average temperature, degrees Fahr.. 
20.56 
23.62 
29.80 
44.33 
56.08 
65.10 
70.52 
68.14 
61.67 
50.83 
36.04 
26.60 
Table 1 is graphically represented in Diagram 1. 
Table 2.-Exhibiting, by months, for the eight years, 1879-1886, the average per- 
centage of reports stating the presence of sickness from Tonsillitis in Michigan, also 
the average temperature at stations in Michigan, for the same period of time. 
8 years, 1879-1886. 
Jan. | 
Feb. 
03 
◄ 
May. 
June. I 
'S 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 
Average percentage of reports of 
sickness 
60 
61 
60 
53 
47 
42 
33 
32 
37 
45 
55 
60 
Average temperature degrees Fahr.. 
19.91 
21.77 
28.82 
43.04 
55.98 
64.79 
69.78 
66.25 
61.11 
50.68 
35.56 
25.82 
Table 2 is graphically represented in Diagram 2. 
Table 3.-Exhibiting, by months, for the nine years, 1877-1885, the average per- 
centage of reports stating the presence of sickness from Bronchitis in Michigan, also the 
average temperature at stations in Michigan, for the same period of time. 
9 years, 1877-1885. 
Jan. 
s 
Pa 
Mar. 
Apr. 
May. 
June. ' 
1 
July. 
Aug. 
Sept. 
Oct. 
Nov. 
Dec. 
Average percentage of reports of 
sickness 
77 
78 
77 
72 
61 
54 
43 
41 
49 
55 
67 
72 
Average temperature, degrees Fahr.. 
20.77 
23 89 
29.76 
44.14 
56.23 
65.30 
70.73 
68.23 
61.73 
50.72 
3623 
27.28 
Table 3 is graphically represented in Diagram 3. 
Table 4.-Exhibiting, by months, for the eight years, 1877-1884, the average per- 
centage of reports stating the presence of sickness from Pneumonia in Michigan, also the 
average temperature at stations in Michigan, for the same period of time. 
8 years, 1877-1884. 
fl 
- 
Pm 
s 
Apr. 
May. 
June. 
*3 
Aug. 
Sept. 
Oct. 
o 
Ä 
Dec. 
Average percentage of reports of 
sickness 
62 
66 
62 
56 
42 
27 
17 
14 
18 
23 
36 
48 
Average temperature, degrees Fahr.. 
21.43 
25.60 
31.04 
44 48 
56.60 
65.54 
70.68 
68.85 
62.05 
51.34 
35.99 
27.25 
Table 4 is graphically represented in Diagram 4. 76 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Table 5.-Exhibiting, by months, for a period of three years, 1862-1864, the sick- 
ness from Pneumonia in the U. S. Armies, also the average temperature for the same 
period of time. 
3 years, 1862-1864. 
fl 
rt 
'S 
X 
Mar. 
« 
o 
fl 
■ s 
a 
bi) 
0 
◄ 
Sept. 
Oct. 
Nov. J 
Average number of cases of sick- 
ness from Pneumonia, per 10,000 
soldiers 
427 
447 
415 
324 
176 
107 
85 
74 
77 
139 
233 
281 
Average temperature, degrees Fahr.. 
36 
38 
45 
54 
66 
74 
78 
76 
69 
56 
46 
38 
Table 5 is graphically represented in Diagram 5. 
Table 6.-Exhibiting, by months, for the thirty years, 1845-1874, the average 
number of deaths from Pneumonia in London, England, also the average temperature 
for the same period of time. 
30 years, 1845-1874. 
Jan. 
Feb. 
Mar. 
Apr. 
May. 
June. 
July. 
Aug. 
Sept. 
Oct. 
Nov. 
8 
Q 
Average deaths per week, from 
Pneumonia 
98 
86 
91 
82 
67 
53 
42 
37 
43 
66 
98 
108 
Average temperature, degrees Fahr.. 
38.6 
40.1 
42.2 
48.6 
52.7 
60 0 
64.2 
63.5 
59.1 
52 2 
44.2 
40.5 
Table 6 is graphically represented in Diagram 6. 
Table 7.-Exhibiting, by months, for the four years, 1882-1885, the average per- 
centage of reports stating the presence of sickness from Pneumonia in Michigan ; also 
the average daily range of atmospheric pressure for the same period of time. 
Jan. 
Feb. 
3 
Apr. 
June. 
July. 1 
bC 
* 
Sept 
- 
u 
O 
Nov. 
Dec. 
Average percentage of reports of 
sickness 
55 
58 
57 
51 
37 
25 
15 
12 
16 
22 
30 
39 
Average daily range of atmospheric 
pressure 
.325 
.294 
.298 
.208 
.171 
.150 
.125 
.136 
.156 
.203 
.228 
.272 
4 years, 1882-85. 
Table 7 is graphically represented in Diagram 7. 
Table 8.-Exhibiting, by months, for a period of ten years, 1877-1886, the relation 
which the sickness in Michigan from Scarlet Fever sustained to the atmospheric 
temperature : Exhibiting the average atmospheric temperature, and what percentage 
of all weekly reports received stated that Scarlet Fever was under observation of the 
physicians who made the reports. (Over 41,000 weekly reports of sickness, and over 
190,000 observations of the atmospheric temperature are represented in this table.) 
• 
Jan. 
"5 
fa 
Mar. 
a 
◄ 
S' 
June. 
July. 
bo 
Sept. 
«t 
o 
Nov. 
Dec. 
Average percentage of reports 
Average temperature, degrees Fahr. 
22.3 
20.56 
23.5 
23.62 
23 9 
29 80 
21.6 
44.33 
19.6 
56.08 
17.0 
65.10 
13.7 
70.52 
11.8 
68.14 
12.5 
61.67 
16.0 
50.83 
17.3 
36.04 
18.1 
26.60 
10 years, 1877-86. 
Table 8 is graphically represented in Diagram 8. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
77 
Table 9.-Exhibiting, by months, for thirty years, 1845-1874, the relation between 
the weekly average number of deaths from Smallpox, and the average atmospheric 
temperature, in London, England. Records of 30,000 deaths are included in this 
table. 
30 years, 1845-1874. 
d 
cS 
Feb. 
Mar. 
Apr. 
It 
5*2 
June. 
Aug. 
Î 
O 
Nov. 
d 
s 
p 
Average weekly No. of deaths 
2.3.00 
24.00 
21.60 
23 75 
24.50 
22.40 
18.00 
11.25 
13.00 
13.00 
14.50 
18.20 
Average temperature, degrees Fahr. 
38.6 
40.1 
42.2 
48.6 
52.7 
60.0 
64.2 
63.5 
59.1 
52.2 
44.2 
40.5 
Table 9 is graphically represented in Diagram 9. 
Table 10.-Exhibiting, by months, for a period of thirty years, 1845-1874, the 
relation of average deaths per week, in London, England, from Phthisis, to the average 
atmospheric temperature for the same period of time. 
30 years, 1815-74. 
§ 
Feb. 
2 
s 
May. 
Q 
s 
's 
Aug. 
Sept. 
Oct. 
o 
ft 
i Dec. 
Average deaths per week, from 
Phthisis 
154 
153.25 
160.2 
162 
157.25 
150 
144.75 
136.50 
132.4 
135.75 
146 
147 
Average temperature, degrees Fahr. 
38.6 
40.1 
42.2 
48.6 
52.7 
60.0 
64.2 
63.5 
59.1 
52.2 
44.2 
40.5 
Table 10 is graphically represented in Diagram 10. 
Table 11.-Exhibiting, by months, for a period of nine years, 1878-1886, the rela- 
tion between sickness in Michigan from Consumption, and the average atmospheric 
temperature for the same period of time. 
Jan. 
Feb. 
3 
Apr. 
§ 
a 
5 
's 
Sept. 
Oct. 
Nov. 
Dec. 
Average percentage of reports of 
sickness 
65 
68 
69 
70 
67 
65 
63 
61 
62 
64 
64 
63 
Average temperature, degrees Fahr. 
20.72 
22.68 
30.23 
44.06 
55.84 
64.83 
70.27 
67 88 
61.43 
35.87 
35.87 
25.47 
Table 11 is graphically represented in Diagram 11. 
Table 12.-Exhibiting, by months, for a period of thirty years, 1845-74, the rela- 
tion of average deaths per week in London, England, from Bronchitis, to the average 
atmospheric temperature for the same period of time. 
30 years, 1845-74. 
5 
Feb. 
Mar. 
Apr. 
** 
June. 
"5 
bi) 
Sept. 
O 
Nov. 
Dec. 
Average deaths per week from Bron- 
chitis 
193.5 
172.5 
165. 
127.5 
90.0 
63.2 
48.25 
41.0 
48.2 
76.5 
141.25 
190.2 
Average temperature, degrees Fahr.. 
38.6 
40.1 
42.2 
48.6 
52.7 
60.0 
64.2 
63.5 
59.1 
52.2 
44.2 
40.5 
Table 12 is graphically represented in Diagram 12. 78 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Table 13.-Exhibiting, by months, for a period of ten years, 1877-86, the relation 
between sickness in Michigan from Membranous Croup, and the average atmospheric 
temperature for the same period of time. 
10 years, 1877-86. 
Jan. 
Feb. 
c8 
S 
Apr. 
& 
s 
June 
July. 
Aug. 
Sept. 
Q 
c 
o 
Dec. 
Average percentage of reports of 
sickness 
.. 
20.56 
10 
23 62 
8 
29.80 
7 
44.33 
5 
56.08 
4 
65.10 
2 
70.52 
3 
68.14 
4 
61.67 
6 
50.83 
9 
36 04 
10 
26.60 
Average temperature, degrees Fahr.. 
Table 13 is graphically represented in Diagram 13, 
Table 14.-Exhibiting, by months, for a period of three years, 1883-85, the relation 
of sickness from "Respiratory Diseases," among the native troops in India to the average 
atmospheric temperature for the same period of time. 
Jan. 
Feb. 
Mar. 
Apr. 
May. ! 
June. • 
July. 
Aug. 
Sept. 
© 
5 
55 
Dec. 
Average cases of sickness per 10,000 
soldiers 
102.8 
71.6 
51.8 
38.6 
33.8 
26 6 
25.5 
23 7 
31.8 
37.7 
59.9 
93.8 
Average temperature, degrees Fahr.. 
68 7 
70.6 
79.1 
83 9 
85 2 
84.8 
83 3 
82.7 
82.3 
80.5 
74.2 
69.1 
3 years, 1883-5, 
Table 14 is graphically represented in Diagram 14, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
79 
THIRD DAY. 
The Section re-assembled at 11.30 A.M., and entered upon the discussion of the 
papers read at the previous meeting. 
DISCUSSION. 
Dr. Bryce, of Toronto, Canada, said he thought it extremely fortunate that two 
papers from two points of view as dissimilar as those of Drs. Denison and Baker should 
be discussed together. One says that excessive dryness and cold are health producing, 
while the other maintains that the same conditions result in increase of lung diseases. 
In all probability the truth between the two positions will be found best expressed in the 
old adage ' ' in medio ibis tutissime. ' ' Dr. Denison ought, he thought, to explain 
the point regarding the greatly increased dryness of cold, external atmospheres, 
when heated at night to the point of comfort of living rooms. How can this condi- 
tion of abnormal dryness be compatible with the equable distribution of the heat of 
the body, usually supposed to be best maintained at a temperature of 60°-70° F., and 
a relative humidity of 75. It may be that such conditions as Dr. Baker states are 
produced in the excess of salts in the mucous membranes, may be caused by this 
excessive dryness ; but it must be evident that if the house air be not as dry as a 
priori consideration would lead us to suppose, then the moisture is due to emanations 
from lungs of animals and from lights, and then we have the prospect of tubercular 
emanations infecting other inmates. What he thought ought not to be forgotten, 
are the frequent day and night, and even hourly changes, in which he believed are to 
be found the beginning of many of the colds, pneumonias, etc., which terminate 
so disastrously, and which are supposed to be due to cold. Cold weather is rather 
favorable to health than otherwise on the ordinarily healthy, but its favorable effects 
are much or little measured by the resisting force of the physical system. Thus a 
draught of a few minutes upon the head will produce an attack of rhinitis or pharyn- 
gitis, and it is in these sudden exposures of old persons or delicate individuals, housed 
up in winter, to cold, either by draughts or a chilling ride in the outer air, that the 
increased mortality of the winter seasons is due. He thought that the insanitary 
influence was attributable to this debilitating effect of house-air, through its dryness, 
its impurities and its draughts, rather than to the mere accidental excess of salts in 
the mucous membranes, if such be proved to be true. 
Dr. Denison, with reference to Dr. Baker's conclusions, suggested that a cause 
of croupous pneumonia particularly could be inferred different from that Dr. Baker 
offered in the correspondence between malaria and pneumonia in general, as shown 
by the record of 1870. This established that elevation and the cold which accompa- 
nies it, were not so much causative of pneumonia as the argument presented would 
lead us to believe. The twelve States which gave the highest ratios of deaths from 
pneumonia to all deaths averaged twelve and-a-half per centum, and included the 80 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
low-lying States, such as Texas, Arkansas, Mississippi, South Carolina, Ohio, Indiana, 
Illinois, Missouri and Kentucky, while on the other hand the twelve States and 
Territories which gave the least percentages averaged about four per centum, and were 
such as New Mexico, Missouri, Idaho, Colorado, Wyoming, Minnesota, Vermont and 
West Virginia. If intestinal, broncho- and catarrhal pneumonia could be excluded 
from the record, the argument in favor of the infectious nature of croupous pneumonia 
would be very much strengthened. 
Dr. W. L. Tuttle, of New York city, said that one point which has not been 
touched upon in the debate this morning is, that any cause which depresses or enfeebles 
the system, whether hard work or a night's debauch, is sufficient, with a slight 
atmospheric change and exposure, to produce a pneumonia where a healthy, vigorous 
person would escape. 
Dr. Edward W. Schauffler, of Kansas City, Missouri, heartily endorsed the 
paper of Dr. Denison, and believed he has ably set forth one of the curative in- 
fluences of the Colorado climate in showing the increased proportion of moisture 
exhaled over that inhaled. In considering the value of mountain climates, however, 
we must always bear in mind that the aseptic character of the atmosphere is of more 
importance than its mere dryness. He found it very natural that physicians residing 
at health resorts should discourage the sending thither of patients in the advanced 
stages of phthisis, since such cases must, of course, to some degree affect the reputa- 
tion of such resorts. From considerable experience he was of the opinion that he 
should not deprive even one severe case of phthisis of the possible benefit of change, 
of climate. Colorado to-day is full of patients living in comparative comfort, who 
went there three years ago in an apparently hopelessly desperate condition. 
With regard to the alluring picture drawn by Dr. Parker, of a wagon trip from 
Leavenworth to Colorado, it must be remembered that the trip taken by the Doctor 
was twenty years ago, since which time the whole state of Kansas has been settled, 
and such a course is now impracticable, or at least, not advisable. In the opinion of 
the speaker, the value of such a trip consists, not in the slow rise from a lower to a 
higher altitude, but in the out-door life it implies. The benefits of this out-door life 
during a period of two or three months can hardly be over-estimated; but he did not 
believe we need fear any ill effects, as a rule, from the rapid passage of a phthisical 
patient from the sea-level to an altitude of six thousand feet, provided, always, we 
exclude cases of weak heart. 
Dr. Kretzschmar indorsed the paper of Dr. Denison, objecting, however, to send- 
ing patients to such high altitudes as ten thousand feet above the sea. He believed that 
the beneficial effect of high altitudes depends upon their influence upon the heart, 
invigorating the heart muscles, but he strongly objected to sending individuals with 
weak heart to high altitudes, and he related an alarming attack of dyspnoea, from 
which he himself suffered during a recent visit to Switzerland. He believed that 
the relative size of lungs and heart, large chest and small heart, has a causative rela- 
tion to phthisis, and for that reason he sends patients to places where they can have 
moderate exercise, but he insists on strict supervision. He objected to the remarks 
of Dr. Schauffler in favor of allowing patients to go direct from the low country to 
high altitudes. Finally, he asked Dr. Denison for an explanation of the number of 
inhabitants in the city of Denver, in reference to the statement that one hundred and 
ninety-five patients had died from phthisis. 
Past Assistant Surgeon Samuel W. Battle, U. S. Navy, of Asheville, North 
Carolina, remarked, upon the curative effects of altitude, that the influence of SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
81 
diminished air pressure relieving internal congestions and thereby forming a most 
important part in the cure of chronic pulmonary troubles, seemed to have been over- 
looked. He did not think that dry cold air favored the production of acute pneu- 
monia, as had been suggested. The climate of our mountainous regions would be 
intolerable, by reason of variability, were it not for the fact that atmospheric dryness 
lessens the danger of sudden changes. 
Dr. Frank F. Smith, of St. Augustine, Florida, spoke of the climatic advan- 
tages, both preventive and curative, of that State for pulmonary affections, being 
similar to those that pertain to the Riviera, to Madeira, and other sheltered seashore 
resorts in the warm temperate zone, and in which elevation, and cold and dryness, 
and rarefaction of the air are not factors. 
Dr. Gihon, of the U. S. Navy, regretted the misplacement of the paper on the 
"Medical Aspects of the Climate of Orotava," by Dr. G. V. Perez, of the Island 
of Teneriffe, from this Section, to which it naturally belongs, to that of General Medi- 
cine, although it was gratifying to find so public and significant a recognition of the 
place which Climate fills in the department of General Therapeutics. Dr. Perez's 
paper is in accord with the claims advanced by Dr. Smith in favor of the preventive 
as well as curative effects of the climate of Florida. Dr. Gihon cursorily referred to 
his own personal acquaintance with the benign influence of the climatic conditions 
which prevail in the Valley of Orotava, and spoke particularly of the equability of 
the meteorological status, as to temperature and moisture and the absence of vicissi- 
tudinal changes, thus leaving the life of the invalid absolutely free from disturbing 
agencies, even the slight difference between summer and winter temperatures being 
overcome by the change of altitude accomplished by removing the residence from the 
Puerto on the seashore in the one season to the Villa on the mountain slope in the 
other. The ever-open doors and windows, making the house atmosphere one with 
that outside, the swiftly running mountain streams, led through the streets past every 
doorway in the town, and the ocean fringing the shore of the port, supplying nature's 
own normal humidity, the simplicity of furniture and the absence of the unsanatory 
impediments of our own dwellings, the abundance of fruits and vegetables, obviating 
over-dependence upon and over-indulgence in animal food, and the mental equilibrium 
induced by the peaceful surroundings, are an ensemble of favorable conditions almost 
peculiar to this secluded island. The affected or menaced pulmonary apparatus is, 
therefore, here in a state of the utmost possible quietude, permitting its reparation 
or retarding its further deterioration. 
Dr. Titus Munson Coan, of New York city, said that the climate of the 
Hawaiian Islands was the most equable of all the climates in his experience at tem- 
peratures of from about 70° to 85° F. All the year round, as at Orotava, it was never 
necessary, at the sea-level, to close doors and windows. Lower temperatures could, how- 
ever, be found on the mountain sides. Dr. Coan had observed the most beneficial results 
in the case of the weak, consumptive invalids sent to these islands, and he believed 
that they would become a favorite health resort within a few years. He had sent 
patients to lower California with benefit, but the Hawaiian climate was preferable, 
because somewhat warmer and more equable, and free from all violent winds. He 
said that the absolute height of the temperature was not, in practice, the important 
thing, but the proper degree of moisture. For years he had recommended his 
patients, whether in Colorado or New York, to evaporate water in their houses 
during the cold days of the winter, in order to obviate the drying of the air. 
Vol. V-6 82 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Denison, in summing up the discussion of his paper, gave, in answer to Dr. 
Bryce, an illustration of a sample day in Colorado as to the relative humidity records 
at different hours of the day, being. 60 to .80 in the morning, .45 to .65 toward 10 a.m., 
even down to . 25 to .40 sometimes by 2 P.M., and then back by gradual increase to . 70 
to . 80 at night, but scarcely ever to complete saturation, except during storms which 
follow incoming or rising moist currents. The facility with which the light air in 
Colorado accommodates itself to the gradual changes in temperature, making a daily 
range of 35° F., gives a different result from what would happen from an immediate 
or sudden decrease of temperature to this extent, especially if the relative humidity 
is as low as .50. As to the chilling effects of draughts upon the body, mentioned 
by Dr. Bryce, the speaker referred to the agency moist air has in depriving the 
body of its heat, which had been considered in his paper. The influence or bad 
effect of air involvement is not by any means so great when the air is dry as when it 
is moist. In reference to the beneficial effect of coolness or cold (which it was not 
claimed should be "excessive," as Dr. Bryce remarked) attention was called to the 
case of Dr. W. H. R., of Kansas City, given in the body of the paper. The necessity 
for large living apartments and of good ventilation in high climates was mentioned. 
In reply to the question of Dr. Kretzschmar as to the ratio of deaths from phthisis 
in Colorado, Dr. Denison said he thought it was about eight per centum of all deaths 
in the State, but much more than that in the city of Denver, where if the cases of 
imported phthisis were excluded, the average would be one-half of one per centum 
of all deaths. In proportion to this low rate in the city, the results in the country 
localities would be much less than this. 
Dr. Coan again called attention to the great influence humidity, rather than cold 
temperature alone, had in the production of the diseases mentioned by Dr. Baker. 
Dr. Baker closed the discussion of his paper, and said that the facts presented 
by Dr. Denison and himself must harmonize, and he hoped that we would soon 
have carefully-recorded facts sufficiently exact and numerous to enable us to see why; 
he thought it quite possible that even the apparently conflicting opinions which Dr. 
Denison and he had formed, from a study of the different classes of facts under the 
observation of each, would be found to be consistent; but it should be noted that his 
point of view was not at all the same as that of Dr. Denison, who undertook to com- 
pare localities, as regards healthfulness from certain diseases, while he (Dr. Baker) 
did not attempt this, but he had presented results of study of great numbers of 
facts, in statistical form, concerning conditions which tend to cause diseases of the 
lungs and air-passages in given localities,-in Michigan, in that part of the United 
States occupied by the United States Armies, during the years 1861-4, in London, 
England, during a series of years, and in India. If the same inquiry had been 
applied to the subject in Colorado, he did not doubt that the same result would have 
been reached-namely, that the diseases of the lungs and air-passages increase after 
the occurrence of cold weather and decrease after the occurrence of warm weather; 
this law holds in every place in which he has studied the subject. He believed it 
was a general law. 
He regarded the attempt to compare different localities as a very difficult under- 
taking, because of the large number of subjects upon which accurate statistics are 
essential for such a purpose ; because these diseases do not affect persons of each 
sex, age and occupation to the same extent ; and localities differ so greatly in the 
proportion of their inhabitants at different ages, in different occupations, etc. If 
his view is correct as to the part played by the non-volatile constituents of the blood, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
83 
left by evaporation on the surfaces of the air passages, then even the difference in 
the saline constituents of the food supplies of different localities must be considered 
in any attempt to compare localities. But to study the subject in any given locality, 
as he had done, is comparatively easy (and the results are correspondingly more cer- 
tain), because in any given locality the proportions of inhabitants at each age, sex, 
occupation and the food supplies, are much the same in one season of the year as 
at another. 
As regards elevation, and atmospheric pressure, he thought the facts which he 
had presented were consistent with those mentioned by Dr. Denison in his discus- 
sion ; and that according to the facts which he had presented, pneumonia was to be 
expected in low malarial States and localities where the atmospheric pressure, and 
especially the range of pressure, is great (Diagram No. 7), and the atmosphere is 
comparatively cold at night. 
HOUSE ATMOSPHERES OR ARTIFICIAL CLIMATES. 
ATMOSPHERE DOMESTIQUE OU CLIMATS ARTIFICIELS. 
HAUSATMOSPHÄREN, ODER KÜNSTLICHE KLIMATE. 
PETER H. BRYCE, M. A., M. D., 
Of Toronto, Canada. 
Without indulging in any speculations regarding what would have been the incre- 
ment of good to the world, existing as we now find it, had the classical nations of 
antiquity lived in a more temperate climate, we have from a scientific standpoint many 
reasons for gratitude for what has been handed down to us by those ancients living in a 
climate where it became possible for them to court nature per silvern, per aquam, during 
all the hours from the ascent of Helios at the breaking dawn till his disappearance, and 
again till the never-failing return of his fiery steeds. 
To us, through them, have come the knowledge of the laws of that larger life 
which, from its very immensity, had filled the least of all their philosophers with an 
awful consciousness of the imminent divinity in things mundane, from an overpowering 
sense of the ever-vivant Power in that superambient world non-tactile, yet sensibly 
real, immense, omnipotential. 
From Cancer to Capricornus traveled what seemed the embodiment of all potentiali- 
ties, and the sun-god ruled the destinies of an Orient where daily orisons were paid, 
and ceased not his beneficent influences when Hesperidean gardens published his 
glory. 
Quaint as are the many observations of the early writers on medecinæ doctrinæ, from 
Hippocrates to the days of Paracelsus Bombastes, they must, nevertheless, be a revela- 
tion to many at the present day, who, accustomed to think but little beyond the special 
medicament for which some particular pain is a supposed indication, learn something 
of the intent of those external influences which are so well summed up in the Hippo- 
cratic treatise 4 4 De aëribus, aquis et locis. ' ' 84 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Remembering the close observation and keen insight of the fathers of medicine, it has 
frequently become a source of interest and surprise to us that the inhabitants of the 
dwellings in our more northern climates have seemed frequently so deficient, not only 
in somewhat of an accurate knowledge regarding the causes and effects of the climatic 
conditions and phenomena of the fluent nature around them, but have also been oblivi- 
ous to the fact that within doors the operations of meteorological influences have never 
ceased; and further, that a new set of causes and effects are superadded, materially 
modifying the conditions surrounding people during their out-door life. It cannot, 
therefore, seem inappropriate for us to discuss the question of ' ' House Atmospheres, or 
of ' 'Artificial Climates, ' ' since the term climate, even so early as the time of Hippocrates, 
had grown to mean much more than was in the original meaning of the term. 
Without attempting a definition of the word "climate," I shall quote words of 
Prof. De Chaumont regarding it. " It is one of the most complex influences in existence. 
It is made up of questions of temperature, humidity, pressure, velocity and direction 
of wind, nature of soil, conformation of surface, presence or absence and kind of vege- 
tation, proximity to the sea or great continents, electrical influences, presence or absence 
of malaria, and probably scores of other things of an obscure or unknown character. 
Its variation is practically infinite, and the integration of its many factors well nigh 
impossible." He further remarks, speaking of the Royal Commission appointed to 
examine into the climatic causes inducing the high mortality among the soldiers in the 
Crimean war, ' ' that the Commission found that so many unhygienic conditions existed 
that it was idle to talk of the influence of climate until these were dealt with and 
removed." 
In these two paragraphs are contained the essence of any practical statements which 
can be made regarding " house atmospheres," since in such there are to be considered 
not only barometric, thermometric, hygrometric and other of the many factors consti- 
tuting climate ; but there are especially the sanitary factors incident to the air of 
dwellings, which, in direct and constant effects upon the health of the household, enter 
far more largely into the question of healthful daily existence than any, however 
potent, of the many external influences ascribed to climate. 
In order that my remarks may be as closely as possible limited to our subject, I pur- 
pose discussing the following points :- 
1. Constituents of house atmospheres. 
2. Temperature and humidity of house atmospheres. 
3. Air currents of house atmospheres. 
4. Effects of house atmospheres on populations. 
5. Remedies for existing evils connected with house atmospheres. 
I. CONSTITUENTS OF HOUSE ATMOSPHERES. 
Without entering into the details of the normal constituents of house atmospheres, 
such as the amounts of oxygen, nitrogen, carbonic acid, ammonia, particles of organic 
matter, etc., it is apparent that in houses built for residence in temperate climates, we 
have conditions superadded which create permanent differences in the constitution of 
the air within them. 
Relative Amounts of Oxygen.-From the experiments made by eminent chemists regard- 
ing variations in the normal amount of oxygen, it does not appear that notable differ- 
ences exist in the air of open spaces. Both experiment and induction teach, however, 
that where, as in the ordinary dwelling house, air movements are but accidental, and 
remembering that a man inspires some 16.6 cubic feet of air per hour, of which more 
than one-fifth is oxygen, it needs no argument in order for us to comprehend the amount 
of loss of this vital principle, still further consumed, to be replaced by carbonic acid, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
85 
by gaslights, lamps, etc. The amount thus lost is still further augmented by the com- 
bustion of the organic matters at all times present in the dust of houses, containing 
particles from the streets, lanes, yards, manure heaps, factories, etc., in varying amounts 
according to location and other circumstances. Evidence of its presence becomes per- 
ceptible to the senses in cellars, the closets and shut-up parlors of many houses, in con- 
sequence of the confined air present in them. Tyndall's and Aitken's experiments 
both further sufficiently prove the abundance of dust particles in the air of rooms, 
while the absence of ozone is a further evidence of the same fact. 
Relative Amounts of Carbonic Acid.-What has been already stated with regard to the 
consumption of oxygen in houses, is equally an indication of the fact that in such 
atmospheres carbonic acid is in excess. The effects of such excess have been shown 
in the historic instances of the Black Hole of Calcutta (where out of 146 persons 123 
died) ; the steamship Londonderry (out of 200 passengers 72 died), etc. ; but experi- 
ments in barracks, in work rooms and in school rooms are multiplied evidences of the 
generally accepted facts regarding its prejudicial influences. Dr. Leeds' (New York) 
experiments on flies in jars tell us the same story. Contrasted with these evidences of 
excess of carbonic acid are the numerous experiments of Professor Angus Smith on Man- 
chester and London air, as also the air on the Scotch mountains, of M. Reiset on the 
air of the open country near Dieppe, and in Paris of MM. Müntz and Aubin, as also 
of Drs. Saussure, Armstrong and others. 
These all point to the same fact, that open country air contains least carbonic acid, 
that of streets and confined air of courts has somewhat more while the air of rooms 
holds still more, increasing with the consumption of oxygen. 
Thus Angus Smith states that- 
The air of streets had 4.03 parts in 10,000 volumes. 
The air of streets in fog had 6.79 parts in 10,000 volumes. 
The air where fields began had 3.69 parts in 10,000 volumes. 
Relative Amounts of Carbon Monoxide.-This constituent, wholly absent from normal 
air, may be present locally in appreciable amounts in the air of cities near gas factories, 
etc., and notably in house air where stoves and hot-air furnaces are used. Where, as 
frequently happens, gas pipes leak, carbon monoxide may be present in water gas in 
dangerous amounts. 
Relative Amounts of Hydrochloric and Sulphuric Adds.-These, normally absent, exist 
in notable amounts in the air of large manufacturing centres, and, as evidenced by the 
facts before the Royal Commission several years ago in Britain, they have produced 
serious effects upon vegetation within several miles of acid manufactories. I have 
experienced on a clear winter morning the presence of sulphureted hydrogen in outer 
air, due to the consumption of soft coal for heating a large building by steam. The 
"Alkalies and Works Regulation Act" has been the means of notably reducing the 
escape of these gases from chimneys. At present, free chlorine from the works there 
does not average more than one grain per cubic foot. 
Relative Amounts of Ammonia and its Compounds.-The presence of this gas in ordi- 
nary air has been so frequently shown that it might fairly be stated to be a normal 
constituent of air under many conditions. As illustrated by Prof. Angus Smith, in one 
of his last published papers, ammonia is constantly present where organic decomposition 
is going on ; and he further demonstrated that it may be detected in close rooms, as 
parlors, not frequently ventilated and where air currents have been few. The amounts 
of organic animal matters, even in the cleanest cities, which are constantly, during the 
warmer seasons, undergoing decomposition, must, without even chemical tests, testify 
to the senses of the most obtuse that this and its various sulphur compounds are 
present ; and if to the ordinary emanations of towns there be added those peculiar to 86 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
slaughter houses, pork-packing houses, fat-rendering establishments, we recognize at 
once that in the air which becomes the house atmospheres of these places we have 
gaseous adjuvants of the ammonia class, which exist nowhere in the air of the open 
country. 
Other gaseous compounds foreign to normal air may be noted as being unfortunately 
present in house atmospheres ; and prominently among these must be mentioned 
those which supply to sewer gases those qualities giving them, to some extent, a specific 
character. In addition to carbonic acid and ammonia, it contains ammonium sulphide 
and animal vapors of indefinite composition. Evidence on every hand indicates that 
this is too common an addition to the house atmosphere in the larger sewered towns 
and cities, not even being absent in many first-class up-town residences. 
Reference has been made to the animal emanations which, in addition to the known 
gases already mentioned, are given off from living bodies, whether human or not. 
Probably they are in some measure particulate, since, as is well known, they cling 
to clothing, and in crowded tenements, long after the air thereof has been renewed. 
Both from the digestive and respiratory tracts come these emanations and, whether or 
not they contain acrolein and other similar hydrocarbons, like those from putrefying 
flesh, certain it is that they often produce deadly results, due either to septicaemia 
or directly poisonous effects upon the blood. This point, of particulate matter, probably 
of the nature of ptomaines, naturally brings us to the question of- 
Bacteria in House Atmospheres.-Numerous recent experiments, notably first those of 
Miquel, and recently and more exactly, those of Koch, have sufficiently demonstrated 
the existence of microorganisms both in the air of houses and that outside, espe- 
cially in cities. Koch's experiments have shown that in rooms where the air for some 
time has been still there are notably few microbes, a fact in keeping with Tyndall's and 
Aitken's experiments, as also with the well-known fact that in houses in which con- 
tagious disease has been, it may be months previously, the stirring up anew of the dust 
by incoming tenants may be the occasion of a fresh outbreak of the disease. That, 
however, the number and character of microorganisms, either in outer air or in house 
atmospheres, varies with causative conditions has been proved by direct experiment. 
Koch tells us that both bacteria and fungi were abundant in the air near the cages of 
his experimental animals, while relatively in the air of his laboratory fungoid spores 
rather than bacteria were abundant. Had the air from the experimental animals blown 
toward the laboratory there can be no doubt but that the conclusions might have been 
different as regards the nature of the microorganisms in house atmospheres. On this 
point nothing can be more conclusive than Miquel's experiments on the air of Paris. 
He says : ' ' The purest air analyzed at the observatory comes from the south ; that most 
impure comes from the hills of Belleville and La VilletteAssuming the 
mean rate of the wind to equal about four metres per second, which is nearly in accord- 
ance with fact, a mass of air sweeps over Paris from north to south in half an hour, and 
charges itself during this course with a number of microbes twice equal to the number 
of those it previously possessed; in a word, its impurity is tripled. Thus infection 
being constant, it is easy to calculate the number of microbes daily furnished by the 
city to the winds whose mission it is to purify it." 
Regarding house atmospheres, Miquel has further beautifully illustrated the fact we 
are endeavoring to impress Thus, while in Paris the relative number of microbes in 
the outer air had, during three years, the following relations, viz., autumn, 121; 
winter, 53; spring, 70; summer, 92, the number in Salle Lisfranc (women's ward) of 
l'Hôpital de la Pitié were, per cubic metre, during 1881 and 1882, as follows : autumn, 
36,700; winter, 52,800; spring, 32,300; summer, 19,300. 
That such must be and are the conditions of outer and house atmospheres in the SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
87 
matter of microorganisms in many of the instances where over-crowding exists, I think 
it not necessary to further demonstrate; but remembering how greatly the outer air of 
cities differs from the air of the champaign, and how to an infinitely greater extent the 
air of a hospital from that of the city air, it may fairly be said that in any view we 
may take of the constituents of house atmospheres there must be and are great and 
constant differences in the number and character of the microbes commonly present 
in such. 
II. TEMPERATURE AND HUMIDITY OF HOUSE ATMOSPHERES. 
If the differences between house atmospheres and normal air be great as respects 
constituents, it will be at once perceived that there are equally great variations between 
normal temperatures of the external air and those of house atmospheres, and that 
thereon in large measure are based the variations of humidity, which have so direct and 
important a bearing upon peoples living in temperate climates. 
Speaking generally, a house atmosphere has a temperature in America between 60° 
and 70° F., although under conditions hereafter to be mentioned, the extremes are 
frequently much greater than these. Probably, more than one would at first thought 
suspect, the barometric changes in house atmospheres follow closely those of the external 
air, showing that the universal law of diffusion of gases, as well as of air movements, 
is never in abeyance. This being the case, it seems natural to think that the relative 
humidity would similarly remain the same. There are, however, several considerations, 
supported by experimental proof, which show that, notably in winter,there are forces at 
work which make this desirable state of affairs practically impossible. The following 
is an instance, taken from some experiments made by a committee of the Provincial 
Board of Health of Ontario, in a building warmed by the Smead-Dowd hot-air system 
of heating by fresh air inlets and outlets for foul air. Upper (girls') room, cubic 
measurement, 10.786feet; cubic space per head, 183 feet; temperature = 67° ; hygrometer 
D. Bulb = 67°, W. Bulb = 53J°; relative humidity, 411 per cent. ; air changed 6.1 times 
per hour. The experiment was made on January 26th, 1887, the weather being very 
severe. It will be noticed that in this case, where temperature and purity are unusually 
good for a public building in winter, the relative humidity is very much below that of 
the ordinary external air. Under the same conditions, had the amount of warm air 
entering the room been less, the purity would have been less but the relative humidity 
greater. 
Speaking more exactly of the differences between house atmospheres and normal 
external air, it may be said that the greater the severity of the external temperature the 
more important and prominent do the variations of the house air from the normal 
become. This is seen not more in the relative impurity of the air in tightly closed 
rooms than in the low relative humidity in well-heated living rooms, and in the unequal 
tëmperature of the air at different parts and levels of the room. Thus, I found in my 
library, on the second floor, on a hot day of the past summer, with as many windows 
and doors open as was possible, that a temperature of 86°-87° F. was maintained, both 
near the ceiling and at the floor, while in the cellar, having an asphalt floor, and but 
little air moving, the temperature varied some 8° between floor and ceiling. During a 
stormy day of the past winter, with a high east wind blowing, I found the temperature 
in a sitting-room on the first floor, having one door opening into the external air, and 
another into a cold hall-way, to be some 15° F. lower at toe floor than at six feet above 
it. I may mention that the room was heated by a hot-water radiator, while a chimney- 
place supplied ventilation by its opening near the floor. C. J. Henderson, Edinburgh, 
in the Sanitary Record, related recently his experience in heating a public hall. 
He says : " I placed a stove in a small adjoining unused engine room, at the south end, 88 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and allowed the heat from it to enter the hall by an opening of three feet square, about 
ten feet above the floor; I next hung thermometers along the centre of the roof, a foot 
from it, and on the four walls about six feet from the floor; these were looked at every 
half hour, and the temperature near the roof was found to be about double that at the 
floor (if 70° at the floor, then 140° at the roof)." 
When it is remembered that in a thermometer at the ground and at four feet above 
it there is ordinarily a difference of 4° F., it will be seen that there are in house atmos- 
pheres conditions frequently as remarkable as they are unsuspected. 
As regards the relative humidity of house atmospheres, we know that the dryness 
of such air is well illustrated by the rapidity with which water evaporates from an open 
pan in the warm room in winter, while the singular aridity of the air of many of our 
best constructed houses is often most perceptible. In these cases, where no proper and 
continuous method is provided for the introduction of warmed fresh air, supplied with 
moisture artificially, it must be apparent, owing to the capacity of air for moisture being 
doubled with every 27° F. increase of temperature, that in any rooms as ordinarily 
heated, in which in winter the relative humidity is high, the moisture must be due to 
exhalations from the bodies of their inmates. In such instances it might be said, that 
the degree of humidity becomes a measure of the contamination of the atmosphere of 
the room, since it is found that two men give off enough vapor from the lungs and skin 
to raise the humidity of air containing 70 per centum of moisture to 100. In 
the instance of the Brockton Street School, already given, the fact of the relative 
humidity is not more an index of the excessive dryness of the fresh air as admitted to 
the rooms than of the frequent changes of it by abstraction during the hour, since, 
taking the temperature of the external air as 5° F. with R. H. 75, its capacity for 
moisture at 67° F. will have been increased 2| times ; in other words, its R. H. has 
been enormously reduced. Remembering that other forms of combustion, as candles, 
gas jets, etc., give off vapors in large amounts, we cannot fail to note that in winter we 
have house atmospheres possessing, if pure, the quality of excessive dryness, and the 
same if moist from combustion, whether from exhalations from animals or lights, 
becoming poisonous from carbonic acid and animal emanations. 
Another feature connected with these points of temperature and moisture is the effect 
which relative humidity has upon the human system at different temperatures, and the 
degree of heat which persons, while in houses and not at actual employment require, in 
order to maintain a warmth compatible with comfort. It is matter of common remark 
that persons from Great Britain commonly withstand the cold of a Canadian winter 
better than do many natives. Remembering the fresh, full-bloodedness of these healthy 
islanders, this is not surprising, but the cause of this phenomenon is a matter of much 
interest. It is frequently said by Americans that the people of the British Isles, France, 
etc., do not know how to heat houses in winter, and certain it is that the dwellings there 
do not ordinarily have the same temperature maintained which is common in the United 
States and Canada. Remembering that grates are there a very common method of 
heating, and that such are found quite insufficient in a Canadian climate, we turn in 
some measure to our stoves, furnaces, steam-heating, etc., for an explanation of the fact 
already stated. Manifestly if the external air in Canada be drier and colder than in 
England, it will become, when introduced into warm rooms, notably drier than house 
atmospheres in the latter country. Galton has remarked that ordinarily the dryness 
of house atmospheres in England does not, owing to the usually great dampness 
of winter atmospheres there, often become a question necessary for practical con- 
sideration. 
What, then, is the secret of this too common evil of over-heating in American 
houses ? Manifestly, there are three principal physical causes at work affecting the SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
89 
amount and rapidity with which heat is given off from the human body, viz., (a) radi- 
ation of heat; (6) loss of heat by evaporation; (c) conduction of heat. 
Regarding the reduction of body temperature by radiation, we recognize the con- 
stant effects of the general law by which the cooling of bodies takes place with a rapid- 
ity, other things being equal, equivalent to the degree of difference between their heat 
and that of surrounding bodies. Remembering that there are from three and a half to 
six units of heat lost to the body every minute, and that the body presents a very large 
radiating surface, we see that loss of heat by radiation is an important element in the 
question of heating in cold climates. Equally important is the loss of heat by evapora- 
tion. Air exhaled from the lungs is practically a saturated atmosphere, and it will at 
once appear that, should the inspired air be of abnormal dryness, the amount of moisture 
lost by evaporation from the respiratory surface, amounting, according to Küss, to more 
than 1800 square feet, of which three-fourths consists of capillaries, must be very great. 
Considering, further, that respirations vary from 16 to 42 in a minute, and that the 
blood is, as stated by the same author, renewed 10,000 times in twenty-four hours, the 
effects of excessive atmospheric dryness upon the general system through the abstrac- 
tion of an excessive amount of moisture and the consequent chilling through evapora- 
tion must be such as to provide much food for thought. Certain it is that with 
abnormally dry atmospheres a notably higher temperature is- necessary to prevent 
a sensation of chilliness; and it is, I believe, to this cause that we are to ascribe 
the fact that in winter women and children and men of sedentary habits are found 
living habitually, in this country, in house atmospheres with a temperature of from 
70° to 80° F. 
The effects of conduction upon the body temperature vary notably, according to the 
humidity and degree of warmth of the surrounding air. As is well known, the 
external atmosphere, if saturated at 32° F., commonly creates, especially with wind, a 
sensation of greater cold than does a still, dry atmosphere at a much lower tempera- 
ture. It is manifest, then, that there is some normal condition of house atmospheres 
at which the body demands a quantity of food, varying somewhat with age and 
employment, which generates a given amount of heat, which is again given off at a 
rate compatible with health and personal comfort. Such temperature must not be too 
low, otherwise radiation and conduction, owing to the humidity increasing with a fall- 
ing temperature, abstract heat too rapidly; nor yet must it be too high, since, if the 
moisture be normal, evaporation and radiation are both insufficient to keep the body 
cool ; while if the sensation of heat be not too great, then the feeling of dryness will be 
noticeable, and its effects on the mucous membrane would continue even if the sensa- 
tion have passed away. Experience proves that such a point lies between 60° to 66°, 
and that should this prove insufficient for comfort, we conclude either that the body is 
exposed to currents of different temperatures, or that air is excessively dry or exces- 
sively moist. 
III. AIR CURRENTS IN HOUSE ATMOSPHERES. 
Perhaps there is no one feature which so well illustrates the difference between external 
and internal air, and can be appreciated so readily by the ordinary observer, as the dif- 
ference between the practically inappreciable currents of house atmospheres and their 
universal presence in out-door air. Yet, in nothing does the startling susceptibility of 
many systems to external influences show itself so much as in the effects of such cur- 
rents. The maximum changes of air of a room without creating injurious currents 
are usually stated as six times per hour, while the average rate of the wind in Britain 
is twelve miles per hour. Galten elaborates this difference by supposing a person 
placed in a box 6 feet by 1 J, and assumes the air to move at the rate of 6 feet per 90 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
second, when in one second 54 cubic feet, in one minute 3240 feet, and in one hour 
196,400 feet would flow over the person. 
Evidently, then, in the very nature of things there are radical differences between 
the two airs as regards their movements. We naturally ask, however, why is it that we 
cannot permit of more rapid movements in house atmospheres without injurious 
draughts? According to Pettenkofer: " The unpleasant sensations from draught arise 
from a one-sided cooling of the body or some part of it; this is frequently caused by a 
corresponding motion of cold air, but also in other ways, as by increased one-sided 
radiation, which causes a local perturbation in our heat economy and thus produces 
local consequences." In some instances, if the passing air be of abnormal dryness, the 
disagreeable sensations of cold will be increased, as in the case of a warm, dry air from 
a furnace register. This question of draughts in a room stands in intimate relation- 
ship with the point already discussed, viz., that of unequal temperatures in different 
parts of a room, as at the floor and the ceiling, as compared with that five feet above 
the floor. Remembering, further, the ordinary construction of windows and doors, we 
need hardly recall the open spaces around them referred to by Longfellow, when he 
sings:- 
" They sat within the farm-house old, 
Whose windows, looking o'er th'e bay, 
Gave to the sea-breeze, damp and cold, 
An easy entrance night and day." 
Manifestly, we have in these unequal currents a condition as opposed to health as it 
is different from that of out-door air. In the latter air, the body, being equally 
exposed and the feet well protected by overshoes or heavy boots, does not experience 
cold to an extent comparable with the difference between the two temperatures; while 
in the house, the body, being unprotected by over-garments and over-shoes, the feet, of 
all parts the most liable to suffer from cold, are exposed to a temperature often much 
below that considered normal for the whole body. 
Not only, however, are there cold floor currents, but there are also in many rooms 
with much outer-wall surface chilly descending currents. A notable difference is often 
to be found between the air of cities and that of the open country. High buildings 
obstructing the sun's rays make marked differences in the temperature on the north 
and south sides of streets, and even between the east and west sides at certain hours of 
the day. With a very diathermanous atmosphere, as in high altitudes, this effect is 
very marked, and I have been informed by a gentleman living in Colorado for his 
health, that the change from one side of the street to the other is often more noticeable 
in its effect on the respiratory tract than the change from day to night. 
IV. EFFECTS OF HOUSE ATMOSPHERES ON HEALTH. 
It is probable that these effects have been and are more capable of being estimated 
in America than in any other country in the world. There are various reasons why 
this should be so. Sociologists and anthropologists, physiologists and climatologists 
have been industriously engaged for years in attempting the quantitative and qualita- 
tive estimation of the changes which have been produced on Europeans, but notably on 
the Anglo-Saxon race, in the production of what has popularly been called the American 
type. As Secretary Bayard well expressed it in his opening address, "we pursue our 
objects with that breathless energy which has left its traces on our physiognomies." 
Speaking from our standpoint it appears to me that some of the explanations given 
for this change have been as absurd as they have been unsatisfactory. By some we 
are informed that every nation is indigenous to some particular soil and climate and 
that, removed from it, its people will degenerate. There can be no doubt but that, as SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
91 
illustrated by Pritchard in the ancient Egyptian and Syro-Arabic races, living in regions 
almost contiguous, there is everywhere evidence of remarkable persistency of type in 
distinct races; and even in modern times we have abundant evidence of the continuance 
of racial distinctions; but apart from the facts that political, social and religious 
differences have, in the history of past centuries, been most potent influences in main- 
taining the purity of type even where conquest has taken place, and notwithstanding 
the fact that absorption of conquered races by the conquerors has in many instances 
been slow, and although hereditary peculiarities of type, both in man, the lower ani- 
mals and plants, are almost ineradicable, yet illustrations of the use of color in nature, 
of the variations in species under domestication, and of many familiar facts regarding 
the human race, all show a marvelous power of adaptation to environment, both among 
plants and animals. 
Regarding many of the facts from which conclusions have in the past been drawn, 
by anthropologists, we cannot forget that they have been for the most part drawn from 
the historic races, living in climates to the South, with the possibilities of an out-door 
existence through the greater part of the year, and at a period when modern progress 
with its thousand appliances for in-door comforts was in large measure unknown. As 
recently as the 14th century the halls of manor houses in England were usually with- 
out chimneys, and the smoke from the brazier in the centre of the room found its way 
through a louvered turret in the roof. Then and for hundreds of years since, even to- 
day, the cabins of the colliers of Britain are primitive in the extreme. 
Assuming that the American type is being evolved constantly from the Anglo- 
Saxon, Teutonic and Celtic races, where intermixed, we have, in tracing out this evolu- 
tion, while giving due prominence to the anthropologists' and sociologists' reasoning and 
arguments, to remember the conditions of life of the first immigrants to this land and 
the changes which time has wrought in their occupations, their habits of life, and espe- 
cially in their dwellings. The wigwam, the structure of poles lapped over with ever- 
greens, the log shanty of one room, the block-house, all with their open fireplaces, the 
semi-nomadic life of the squatter, and frontiersman and trapper, the largely out- 
door lives of men, women and children among the early settlers and their never ceasing 
manual toil at felling the monarchs of the forest and clearing the fields for future crops 
of golden grain, the pure cold mountain streams, and the grand and lordly rivers, and 
the vast primeval forests tempering the winter's cold, and breaking the force of hyper- 
borean blasts ; all such and much more, never to return again, were the rude and 
primitive conditions to which the most vigorous, energetic and adventurous of the 
toiling rural classes of Great Britain, especially, and the continent of Europe, were 
inducted on their arrival on the American continent. To realize the change which but 
a few decades have wrought we need only remember the Glasgow of a hundred years 
ago with its 70,000, and that of to-day with its 700,000 people, or to recall to view 
the cottages and habits of life of the rural populations of Europe to-day. All Ameri- 
cans and Canadians know, for the race is hardly extinct, the fathers of the greater 
portion of the present American people were men of the times when the logs blazed on 
the fireplaces and the boys in the garret were in no measure disturbed if the snow 
drifted in beneath the rafters. They were of the days before railway trains and tele- 
phones, the cast-iron stoves and the base-burner-too well named ; of the days when 
old Uncle Jake fiddled sitting by the hearth, while the daughters of the house, bare- 
ankled and with the figures of Hebe, spun the wool and the mothers handled the dis- 
taff. 
To-day we look about us, visit the rural homes even, and can we doubt-does any 
deny-that the type is changing ? Said a very highly cultivated unmarried city lady to 
me recently, while defending the higher education of women, " It's true we ladies have 
grown to be nothing but bundles of nerves, but it is not over-education, it is wrong 92 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
education." Sufficient it is, for our purpose, that a keen-sighted woman observer 
admitted that her sex are becoming but bundles of nerves. On every hand the fact 
will readily be admitted, as regards both men and women in America, except in so 
far as the fresh air and outdoor exercise are mostly in favor of the male sex. Accepting 
the proposition that all men and animals tend to deteriorate on this continent, one of 
the foremost gynaecologists says: " The cause of this tendency to deteriorate is as yet 
obscure, but it is not impossible that the peculiar nature of our climate has a share in 
it ... We certainly possess a most changeable climate ; one which stimulates 
the nervous system at the expense of nutrition and renders us restless both in mind and 
body." Now, how much probable truth there may be in these statements from a high 
authority, it may not be proper for me to estimate; but a large part of the results 
which at the present day are set down as directly due to climate in general, we have, I 
think, seen to have been absent in the case of the pioneers and their more immediate 
descendants; and further, I believe we are fairly entitled to state that these changes in 
physical type have been to a much larger extent brought about by house atmospheres, 
or house life, with all this implies of either the occupations of both sexes, the hours 
lived as waking hours, or the atmospheres of the living rooms as affected either by 
imperfect ventilation, deficient methods of warming, or for the disposal of sewage. 
Referring to these effects the ordinary observer need only notice the rosy, healthy 
children of the poor in November, when they are being housed for the winter, and 
again in March, or April, when released from their prison house, in order to estimate 
what house air can effect on the child system. 
To measure such effects I may state, that in all of our Canadian cities a new, but 
well-built, well-heated and ventilated school had, according to the official register, 
fully 25 per centum less children reported absent through sickness than any other public 
school in this city ; and this too where the children were from among the artisan 
classes. The same report showed that the absentees from all the schools, through sick- 
ness, increased by 50 per centum from September to October. And that the increase of 
absentees rose steadily till March, and again had fallen from April to May, by 50 per 
centum. With the mothers, practically the whole female portion and the young children 
of our population, living in an artificial climate during five or six months of the year, 
can there be any room for question as to whether their dyspepsias, their neuralgias and 
their generally anaemic condition are not due rather to vitiated air than to the over- 
stimulating effects of an unduly ozonized atmosphere. 
This essentially artificial climate must, however, be further studied in its direct 
effects in the matter of the spread of infectious diseases. Regarding the prevalence of 
these diseases when, as during winter, the people are most influenced by house atmos- 
pheres, I quote from a statistical study of disease in Ontario, printed in the ' ' Second 
Annual Report of the Provincial Board of Health :- 
' ' From what has been observed by many writers, it would appear that most of the 
diseases in Class IV have appeared in mortality tables as increasing in the cold weather. 
For instance, the smallpox curve of the tables drawn up for London for a period of 
thirty years, by Buchan and Mitchell, show that from January to June the mortality 
curve is above the average. A similar curve is given as representing the prevalence of 
whooping-cough; scarlatina varies by having in the second half of the year the mor- 
tality curve above the average; while measles is exhibited with two maxima and 
minima, the maxima being at the beginning and end of the first half of the year. It 
would seem, then, that the statistics obtained by this Board for the existing prevalence 
of those diseases, without any regard to mortality, roughly coincide, with the excep- 
tion of whooping-cough, with the London mortality tables, and show that the winter 
season is, on the whole, most favorable to these diseases. 
"From a sanitary point of view, this apparent fact is of the greatest importance, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
93 
though from a biological standpoint it is, at first sight, one of much difficulty. The 
following observations regarding the two may be made:- 
"1. Assuming that each has its specific bacillus, which develops under favorable 
conditions, how is it that in low winter temperatures those whose activity, in probably 
every case, is in abeyance, should not only break out, but multiply ? Are Miquel's 
statements about the very greatly less number of spores in the atmosphere of Paris in 
winter, to show that such diseases have no connection with spores ? How is it that, 
with his facts before us, we are going to recognize at once the greater prevalence of 
these diseases in winter, along with this specific character? Without in any way 
detracting for a single moment from the important influence of the weather on these 
diseases, it does seem to me that a much greater matter has, in this way, been lost sight 
of. Hence I observe- 
" 2. That let the temperature of the outer air be what it may, either in London or 
in Ontario, the air in which the specific germs of these diseases develop is always at a 
temperature favorable for their multiplication. 
' ' Miquel, in the following table, shows us that in hospitals these germs are much 
more abundant in winter than in summer; and why? Because they are in a warm, 
equable atmosphere favorable to their development; they are not lessened by frequent 
change of the air by ventilation, and they have, moreover, abundant and proper food 
by which to be nourished." 
TABLE SHOWING BACTERIA COLLECTED FROM ONE CUBIC METRE OF AIR AT 
L'HÔPITAL DE LA PITIÉ, PARIS. 
MONTH. 
SALLE MICHON. 
(MEN.) 
SALLE LISFRANC. 
(WOMEN.) 
March, 
1881 
11,100 
10,700 
April, 
It 
10,000 
10,200 
May, 
10,000 
11,400 
June, 
4C 
4,500 
5,700 
July,' 
cc 
5,800 
7,000 
August, 
u 
5,540 
6,600 
September, 
Cl 
10,500 
8,400 
October, 
u 
12,400 
12,700 
November, 
u 
15.000 
15,600 
December, 
<< 
21,300 
28,900 
January, 
1882 
16300 
12'800 
February, 
U 
14,400 
11,100 
March, 
I I 
14,800 
10,550 
April, 
Cl 
11'120 
7,'560 
May, 
u 
6,300 
5,930 
" 3. These domiciled atmospheres, it will at once be seen, will not be influenced by 
meteorological changes in anything like the same degree as will the outer air, and 
hence can be explained some of the apparently contradictory conclusions found, for 
example, in the next table. 
" 4. The fact of the general decline of these diseases in warm weather, while doubt- 
less depending, to some extent, on atmospheric conditions, especially temperature, 
depends, it would appear, first, upon the fact that the victims of them, notably chil- 
dren, are not exposed, in anything like the same degree, in close, ill-ventilated, and, 
therefore, filthy houses-being much in the open air; second, upon the fact that even 
were they as much indoors, they are not so much exposed, because the temperature 
allows very largely of natural ventilation, so that the oxidizing influences upon germs 94 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
can be carried on then much more thoroughly, and hence, by means of this ventilation, 
the materials on which they flourish-animal emanations, etc.-are not present in at 
all the same amounts; and, finally, children much in the open air are stronger and 
better able to resist disease. » 
" 5. Another point worthy of note is, that the much greater mortality from all these 
diseases in winter does not, necessarily, mean that they are then more prevalent, since 
warm weather is much more favorable to recovery from them. 
"6. The communication carried on with houses affected with some of these diseases, 
directly or indirectly, is the prime and necessary condition of their free spread ; and 
hence it becomes the imperative task of sanitarians, whether medical or lay, to take the 
most energetic and stringent measures both to educate and compel the people to take 
such precautions as have been proved most effectual in restricting their spread." 
BRITISH AUTHORITIES, REGARDING METEOROLOGICAL CONDITIONS AFFECTING 
PREVALENCE OF SCARLATINA. 
Temperature. 
Humidity. 
Pressure. 
Authority. 
F* 
U. 
Moderately low. 
Above average. 
Excessive. 
Sudden fluctuations. 
Diminished pressure. 
Dr. Ransome. 
ri 
Between 56°-60°. 
Fall of mean temperature 
below 53°. 
Mot above 86°, or much less 
than 74°. 
Dr. Ballard. 
F. 
ü. 
A temperature higher 
than 44.6°. 
A temperature below 44.6°. 
If humidity of air is less 
than usual. 
Dr. Tripe. 
F. 
U. 
When it rose much 
above 50°. 
A fall below 50° in autumn. 
Dr. Moore. 
•F. Favorable; U. Unfavorable to the development of the disease. 
Such are the widespread and almost universal effects upon the physical constitution 
of these house atmospheres, that they might be illustrated to an almost unlimited 
extent; but enough has been said to fully illustrate their character. Associate with 
these facts what has been said by a writer already quoted: " Repose and quiet recrea- 
tion, in a European sense, are unknown to the mass of the population," due, I consider, 
largely to the commercial necessities of a new and rapidly developing country, without, 
to a large extent, any specially favored class either by birth, law or wealth, and where 
every person, practically, has the opportunity of becoming a premier or a president; 
and it appears to me that, instead of our American continent having a climate respon- 
sible for the "killing off by inches" of an exotic human population, we have most 
potent reasons for heeding the prophet's words: " Stand ye in the ways, and see and ask 
for the old paths, where is the good way, and walk therein." Our so-called civilization 
is costing us much, and if we cannot in this instance follow the old paths, we must, 
at any rate, see it to be our plain duty to maintain in our house atmospheres, to the 
highest degree possible, the God-given air of " the green pastures and the still waters." 
V. REMEDIES. 
From the many considerations which have already been presented, it will not be 
difficult for us to appreciate the nature of the remedies necessary for lessening the evils 
which have been pointed out. Though no complete definition has as yet been given, 
and while, probably, no two climatologists are wholly agreed as to what constitutes a 
perfect climate, still we have a number of well-defined elements in all chmates which, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
95 
by common consent, are considered good. To assimilate the atmospheres of our dwelling 
houses to these must be our aim. 
Following some order, we first draw attention to that potent influence upon all life 
-sunlight. The advantages of large, clear glass windows in aiding the diathermancy 
of the atmospheres of rooms are obvious to all. We must next pay attention to the 
purity of house atmospheres. Where rural or suburban residence is not possible, then 
it is desirable that residence on that side of a city toward the most prevalent winds will, 
generally speaking, be desirable. Since this cannot be possible for all, it should be our 
constant endeavor to obtain, by strict scavenging and every other measure necessary to 
municipal sanitation, the highest available degree of cleanliness in the atmosphere of 
the city. 
To prevent the introduction of foul air, either as ground air or from sewers, every 
endeavor must be made to improve the methods of construction of foundations, cellars, 
plumbing, etc. Following this, we have to deal with the most difficult of all problems, 
especially in cold climates, viz , the attainment of equable heating and thorough ven- 
tilation. The points to be either avoided or remedied have already been referred to ; 
but how to apply adequate and economical remedies has been, and is still, a matter 
for serious study. Any lengthened consideration of the subject would extend the paper 
to a length already too great, and I shall, therefore, only say that, after carefully viewing 
the matter in its various aspects, I feel convinced that our solution will ultimately be 
found in a system of indirect heating, whereby fresh air, drawn from the exterior in 
such a manner as to apply the warmth of the subsoil to raising the temperature of the 
cold air, will be further heated over steam or hot-water coils, over which evaporating 
basins of sufficient area are placed for supplying as much moisture as may be required 
to keep the air of a proper humidity. Such' air may thence be transmitted to the living 
rooms by a sufficient number of openings at the top of walls to prevent draughts. 
The vitiated air ought thence to be abstracted by similarly distributed openings near 
the floor and carried under the floors, thereby keeping them warmed. From upper 
rooms the air, similarly supplied and abstracted, ought to be carried downward between 
the outer wall and that of the rooms, thereby preventing loss of heat by radiation and 
preventing cold currents near the outer parts of the rooms. Modifications of these 
principles can, with comparative ease, supply warmth and ventilation, even in the 
instance of the tenements of the poorer classes. 
In conclusion, it must be recognized by every one, from the many illustrations which 
have been supplied in the discussions and by other observers regarding the fatal effects 
of the imperfect condition of home life under which Indians, negroes and many of the 
people of limited means exist, that this subject demands the earnest consideration of 
all workers in this broad field of climatology and demography ; and since occupations, 
urban residence and limited means make it impossible for an increasing proportion of 
our population to enjoy the health-giving influences of rural residence and the stimu- 
lating effects of life by the ever-restless ocean or upon the mountain side, we shall, I 
conceive, best fulfill the duties which have been assigned to us by making it possible 
for every willing citizen to so live under his own roof as to maintain a vigor unimpaired 
for the discharge of the work lying nearest him, and to transmit to the race that is to 
be a legacy of physical health, heaven's sweetest blessing and greatest source of un- 
alloyed joy. 96 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Vice-President, Dr. Woolverton, U. S. Navy, in the chair. 
GROUND AIR IN ITS CLIMATOLOGICAL AND HYGIENIC RELA- 
TIONS. 
AIR DU TERROIR DANS SES RAPPORTS CLIMATOLOGIQUES ET HYGIENIQUES. 
ÜBER BODENLUFT UND IHRE KLIMATOLOGISCHEN UND HYGIENISCHEN BEZIEHUNGEN. 
JOHN DENIS MACDONALD, M.D., F.R.S., 
Of Surbiton, Surrey, England. 
1. Referring to the Gulf Stream, that distinguished physical geographer and orna- 
ment of the United States Navy, Captain Maury, makes the beautifully poetic remark 
" There is a river in the ocean; " and we may add that there is an atmosphere in the crust 
of the earth in immediate communication with that which everywhere invests our globe. 
This other atmosphere, which we designate the ground air, while it preserves its own 
identity, is truly also within the scope of meteorology. Its constitution and pathogenic 
properties, however, have attracted much attention of late years, being intimately asso- 
ciated with climatic conditions and the nature of the soil, whether porous, bibulous or, 
to some extent, impermeable. 
2. Just as by evaporation from the surface of the earth moisture accumulates in the 
atmosphere, so, also, by what has been aptly termed the ascensional force of evaporation, 
much organic matter and a large amount of minute protozoa and protophyta are carried 
upward and widely distributed by winds and aerial currents, only to be again brought 
down to the earth in the rainfall and taken up by the porosity of the soil. 
3. Although by the law of the diffusion of gases the normal constituents of the 
atmosphere are equably mixed, we know that, besides the visible clouds, moist layers of 
air, quite invisible to us, are usually present, with intervals of more or less dry air. 
Organic particles will be held by the moisture, living forms will grow and multiply, 
and, when disengaged, may actually fall from one humid stratum to another. The 
very remarkable and apparently fitful appearance of blight in agricultural districts may 
often be accounted for in this way. The little colonies of bacteria in their gelatinous 
fronds, frequently found attached to cotton or woolen fibres, floating freely in the air, 
are ready to spread quickly under suitable conditions within the zone of the ground air. 
4. Notwithstanding the large amount of organic matters carried off by the rivers 
into the sea, the surface of the earth must receive and retain a much larger amount, 
and it will be seen from the foregoing facts that, but for the eliminating processes 
referred to, the ground air would be quite as poisonous generally, as it is now known to 
be locally. 
5. When organic substances, animal and vegetable débris and organisms are carried 
into a porous soil by rainfall, they readily find a holding ground, aided either by the 
moisture surrounding them, or by their own plasticity. They may also percolate to a 
considerable depth, according to the porosity of the surrounding materials. 
6. Looking upon every epithelial cell thrown off in a case of scarlatina as a little 
cartridge of infection, let us only suppose the millions of such cartridges shed in an 
ordinary epidemic of the kind to be carried into the soil to a certain depth, or under 
physical circumstances, to accumulate in one place more than another in the ground 
air spaces, and it is quite easy to understand the little more that would be necessary to 
develop the disease spontaneously, or without any clearly traceable origin, according to 
our former knowledge. 
7. Those who may desire to study the chemistry and physics of the ground air SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
97 
should study also the ground water, and how perturbations in the elements above may 
affect the elements below. The forcible impress of the atmosphere upon the soil and 
thereby upon the ground air, and alterations of level in the ground water may develop 
results that have been referred to other causes, or, possibly, in ignorance, to no cause 
at all. 
8. The chemical examination of the ground air has shown an increase in the rela- 
tive amount of CO2 in proportion to the depth, and just at the surface of the soil (doubt- 
less by the persistent action of the law of diffusion) a near approach to the ordinary 
composition of the atmospheric air. 
9. The pioneers in this investigation appear to have been Drs. Cunningham and 
Lewis, of the A. M. D., in India; Prof. Pettenkoffer, in Germany, and Professors Parkes 
and de Chaumont, of the Army Medical School, Netley. It was in the latter institution, 
however, that the products of ground air obtained by aspiration at some considerable 
distance from the outlet of the main drain were submitted to microscopical examination 
for the first time. 
10. Mr. Center, the government analyst for India, was then attending the school, 
and he supervised the aspiratory arrangement, while I undertook the microscopy of the 
specimens obtained. They were found to be rich in all descriptions of animal and vege- 
table débris, epithelium in large amount, fungal spores and mycelium, wool and cotton 
fibres, starch grains, bacteriaceæ, etc. I showed my drawings to the late great and 
good Professor Parkes, just before his lamented death, and while he was much pleased 
with the results, he said that they should not be hastily made known until they could 
be backed up by a wider series of experiments and further practical study of the sub- 
ject, and there the matter stood for several years, and, so far as I know, though we now 
possess most accurate chemical analyses of the ground air in different localities, no 
microscopical results have yet been recorded. Here, then, is an interesting field open 
for original investigation. 
11. Most medical men in public service will recall examples in their own experience 
to illustrate the importance of this subject in all its bearings. Thus, we know that in 
malarious districts, where old ground has been excavated for railway cuttings, building 
or other purposes, illness among the operatives is not at all unusual. Again, fires on 
the ground floor act very powerfully in drawing up the ground air into the apartments, 
and when a large ground space is occupied by buildings crowded together, possibly with 
cellarage but without open courts, no amount of artificial ventilation can remedy the 
defect. At Port Royal, Jamaica, formerly, the quarters of the senior medical officers 
were built directly upon the ground floor, and the mortality among them was consider- 
able. But since the quarters were raised upon arches the mortality was sensibly 
arrested by cutting off the ground air. Instances of this kind might be given to almost 
any extent, but enough has been said to show the importance of the subject, and with- 
out attempting to treat it exhaustively, if I have only succeeded in calling the atten- 
tion of practical workers to its further development the object of this short paper will 
be answered. 
Vol. V-7 98 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
EXPOSÉ METHODIQUE DES ACTIONS THÉRAPEUTIQUES DES 
EAUX MINÉRALES. 
METHODICAL STATEMENT OF THE THERAPEUTIC ACTIONS OF MINERAL 
WATERS. 
METHODISCHE DARLEGUNG DER THERAPEUTISCHEN WIRKUNGEN DER MINERALWASSER. 
PAR LE DR. MAX DURAND FARDEL, 
De Paris, France. 
Les applications des eaux minérales, ou mieux de la médication thermale, sont très 
étendues. Elles s'adressent légitimement à la plupart des maladies chroniques, et à 
un grand nombre A'états de l'organisme qui n'offrent pas un caractère précisément 
pathologique, tout en s'écartant de conditions à proprement parler physiologiques. 
Il y a donc à considérer dans le champ de leurs applications -de simples états cons- 
titutionnels-et des états diathésiques déterminés. 
Si leur objectif est souvent le traitement de quelque lésion locale, il faut bien savoir 
que c'est surtout leur action générale sur le système qui est mise alors en jeu, et que tel 
est effectivement le caractère essentiel de la médication thermale. 
Les applications de la thérapeutique ordinaire s'adressent spécialement aux lésions 
locales déterminées. Ce n'est que d'une manière très imparfaite qu'elles parviennent 
à atteindre les modalités constitutionnelles et les maladies diathésiques. Telle est, au 
contraire, la portée essentielle de la médication thermale, et c'est surtout en raison de 
l'action que celle-ci exerce sur les conditions générales de l'organisme qu'elle enraye les 
états pathologiques nés ou entretenus par leur influence. 
Tels sont les principes généraux qui doivent présider à toute compréhension de la 
médication thermale. Je me borne à les indiquer ici, n'ayant pour objet, dans ce tra- 
vail, que d'exposer d'une façon méthodique les actions thérapeutiques propres aux 
diverses espèces d'eaux minérales. 
I. 
Avant d'étudier les actions thérapeutiques des eaux minérales, au point de vue où 
leur connaissance peut aider à en établir les indications, il sera utile d'exposer en quoi 
consiste la médication thermale elle-même, ce que nous en connaissons, en un mot, 
l'idée qu'on peut s'en faire. 
En réalité, nous ne connaissons des eaux minérales que ce que la chimie nous a 
appris à leur sujet, quelque soit le degré d'avancement auquel est parvenue la chimie 
analytique, elle est loin d'avoir dit son dernier mot. L'analyse a fait découvrir, depuis 
plusieurs années, dans les eaux minérales, des matières que l'on n'y avait pas soupçon- 
nées jusqu'alors ; nous n'avons aucune raison d'affirmer qu'elle s'en tiendra là ; et il 
est certain qu'elles possèdent en outre des éléments particuliers d'activité que nous ne 
connaissons pas. Mais, comme on ne saurait raisonner sur l'inconnu, nous ne trouvons 
que la constitution chimique à faire intervenir dans l'interprétation des phénomènes 
observés. On ne saurait admettre d'ailleurs qu'elle leur reste étrangère, tout en recon- 
naissant qu'elle ne représente sans doute qu'une partie des éléments qui y président. 
Les eaux minérales se partagent en groupes, classes ou familles, déterminés par des 
analogies de constitution chimique et par la présence caractéristique d'uu principe pré- 
dominant, d'un sel, dont l'acide sert à les distinguer entre eux. 
Je reproduis la classification que j'ai établie dans mon traité des eaux minérales, 
et suivie dans mes cours, et qui est aujourd'hui généralement adoptée. 
Dans chacun des groupes déterminés, il est une série d'eaux minérales nettement SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
99 
caractérisées par une constitution chimique précise et analogue, et qui ne le sont pas 
moins par le rapprochement de leurs applications thérapeutiques. Mais, auprès de ces 
types précis, on en rencontre d'autres chez lesquels l'amoindrissement de leurs prin- 
cipes, et par suite de leur caractéristique constitutive, préside à des applications moins 
bien déterminées également. 
CLASSIFICATION DES EAUX MINÉRALES.1 
Famille des Sulfurées {une classe).2 
lre division, sulfurées sodiques.3 
2e " sulfurées calciques ou sulfhydriquées.4 
Famille des Chlorurées {quatre classes). 
lre classe, chlorurées sodiques.5 
2e " chlorurées et sulfurées.6 
3e " chlorurées et bicarbonatées.7 
4e " chlorurées et sulfatées.8 
Famille des Bicarbonatées. 
lre classe, bicarbonatées simples : lre division, sodiques.9 
2e ' ' calciques.10 
3e " mixtes.11 
2e classe, bicarbonatées chlorurées.12 
3e " bicarbonatées sulfatées.13 
4e " bicarbonatées sulfatées, chlorurées.14 
Famille des Sulfatées (une classe). 
lre division, sulfatées sodiques.16 
2e ' ' sulfatées calciques.16 
3e ' ' sulfatées mixtes.17 
4e " sulfatées magnésiques.18 
1 Ne possédant que des données insuffisantes sur les eaux d'Amérique, j'ai craint de fournir 
des indications inexactes, et préféré ne pas les mentionner dans les exemples cités. 
2 Les familles sont établies sur la prédominance essentielle d'un acide commun; les classes sur 
la prédominance simultanée de plusieurs acides ; les divisions sur la prédominance (secondaire) 
d'une base sodique ou calcique (alcaline ou terreuse). 
3 Cauteret, Ludion, Barèges, Eaux Bonnes, Amélie, etc. (France). 
4 Allevard, St. Honoré, Enghien, etc. (France); Acqui, Viterbe, etc. (Italie); Schinznach (Suisse). 
6 Salins du Jura, Salier de Béarn, Balaruc, Bourbonne, Bourbon l'Archambault, etc. (France); 
Creuznach, Nauheim, Wiesbaden, Hombourg, etc. (Allemagne); Monte Cattini (Italie). 
6 Uriage, (France); Aix la Chapelle (Allemagne); Archena, la Vuda (Espagne); Harrogate 
(Angleterre). 
T La Bourbonle, Saint Hectaire (France). 
s Saint Gervais, Brides (France); Baden Baden (Allemagne); Baden (Suisse); Cheltenham 
(Angleterre). 
9 Vichy, Vais, le Boulou (France). 
10 Alet, Foncaude, etc. (France); Saxon (Suisse). 
11 La Malon, Pongnes, etc.-Eaux digestives ou de table : Chateldon, Desaignes, Condillac, etc. 
(France). 
12 Royat, Chatelguyon, etc. (France) ; Ems (Allemagne). 
13 Contrexéville, Vittel, etc. (France); Rippoldsan (Allemagne). 
14 Carlsbad, Marienbad, Franzenbad (Autriche-Bohème). 
15 Miers (France). 
16 Bagnères de Bigorre, Capvern, Aulus, etc. (France) ; Bath (Angleterre) ; Loèche (Suisse). 
U et I8 Montmirail (France); Eaux laxatives médicamenteuses: Hunyadï-Lazlè (Hongrie); 
Pullna, Seidlitz (Bohème) ; Birmenstorf (Suisse). 100 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Familles des indéterminées {deux classes). 
lre classe, eaux thermales simples.1 
2e ' ' eaux faiblement minéralisées.2 
Classe Supplémentaire. 
Eaux ferrugineuses.3 
Théoriquement, c'est-à-dire en faisant abstraction de ce que nous ignorons encore 
sur ce sujet, il faut admettre que les eaux minérales de ces différentes familles et classes 
doivent leur propriétés thérapeutiques à l'ensemble des principes qui y sont rassemblés, 
mais que cet ensemble se trouve en quelque sorte dirigé par le ou les principes qui y 
prédominent. Car, retranchez aux eaux essentiellement sulfurées, ou chlorurées, ou 
bicarbonatées sodiques, leur principe prédominant, elles n'auront plus de raison d'être. 
Et comme, d'un autre côté, du soufre, du chlorure de sodium ou du bicarbonate de 
soude, employés isolément, on n'obtient pas d'effets semblables, ou seulement des effets 
très éloignés, il faut encore admettre que ces principes prédominants n'agissent ainsi 
qu'en vertu de leur rapprochement de ceux qui les accompagnent. 
Il semble que l'on pourrait rapprocher ceci de ce qui a trait aux principes élémen- 
taires de l'assimilation. Celle-ci ne saurait être réalisée par l'emploi de ces principes 
chimiquement isolés ; il faut, pour qu'ils agissent dans le sens auquel ils sont destinés, 
qu'ils se trouvent accompagnés d'autres principes en apparence inutiles, mais indispen- 
sables en réalité. Une telle comparaison ne saurait être prise dans un sens littéral; 
mais elle me parait propre à aider à comprendre la part réciproque des divers agents 
dont se compose une eau minérale. 
Il ne faut pas envisager seulement les acides qui servent à determiner les familles et 
les classes d'eaux minérales, et qui semblent présider à leur spécialisation thérapeu- 
tique ; leurs bases prêtent également à des considérations intéressantes. 
Il est à remarquer que les bases qui prédominent dans les eaux minérales sont en 
très petit nombre. Si nous mettons de côté les bases ferrugineuses qui, lorsqu'elles 
viennent à leur imprimer un caractère thérapeutique exclusif, forment le titre d'une 
classe à part, nous ne trouvons guère à tenir compte que de la soude et de la chaux, la 
magnésie accompagnant souvent la chaux, comme la lithine accompagne la soude, 
sans que la médication paraisse en acquérir des caractères particuliers. 
En somme, on peut dire que toutes les eaux minérales sont ou sodiques ou calciques. 
Quelquefois cependant ces deux bases se rencontrent en proportions sensiblement égales: 
c'est ce qu'expriment les divisions mixtes, signalées dans la classification. 
Or, toutes les grandes actions thérapeutiques, que peut revendiquer la médication 
thermale, appartiennent aux eaux franchement sodiques. Il ne s'agit pas d'établir entre 
les eaux minérales une hiérarchie dans un certain sens. Une eau minérale le mieux 
appropriée à un état morbide quelconque sera toujours la première médication pour cet 
état particulier. Mais il est des applications, comme on le verra plus loin, qui réalisent 
des effets plus ou moins considérables en importance et en profondeur dans l'organisme. 
Ces actions les plus importantes et les plus profondes sont les actions altérantes ou dia- 
thésiques, reconstituantes et résolutives. Telles sont celles qui sont très spécialement 
dévolues aux eaux à minéralisation accentuée et surtout à bases sodiques prédomi- 
nantes. Ceci est un des faits les plus frappants de la médication thermale. 
1 Nèris Dax, Plombières, Ussat, Luxeuil, etc. (France); Alhama de Aragon (Espagne); 
Sartein (Autriche); Wildbad, Schlangenbad (Allemagne); Pfeffers (Suisse). 
2 Eaux difficiles à classer: Mont-Dore, Saint Christau, Evian (France); Panticosa (Es- 
pagne). 
8 Forges, Sylvanés, Renner, Campagne, etc. (France) ; Spa (Belgique) ; Schwalbach (Alle- 
magne). SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
101 
Si donc l'on rencontre une eau minérale franchement et fortement sadique, ou pourra 
être assuré, a priori, qu'elle possède à un haut degré les propriétés que je viens de 
signaler. Si c'est une eau qui soit dépourvue de bases semblables, ou ne les tienne 
qu'en sous-ordre, on peut être assuré qu'elle ne possède ces mêmes propriétés qu'à un 
rès faible degré. 
D'un autre côté, toute eau minérale riche en bases calciques se trouve douée de 
propriétés sédatives, dans le sens qui sera exposé plus loins. 
Je ne voudrais pas présenter ces diverses propositions comme des lois : mais elles 
sont l'expression de faits très positifs, et qui ne me paraissent pas avoir été signalés 
encore. Quelle interprétation peut-on leur donner? Je ne le cherche pas ici, ne me 
proposant que de faire connaître ce qui a trait le plus directement aux applications pra- 
tiques. 
La thermalité des eaux minérales est un de leurs éléments d'action ; mais il ne 
faudrait pas en exagérer l'importance. Leur calorique n'est certainement pas d'une 
nature particulière. Un des grands avantages des eaux douées de thermalité est, 
outre le fait de procurer des boissons chaudes ou tièdes, de se prêter aux usages externes 
(bains, douches, etc.), sans mélange ou sans réchauffement artificiel. Mais il y a quel- 
que chose de plus. On doit établir, comme une règle générale, que, dans une station 
thermale possédant plusieurs sources, ce sont les plus chaudes qui en représentent les 
applications les plus effectives et les plus complètes. Il faut penser qu'une thermalité 
effective leur suppose une migration plus directe et une intégrité plus parfaite, c'est-à- 
dire une conservation plus intacte des qualités, encore indéfinies, qui font de la médica- 
tion thermale une médication à part, et absolument différente de toute autre sorte de 
médication. 
Lorsqu'il est question d'un traitement thermal, il faut toujours tenir compte des 
conditions hygiéniques que comportent le déplacement, les conditions nouvelles de cli- 
mat, d'attitude, de genre de vie. Il y a là des éléments d'action sur l'organisme, quel- 
quefois considérables, que l'on ne doit point perdre de vue, bien qu'on en ait souvent 
exagéré la portée. 
Enfin, il faut encore tenir grand compte des modes divers d'administration des eaux 
minérales, et de la part que la balnéation, si variée elle-même, et les agents balnéothé- 
rapiques si multipliés, peuvent prendre aux résultats obtenus. 
On voit combien sont complexes les considérations auxquelles peut se prêter un 
traitement thermal quelconque. Il conviendra de faire abstraction de toutes les cir- 
constances qui peuvent s'y rattacher, et ne considérer cette médication que dans son 
ensemble, dans l'étude qui va suivre des actions thérapeutiques qu'elle comporte. 
IL 
Les indications des eaux minérales ayant trait soit aux conditions générales de l'or- 
ganisme qui président au développement et à l'évolution des maladies chroniques, soit 
aux conditions particulières des organes ou des tissus qui s'y rattachent ou qui dé- 
pendent de causes hygiéniques persistantes, nous devons rechercher dans la médication 
thermale les actions thérapeutiques qui se trouvent en rapport avec de telles sources 
d'indications. 
Les actions altérantes, reconstituantes et sédatives s'adressent aux conditions pathogé- 
niques et à l'état animal, primitif ou secondaire de l'organisme. 
Les actions substitutives et résolutives s'adressent aux lésions d'organes ou de tissus. 
Ne pouvant, dans un travail concis, prétendre à exposer d'une manière complète 
tout ce qui a trait à des questions aussi étendues, je me bornerai à signaler d'une mani- 
ère succincte les ressources que les eaux minérales offrent aux actions thérapeutiques 
que je viens d'énumérer, et aux indications auxquelles celles-ci se rapportent. 102 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Je dois faire remarquer avant tout que le caractère essentiel de la médication ther- 
male, et ce qui lui marque une place à part dans la thérapeutique, c'est la faculté que 
possèdent la plupart de ses agents de réaliser simultanément plusieurs de ces actions 
thérapeutiques, et par conséquent de fournir le moyen de remplir à la fois des indica- 
tions multiples. C'est peut-être à cela, plus encore qu'à l'énergie de ces actions, que 
sont dus les résultats si remarquables qu'on en peut obtenir. 
ACTIONS ALTÉRANTES. 
La médication dite altérante est celle des états constitutionnels et des diathèses. 
L'idée que l'on peut s'en faire est celle d'une médication donnée de propriétés spé- 
ciales en vertu desquelles elle change la manière d'être de l'organisme, en s'addressant 
aux phénomènes intimes de la nutrition. Ce milieu, de la nutrition ou de l'assimila- 
tion, nous essayons bien de pénétrer dans les actes chimiques qui s'y accomplissent ; 
mais il est probable que, quelque avant que nous y poussions nos incursions, nous nous 
y heurterons toujours à la rencontre des actes chimiques avec les éléments cellulaires, 
c'est-à-dire de la chimie avec la vie. 
Le propre de la médication altérante est de ne se traduire que par ses effets curatifs, 
et non par des modifications physiologiques saisissables, telles que l'on en observe dans 
la substitution, la dérivation et la révulsion. C'est une médication intime, et qui 
s'exerce dans un milieu où il est fort difficile de la suivre et d'assister aux modifica- 
tions chimiques, histologiques ou dynamiques qu'elle peut exercer. Les résultats de la 
médication dite altérante (dénomination mauvaise et qui tend à être prise en mauvaise 
part) dans les maladies chroniques, les seules envisagées ici, ne nous montrent autre 
chose qu'un changement dans un sens favorable apporté dans la direction vicieuse suivie 
jusqu'alors par l'organisme. Aussi ne comporte-t-elle pas nécessairement l'idée de 
guérison. Tout ce qui est gagné par elle est un bien acquis. La plupart des diathèses 
ne menacent guère directement l'existence, ou ne la troublent à un degré profond que 
lorsqu'elles sont abandonnées à une évolution librement croissante. La vie se trouve 
donc parfaitement compatible avec elles, du moment qu'elles n'ont acquis spontané- 
ment qu'un certain degré de développement, ou qu'elles sont maintenues artificielle- 
ment dans de certaines limites. 
Les actions altérantes sont très spécialement dévolues aux eaux à bases sodiques 
prédominantes, et aux eaux possédant une minéralisation bien déterminée. Ce sont 
des actions essentiellement médicamenteuses. Les modes d'administration les plus 
simples sont ceux qui les réalisent le plus sûrement. Aussi les divers procédés balnéo- 
thérapiques n'y prennent aucune part directe. 
Le type de la médication altérante est fourni par les eaux chlorurées sodiques et les 
modifications qu'elles impriment à la diathèse scrofuleuse. Et il suffit que, dans une 
eau minérale quelconque, le chlorure de sodium se rencontre en une proportion un peu 
notable pour qu'elle présente des applications afférentes à la scrofule. C'est donc bien 
sur la diathèse elle-même que s'exerce l'action des eaux chlorurées ; si elles intervien- 
nent en temps opportun, elles sont propres à en prévenir ou à en enrayer les manifes- 
tations. En un mot, elles constituent une médication essentiellement diathésique. 
Les eaux bicarbonatées sodiques, dont Vichy est le type, représentent de leur côté la 
médication altérante de Y arthritis qu'il vaut mieux appeler Yuricémie. Et, de même 
que la présence notable du chlorure de sodium dans une eau minérale quelconque lui 
assurent des appropriations afférentes à la scrofule, la présence du bicarbonate de soude 
témoigne, dans une eau quelconque où elle est signalée dans une proportion notable, 
une spécialité d'action relative à l'uricémie. 
Sous les formes typiques, la goutte et la gravelle urique, l'arthritis, ou l'uricémie, 
se présente comme le résultat d'une assimilation imparfaite ou irrégulière des principes 
azotés, lesquels s'accumulent dans l'appareil uro-poiétique sous la forme de concrétions SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
103 
uratiques, ou bien dans les jointures ou ailleurs sous la forme de dépôts d'urate de 
soude. 
Ce n'est pas ici le lieu de chercher ä suivre cette urate sodique. Dans le reste de 
l'économie, et à rattacher à sa présence en nature l'ensemble des phénomènes dits 
arthritiques, comme on peut chercher à suivre le sucre des diabétiques et à en retrouver 
la trace effective dans les altérations fonctionnelles et organiques propres au diabète. 
Ce que je veux supprimer ici c'est que, sous l'influence de la médication bicarbonatée 
sodique, l'assimilation des principes albuminoïdes se rétablit, ou au moins tend à se 
rétablir. Il ne s'agit pas ici d'une action sur les déterminations de la maladie, mais 
d'une action sur ses conditions pathogéniques. 
Ici, comme dans l'applications des eaux chlorurées sodiques à la scrofule, il s'agit 
d'une action à proprement parler médicamenteuse, par la boisson et les bains, et qui 
n'a rien à emprunter aux artifices balnéothérapiques. Quant à sa portée définitive, ce 
que l'on peut dire le plus juste c'est qu'elle agit dans un sens curatif. Il est des ten- 
dances scrofuleuses, comme des tendances uricémiques, (états constitutionnels plutôt 
que diathésiques), que les eaux minérales appropriées peuvent absolument enrayer. 
Mais les diathèses déterminées ne se guérissent pas. On parvient seulement à les 
amoindrir, à en amoindrir ou à en écarter les manifestations. Mais elles continuent 
d'exister virtuellement. Il est inutile d'ajouter que l'emploi des eaux minérales ne 
saurait à lui seul suppléer aux conditions hygiéniques dont l'indication est toujours et 
absolument dominante. 
Il est une diathèse au sujet de laquelle il est très difficile de définir les indications, 
attendu que nous ne savons trop sur quelles bases la constituer elle-même, c'est l'her- 
pétis. L'herpétis fournit un champ doctrinal sur lequel le dogmatisme contemporain 
s'est largement exercé Je pense que l'expression de dartre, et de diathèse dartreuse, 
plus compréhensive que celle d'herpétis, devrait lui être substituée. L'arsenic, les 
alcalins et les sulfures représentent les médications les plus spéciales des dermatoses 
que comprend la dénomination générale de dartres. Bazin considérait les alcalins 
comme la médication spéciale des arthritides, et l'arsenic; des herpétides. D'un autre 
côté, il est impossible de tenir les sulfureux en dehors des médications qui peuvent s'y 
rapporter. 
Si, mettant de côté toutes préoccupations théoriques, on veut s'en tenir à la pratique 
des choses, je crois que l'on aura quelque peine à déterminer exactement la part respec- 
tive de ces divers agents au point de vue de la pathogénie. L'arsenic et les eaux qui 
en contiennent sensiblement représentent peut-être seuls ici une médication véritable- 
ment altérante. Les eaux alcalines et les sulfurées offrent plutôt le caractère de mé- 
dications topiques, dont le choix dépendrait plus du caractère excitable ou torpide des 
lésions cutanées que de leur origine attribuée. Je n'affirme pas que leur action n'offre 
rien de plus spécial et de plus intime ; je veux dire que cette dernière considération 
me parait en général devoir dominer dans l'indication. 
Il est, en résumé, fort difficile de déterminer la part précise qu'il serait permis 
d'attribuer aux eaux sulfureuses dans la médication dite altérante* Leur action est 
certainement celle du soufre, principe qui se dégage très nettement de tous leurs modes 
d'administration. En dehors de leur action spéciale sur les catarrhes muqueux ou 
cutanés, je pense qu'il faut tenir compte surtout de leur action reconstituante, qui me 
parait propre à expliquer leur intervention effectivement salutaire aux lymphatiques et 
aux scrofuleux, plutôt qu'une action précisément altérante, dans le sens où il faut en- 
tendre celle des eaux chlorurées sodiques. 
ACTIONS RECONSTITUANTES. 
Lorsqu'un traitement thermal est appliqué d'une façon opportune et méthodique, 
voici ce qu'on observe habituellement : l'appétit se développe, la digestion s'opère plus 104 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
facilement, les fonctions de la peau s'animent, la circulation s'opère avec plus de liber- 
té, les secretions glandulaires s'activent, les règles apparaissent ou se montrent plus 
régulières, la caloricité s'accroit, les forces s'améliorent, les facultés affectives s'épa- 
nouissent. 
Cet ensemble de phénomènes, qui comprend la stimulation générale des fonctions, 
et entraine une reconstitution générale de l'organisme, parait l'expression de l'action 
du traitement thermal sur la partie saine du système, tandis que l'action altérante 
s'addresserait plus spécialement à la partie malade. C'est le propre des eaux minérales, 
administrées dans les conditions que j'ai dites plus haut, aussi bien des plus minéra- 
lisées et des plus significatives que de celles dont la minéralisation négative et les indi- 
cations apparentes ne semblent tendre qu'à des actions purement sédatives. 
" Si l'action reconstituante des eaux minérales a pour caractère de se faire sentir sur 
l'ensemble du système et en particulier sur les parties saines, ou au moins sur les par- 
ties indemnes de l'état morbide dominant, on y rencontre aussi des éléments de recon- 
stitution spéciaux, semblables à ceux que nous fournit la thérapeutique usuelle. C'est 
ainsi que les eaux ferrugineuses offrent un reconstituant spécial du sang, que les eaux 
à base de chaux possèdent un reconstituant spécial du système osseux, et que l'arsenic 
présent s'adresse au système nerveux. 
Les eaux à àases sodiques et à minéralisation déterminée représentent les reconsti- 
tuants généraux les plus énergiques. Telles sont d'abord les chlorurées sodiques recon- 
stituantes spéciales des constitutions lymphatiques et scrofuleuses, indépendamment de 
leur action spéciale altérante de la scrofule. 
Les eaux bicarbonatées sodiques possèdent également une action énergiquement recon- 
stituante, mais qui s'exerce sur des conditions différentes. La soude est à proprement 
parler un médicament de l'assimilation, et ces eaux, dans lesquelles son action parait 
le mieux dégagée, reconstituent le système en rectifiant et en activant l'assimilation. Les 
eaux de Vichy ne sont pas reconstituantes des lymphatiques et des scrofuleux. Mais 
elles le sont des individus chez qui l'assimilation, entravée dans son accomplissement, 
ne s'opère que d'une manière incomplète, ainsi des anémiques et des atoniques par 
suite, d'habitudes dyspeptiques, de longues diarrhées, d'obstruction abdominales, d'im- 
paludisme, impuissantes et même nuisibles, dans certaines cachexies, dans les cachexies 
goutteuses en particulier, et dans toutes les cachexies à tendance hydrémique, elles 
offrent de précieuses ressources dans les cachexies abdominales, spécialement des pays 
chauds, et dans les cachexies paludéennes, dans des cas même où le degré d'abaissement 
de l'organisme semblerait contre-indiquer toute médication de ce genre. 
L'action reconstituante des eaux sulfurées parait d'une nature différente. Moins 
profonde et moins médicamenteuse, elle semble consister surtout en une stimulation 
générale des fonctions, des fonctions périphériques en particulier. Les eaux sulfurées, 
en effet, s'attachent plutôt aux surfaces, muqueuses et cutanées, tandis que les chlo- 
rurées s'adressent plus spécialement au système glandulaire et lymphatique, et les 
bicarbonatées sodiques aux milieux où s'accomplissent les phénomènes de l'assimila- 
tion. 
Quant à l'action reconstituante des eaux indéterminées {indifferenten quellen des 
Allemands), elle est sans doute plus foiblement caractérisée, et ne saurait en aucune 
manière reproduire les résultats que l'on obtient des eaux à minéralisation déterminée 
et riches en bases sodiques. Elle est peut-être en partie indirecte, et dûe principale- 
ment aux conséquences de la sédation et de la régularisation de l'innervation, qui sont 
les effets les plus apparents de ces sortes d'eaux minérales. Mais ce qu'il y a de plus 
apparent à ce sujet, c'est la tolérance de l'économie pour des traitements qui semble- 
raient devoir entraîner une débilitation notable, et que suit toujours un certain degré 
de restauration des forces. C'est ainsi que des bains tièdes multipliés, et prolongés 
bien au delà des mesures ordinaires, par exemple près des eaux de Néris (dépourvues SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
105 
de toute minéralisation significative), sont tolérés par des sujets affaiblis, dépourvus en 
apparence de réaction, et qui ne peuvent que difficilement supporter la balnéation ordi- 
naire. Ici, comme dans bien d'autres stations, nous ne rencontrons aucune condition 
médicamenteuse qui puisse rendre compte de pareils effets. 
ACTIONS SÉDATIVES. 
L'action sédative des eaux minérales est un fait plus facile à constater qu'à expli- 
quer. Elle appartient, à des degrés divers, aux eaux foiblement minéralisées qui con- 
stituent la classe des indéterminées (Néris, Ussat, Schlangenbad), et aux eaux à bases 
calciques et sulfatées prédominantes, comme Bagnères de Bigorre. Et de même que, 
lorsqu'on voit prédominer dans une eau minérale des bases sodiques, on peut lui attri- 
buer par avance des propriétés altérantes et reconstituantes, de même, quand on voit 
prédominer des bases calciques, on peut s'attendre à rencontrer des actions sédatives. 
Ces propriétés sédatives sont très difficiles à définir. Elles tendent à calmer l'hy- 
péresthésie ; elles tendent également à rétablir l'équilibre dans les désordres de l'in- 
nervation. Ici point d'explications satisfaisantes ; les matières organiques onctueuses 
n'y prenant sans doute qu'une part très secondaire. Il ne s'agit plus à ce sujet de 
médication internes. Ces traitements sont à peu près exclusivement externes, et con- 
sistent uniquement, au point de vue qui nous occupe, dans la balnéation, souvent très 
prolongée. La haute thermalité de la plupart de ces eaux en est cependant un incon- 
vénient, auquel on ne pare qu'à l'aide de moyens artificiels, la sédation ne s'accommo- 
dant que de températures peu élevées. 
Les propriétés de ces sortes d'eaux minérales ne sont pas mises en jeu seulement 
dans le traitement des névroses elles-mêmes. Les eaux dites sédatives servent encore à 
suppléer des eaux minérales plus actives, alors que l'irritabilité des sujets ou des tissus 
rend celles-ci difficilement applicables. 
Ceci est dû précisément à ce caractère encore inexpliqué dans la médication ther- 
male qui fait que ces représentants les plus insignifiants en apparence, quant à leurs 
caractères constitutifs appréciables, participent pour une certaine mesure aux propriétés 
les mieux accusées des eaux fortement constituées, et que nous y retrouvons des actions 
reconstituantes, peut-être même des actions substitutives, sans doute très atténuées, 
en l'absence des principes qui, ailleurs, en sont les agents manifestes, sinon exclusifs. 
Les maladies utérines en fournissent chaque jour des témoignages. Le nervosisme 
qui domine si souvent la métrite chronique, l'irritabilité si commune des lésions uté- 
rines, trouvent, dans les eaux indéterminées et dans les eaux à bases calciques appro- 
priées, des médications qui, d'abord, sont tolérées, et qui ensuite modifient suffisam- 
ment l'organisme pour atténuer dans une mesure considérable des états rebelles à toute 
autre médication et les rendre souvent susceptibles de guérison; car, sur ce sujet comme 
sur bien d'autres, un des effets que l'on obtient de la médication thermale est de rendre 
aux agents curatifs ordinaires une efficacité qu'ils avaient perdue. 
Ces mêmes eaux fournissent également à beaucoup de dermatodes irritables, malgré 
l'absence de principes sulfurés, arsenicaux ou sodiques, des modificateurs précieux dans 
des cas où les médications sodiques, sulfureuses ou arsenicales se trouvaient inappli- 
cables. 
ACTIONS SUBSTITUTIVES. 
La substition en thérapeutique, consiste à changer la nature d'une inflammation, 
ce mot pris dans son sens classique, pour lui en substituer une autre plus facile à gué- 
rir. Dans les états aigus, on cherche à provoquer une inflammation plus vive qui 
vienne se substituer à une inflammation de moindre intensité. Dans les états chro- 
niques, on cherche à ramener de l'acuité dans une inflammation lente et habituelle, ou 
encore à ramener à l'activité un état passif. Telle est l'expression la plus sommaire de 
la substitution thérapeutique, laquelle du reste est sans doute beaucoup moins simple 106 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dans son évolution effective que cette expression ne le comporte. Mais c'est une action 
essentiellement locale, et différant en cela de celles qui viennent d'être étudiées. 
L'action substitutive tient une place intéressante dans la médication thermale, et 
appartient essentiellement à une famille d'eaux minérales, les sulfurées. Elle repré- 
sente en réalité une médication des surfaces, et elle s'adresse à peu près exclusivement 
aux surfaces tégumentaires, externe et interne, c'est-à-dire à la peau et aux muqueuses, 
mais aux muqueuses périphériques et voisines de la périphérie, car elle ne trouve guère 
d'application aux muqueuses viscérales profondes, et surtout d'applications qui se 
trouvent du ressort de la médication thermale. 
Les catarrhes et les dermatoses, tel est donc le change d'action à peu près exclusif 
de la médication substitutive thermale. Tel est également le champ d'action particu- 
lièrement dévolu aux eaux sulfurées. 
Borden, le promoteur de l'hydrologie scientifique en France, avait été frappé des 
effets que les eaux sulfurées exercent sur les surfaces catarrhales, et y reconnaissant 
le témoignage d'une action substitutive manifeste, il avait généralisé cette observation 
et croyait y trouver la clef des actions de la médication thermale. 
L'observation du Borden était juste, mais beaucoup trop exclusive. Il importe, en 
effet, de savoir : d'abord que l'action des eaux sulfurées est loin de se borner à la sub- 
stitution ; ensuite que ce mode n'est nullement nécessaire à leur action curative. 
S'il parait difficile d'attribuer aux eaux sulfurées des propriétés altérantes très 
développées, on ne peut leur méconnaître une influence sur certains états constitution- 
nels, laquelle combinée avec des propriétés reconstituantes très réelles, étend leur action 
bien au delà du cercle assez restreint de l'action substitutive. 
Cependant cette dernière est manifeste dans les affections catarrhales des membranes 
muqueuses, et spécialement dans les catarrhes respiratoires. Elle est inhérente à la 
médication sulfurée et à peu près indépendante de la direction qui lui est imprimée, 
de telle sorte qu'elle se soustrait, pour la plus grande part au moins, à l'intervention 
directe des médecins. Toujours innocente dans les affections catarrhales simples, elle 
peut être à redouter dans les affections irritables qui accompagnent si souvent la tuber- 
culose pulmonaire. 
En général, au début d'un traitement sulfureux dans les catarrhes chroniques des 
voies respiratoires, on voit apparaître des signes d'acuité, augmentation de la toux, de 
l'oppression, sécheresse de la muqueuse, puis accroissement des secrétions. Tel est le 
témoignage, plus ou moins accentué et prolongé, de l'irritation substitutive, rarement 
assez intense elle-même pour que la direction du traitement en doive être modifiée. 
Mais, si la substitution constitue un mode incontestable d'action des eaux sulfurées sur 
les catarrhes respiratoires, elle n'est pas la condition nécessaire de leur efficacité. La 
preuve en est dans l'influence que le traitement sulfureux exerce sur les catarrhes à 
répétition, alors qu'il se trouve adressé à des surfaces actuellement saines, dans l'inter- 
valle des manifestations catarrhales. 
Les signes d'une action substitutive sont moins régulièrement saisissables dans les 
dermatoses, ce qui doit tenir au caractère peu excitable d'un grand nombre d'entre- 
elles. Cependant ils se révèlent d'une manière très manifeste dans les dermatoses 
humides. L'action directement topique de la médication balnéaire et la surface con- 
sidérable sur laquelle elle s'opère, à l'entour des parties malades, lui prêtent quelque- 
fois une intensité redoutable ; aussi le traitement de l'eczéma par les eaux sulfurées 
est-il toujours un traitement très délicat. L'irritation exercée sur les surfaces eczéma- 
teuses n'est peut-être pas toujours assez vive pour opérer une véritable substitution, 
tout en l'étant assez pour accroître l'état inflammatoire. En outre l'irritation exercée 
sur les surfaces saines peut réagir sur les premières dans un sens qui n'a rien de salu- 
taire. Il faut donc n'employer qu'avec infiniment de réserve les eaux sulfurées dans SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
107 
les dermatoses humides, prurigineuses, excitables en un mot, et ce sera toujours une 
grande faute d'y recourir d'une manière banale dans les dermatoses. 
On peut, il me semble, rapprocher de ce qui vient d'être étudié sous le titre d'action 
substitutive, certains phénomènes auxquels on a attribué une place en quelque sorte 
régulière dans la médication thermale, mais à tort en ce sens que ces phénomènes 
manquent beaucoup plus souvent qu'ils ne se laissent entrevoir ; je veux parler de la 
fièvre thermale, et de la poussée. Seulement, tandis que l'action substitutive s'exerce 
exclusivement sur les parties malades, c'est sur les parties saines du système que parais- 
sent surtout agir les phénomènes dont je parle. 
Ce qu'on appelle fièvre thermale, et qui est rarement de la fièvre, mais simplement 
de la courbature, ou de l'embarras gastrique, est bien souvent l'effet du déplacement, 
du changement de climat ou de l'intervention trop brusque d'une médication générale. 
Mais il faut reconnaître que la nature de l'eau minérale y entre pour quelque chose, 
car, très commune près des eaux sulfurées, elle se montre à un moindre degré près des 
chlorurées (et ici plus volontiers sous forme d'embarras gastrique), et à peine près des 
bicarbonatées sodiques les plus actives, comme auprès des indéterminées. 
Quant à la poussée, c'est-à-dire à l'apparition d'éruptions miliaires ou papuleuses, 
souvent très prurigineuses, elle dépend d'une action topique de balnéations plus ou 
moins excitantes, en raison de leur nature, eaux sulfureuses, eaux chlorurées addition- 
nées d'eaux mères, ou de leur mode, près d'eaux faiblement minéralisées et plutôt 
sédatives, s'il s'agit de balnéations à haute température ou très prolongées (comme à 
Löesche). 
Ne pourrait-on pas aussi rapporter à une véritable action substitutive une propriété 
commune à toutes les sortes d'eaux minérales, hormis les bicarbonatées sodiques fortes, 
la propriété cicatrisante? Sans doute il faut faire la part de l'action altérante et de 
l'action reconstituante qui ont modifié dans un sens salutaire le travail ulcératif ou 
érosif : mais il est difficile de méconnaître ici une action directement topique. Je ré- 
pète que cette action parait refusée aux eaux bicarbonatées sodiques fortes. Celles-ci 
irritent en général les surfaces ulcérées ou érodées, sans aucun bénéfice pour elles. Je 
n'ai jamais vu que les plaies diabétiques qui, par exception, subissent de la part des 
eaux de la Vichy une influence directement salutaire. 
ACTIONS RÉSOLUTIVES. 
L'action résolutive est très complexe. Je la prends dans l'acception de la dispari- 
tion, ou la guérison, d'états complexes eux-mêmes, où. l'hypérémie passive et l'hyper- 
plasie prennent une part diverse, tumeurs, empâtements, engorgements, susceptibles de 
disparition par résorption interstitielle, ou par réintégration dans le cercle normal de 
la circulation sanguine. On doit admettre ici une action fondante, directe ou indirecte, 
non pas dans le sens chimique que comporte cette expression, mais dans le sens de son 
résultat. 
C'est une action locale, si nous la prenons dans cette dernière expression et si nous 
considérons la lésion à laquelle elle s'adresse ; mais c'est plutôt une action générale, 
si nous tenons compte de son évolution complète. Le type nous en est fourni par les 
mercuriaux dans les affections aigues, par l'iode dans les maladies chroniques. 
Bien des modes divers président sans doute à la résolution, sans qu'il soit toujours 
possible, si l'on cherche à s'en rendre compte, de déterminer quelle part il faut faire à 
l'irritation locale, à la dénutrition ou à l'arrêt de la nutrition morbide. 
Les eaux minérales possèdent précisément ce caractère ; de pouvoir mettre en jeu 
simultanément ces modes multiples, et reproduire, d'une façon manifeste ou obscure, 
mais saisissable au moins par la pensée, les diverses actions qui viennent d'être passées 
en revue, altérantes, reconstituantes et substitutives. La résolution n'est sans doute 108 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
elle-même en définitive que la résultante,de ces diverses actions combinées pour un but 
vers lequel les fait converger ce qu'on pourrait appeler l'attraction thérapeutique. 
C'est encore aux eaux fortement minéralisées et à bases sodiques prédominantes qu'il 
faut recourir s'il s'agit de résoudre des tumeurs ou des engorgements, c'est-à-dire aux 
chlorurées et aux bicarbonatées sodiques très particulièrement. Ce sont là des eaux à 
proprement parler fondantes, surtout si l'on compare leurs résultats avec ce que l'on 
peut obtenir dans ce sens des autres eaux minérales. Aux chlorurées reviennent spécia- 
lement les engorgements strumeux; aux bicarbonatées sodiques les engorgements viscé- 
raux de tous autres caractères. Voici des termes qui peuvent paraître très généraux, 
mais qui cependant rassemblent des faits bien définis. 
Qu'il s'agisse d'engorgements ganglionnaires, d'empâtements péri-articulaires, d'é- 
paissements périostiques, d'infarctus du tissu cellulaire, si la scrofule est en jeu, on peut 
compter sur l'action résolutive et fondante des chlorurées sodiques (Salins, Salies, 
Kreuznach, Balaruc, Sourbonne, etc.) S'il s'agit d'engorgements viscéraux qui dé- 
pendent de l'impaludisme, ou de la pléthore abdominale, ou de l'arthritis, ou de cir- 
constances moins définies dans des conditions constitutionnelles indifférentes, les bicar- 
bonatées sodiques fortes, comme Vichy (ou Carlsbad, dans la composition est beaucoup 
plus complexe), seront aussi résolutives ou fondantes que les chlorurées le sont dans le 
cercle de leurs indications propres. 
Je ne sais pas bien quelle part on doit faire en pareille circonstance à une action 
directe et immédiate, chimique ou dynamique, sur les lésions à résoudre. Je ne 
saurais nier qu'il puisse se passer rien de semblable ; mais je ne pense pas non plus 
qu'on puisse émettre à ce sujet autre chose que de pures suppositions. Nous 
sommes mieux assurés au sujets des actions indirectes ou médiates qui président à la 
résolution. 
C'est ainsi que dans la résolution des indurations fistuleuses de l'écrouelle par les 
eaux de Salins ou de Balarne, nous pouvons reconnaître en même temps une action alté- 
rante sur la scrofule, reconstituante sur l'ensemble du système, et substitutive sur les 
surfaces fistuleuses. Dans la résolution des engorgements goutteux par l'eau de Vichy, 
nous devons admettre à la fois une action altérante sur l'état diathésique propre à tarir 
la source des dépôts uratiques, et un arrêt de la nutrition morbide dans les engorgements 
eux-mêmes. 
Dans le traitement thermal des maladies chirurgicales, il faut tenir grand compte 
des propriétés respectives, à l'endroit de l'action résolutive, qui appartiennent à telle 
ou telle série d'eaux minérales. S'il s'agit simplement, chez des sujets exténués, de 
remonter vivement l'organisme, de modifier des plaies très atoniques, de provoquer 
l'élimination de corps étrangers, c'est aux eaux sulfurées sodiques qu'on s'adressera 
de préférence, Barèges, Luchon, Amélie, etc. Mais s'il est question de tissus épaissis, 
engorgés, indurés, enfin de lésions de tissu plus que de lésions de fonction, c'est aux 
chlorurées thermales, Bourbonne, Balarac, etc., qu'on demandera les éléments d'une 
médication résolutive que les sulfurées ne fournissent que très incomplètement. 
Cependant il est un terrain sur lequel ces mêmes eaux sulfurées peuvent revendi- 
quer des propriétés résolutives que nous ne retrouvons point ailleurs, c'est celui des 
engorgements pulmonaires. Cette circonstance est due sans doute à l'action élective de 
ces eaux sur l'appareil pulmonaire qu'elles touchent par deux côtés à la fois, agissant 
sur la face libre de la muqueuse bronchique par l'inhalation et en vertu de leurs pro- 
priétés auticatarrhales spéciales, et sur sa face profonde en raison de l'élimination par 
l'appareil respiratoire des principes sulfureux introduits dans l'économie. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
109 
III. 
Je n'ai pas eu la prétention, dans ce travail, d'épuiser le sujet des actions thérapeu- 
tiques des eaux minérales et des indications qui en découlent. J'ai pensé présenter 
plutôt une méthode qu'une étude complète. Je n'entend même pas que les actions des 
eaux minérales doivent être précisément limitées à celles que j'ai exposées ; nous 
sommes nécessairement bornés dans l'idée que nous pouvons nous en faire, et, dans 
l'impuissance où nous nous trouvons d'en pénétrer le sens intime, il faut nous con- 
tenter d'en saisir les expressions les plus extérieures. Ce qu'il faudrait surtout c'est, 
de l'analyse, quelque peu artificielle peut-être, que j'en ai présentée, passer à une syn- 
thèse qui permit de s'élever, des modifications subies par les tissus et les fonctions, aux 
résultats que j'ai pris réalisés. C'est là précisément une difficulté qu'il ne me parait 
guère possible de réaliser aujourd'hui. 
D'un autre côté, lorsque je me suis attaché à distinguer entre elles les actions res- 
pectives des différentes classes d'eaux minérales, j'ai pu forcer un peu les oppositions 
pour les rendre plus saisissables. L'étude, comme l'application de la thérapeutique, est 
pour beaucoup une affaire de comparaison. Il ne suffit pas de connaître si l'on peut 
obtenir tel résultat de telle médication ; il importe surtout de savoir si l'on ne peut en 
obtenir un meilleur de telle autre. Je m'efforce depuis longtemps d'attirer l'étude de 
la médication thermale hors des méthodes d'isolement où on l'avait toujours tenue. Il 
est utile assurément de connaître toutes les ressources que l'on peut tirer d'une certaine 
eau minérale ; mais ce n'est pas utile à un égal degré pour tout le monde. Quand un 
médecin a à choisir un traitement thermal pour un cas déterminé, ce qu'il lui importe 
c'est moins de savoir s'il pourra y trouver, ici ou là, quelques applications effectives, 
que de savoir où il devra s'adresser pour y rencontrer les applications les plus certaines. 
C'est pour cela que j'ai montré, depuis longtemps, que la spécialisation des eaux miné- 
rales était la base la mieux assurée de leur étude et de leurs applications, comme elle a 
toujours fait celle de mon enseignement. 
AMERICAN MINERAL WATERS, WITH SOME REMARKS ON 
AMERICAN CLIMATES. 
EAUX MINÉRALES AMÉRICAINES AVEC QUELQUES REMARQUES SUR LES 
CLIMATS D'AMÉRIQUE. 
ÜBER AMERIKANISCHE MINERALWÄSSER, NEBST EINIGEN BEMERKUNGEN ÜBER 
AMERIKANISCHE KLIMATE. 
TITUS MUNSON COAN, M. D., 
Of New York City. 
Those of us who may be more familiar with the mineral waters of the Old World 
than with those of the New will not unnaturally endeavor to find peculiarities of type in 
those of the Western Continent. The constancy of long-known springs to their first- 
observed individual constitution is well known, the variations from such type, when 
observed, having generally been due to volcanic disturbances, as when for an hour and 
a half after the earthquake of Lisbon the waters of Töplitz, in Bohemia, turned a reddish 
yellow, and more or less disturbance was noted in a multitude of the warm springs of 
Europe at great distances from the centre of disturbance. Almost the same constancy NINTH INTERNATIONAL MEDICAL CONGRESS. 
110 
holds in respect even to the working classification of springs ever since the earliest times. 
Pliny, in the fifth century, divides mineral waters into six classes-acidulous, saline, 
nitrous, albuminous and bituminous. If, now, we add to these the arsenical springs 
which have come into such European prominence of late, we shall have a classification 
that is not very far from that which is the most serviceable in the balneology of to-day, 
and we shall be disappointed if we look to find any absolutely new types of spring 
waters in the United States. We must bear in mind that, geologically speaking, this 
Western Continent is the Old World and not the New. It has been made clear by 
Prof. Dawson, of Montreal, among other geologists, that a large area of the Eastern 
mountain system, at least, is quite as early a formation as any geologic formation of 
which we have knowledge. It is only in the Western and Pacific States that we are 
to look for comparatively recent formations, and consequently, in particular, for thermal 
waters in abundance ; while in the East we shall rather expect to find the mineral 
waters mainly that characterize the other European formations. 
And what data have we for the survey of this vast territory from the balneographic 
point of view? We have the various surveys, whether made by States or by the general 
government, a considerable number of monographs by different geologists and physicians 
and medical societies, notably the American Medical Association, and a lesser number 
of general treatises. We have as yet little to show that will compare with the learned 
works of Trousseau, Durand-Fardel, Braun, Hellft-Thilenius, Rotureau, Leichtenstein. 
Dr. Walton has produced an excellent manual, one that may be called a pioneer work 
in this direction, though it is necessarily incomplete, from the lack of sufficient data. 
These, however, are now being developed on every hand, and particularly by the United 
States Geological Survey, to whose publications the student of American mineral waters 
is under great obligations, and especially to Dr. Albert C. Peale's recent monograph, 
"Lists and Analyses of the Mineral Springs of the United States, " published as Bulletin 
32 of the Geological Survey, a work which must be consulted for the fullest data yet 
available in the matter of analyses, of which 859 are given. 
These analyses come from nearly every part of the great territory of the United 
States, but, naturally, they are the more numerous from the older-settled part of 
the country. Even in such regions, however, they are not yet a completed list, and it 
is curious to follow their positions upon the map, where often the mineral water stations 
appear to be strung along the lines of the principal railways. This apparent connec- 
tion reminds one of the conclusion of the geographer who had been studying the river 
systems of America: "It is a remarkable fact," he concluded, "that Providence has 
always caused great rivers to run by great cities." It is certainly a fact that great 
railroads run by most of the more frequented mineral springs of this country. The 
fact may have a partial explanation in the circumstance that our American engineers 
have, for the most part, built their railways in valleys, and that a large proportion of 
mineral springs flow also in valleys. But the more important fact is, that only a small 
part of our mineral waters have been explored. Thus, in the State of Mississippi a 
geologist has said that " Few neighborhoods in the State are without a mineral spring 
or well of some sort-good, bad or indifferent." 
Turning now to a general survey of the subject, we shall simplify it if we use 
Bennett's division of the territory of the States into five areas, as follows: - 
1. The Northern Atlantic States: New England, New York, New Jersey, Penn- 
sylvania. 
2. The Southern Atlantic States: Delaware, Maryland, District of Columbia, Vir- 
ginia, West Virginia, North Carolina, South Carolina, Georgia, Florida. 
3. The Southern Central States: Alabama, Mississippi, Tennessee, Kentucky, Arkan- 
sas, Indian Territory, Louisiana, Texas. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
111 
4. The Northern Central States : Ohio, Indiana, Illinois, Michigan, Wisconsin, 
Minnesota, Dakota, Iowa, Missouri, Nebraska, Kansas. 
5. The Western States and Territories : Montana, Idaho, Wyoming, Utah, Colorado, 
New Mexico, Arizona, Nevada, California, Oregon, Washington, Alaska. 
This division is not only a political one, but it is also to some degree a geological one. 
Yet we shall be struck by the constancy of the types of the spring waters over great 
ranges-that is to say, by the less rather than the greater variety of range in the 
character of the springs over thousands of miles of territory in the East. This 
uniformity denotes a far maturer geological formation than that, for instance, of 
that wonderful district in Auvergne where, within a radius of a few miles there flow 
springs that represent nearly every known type of mineral water. The American 
springs may be, indeed, properly reduced, as regards their geographic origin, to four 
classes :- 
1. Springs of the Atlantic States. 
2. Springs of the Southern Central States. 
3. Springs of the Northern Central States. 
4. Springs of the Western States and Territories. 
As to their classification chemically, I use the following, for the sake of practical 
convenience, as being more serviceable than one of more elaborate scientific accuracy, 
though, as I have said, it is not removed toto cœlo from that of Pliny. 
1. Alkaline waters, containing soda, potash and magnesia. 
2. Calcic waters, containing the salts of lime. 
3. Saline waters, either with the chloride of sodium alone, or with bicarbonates. 
4. Chalybeate or iron waters. 
5. Sulphur waters. 
6. Arsenical waters. 
7. Thermal waters. These, while not strictly in this line of classification, must yet 
be included, for practical convenience. Even the best of them have sometimes less min- 
eralization than ordinarily pure drinking water. With us, as in the old world, their 
effects are due to their use as baths, in conjunction with the regimen, which everywhere 
is an important point of the treatment. 
And this, let me say in passing, is a point which is not quite so well understood by 
the American as by the foreign patient. In this matter our spirit of independence is not 
very happily at play, for it leads the American patient, often enough, to think that in 
affairs of diet and regimen he can prescribe well enough for himself. It has happened 
to me more than once to send one of these refractory patients to Royat or to Carlsbad. 
Arrived there, and receiving from the local physician the same injunctions as to diet 
and, exercise that I had vainly tried to impress upon him here, the patient has been 
affected somewhat as by the culminating action of repeated doses, and has said to the 
French or German doctor, "Well, I believe that my physician at home must have been 
right. He told me just what you do, and I didn't do it. Now, I'll begin to obey 
orders." And some patients, after neglecting hygiene at home, have been cured 
abroad by obeying the injunctions that were laid down for them for months before they 
sailed. 
Our survey of the American mineral waters can only be a rapid and general one, 
the field being so extensive. Let us take a glance at some of the typical springs in the 
areas that I have enumerated. 
1. Springs of the Atlantic States.-What is their most frequent type? The answer 
is a simple one. From Maine to Florida the chalybeate and the sulphureted springs 
predominate, forming more than one-half of the whole number that have been analyzed. 
In the northern part of this tract there are hardly any thermal springs, in the southern 
there are quite a number. Massachusetts has a large number of slightly mineralized 112 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
iron springs, and but one or two that are even slightly thermal ; that near Williams- 
town has a pleasant warmth, but is little used. The Poland Springs, in Maine, are 
mildly saline and calcic : they are a favorite place of resort. It is not until we come 
to New York that we find any mineral springs that are of importance as resorts. Of 
these the Saratoga Springs are the best known, and, indeed, the most resorted to of any 
springs in the country. They owe their great popularity to strong saline waters, 
varying in composition at each of the twenty or more springs that are in use, to their 
splendid hotels and to the long established tide of fashion that turns to the pleasant 
town during the summer months. There is not, however, any establishment or cure 
of importance, and patients drink the waters, for the most part, according to their 
own prescription, and often more freely than is consistent with the best therapeutic 
effect. The wise maxim of Sancho Panza, that "too much water killed a miller," 
is for the most part forgotten by such of the patients as go to Saratoga to be cured. 
They would do better to follow the treatment given at the analogous waters of 
Salins, in Eastern France, and depend upon very moderate doses continued for a longer 
time. 
Among the sulphurated springs of New York those of Avon, of Clifton and of 
Richfield may be mentioned. The two former have good establishments and their 
waters are serviceable in the cure of gout and rheumatism. The Clifton Springs are 
calci c-sulphureted, and similar in composition to the Greenbrier White Sulphur, of 
Virginia, which are deservedly famous in the same treatment. The establishment is 
open all the year round. The Sharon Springs are in a ravine, with charming views 
around them, and the place is very attractive. These are calcic-alkaline waters, sul- 
phurated, and are used both internally and externally with much success. Inhalation 
rooms have recently been established, where, as at Aix-les-Bains, Mont-Dore, La 
Bourboull and other great French establishments, the waters can be inhaled in dif- 
ferent ways, as by the so-called dry inhalations, or by " pulverization, ' ' or spraying. 
For catarrhs and for rheumatism these waters are excellent. The Dansville Springs 
are mildly calcic ; there is an admirable sanatorium with elaborate baths, and the 
establishment is open all the year round-a feature not common in our summer 
cures. 
The Oak Orchard Acid Springs, in Genesee county, share with a group of springs 
in Texas the distinction of containing free sulphuric acid in considerable quantity- 
no less, at Oak Orchard, than two parts in a thousand ; a sample which I tasted a few 
weeks ago was so strong as to be undrinkable, and it is usually prescribed diluted with 
an equal quantity of water. There is no establishment at the spring. 
Pennsylvania gives us, among other good waters, the Gettysburg Katalysine, a clear 
alkaline-calcic water, used for gravel and for catarrh of the stomach and bladder. The 
Cresson Springs are a good chalybeate water and a pleasant place of resort. 
Virginia and West Virginia have about fifty places of resort among their springs, 
many of them, indeed, quite primitive as compared with the establishments of the Old 
World, but many of them also possessing both elegance and comfort. The springs are 
mostly found in the Apalachian region and are predominantly chalybeate. Many of 
them are sulphurated, and a number of thermal springs are found in the mountain 
regions. Most of the Virginia resorts are among beautiful scenery. Among them may 
be mentioned the Alleghany Springs, near the head waters of the Roanoke river, at the 
eastern foot of the mountains, in a pleasant country. They are a calcic water, purga- 
tive, diuretic and in small doses tonic. Dyspepsia, gall-stones and enlargement of the 
liver are the ailments mainly treated here. The Blue Ridge Springs in Botetourt county 
have almost exactly the same composition as the Alleghany, and are used in the cure 
of the same complaints. The waters of the Rockbridge Alum, in Rockbridge county, 
a charming place ; of the Bath Alum Springs, in Bath county ; and of the Bedford SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
113 
Alum, in Bedford county, are excellent chalybeate tonics. The Buffalo Lithia Springs, 
in Mecklenburg county, are three in number : two are calcic-alkaline and the third is 
ferruginous. They are effective in inflammations of the bladder and kidneys, and in 
many cases of gout and rheumatism. The Capon Springs, in Hampshire county, West 
Virginia, are an abundant alkaline water, highly carbonated. They are used in the 
cure of acid dysyepsia, uric-acid gravel, catarrh of the bladder and gastric catarrh. 
The Rock Enon Springs, long known as Capper's, are eight in number : iron, alkaline, 
saline and sulphureted. They are especially adapted to the treatment of delicate 
and "nervous" invalids. The Fauquier White Sulphur, in Fauquier county, is an 
alkaline-carbonated water, purgative and diuretic in large doses, and valuable in 
the treatment of dyspepsia, anaemia, catarrh of the bladder and in some forms of 
dropsy. 
The town of Bath was named a,year before the birth of Beau Brummell, the man 
who was to be called the 11 King of Bath ' ' in later years, to confer new distinction upon 
an already famous place. In Bath, West Virginia, are the Berkeley Springs, which have 
been in use as baths since the colonial times. They were the property of Lord Fairfax, 
and one of the springs still retains his name. Log huts and tents formed the only 
shelter. The day was passed in horse-racing, hunting, fishing, and certain hours were 
devoted to the bath. The pool was a hollow formed in the sand, screened by a thatch- 
ing of interwoven pine boughs. At a predetermined signal from a tin horn, the gen- 
tlemen retired, while the ladies bathed, and the gentlemen, in turn, at a similar signal, 
occupied the bath. " Peeping Toms ' ' were dealt with unmercifully. The waters are 
thermal and mildly calcic, and are used with much benefit in cases of neuralgia and 
chronic debility. There is a comfortable hotel, and the screen of interwoven pine 
boughs was long ago superseded by a spacious pavilion. 
The Greenbrier White Sulphur Springs, in West Virginia, are the most fashionable 
springs of the South. They are in the Greenbrier mountain, at an elevation of nearly 
2000 feet above sea level ; it is a beautiful place. The grounds of the great hotel are 
very attractively laid out, the walks and so-called ' ' mazes ' ' are provided with romantic 
names, and the mountains rise on the south and west. The waters are calcic, sulphur- 
eted and chalybeate; they act on the bowels, kidneys and skin. The principal com- 
plaints treated here are dyspepsia, diseases of women, engorgements of the liver and 
some cases of chronic skin diseases. The bathing arrangements are complete. The 
main caution needed at this very pleasant place is against excessive pleasure-seeking; 
this being guarded against, I have seldom seen better effects from spring treatment 
than here. But here, as elsewhere-particularly in this country-the physician will 
find many who have chosen their spring for themselves, and who would have done 
better had they chosen another. 
In West Virginia, also, are the Salt Sulphur Springs, a calcic-sulphureted water. 
It is given for diseases of the kidney and liver, for metallic poisoning and for chronic 
skin complaints. The place is an attractive one, 2000 feet above sea level, and the 
hotel stands in a pretty rural spot. 
In North Carolina the type of the springs is much the same, chemically, as those 
that we have been examining. The warm springs of Madison county may be men- 
tioned here. They are calcic-sulphureted waters, resembling in composition those of 
Leukerbad, in the valley of the Rhone. Their temperature is 100° to 102° F.-38° to 
39° Centigrade. Baths are given in spacious piscines. These waters are efficacious in 
chronic rheumatism, gout, paralysis, and in certain skin diseases. The scenery of the 
region is very wild. 
Georgia has a number of improved springs, most of them chalybeate and sul- 
phureted. 
"Thesprings of Florida," says Dr. Peale, "are remarkable for their great size rather 
Vol. V-8 114 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
than for the quantity of mineral matter that they contain. Some of the streams pro- 
ceeding from them are large enough " to float steamboats." Few of the springs have 
been analyzed, but it is known that many of them are thermal. They are used mainly 
as winter resorts, the atmospheric temperatures being, at that season of the year, milder 
than in the North, yet they are almost as variable. 
2. Springs of the Southern Central States.-With about the same proportion of iron 
and of sulphur springs as in the Atlantic States, the ratio of saline springs is increased 
and that of thermal springs is diminished, a large part of this area being of compara- 
tively recent formation. 
In Alabama the Bladen Springs are among the best known. They are an alkaline 
water, given with much success in the treatment of dyspepsia in many forms. The Ocean 
Springs, on the coast, between New Orleans and Mobile, are much frequented by those 
who suffer with skin diseases that are allied to the scrofulous diathesis. They are 
saline, with the protoxide of iron-an unusual but effective combination. 
Tennessee has numerous springs, of which a considerable number are used as resorts. 
The Montvale Springs are a calcic-chalybeate water, laxative, and diuretic in small 
quantities, cathartic in large ; they have a good reputation in chronic diarrhoea, scrofula 
and engorgements of the liver. 
The springs of Kentucky are numerous and excellent. Prominent among them are 
the Upper and the Lower Blue Lick Springs, in Nicholas county. They are salihe, 
sulphureted waters, and are very salt. It was from the Lower Blue Lick that Daniel 
Boone and others of the pioneers got their supplies of salt for curing venison, and here 
one of the deadliest battles of the colonial times was fought with the Indians. The 
springs are frequented for the cure of liver and kidney complaints, of dyspepsia and of 
chronic constipation. The Harrodsburg Springs, in Mercer County, are highly charged 
with sulphates of magnesia and of lime and are cathartic in their effects, so strongly so 
as to offer a very sufficient answer to the skeptics who ascribe the entire effects of the spring 
treatment to the environment, and deny efficacy to the waters. They are useful in 
hepatic disorders. 
Only five of the many springs in Arkansas have been analyzed. The famous hot 
Springs of Garland Co., sixty or more in number, pour out an immense volume of 
water at from 34° to 70° Cent.-93° to 157° Fahr.-1020 litres, or 360 gallons per 
minute. This is used freely for culinary purposes as well as for the baths. Any one 
of the springs will cook an egg in a few minutes. The water is but very slightly 
mineralized, but the baths are much frequented, in spite of rather primitive accom- 
modations. 
3. Springs of the Northern Central States.-Calcic waters are here more numerous than 
in the other divisions. Thermal springs are few, except as found by boring. The geologic 
formation is for the most part carboniferous rock, with underlying Devonian and Silurian 
strata, but in the northern part of the division we find metamorphic areas, and the springs 
become more like those of the New England States (Peale). Many of the springs are 
used as places of resort, and many analyses have been made. 
In Ohio there is an almost indefinite number of iron, calcic and sulphurous springs. 
Prof. Orton says that only a few of these have come into recognition, " possibly through 
the superior intelligence or energy of the proprietors. ' ' The Sulpho-saline springs, in 
Hamilton County, are a valuable, saline, sulphureted water. There is a large estab- 
lishment, and skin diseases and syphilis are successfully treated. 
Indiana, both as to the number of springs and of establishments, has a similar 
record to that of Ohio. Peale gives 28 analyses. 
Michigan is full of salt wells, nearly half of the entire salt product of the United 
States being derived from this State. Other than these there are calcic, alkaline, and 
sulphureted springs, and a number of these are places of resort; Alpena, on Thun- SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
115 
der Bay, Lake Huron, is one of them, a cool place of refuge during the terrible summer 
heat of the Mississippi valley. These are artesian well-waters, and are excessively rich 
in sulphureted hydrogen. Eaton Rapid Wells, in Eaton County, are a good calcic 
water, and there are facilities for baths. The Mount Clemens Mineral Well, in Macomb 
Co., is a strong brine, containing no less than 200 grammes to the litre, or nearly 12,000 
grains to the gallon of chloride of sodium, but also such a large amount of the chlorides 
of calcium and of magnesium that the salt works for which the well was sunk had 
to be abandoned. It was a matter of chance that the waters came to be used medicin- 
ally ; a foundered pony, it is said, gave the first hint to the public of the virtues of this 
spring. Turned out to shift for himself, he found shelter in an abandoned shed near 
the well, and by continual stamping in the saline mud he formed a mud bath and cured 
himself. "Thence," says Walton, "began the fame of the well." There are several 
hotels and a good bathing establishment. The place has a wide reputation for the cure 
of scrofulous diseases. The water is much diluted before using. 
Wisconsin has valuable waters, some of which are largely exported, as the Bethesda 
and the Clysmic, both from Waukesha. The Clysmic is a delicious table water, almost 
comesting with the Giesshiibler water, from Bohemia, the palm of super-excellence 
among many other delicious mineral waters. Both are calcic alkaline, and are used 
with success in affections of the kidneys and bladder. 
4. Springs of the Western States and Territories.-The greater part of this territory is 
of much later geologic formation than the areas that we have briefly considered. Ther- 
mal springs are consequently more abundant. This area, as already defined, contains 
only 39 per centum of the total area of the country; yet it has more than 30 per centum 
of its known thermal springs, and it must be borne in mind that it is less completely 
surveyed than any other of the areas that I have enumerated. The phenomona of these 
thermal springs culminate in the splendid spectacle of the Yellowstone Park Geysers. 
But alkaline, saline, chalybeate, and calcic springs also abound ; and silicious springs, 
not frequent in other parts of the country, are found abundantly in the areas of hot 
springs. (Peale.) 
In New Mexico the exceedingly valuable thermal waters, the Las Vegas Hot 
Springs, somewhat resemble both the Arkansas Hot Springs and the waters of Töplitz 
in Bohemia. Like the latter, they are very effective in the cure of contractions, stiff- 
ness of joints, of gout, of rheumatism. There is an elegant hotel ; all the bathing 
appliances are excellent, and the place is in every way a most attractive one. The 
springs are at an elevation of more than 6800 feet above the sea level. The climate 
of the place is somewhat freer than that of most of our eastern resorts from the racking 
changes of temperature which are as characteristic of our southern as of our northern 
climates, though not so severe in the south, and which are the despair both of the 
invalid and the physician. 
Both in New Mexico and in Nevada it is often easier to find an alkaline or a saline 
spring than a stream of pure water. Hot Springs predominate in Nevada, but few of 
these have been utilized. 
Our rapid recital must close with mention of California, which has probably more 
mineral springs, both hot and cold, than any other State. They are of all the usual 
varieties. Many of these springs are utilized as places of resort, as the Napa Soda 
Springs, the Paso Robles, an excellent thermal water similar to that of Aix-la-Chapelle 
and the Calistoga, a name formed by joining together the first half of the word Cali 
fomia and the last half of the word Sara-toga. It must be added, however, that the water 
is sulphureted and only mildly saline. Near the Calistoga is a remarkable petrified 
forest, a natural curiosity, which some of our foreign delegates will doubtless take the 
opportunity of seeing during their California trip. 116 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The range of our waters, as will be evident from even this brief sketch, will compare 
favorably with those of Europe. The most notable deficiency upon the list is that of 
such arsenical springs as those of France, which are still missing on the American list ; 
but with that exception the "gamut" of American mineral springs is, I believe, as 
complete as that of the European. As to the comparative efficiency of the American 
waters, there can be no doubt that they are equal to the foreign. Our springs are as 
good as any. But should our delegates from abroad travel as far as some of our most 
famous watering places, they would be struck, in most instances, by the total absence 
of establishments or "cures," to use the cheerful terminology of the German hotels. 
Springs we have, physicians we have, but of systematic treatment in institutions 
especially devoted to this purpose there is far too little. There are exceptions, as 
notably at Dansville in this State, where a completely-appointed establishment, open all 
the year round, with a resident staff of physicians, supplies to the American patient 
that of which he is peculiarly in need-suitable restraint and guidance in the pursuit 
of health. This is the rock upon which a large part of the efforts of the physician are 
broken-the independence of the patient. Left to his own devices, he discredits both 
the doctor and the spring by the slowness or by the failure of his cure. Put under such 
imperative surveillance as he has learned to expect at such a place as Aix, or Royat, or 
Vichy, or Carlsbad, he is cured if he is curable. 
One word, in closing, upon the importation of mineral waters may be of interest. 
In this matter there is no exchange ; we export no mineral waters at present. We 
imported, in 1873, 394,423 gallons of natural waters, at an appraised value of $98,000. 
In 1885, an interval of but twelve years, the amount was multiplied fourfold ; we 
imported 1,660,000 gallons ; paid for drinking them the sum of $398,000. It will not 
be long, it is to be hoped, before the residents of distant Bohemia may have the oppor- 
tunity of comparing, upon their own tables, the quality of such a pleasant table water 
as the Clysmic or the Waukesha, of Wisconsin, with their own delicious Giesshübler 
spring. 
The development of American mineral springs is a rapid one. About six hundred 
of them, as I have said, are now utilized as places of resort. At few of these, indeed, 
are there fine hotels ; at fewer still are there regular establishments. But the constant 
process of natural selection, swifter among us than elsewhere, will cause rapid progress 
in all that relates to balneology among us. Of all communities in the world, that of 
the United States is the one for which the restful influences of spring treatment are 
indicated. 
And as our springs are better developed from year to year, I look for a sort of 
international exchange in the matter of spring treatment. We have long sent a large 
number of our chronic invalids to the famous healing waters of the Old World, and 
with reason, for it is not only the waters and the treatment that effect the cure, but 
also the change of scene and circumstance. When Milton said of the traveler, 
"Cœlum, non animam mutant qui trans mare current," 
" He finds new skies; his mind remains the same," 
he was far from the truth as regards the invalid. For one who travels for his health, 
the change of sky, of climate, of circumstances is often half the cure, or more than half. 
It is, indeed, wonderful how small a "change of skies" is sometimes needed to produce 
a curative and transforming change of mind. A patient of mine had suffered for a year 
with hypochondria, with threatening melancholia, and she was steadily growing worse 
under a carefully-restricted home treatment. I sent her at last to try a five-weeks' 
course at a spring not thirty miles distant from her home, and she was cured. And if 
we find it to our advantage to cross the seas and to drink the waters of springs not SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
117 
intrinsically more curative than our own, so will the European invalid find it to his 
advantage to make the Westward journey and try the waters of our Jordans. I send 
my patients either to American or to European springs, choosing for them not merely 
according to my judgment of what the climate, the waters, the dietary of the spring in 
question may be, but also-and I consider this an important point in practical thera- 
peutics-to the place and the country where their minds will be the most favorably 
influenced by the changed surroundings. Thus the very atmosphere of the quiet hills 
of Sussang, in the Vosges, is a cure for the weary person who has broken down under 
the stress of a society life ; and, on the other hand, there are few cases of depression of 
spirits that would not be relieved by Saratoga or Vichy, even before a single glass of 
their excellent waters had been taken. The change of skies is an essential feature in 
the treatment which seeks for a curative change of mind. And for this reason I look 
for a yearly larger resort on the part of invalids from abroad to our own excellent 
American mineral waters. 
NOTES ON THE MINERAL AND THERMAL SPRINGS OF 
CALIFORNIA. 
NOTES SUR LES EAUX MINERALES ET THERMALES DE CALIFORNIE. 
ÜBER DIE MINERAL- UND WARMBRUNNEN CALIFORNIENS. 
BY W. F. McNUTT, M.D., M.R.C.S.,ED., L.R.C.P.,ED., 
Of San Francisco, California. 
Prominent among the various elements which contribute to California's fame as a 
great sanitarium are her numerous mineral and thermal springs. Scattered throughout 
the State, from the southern boundary to Oregon, and from the ocean to the Sierras, 
more than two hundred localities are known, where waters, varying in temperature 
from 27° to 212° F., and charged with salts and gases of high therapeutic value, pour 
forth from the earth in great profusion. The number of individual springs in different 
localities ranges from one to thirty, each varying in composition, temperature and 
possibly other, as yet, undetermined physical qualities. Although the general char- 
acter of most of these springs is known, only a few of them have as yet been carefully 
analyzed,, and at still fewer have patients been under a competent observer's care, so 
that with the insufficient data at hand, and the limited time at the writer's disposal, it 
was found impossible, during the two weeks intervening between the notice that a paper 
on this subject was desired and the date of mailing, to attempt more than to briefly 
call the attention of this Congress to the great number and diversity of medicinal 
waters found in California, and to give the analysis of a few of the most frequented 
springs. 
In the southern portion of the State, close to the Mexican line, we find on Warner's 
Ranch, fifty miles from San Diego, a number of thermal sulphur springs, known as 
Aguas calientes. 
There are said to be seven springs in all, varying in temperature from 58° to 142°. 
They flow from small openings in a ravine, and bubbles of sulphureted hydrogen are 118 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
continually escaping. At one orifice a jet of steam issues with a hissing sound. The 
water has a pleasant acid taste, but no analysis has yet been published. These 
springs enjoy a greater reputation among the native population for the cure of 
syphilis than any others, and have enjoyed this reputation since the settlement by 
the Americans. 
Other springs in this country are the Temescal Hot Springs, De Luz Hot Springs and 
the Springs of Dos Palmas, the latter being saline and having a temperature of 80°. 
Near Elsinore there is, according to the San Diego Union, a wonderful little valley con- 
taining mineral springs of hot and cold water, sulphur, soda, white sulphur, magnesia, 
iron, borax, hot mud, fresh water, etc.-one hundred and eighty-six springs in all. 
The San Bernardino Hot Springs, further inland, in San Bernardino County, are calcic 
and form a deposit or incrustation on twigs and pebbles which is snow white. The 
temperature is from 108° to 172°, the waters gushing out from crevices in the granite 
rock in sufficient quantity to raise the temperature in a small stream near by to 130° F., 
the water so heated being ample to constitute an efficient water power. The altitude 
of these springs is about sixteen hundred feet above the sea. 
Arrow Head Hot Springs, at an altitude of over two thousand feet, and consisting 
of a number of springs, varying in temperature from 140° to 210°, first came into 
notice in 1858. An artificial pond for bathing has been prepared, the dimensions of 
which are one hundred by seventy-five feet. There are mud baths also which are 
deemed of great value in cutaneous diseases. 
Among the mineral and thermal waters found in this region are the Anti-fat Springs, 
Bear Valley Hot Springs, Borax Marsh Springs, Borax Patch Springs, Salt Wells, Soda 
Lake and Waterman's Springs. 
Fulton's Sulphur Wells, two in number, now called the Santa Fé Springs, thirteen 
miles from Los Angeles, yield a water containing per gallon- 
Sodium bicarbonate 2.20 grains. 
Magnésium bicarbonate 16.50 " 
Calcium bicarbonate 12.00 " 
Iron subcarbonate 13.00 " 
Sodium sulphide 90 " 
Sodium chloride 10.40 " 
Sulphur 23.00 " 
78.00 " 
In addition the water is strongly charged with carbonic acid and sulphurated 
hydrogen gases. The San Juan Hot Springs enjoy a great local reputation, especially 
among the native Californians, for the cure of rheumatism. 
The Santa Barbara Hot Sulphur Springs, seven in number, are located about five 
miles to the northeast of Santa Barbara, at an elevation of fifteen hundred feet. 
They seem to be of two distinct varieties. Those nearest to the canon escape from 
crevices in the rock and are four in number, all appearing to have the same properties, 
the most sensible of which are free sulphur, held in suspension, and sulphurated 
hydrogen; their temperature is 114°. 
Another spring, situated about one hundred yards off, in a westerly direction 
from the first mentioned, contains sulphate of alumina, the under surface of the 
rock beneath which this water escapes being covered with a thick incrustation of 
this salt. 
It also tastes strongly of sulphate of iron, and is said to contain soda, potassa, and 
a trace of arsenic. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
119 
Other springs in this county are the Las Cruces Hot Sulphur Springs, Mountain Glen 
Hot Springs and San Marcos Sulphur Springs. 
As worthy of mention is an immense petroleum spring, some ten miles in a westerly 
direction from Santa Barbara, situated in the bed of the ocean, about one and a half 
miles from shore, the product of which continually arises to the surface of the water, 
apd floats upon it over an area of many miles. 
Dr. Brinkerhoff suggests that the prevailing westerly sea breezes passing over the 
vast expanse of sea-laden petroleum may take up from it and bear along with them 
some subtle power which serves as a disinfecting agent, and which may account for the 
superior healthfulness of the climate of Santa Barbara. 
The Paso de Pobles Thermal Springs, five in number, ranging in temperature from 
110° to 140°, are situated in San Luis Obispo county, and are among the most valuable 
springs in the State. 
The following analysis shows the composition of two of the springs:- 
MAIN SPRING, 112° Fah. 
mud spring, 122° Fah. 
Sodium carbonate 
3.664 grains. 
0.543 grains. 
Magnesium carbonate 
0.057 " 
0.323 " 
Sodium chloride 
2.830 " 
10.047 " 
Potassium sulphate 
0.092 " 
Trace. 
Sodium sulphate 
0.818 " 
4.281 " 
Calcium sulphate 
0.334 " 
1.864 " 
Iron protoxide 
0.037 " 
Iodides and bromides 
Traces. 
Alumina 
0.023 " 
Silica 
0.046 " 
0.116 " 
Organic matter 
0.171 " 
0.361 " 
8.072 " 
17.535 " 
Carbonic acid 
2.31 cubic inches. 
10.53 cubic inches. 
Sulphureted hydrogen 
saturated. 
saturated. 
These springs are situated in a valley on the northern slope of the Santa Lucia 
Mountains, and are well appointed. 
There are over twenty sulphur baths and a mud bath. Numerous other springs are 
scattered throughout the country. There are a number of springs both in Kern and 
Tulare county, of which, however, we have no reliable information. 
Inyo county abounds in mineral and thermal waters. The Thermal A cid Springs, 
situated in the Coso Kange, are of rare and remarkable composition, one hundred 
thousand parts containing- 
Free sulphuric acid 78.4 parts. 
Potassium sulphate 2.5 " 
Sodium sulphate 15.1 " 
Calcium sulphate 15.3 " 
Magnesium sulphate 1.2 " 
Aluminium persulphate 127.0 " 
Iron persulphate 33.2 " 
Nitric acid, chlorine, ammonia and lithium. Traces. 
272.7 " 
The waters have but a limited flow, and from crevices in the mountain side, through 
which steam is continually ejected; and thousands of tons of pure sulphur cover the 
surrounding locality, deposited there in former times, when the water must have con- 
tained large quantities of sulphureted hydrogen. 120 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Owens Lake is another remarkable body of water, containing per gallon- 
Sodium chloride 2942.15 grains. 
" sulphate 956.80 " 
" carbonate 2914.43 " 
Potassium sulphate ; 35.74 " 
" silicate 139.54 " 
Organic matter 16.94 " 
7005.60 " 
This lake, then, is more than twice as salt as the Atlantic Ocean. 
Volcanic Mineral Springs, situated in Death Valley, contain per gallon- 
Sodium chloride 1840.72 grains. 
Potassium chloride 132.30 " 
Sodium carbonate 1724.11 " 
" sulphate 651.02 " 
" sulphide 46.34 " 
Lime and magnesia Traces. 
Silica 14.28 " 
Organic matter 13.48 " 
Iodine, bromine, iron, boracic and phos- 
phoric acids Traces. 
4422.25 " 
Other springs in this county are the Boiling Springs, Castilian and Saratoga. The 
last mentioned springs are said to be located at the south end of Funeral Range, 
south of Death Valley-certainly rather suggestive names for the location of a health 
resort. 
The Paraiso Hot Springs, Monterey county, situated at an elevation of twelve 
hundred feet above the valley, range in temperature from cold to 118°. They are 
saline, one gallon containing- 
Organic matter 5.25 grains. 
Silica 2.62 " 
Alumina and iron 1.60 " 
Magnesia Trace. 
Potassium chloride 0.35 " 
Sodium chloride 3.50 " 
" sulphate 35 50 " 
" carbonate 4.23 " 
Calcium carbonate 1.43 " 
" sulphate 4.32 " 
58.80 " 
4 
Of the Tassajara Hot Springs in this county we have no reliable information, nor of 
the Fresno Hot Springs in the adjacent county of that name. 
In Mono county are found a number of mineral springs and lakes, the most remark- 
able of which is Mono Lake, which, in many of its features, resembles the Dead Sea of 
the Holy Land. It lies in a depression, in a desert basin, which was, probably, in 
ancient times, an extensive volcanic crater, and from which can be traced streams of 
volcanic lava, which flowed in several directions. 
The water of this lake is strongly saline, containing, it is said, nearly 11,000 grains 
to the gallon of chlorides of sodium, potassium, calcium and magnesium, with traces 
of other salts and free acids SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
121 
Santa Clara county has been highly favored in the distribution of springs. Among 
the most valuable are Pacific Congress Springs, situated twelve miles west of San Jose. 
The water is alkaline, saline and chalybeate, containing 335,857 grains of solid matter 
to the gallon, consisting of- 
Sodium chloride 119.159 grains. 
" sulphate 12.140 " 
" carbonate 123.351 " 
Iron carbonate 14.030 " 
Lime carbonate 17.295 " 
Silica, alumina and magnesia 49.882 " 
335.857 " 
The temperature of this water is 50° F. 
The Azule is an excellent alkaline-saline water, containing a large amount of free 
carbonic acid gas, which renders the water very pleasant to the taste. One gallon con- 
tains- 
Carbonic acid 152.24 grains. 
Sodium chloride 90.88 " 
Magnesium chloride 18.48 " 
Potassium chloride 12.44 " 
Magnesium carbonate 77.20 " 
Sodium carbonate 50.88 " 
Calcium carbonate 9. 
411.12 " 
Vichy Springs, of New Almaden, is another excellent alkaline-saline water, contain- 
ing to the gallon- 
Sodium carbonate 200.12 grains. 
Calcium carbonate 32. " 
Calcium sulphate 40.20 " 
Magnesium sulphate 12. 
Sodium chloride 32.16 
Carbonic acid ... 112.08 " 
Iron 4.08 " 
432.64 " 
Gilroy Hot Sulphur Springs is another popular resort. The temperature of the water 
is from 109° to 116°. It is said to contain sulphur, magnesia, iron, arsenic and iodine. 
No reliable analysis has, however, been made, as far as I know. 
The Alum Roch Springs are saline and sulphurated. A careful analysis is wanting. 
The Summit Soda Springs are located near the summit of the Sierra Nevada, in Alpine 
county, at an altitude of 6090 feet above the sea. One gallon of the water yields- 
• 
Calcium carbonate 43.20 grains. 
Magnesium carbonate 4.20 " 
Sodium carbonate 9.50 " 
' ' chloride 26.22 " 
Iron oxide 1.75 " 
Silica 2.06 " 
Alumina 1.75 " 
Potassium Trace. 
88.68 " 
Carbonic acid 186.36 cubic inches. 122 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The water is clear, cold and sparkling, and constantly more or less agitated by 
escaping carbonic acid. 
Byron Springs, Contra Costa county, are gaining considerable reputation. There are 
fourteen springs, differing both in temperature and chemical constituents. They range 
from cold to 135°. One spring, called "Surprise," is both cathartic and emetic in half- 
ounce doses. It is said to contain chloride of sodium and sulphate of magnesium in 
large amounts. Some of the springs are sparkling with carbonic acid, others contain 
sulphureted and phosphureted hydrogen gas ; also hot mud baths. 
The proprietor is now having all the springs analyzed. 
Tolenas Springs, in Solano county, nineteen in number, alkaline-saline, and contain 
free carbonic acid gas. 
The Geysers and Little Geysers, situated in Sonoma county, consist of a large number 
of springs, ranging in temperature from 190° to 212°. At present they are visited as 
objects of curiosity rather than a health resort, though many of the springs are said to 
possess active therapeutic qualities. 
Litton's Seltzer Springs contain boracic, carbonic, hydrochloric, sulphuric and silicic 
acids, in combination with alumina, ammonia, iron, lime, silica, magnesia, potassa, 
soda and organic matter in proportion of 228.69 grains to the gallon. 
Skaggs' Hot Springs, three in number, varying in temperature from 128° to 140°, are 
alkaline. One gallon contains- 
Potassium sulphate 0.260 grains. 
Potassium chloride 0.200 " 
Sodium chloride 5.900 " 
Sodium iodide Trace. 
Sodium bicarbonate 161.670 " 
Sodium biborate 26.470 " 
Lithium carbonate 0.060 " 
Barium carbonate 0.240 " 
Strontium carbonate 0.024 " 
Calcium carbonate 2.197 " 
Magnesium carbonate 11.113 " 
Iron carbonate 0.054 " 
Alumina... . 0.004 " 
Silica 7.023 " 
215.215 " 
The Napa Soda Springs, twenty-seven in number, having a temperature of 68°, are 
situated on the mountain side, a thousand feet above the rich and beautiful Napa 
Valley. The climate and scenery are unsurpassed, and the accommodations for visitors 
are excellent, the cottages being of stone cut from the lava beds of the mountain, 
and the grounds arranged with much taste and at great expense. One gallon of 
the water contains- 
Sodium bicarbonate 13.12 grains. 
Magnesium carbonate 26.12 " 
Calciumcarbonate 10.88 " 
Sodium chloride 5.20 " 
Iron subcarbonate 7.84 " 
Sodium sulphate 1.84 " 
Silicious acid 0.68 " 
Alumina 0.60 " 
Loss 2 48 " 
68.76 " 
It is an excellent table water. 
Ætna Springs, thermal (98° and 106°), alkaline, and charged with carbonic acid. 
One gallon contains- SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
123 
Sodium carbonate 75 grains. 
Magnesium carbonate 14 " 
Calcium carbonate 10 " 
Sodium sulphate 08 " 
Sodium chloride 29 " 
Silica Trace. 
1.36 " 
Carbonic acid 58 cubic inches. 
The St. Helena White Sulphur Springs are saline-sulphur waters, mildly aperient. 
Calistoga Hot Springs, twenty in number, saline and sulphurated, with a tempera- 
ture ranging from 97° to 186°, are situated in the town of that name in Napa county. 
Twenty miles from there are the Harbin Springs, saline, chalybeate and sulphurated; 
temperature 118° F. 
Lake county possesses a great number of valuable springs. Adam's Springs, alka- 
line and carbonated, contain about 200 grains to the gallon, the principal constituents 
being carbonate of magnesia, soda and lime with silica, chloride of sodium and a small 
amount of iron. 
Allen's Springs, five in number, temperature of water 50°, alkaline, saline and chaly- 
beate. They are highly charged with free carbonic acid gas. 
Anderson's Springs, nine in number, hot and sulphureted. 
Bartlett Springs, cold, alkaline-saline, also said to contain arsenic. 
Bonanza Springs, three in number, cold, sulphureted and chalybeate. 
ÆyAZand Springs, a popular resort, situated among highly picturesque surroundings, 
forests, lakes and mountains. 
There are ten springs known by different names, as ' ' Magnesia Spring, " " Dutch 
Spring," " Magic Spring," etc. The water is cold, 60° to 82°, alkaline, and highly 
charged with carbonic acid. The following analysis gives the number of grains per 
gallon of three of the principal springs:- 
SELTZER. 
DUTCH. 
MAGIC. 
Sodium carbonate 
8.87 
12.72 
15.10 
Magnesium carbonate 
20.67 
40.08 
41.63 
Calcium carbonate . 
34.76 
39.80 
35.02 
Potassium carbonate 
0.38 
0.58 
0.42 
Manganese carbonate 
Trace. 
Trace. 
Trace. 
Iron carbonate 
0.92 
0.98 
0.78 
Sodium chloride 
0.72 
1.68 
1.28 
Alumina 
0.11 
0.17 
Silica 
5.24 
7.12 
7.39 
73.12 
103.07 
101.79 
Carbonic acid (cub. in.) 
212.20 
184.30 
156.80 
Hot Borate Spring. This spring pours out 18,000 gallons of water per hour. It is 
alkaline-saline, and is said to contain large quantities of potassium, ammonia, bromine 
and borax. 
Howard Springs are situated at an altitude of 2225 feet. They are fourteen in 
number, hot and cold, temperature ranging from 58° to 109°. They are saline, 
chalybeate and highly charged with carbonic acid. 
Iodine Springs, situated at the entrance of G-rizzly Canon, contain iodine in con- 
siderable quantities. 
Ziegler Springs, at an elevation of 2500 feet, is a popular resort. The waters, both 
hot and cold, are alkaline and chalybeate. One spring is said to contain arsenic. 
Witter's Springs, sulphureted and chalybeate, are situated in the coast range of 
mountains, and have considerable reputation as yielding healing waters. 124 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The Tuscan Springs, Tehama county, saline and sulphurated ; also said to contain 
iodine. 
An, as yet, unnamed spring, said to have been known to the Indians, who ascribed 
to it remarkable curative powers, has recently been discovered in Eureka, Humboldt 
county. The water issues from the bank at the head of the bay and at high tide the 
waters of the bay cover the spring. It is a strong saline-sulphur water, containing 
also a small amount of free carbonic acid. One gallon contains:- 
Sodium chloride 1403.00 grains. 
Magnesium chloride 101. " 
Magnesium sulphate 211.30 " 
Calcium sulphate 42.50 " 
Sodium bromide 14. " 
Potassium sulphate 12.20 " 
Sodium carbonate 10.10 " 
Calcium carbonate 3.80 " 
Silica .95 " 
Iron carbonate .12 " 
Manganese, boracic acid, iodine, lithium Traces. 
1798.97 " 
Sulphurated hydrogen Saturated. 
The Soda Springs, in Shasta county, situated at an altitude of 236 feet, are strongly 
chalybeate, the water, as it runs from the springs, depositing an extensive bed of iron. 
There are a number of springs, both hot and cold, in this county, about which, how- 
ever, reliable information is yet wanting. 
Lassen county is full of hot (boiling) springs, having a temperature from 200° to 
212°. 
In all the northern counties mineral and thermal springs abound, though but little 
has, as yet, been done to popularize and develop them. 
It will readily be seen from the foregoing that the composition of our mineral 
waters compares favorably with that of the most celebrated springs of Europe. Some 
of our chalybeate waters, for instance, contain more than twice the amount of iron 
found in the strongest European springs. 
In the thermal acid springs of Coso Range, Inyo county, the iron is in the form of 
persulphate, about 19 grains to the gallon. The water, it will be remembered, con- 
tains also a large amount of persulphate of aluminium, and free sulphuric acid, a rare 
combination, which it is believed will prove highly efficacious in the treatment of 
many diseases, where iron and astringents are indicated. 
Our hot springs are rich in sulphureted hydrogen and other sulphides, which 
materially enhance their value in the treatment of syphilis, rheumatism and cutaneous 
affections. Most of the alkaline and saline waters are highly charged with carbonic 
acid gas, rendering them agreeable to the taste and easily tolerated by the most sensi- 
tive stomach. The silica contained in some of the waters is supposed to impart to 
them a smoothness of texture or " unctuosity," a term applied to that peculiar quality 
of certain waters which give to the body, when immersed, a sensation as if covered 
with a bland oil. It is, however, held by some that this is due to organic matter. 
At the urgent request of the State Medical Society and the State Board of Health, 
a State analyst has been appointed, whose duty it is to examine all waters in equal 
quantities, and on one uniform plan. 
Professor Rising, of the State University, now fills this position, and we may soon 
hope to obtain positive knowledge regarding the composition and physical qualities of 
all the mineral springs of California, that is, when the State Legislature will sufficiently 
appreciate the importance of the work and make the necessary appropriation ; and SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
125 
when this shall have been supplemented with sufficient clinical observations, carefully 
recorded and generalized, then, and not till then, may we hope to be able to apply 
intelligently and efficiently in the treatment of disease these powerful remedial agents, 
which, prepared in nature's own laboratory, are furnished to us in such abundance. 
To make no higher claim for our springs than that they are equal to those of any 
other country, will, with the advantages of the climate of California, render them the 
more efficient. 
SOME REMARKS ON THE CLIMATE OF THE SWISS ALPS, WITH 
PULMONARY CASES TREATED AT SIX THOUSAND FEET. 
QUELQUES REMARQUES SUR LE CLIMAT DES ALPES HELVÉTIQUES, AVEC DES 
CAS PULMONAIRES TRAITÉS A SIX MILLE PIEDS DE HAUTEUR. 
EINIGE BEMERKUNGEN ÜBER DAS KLIMA DER SCHWEIZER ALPEN, NEBST FÄLLEN 
VON LUNGENKRANKHEITEN, WELCHE IN EINER HÖHE VON SECHSTAUSEND 
FUSS BEHANDELT WURDEN. 
BY A. TUCKER WISE, M.D., L.R.C.P., M.R.C.S., 
Of London, England. 
It is no exaggeration to say that the conditions of bright Alpine weather during 
midwinter are difficult to describe, without being accused of extravagance; therefore, 
the only reply to be made to theoretical critics who quote meteorological details to 
demonstrate the impossibility of feeling warm in the snows of the mountains is, that 
the practical experience of a visit to high lands should be undertaken by any one who 
desires to speak with authority on the subject of climate. The high level health resorts 
are, however, greatly appreciated by a section of the public increasing in numbers 
each year. The interest attached, in the present day, to mountain climates all over 
the world may be some excuse for a brief re-statement of my views on the theoretical 
points of the subject, as published in England during the last seven years. Latterly I 
have been struck with the importance of observations on atmospheric electricity. 
Doubtless electricity should be regarded as a curative factor, in the study of climate. 
Dr. Denison, of Denver, has already made some interesting remarks on this matter: 
writing of Colorado, he says : "You lie down to sleep on the ground, as only a tired 
camper can, and rise in the morning from your negative electric bed, to stretch yourself 
in the positive electric air. I have yet to meet with an experience which will dissuade 
me from advising a consumptive to live in the open air, and sleep on the ground, 
whenever conditions are favorable for so doing. ' ' 
My notes on atmospheric electricity are not yet sufficiently complete to justify any- 
thing but the statement that the dryness of the air in the Swiss Alps favors electrica] 
commotions, affecting principally the cutaneous circulation. The slightest friction of 
clothes, walking across a carpeted room, the impact of air on the body, etc., will give 
evidence of changes being evoked in the electrical condition of the surface of the body. 
This can be tested clearly by a condensing electroscope. Electric tension, too, is more 
marked in dry, mountainous regions, giving origin to the formation of large quantities 
of ozone, which body plays a very important part, as regards climate. 
Putting aside all observations by instruments of precision, there is one unique fea- 
ture of Swiss mountain climate which must be kept in mind, especially with respect to 
pulmonary troubles, viz., the possibility of respiring cold, dry air, without the sensation 
of feeling chilled and pinched by the low temperature. Various explanations have been 126 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
given for this; the main reason, however, for the immunity from the sensation of cold is 
the small amount of watery vapor suspended in the air. Whether the dread of a low 
temperature exists in the minds of Americans to the same extent as among many Eng- 
lish in Europe I am unable to say; this fancy, nevertheless, drives hundreds to the 
shores of the Riviera who would obtain more amusement, and do much better as regards 
permanent benefit to their health, among the ice and sunshine of the Alps. 
As far as my personal observations extend, the marked peculiarities of Alpine winter 
climate may be enumerated thus :- 
1. Dryness of the air and its freedom from microorganisms, mechanical irritants and 
noxious gases. 
2. Low temperature. 
3. Profusion of sunlight. 
4. Diminished barometric pressure. 
5. Ozoniferous atmosphere. 
The result on pulmonary complaints may be stated as- 
1. By breathing aseptic air, free from dust, irritation or perhaps recurrence of infec- 
tion by microbes in the respiratory tract, is greatly lessened. 
2. Vaporization of morbid secretions in the lungs takes place, promoted by reduced 
barometric pressure and dryness of the atmosphere. 
3. Increased oxidation of blood and tissue, from sunlight, cold air and reduced 
pressure. 
4. Increased quantity of blood circulating in the lungs, caused by the low tempera- 
ture, the freedom of the circulation being aided by extended chest movements. 
5. Increased activity in the pulmonary lymphatics (depending on circulation and 
expansion) and a general improvement in nutrition and glandular secretion; also an 
exhilarating effect on the nervous system. 
Some of these results are obtainable under no other conditions than those presented 
at high cold regions. With regard to the increased quantity of blood circulating in 
the lungs (presumably influencing the nutrition of these organs), it may be contended 
that this is not a desirable sequence. Perhaps it is not in hemorrhagic phthisis ; but 
in some other forms, especially early tubercular deposits, it would not seem to be 
disadvantageous. What would lead one to suppose this, is the rare occurrence of 
tubercular phthisis in persons affected with mitral disease. Even when haemoptysis 
takes place, and when some of the blood presumably gravitates into the air cells, 
tubercular disease rarely follows; while, on the other hand, phthisis is not an uncom- 
mon consequence after haemoptysis from other causes. This would appear to indicate 
that a general hyperæmic condition of the lungs impedes the deposition of tubercle and 
restrains phthisical processes. Support is also lent to this view by tubercle generally 
attacking the apices of the lungs, which parts contain rather less blood, owing to gravi- 
tation. Conversely, where the quantity of blood circulating in the lungs is diminished, 
as in hot climates, phthisis is frequently seen to run a very rapid course. 
The four principal health resorts of the Grisons, in Switzerland, are- 
Maloja, highly stimulating, bracing and exciting, with strong electric conditions of 
the atmosphere and excess of ozone. 
Wiesen, less exciting, and although very dry and restorative, more sedative than any 
of the higher stations. 
Davos, stimulating, bracing and exciting, but in a less degree than the Engadine. 
St. Moritz, stimulating, bracing and exciting, with strong electric conditions of the 
air and excess of ozone. 
The out-door amusements which really enter into a part of the ' ' treatment ' ' at 
these places, are skating, sleighing, tobogganing and snow-shoeing, besides the ordinary 
exercise of walking, sitting out in the open air and in shelters, sketching, reading, etc. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
127 
In-door amusements are the usual ones of music, dancing, amateur and other concerts, 
theatricals and various social gatherings. 
In the Engadine a day may be spent thus : At 8.30 or 9 A. M. breakfast ; as soon 
as the sun appears on the snow a walk is taken, or the skates put on and the ice rink 
visited. Some sit in shelters or on the ice watching the skating, protected from the 
glaring sun by smoked-glass spectacles and parasols. About 12.30 P.M. lunch is taken. 
Those desirous of getting as much open-air exposure as possible, have their lunch sent 
to them on the ice, or in the wooden sheds constructed for these purposes. After lunch 
the skates can be changed for the toboggan, or a sleigh drive taken to some village or 
place of interest. A snow-shoeing party may be got up and a small excursion made 
to the inaccessible nooks of the woods and side valleys, all of which are rendered easy 
of exploration by the Canadian snow-shoe. Picnics, too, are undertaken in this way 
or by sleigh, combined with a run down a sloping road on the Canadian sled. The 
temperature on these occasions may be from 15° to 25° F. The snow and roads are 
quite dry, and a shawl thrown over the surface of the crisp, dusty snow serves well for 
reclining or sitting down. 
As I am principally responsible for bringing forward both Wiesen and Maloja as 
winter resorts for early pulmonary cases, it is a satisfaction for me to be able to show 
some results which have been obtained by winter residence at the latter place. Details 
of the climates of Wiesen and Maloja can be found in my third edition of "Alpine Win- 
ter in its Medical Aspects " (Churchill). 
In the following cases treatment has been omitted, but it may be mentioned that 
the practice carried out varied somewhat with each patient, and consisted of graduated 
exercise, with suitable clothing and diet, and plenty of fresh air, dry cupping, medical 
rubbing and counter-irritation ; milk, cod-liver oil and medicines, when circumstances 
demanded it ; drugs were, however, avoided as much as possible. 
The cases are taken as they occur in my note book of pulmonary complaints of the 
past winter ; there are no omissions of unsatisfactory results. 
Case I.-Age twenty-six. Congestion of right apex ; dullness; feeble breath sounds; 
vocal resonance increased, and slight recurring crepitation. Pulse 64 ; temperature 
97.2° F. ; weight 8 stone, 7 pounds ; slight cough, no expectoration. 
Result.-Increased expansion of chest; right side 1 centimetre, leftside J centimetre; 
pulse 68; temperature 97° to 98.4°. No abnormal physical signs ; marked gain in 
strength ; appetite good ; weight 9 stone, 6 pounds. 
Case II.-Age twenty-nine. Congestion of right apex ; slight dullness with harsh 
expiratory murmur ; haemoptysis on three or four occasions during the previous twelve 
months ; no cough nor expectoration ; weight 9 stone, 3 pounds. 
Result.-No haemoptysis during the winter; great gain in strength and capacity for 
exercise-skating, walking, etc. ' Voice power increased; is now able to sing, although 
previous attempts during the last three or four years had always resulted in failure and 
hoarseness. Weight 9 stone, 5| pounds. 
CASE III.-Age twenty-four. Cough and haemoptysis two years ago, when in the 
United States. The appetite failed at that time, and there was great loss of flesh with 
night perspirations. After spending three months in Europe he has undergone much 
improvement. On examination, moist râles were heard over the apex of the left lung 
with pleuritic crackling and slight dullness. On the right side jerky breathing was 
heard underneath the clavicle. Yellow expectoration with morning cough. Tempera- 
ture 98° to 100°. Weight 9 stone, 13 pounds. Bacilli in sputum. Pulse 100 
to 116. 
Result.-After summer residence dry sounds replaced moist sounds. The expecto- 
ration was about the same. Weight, 10 stone. After winter residence the weight 
was 9 stone, 13 pounds ; it had been up to 10 stone, 5 pounds, but was reduced 128 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by indiscreet exercise, as all abnormal physical signs and general health had im- 
proved. Pulse 84 to 96 ; temperature 98.4°. Bacilli in sputum undiminished in 
number. 
Case iv.-Age forty-nine. Consolidation of the superior lobe of left lung. Com- 
menced with slight hæmoptysis a few months ago. There was no loss of flesh nor night 
perspirations. Cough frequent with expectoration of yellow, heavy mucus, occasion- 
ally streaked with blood ; pulse 88 to 104 ; temperature 98.4° to 99°; weight 9 stone, 
101 pounds. Bacilli in sputum. 
Result.-Strength greatly increased after the winter's residence, and expectoration 
lessened. Weight 9 stone, 91 pounds; pulse 96 to 120. 
This patient died in Italy during the subsequent spring, from an attack of 
pericarditis. 
Case v.-Age twenty-eight. Left front of chest immobile; portions of three ribs 
have been excised, for empyema. Respiratory murmur inaudible over the left lung, 
where there was a cavity in the apex communicating with pleura. Harsh breathing in 
right apex, extending to second rib, otherwise the right lung was normal. Pulse, 96 ; 
temperature 98.4°; morning cough and occasionally violent fits of coughing after 
meals ; breathlessness on exertion; appetite good; sleeps well; weight 10 stone, 8 
pounds. 
Result.-General improvement. Recommended a sea voyage and then to return to 
Maloja for a second winter. Weight 10 stone, 12 pounds; pulse 92. 
Case VI.-Age fifteen. Illness commenced in the spring of 1882, with slight 
cough and hemorrhage on two occasions, malaria and anæmia. The winter of 1882-3 
was spent at Bournemouth; 1883-4, Algiers ; 1884-5, Tunbridge Wells, and Riviera. 
There was always a little cough and yellow expectoration. The sputum was tinged 
with blood at Alassio in April, 1885, and the temperature at that time ranged from 
99.4° to 101° Fahr. Came to the Engadine in July, 1885, when the following notes 
were made: Mucous membrane of mouth and fauces anæmic. Dullness over the whole 
of left lung, with numerous dry and moist râles. Rhonchi heard over the lower lobes of 
right lung. There was retraction of the cardiac lobe and displacement of the heart, 
with flattening beneath the clavicle extending to fourth rib. Fatigued easily and 
breathless on slight exertion. Pulse 116; temperature 98.8° to 99°; bacilli in sputum. 
Result.-There was gradual improvement during the summer of 1885. On No- 
vember 19th, 1885, she weighed 7 stone, 5 pounds. At the end of March, 1886, 7 
stone, 10 pounds. March, 1887, 8 stone, 13 pounds. 
The aspect of this patient was greatly changed for the better; she was able to skate, 
toboggan, and mount 500 feet of the Maloja pass without fatigue. The left side of the 
chest was considerably contracted, but gave signs of slight filling out again. A mod- 
erate sized cavity was dry and contracting. There was still a little cough with nummular 
expectoration in the mornings; bacilli were found in large numbers. Pulse 80 to 100; 
temperature normal. The gain in weight in sixteen months was 22 pounds. 
Case vii.-Age twenty-six. Contracted pneumonia in 1877, 1883 and 1885. 
Absorption of inflammatory products was incomplete in right apex. Expiratory mur- 
mur was harsh and prolonged over the whole of right lung. Weight 11 stone, 2j 
pounds. 
Result.-Respiration normal ; the right infra-scapular region still remained dull on 
percussion, but the fringes of the lungs in front gave signs of compensatory emphy- 
sema. Weight 11 stone, 7 pounds. 
Case viii.-Age twenty. Insidious consolidation of right apex; dullness over right 
subclavicular region, with augmented vocal vibrations ; rough and prolonged vesicular 
murmur ; bronchophony and morning cough with muco-purulent expectoration ; loss of 
appetite and strength with night perspirations. Temperature 98.4°. Bacilli in sputum. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
129 
Result.-The ten months from June to March were passed between Davos and Maloja; 
at the end of this time there was a disappearance of all serious signs. Slight flattening 
could be discerned beneath the right clavicle, where the dullness and excessive vocal 
vibration were almost indistinct ; bronchophony insignificant ; no cough nor expecto- 
ration. Weight 10 stone, 10 pounds. 
Case IX.-Age thirty-five. Loss of weight gradually for eighteen months, with 
dyspepsia ; loss of voice after speaking for ten or fifteen minutes ; perspires a little at 
night. There was harsh vesicular murmur over the right apex and feeble breathing in 
the right base, but no râles or other adventitious sounds. Pulse 84 ; weight 11 stone, 
10 pounds. 
Result.-A slight harshness in expiration alone perceptible, over the right lung ; 
voice stronger and appetite good. There was no dyspepsia and the strength was greatly 
increased. Weight 12 stone, 2J pounds ; pulse 80. 
Case x.-Age twenty-seven. Subject always to winter colds which end in cough. 
Dullness over the apex of right lung, with bronchophony and harsh expiration ; no 
râles nor crepitations ; becomes breathless and fatigued after exercise. Pulse 76 
(sitting), 100 (standing) ; weight 11 stone, 5J pounds. 
Result.-He could mount 1100 feet without breathlessness or fatigue. All ab- 
normal signs had disappeared. Pulse 76 (sitting), 92 (standing) ; weight 11 stone, 
6 pounds. 
Case XI.-Age thirty-two. Haemoptysis for four or five years ; loss of flesh and 
bad family history. Never much expectoration nor high temperature. There were 
pains complained of over the apex of right lung, where there was high-pitched, jerky 
respiration, but no râles ; liver enlarged. Pulse 80 ; weight 8 stone, 8| pounds. 
Result.-After twenty-three days' residence, in the month of February, the body 
weight increased to 8 stone, 13 pounds, but there was no change in the physical signs. 
Pulse 72. A little haemoptysis occurred on one occasion, attributable solely to indis- 
cretion while mounting the pass. 
Case xii.-Age forty-five. An Anglo-Indian on two years' sick leave. There was 
dullness under left clavicle, with a small area of increased vocal resonance. No râles 
of any kind. Pulse 80. Loss of muscular force. 
Result.-This gentleman diminished in weight while in Europe, from 13 stone, 
4 pounds to 12 stone, 4| pounds, with great advantage. He could take much exercise, 
descending the Maloja Pass (1150 feet) on a toboggan and mounting again on foot, 
sometimes twice daily. No abnormal signs remained. 
Case xiii.-Age twenty. Convalescent from typhoid fever and pneumonia. Pulse 
100 (sitting), 112 (standing) ; weight 11 stone, 3| pounds. 
Result.-After one month's residence, in February and part of March, there was con- 
siderable gain in strength and respiratory power. Pulse 92 (sitting), 100 (standing) ; 
weight 11 stone, 8 pounds. 
Case xiv.-Age forty. Was at Davos about six years ago with catarrh of right 
apex, which was completely cured by three or four months' residence. There was now 
shortness of breath and dullness over both apices, with harsh expiratory sound and dry 
rhonchus. Very slight increase of vocal resonance anywhere, but limited expansion of 
upper part of chest. Pulse 80 (sitting), 84 (standing). Bacilli in sputum. Tem- 
perature 98.4°. 
Result.-Beyond an increase in the capacity for exercise and a diminution of dry 
rhonchi, there was nothing to note. 
CASE xv.-Age nineteen. Slight cough for four years; no expectoration nor loss 
of flesh. There were imperfect respiratory sounds in both apices of the lung, especially 
marked on the left side, with deficient entry of air over the whole of left dorsal region, 
Vol. V-9 NINTH INTERNATIONAL MEDICAL CONGRESS. 
130 
which was somewhat dull on percussion ; no râles; pulse 92; temperature 99°; weight 
8 stone, 6 pounds. 
Result.-Normal entry of air was manifest in both apices. The dullness over the 
whole of the left lung was greatly lessened; temperature 98.4°; pulse 78; weight 8 
stone, 4 pounds. 
Case XVI.-Age forty. Obtained great benefit from wintering at Davos six years 
ago. During the last twelve months constant "colds" have ended in a cough with 
yellow expectoration, sometimes streaked with blood. There was bronchial breathing 
and dullness over the left apex of the lung, with marked vocal resonance and broncho- 
phony back and front. The signs indicated congestion around and in the neighborhood 
of a cavity which had cicatrized and contracted six years ago. An occasional dry 
rhonchus was heard in the left base. Pulse 120; Temperature 99°; respirations 24. 
Result.-The time spent in Maloja (one month at the end of winter) was insufficient 
to produce any very marked improvement in the physical signs. The cough, however, 
was much diminished and appetite improved. Pulse 84 (sitting), 100 (standing); tem- 
perature 97.8°; respirations 20. 
Case xvii.-Age twenty-three. Prolonged expiratory murmur in both apices, 
especially perceptible on the right side, with increased vocal resonance and fremitus. 
There was slight cough with muco-purulent expectoration containing bacilli. Pulse 
100 (sitting), 124 (standing). Intermits on deep inspiration. Temperature 98.2°; 
weight 11 stone 3 pounds. 
Result.-Entire disappearance of all abnormal signs in the chest. He was able to 
take ordinary exercise without any fatigue. Pulse 92 (sitting), 100 (standing). No 
intermissions on deep inspiration. There still remained a slight expectoration in which 
bacilli could be distinguished. Weight 11 stone, 13 pounds. 
Case xviii.-Age thirty-seven. Consolidation of the whole of left lung, dry 
rhonchus, whispering sounds and crackling over the upper lobe, with shrinking 
and uncovering of the heart; a troublesome cough, dyspnoea and loss of appetite. 
Respirations 26 ; the temperature varied from 97° to 101°; pulse 116 to 125. Bacilli 
in sputum. 
Result.-This case was confined to bed a good deal during the whole winter, on 
account of dyspnoea. Improvement was, however, noticeable by a slight expansion of 
the left chest and marked expansion of the right, taken by cyrtometric tracings. 
Pulse 92 to 100; temperature 97° to 99.4°; weight 7 stone, 12 pounds Bacilli undi- 
minished. 
Case xix.-Age twenty-three. Illness commenced three years ago with a cough 
and loss of flesh. There was dullness and imperfect entry of air in both apices, more 
marked on the left side, where crackling was heard. The mucous membrane of palate 
and fauces was pale and anæmic. Cough and yellow expectoration containing bacilli. 
Pulse 116 (sitting), 124 (standing), 140 (after examination of the chest); weight 8 
stone, 11 pounds. 
Result.-Cough almost gone and expectoration much lessened; air entered more 
freely in both apices and left base, but the dullness had not disappeared. Pulse 88 
(sitting), 108 (standing); temperature 97° to 99.6°; weight 9 stone, 11} pounds. 
Case xx.-Age forty-three. Was cured fifteen years ago, of a " breaking down of 
lung tissue" in left apex, by one winter's residence at Davos and several years spent 
afterward in South Africa. Recently, after a bad attack of bronchitis in Germany, a 
return of old symptoms appeared. 
There was considerable flattening of the right subclavian region, with impaired 
resonance ; moist rhonchi were heard over the whole of the lung, especially clear in the 
interscapular space ; vocal fremitus was not increased, nor was absolute dullness per- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
131 
ceived anywhere. In both apices there was a harsh expiratory murmur on deep respi- 
ration. Pulse 120 (sitting). Temperature varied little from the normal. Bacilli in 
sputum. Occasional cough, with muco-purulent expectoration. Weight 10 stone. 
Result.-During the portion of the winter (three months) spent at Maloja he had 
two or three attacks of feverishness in the afternoons, the temperature rising to 100.6°. 
At the end of three months, dry rhonchus was heard in the right lung and increased 
resonance in both lungs could be made out. There was a gain in strength and respira- 
tory power. Pulse 112 (sitting), 120 (standing). Temperature 100° (taken on feverish 
day). Weight 10 stone pound. 
This patient had to leave on business before completing a whole winter's residence. 
Case xxi.-Age thirty-three. Enjoyed good health up to four or five months ago, 
when haemoptysis occurred. The chest presented signs of congestion of left apex, dull- 
ness, increased vocal fremitus, slight bronchophony and harsh expiratory murmur. 
Pulse 76 (sitting), 100 (standing) ; intermits on deep inspiration. Temperature 98°. 
Weight 8 stone 12f pounds. 
Result.-All dullness of chest disappeared ; the expiratory murmur was still a little 
harsh on both sides of the chest, in the subclavicular regions ; otherwise there were no 
abnormal signs. Pulse 68 (sitting), 92 (standing). Temperature 98°. Weight 9 stone 
7 pounds. 
Case xxh.-Age twenty-two. Extremely bad family history (mother and three 
sisters died of phthisis). There was imperfect expansion of the chest, with cooing 
rhonchus in left apex, extending over the cardiac lobe, and heard plainly between the 
scapulae. Dry click in right apex ; slight expectoration, colored once or twice with 
blood. Pulse 88 (sitting), 104 (standing). Temperature 99°. Weight 9 stone 1| 
pounds. 
Result.-With the exception of a slight increase of vocal resonance over the right 
apex, there was no dullness nor abnormal sounds anywhere. Pulse 76 (sitting), 80 
(standing). Temperature varies from 96.8° to 98.1°. Weight 10 stone 3 pounds. Was 
able to take plenty of exercise, skating, snow-shoeing, tobogganing, etc. 
Case xxiii.-Age nineteen. Was in an anaemic and debilitated condition, from 
over-study. There were no signs of any damage to the lungs, but the expansion of the 
upper portions of the chest was insufficient, and the family history was bad. Pulse 
108 (sitting), 120 (standing). Temperature 98.4°. Weight 9 stone 8 pounds. 
Result.-Complete disappearance of anaemia and much gain in strength ; takes a fair 
amount of exercise. Pulse 92 to 100. Weight 9 stone 6) pounds. Expansion of chest 
increased one centimetre. 
The gain in weight being such a striking feature in the majority of these cases, I 
append a table of ages, duration of residence, etc. There is also a point in all chest 
troubles which I find useful in determining progress or retrogression, viz., the difference 
in the number of pulse beats in the sitting posture and standing position, after walking 
across a room. 132 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
No. 
Age. 
Duration 
of 
Residence. 
Weight 
Gained. 
Weight 
Lost. 
Diminution 
in 
Pulse Rate. 
Remarks. 
1 
26 
months. 
13 lbs. 
None. 
Remarkable improvement. 
2 
29 
<c 
2% lbs. 
0 
Great improvement. 
3 
24 
ll 
0 
16 
Improved. 
4 
49 
ll 
1 i'b. 
None. 
Slight improvement. 
5 
28 
4 lbs. 
4 
General improvement. 
6 
15 
16 
ll - 
22 lbs. 
26 
Remarkable improvement. 
7 
26 
ll 
4J4 lbs. 
0 
Great improvement. 
8 
20 
5 
Not noted. 
Not noted. 
Great improvement. 
9 
35 
fi 
4U lbs. 
4 
Great improvement. 
10 
27 
4% 
ll 
y lb. 
0 
All signs of disease disappeared. 
11 
32 
23 days. 
4% lbs. 
8 
Marked improvement. 
12 
45 
months. 
15% lbs. 
8 
All signs of disease gone. 
13 
20 
1 
4% lbs. 
8 
Marked improvement. 
14 
40 
3 
Not noted. 
0 
General improvement. 
15 
19 
4/4 
ll 
2 ibs. 
14 
Slightly better. 
16 
40 
1 
ll 
Not noted. 
36 
Marked improvement. 
17 
23 
4/4 
ll 
10 lbs. 
8 
All signs of disease gone. 
18 
37 
4 
ll 
5 lbs. 
16 
Slightly better. 
19 
23 
4'/4 
ll 
14'4 lbs. 
34 
Remarkable improvement. 
20 
43 
3 
ll 
1% lbs. 
8 
Slight improvement 
21 
23 
5*4 
8'4 lbs. 
8 
Great improvement. 
22 
22 
$ 
15J4 lbs. 
12 
Remarkable improvement. 
23 
19 
2 
1% ibs. 
16 
Improved. 
INFLUENCES CLIMATÉRIQUES ET SANITAIRES DES FORÊTS- 
DANGERS DU DÉBOISEMENT. 
CLIMATIC AND SANITARY INFLUENCES OF FORESTS-DANGERS FROM THEIR 
DESTRUCTION. 
KLIMATISCHE UND SANITÄRE EINFLÜSSE DER WÄLDER-GEFAHREN DER ABHOLZUNG. 
PAR LE DR. EUGENIO FAZIO, 
Of Naples, Italy. 
I. 
Messieurs.-L'homme à l'état sauvage, se trouva, comme tout animal et tout être 
vivant, au sein de la nature, en rapport immédiat avec celle-ci, et soumis par consé- 
quent à l'influence directe des différents agents qui en réglaient l'existence. Les ani- 
maux absorbaient l'oxygène libre de l'atmosphère, que l'exhalation des plantes renou- 
velait sans cesse, tandis que, contemporainement, les plantes s'appropriaient l'acide car- 
bonique fourni par les animaux. Les végétaux et les animaux puisaient ainsi à la sur- 
face de la terre dans cette circulation constante, et dans ces rapports d'échanges et de 
•dépendances, une vie puissante et vigoureuse. 
Une Flore variée et luxuriante, étendait, selon les latitudes et les altitudes, son riche 
manteau vital sur tous les continents Réglant la répartition exacte de la chaleur rayon- 
de de V électro-magnétisme, elle activait et tenait en équilibre l'échange 
des gaz entre animaux et végétaux-et préparait largement les conditions climatériques SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
133 
ou mésologiques sur lesquelles une Faune riche et variée se forma. La paléonthologie 
vint confirmer le lien étroit qui s'établit entre la Flore et la Faune pendant la longue 
période qui précéda l'apparition de l'homme, ou bien tant que celui-ci resta à l'état 
sauvage, sans cesser de faire partie intégrante avec la nature. 
Du moment que l'homme s'émancipe de la nature, il abandonne la vie sauvage, et 
entre dans le chemin sans bornes, difficile, solennel, de la sélection-lequel, après des 
milliers d'années, devait le conduire où. nous nous trouvons aujourd'hui, sous le soleil 
brillant de la liberté américaine, d'où nous pouvons suivre les efforts continuels que 
l'homme accomplit chaque jour pour se débarrasser de l'enveloppe dont il est sorti. Il 
a dû. se garantir des bêtes féroces qui peuplaient les forêts, et se prémunir contre tout 
ennemi; il a dû ouvrir un vaste et libre champ à l'agriculture, à l'élevage des bestiaux, 
à la vie en commun : pour cela il lui a fallu se garantir de l'inclémence des climats, se 
procurer les moyens de chauffage, de logement, de transport d'un point à un autre, et 
créer des industries relatives. Vraisemblablement toutes ces nécessités imminentes 
concoururent à son avancement. Il est certain qu'à mesure que sa civilisation se 
développait, il attaqua plus vigoureusement les forêts, au point de dépouiller une 
bonne partie de la surface terrestre, de ces facteurs météorologiques, climatériques et 
sanitaires. 
Le culte sacré que les Druides, dans les Gaules et en Ecosse, les Assyriens, les 
Grecs, les Romains et les Germains rendirent aux forêts ne fut point à lui seul, la ma- 
nifestation d'un sentiment poétique, mais l'expression fidèle de cette fine intuition que 
les premiers peuples civilisés reçurent des phénomènes et des lois de la nature. 
En Italie, les premiers travaux de défrichement, marquent l'époque de la corruption 
impériale, quand la volonté du plus fort avait force de loi, et que le patrice, gorgé de 
richesses, utilisa pour son propre avantage les sols déboisés, qui, au dire de Pline, cau- 
sèrent la perte de VItalie ; et ce fut seulement de ce moment, que Von commença à parler de 
la malaria. D'après Pline encore ce fut le christianisme qui, bravant l'inviolabilité 
sacrée que l'on attribuait aux forêts, ouvrit le chemin au défrichement. Aujourd'hui, 
non-seulement les vieux continents de l'Europe et de l'Asie déplorent les fautes des 
aïeux, que leurs descendants vivants n'ont pas réparées, mais, dans les nouveaux con- 
tinents même, la cognée aveugle du colon, et le feu destructeur du colonisateur, ont 
abattu et réduit en cendre, en quelques années, d'immenses étendues de forêts vierges ! 
IL 
Désormais les climatologues s'accordent à donner une importance climatérique aux 
forêts-comme réglant la chaleur rayonnante, l'humidité, Vélectro-magnétisme, les cou- 
rants et Impureté de l'air. 
Si d'un côté les arbres, par leurs branches, en interceptant les rayons solaires, mo- 
dèrent l'accumulation totale de la chaleur à la surface de la terre-de l'autre ils 
empêchent l'irradiation, et la déperdition de la chaleur solaire concentrée. Tandis que 
les climats des forêts-tout en étant plus frais-subissent de légers changements de 
température-les climats des terrains déboisés présentent des variations journalières ou 
annuelles de températures extrêmes : un froid intense et une chaleur suffocante. En 
sorte que le climat des forêts offre plus d'uniformité dans la moyenne de la température 
journalière et annuelle. 
Par un effet de l'action tempérée du soleil, qui fait que la température des forêts est 
toujours plus basse, ce qui empêche l'eau contenue dans le sol de s'évaporer, on ren- 
contre sous les ombrages épais un degré plus grand d'humidité relative. En effet, les 
courants d'air, chargés de vapeur aqueuse, en pénétrant dans le milieu ambiant le 
plus frais des forêts, viennent en partie s'y condenser et s'y arrêtent. 134 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Ces rapports constants pendant toute l'année dans les forêts à feuillage vert et persis- 
tant, sont bornés à la durée des feuilles dans celles à feuillage caduc. 
Il s'ensuit, de ce qui précède que, pour radoucir les climats froids,-surtout ceux 
des bas-fonds humides-foyers évidents de la malaria,-l'élagage des forêts est un 
moyen d'assainissement très utile. Dans les climats chauds et dans les localités sèches; 
il faut au contraire conserver les forêts et en créer de nouvelles dans les endroits où 
elles font défaut ; non seulement pour adoucir l'air, mais pour provoquer aussi la con- 
densation des vapeurs aqueuses et les pluies, sans lesquelles toute végétation ne sau- 
rait avoir lieu. En effet, différentes contrées de la Perse, de la Mésopotamie, de l'Idu- 
mée, jadis si florissantes par leur agriculture et par leurs pâturages, sont devenues des 
landes stériles et inhospitalières, depuis que les forêts y ont été détruites. Et aujourd'hui, 
dans la Caroline et dans P Alabama, les récoltes récentes commencent à s'épuiser ; on 
peut en dire autant de plusieurs vastes contrées de l'Italie, qui sont restées incultes 
parce qu'elles sont incapables de production. Tandis que, dans la Basse-Egypte, où il 
ne pleuvait jamais, les pluies sont devenues fréquentes et la végétation prospère, aussi- 
tôt après que de vastes plantations y ont été faites. 
L'entrelacement des racines des arbres et des petits conifères, des fougères, des thy- 
mélées (daphnés, rhododendrons, myrtilles, etc. ) en retenant les terres végétales sur les 
flancs abruptes des montagnes, régularisaient la distribution des eaux, qui, s'infiltrant 
lentement, allaient se réunir dans les vastes excavations souterraines des rochers, pour 
en jaillir de nouveau, limpides, fraîches et pures, dans ces sources que l'on suppose 
devoir servir d'aliment aux fleuves. Au contraire, les eaux en tombant abondamment 
sur les montagnes dépouillées de végétation arborescente, et ne rencontrant aucun 
obstacle à leur courant impétueux, s'échappèrent sur leurs flancs crévassés, et, entraî- 
nant les couches superficielles du terrain, envahirent avec impétuosité les vallées et les 
plaines. Une fois que le courant dévastateur se fut ouvert un chemin, il enleva chaque 
jour une certaine quantité de terre, et finit par creuser, peu à peu des sillons larges et 
profonds, où se formèrent les torrents, qui emportèrent des blocs ; et, poursuivant leur 
œuvre destructrice, créèrent dans la plaine des éboulements et des ravins. Les amas 
de roches désagrégées, les ciments, qui en soudaient les différentes parties, roulèrent 
avec les flots bourbeux et augmentèrent la désolation dans les espaces devenus stériles. 
Les fleuves, grossis dans leur masse, ne pouvant plus être contenus dans leurs lits pri- 
mitifs, débordèrent, en envahissant les plaines, en inondant les villes, en abattant les 
édifices, enfin, en semant partout la misère et la mort. D'un autre côté, les eaux ne se 
rassemblant plus dans les creux des montagnes, n'alimentèrent plus les sources, dont 
plusieurs disparurent pour toujours ; ainsi le volume des eaux des fleuves, dont le lit 
avait été comblé en partie par le terreau qui s'y était amoncelé, fut singulièrement 
réduit. Plusieurs parmi ces fleuves, tels que l'Ebre, le Guadalquivir, le Mançanarès, 
le Tibre et autres, en Europe, ne furent plus aptes à la navigation. 
Boussingault cite un certain lac isolé dans l'état de Vénézuela, dont la surface lim- 
pide comme une glace, se troubla aussitôt qu'on eut coupé les forêts adjacentes, et qui 
reprit son aspect primitif aussitôt qu'on eut reboisé. La superbe cascade du Palais 
royal de Caserte n'est plus qu'un simulacre de ce qu'elle était il y a vingt ou trente 
ans, et cela depuis que l'on a détruit les forêts oïl les eaux qui l'alimentaient prenaient 
leur source. Et comme on déplore les crûes des fleuves, on se plaint aussi quand 
l'eau manque, là où il y en aurait besoin. En sorte que les alluvions qui descen- 
dirent des montagnes et les débordements des fleuves, couvrirent de vastes bas-fonds, 
où les eaux en se corrompant formèrent des marais qui constituèrent d'immenses zones 
de mauvais air. 
Les forêts qui couvraient les flancs des montagnes et les plateaux élevés diminuaient 
la violence des vents au profit des vallées et des campagnes qu'elles dominaient. Par SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
135 
les coupes inconsidérées et trop étendues des forêts plusieurs climats des plus doux sont 
devenus tout à coup rigides et impropres à de certaines cultures. Et l'on est d'avis que 
les hivers plus cruels que ceux d'autrefois, qui désolent de nos jours la Suède, sont 
causés par les déboisements successifs. Le vent violent, qui souffle souvent en Pro- 
vence, se perdait jadis dans le feuillage des anciennes forêts des Cévenues. Les arbres 
faisaient la force des Alpes ; à présent ces majestueux remparts subissent une destruc- 
tion lente et continuelle, et leur ruine est accélérée par la cognée dévastatrice, qui fait 
que l'époque n'est pas éloignée où les vents du midi brûleront de leur haleine enflam- 
mée les plaines de la Haute-Italie, au milieu desquelles l'on remarque déjà une éléva- 
tion de température et une suite de saisons arides.-C'est précisément dans les Alpes 
françaises et sur le versant des Alpes suisses que les torrents produisent surtout leurs 
effets désastreux ;-car ces monts, complètement déboisés, sont directement exposés au 
souffle du Foehn, vent chaud, qui fond immédiatement les neiges, et amène, dans ce 
climat sec, de violents ouragans, que l'on voit se déchaîner à l'improviste sur ces 
coteaux à la croûte fragile. Les Alpes centrales, qui ont conservé une végétation boi- 
sée et herbacée, suffisante pour protéger le sol, et où. naturellement les pluies sont plus 
fréquentes, sont moins exposées à ces ouragans. Stoppani trouvait qu'il existait une 
relation très étroite entre le déboisement progressif des Alpes, et la disparition des 
glaciers, sur la hauteur et la déperdition des sources au bas des montagnes. 
Les forêts exercent une influence sur la (pluviométrie) périodicité des pluies et sur 
V électricité atmosphérique. Pour les causes que nous venons de développer, les forêts 
attirent les nuages et absorbent lentement la vapeur d'eau contenue dans l'atmosphère. 
Mathieu a calculé que la quantité de pluie qui tombe dans une région boisée est du 
six pour cent plus grande que celle qui tombe sur une région privée de végétation. 
Cette assertion a été confirmée par Satriaux et Fautral, qui ont constaté que, lorsqu'il 
tombe 421 mm. de pluie sur un sol nu, il en tombe 455 mm. au milieu d'un bois. Ainsi 
donc, les pluies sont beaucoup plus fréquentes sur un sol boisé, que sur les terrains 
incultes et pierreux, qui sont très souvent sujets à de violents ouragans. Les forêts, en 
provoquant des pluies plus fréquentes, débarrassent l'atmosphère de l'électricité qu'elle 
contient ; c'est pourquoi Arago comparait les arbres à autant de paratonnerres. Bec- 
querel, en marquant sur la carte les points où. les ouragans à grêle éclataient, a remar- 
qué que les forêts en étaient généralement préservées. J'ai eu l'occasion de vérifier 
plusieurs fois l'observation de Cantigril, qui suivit le cours d'un ouragan épouvantable, 
lequel traversa la partie Sud du département de l'Aude couverte de sapins. L'ouragan, 
venant dans la direction du N-0 au S-E, avait dévasté le département de l'Ariége avant 
d'arriver dans l'Aude. Au moment que la tempête atteignit la zone boisée, la grêle 
cessa de tomber ; mais, une fois parvenue aux Pyrénées-orientales, tout-à-fait privées 
d'arbres, la grêle recommença et dévasta cinq à six communes, qui se trouvèrent sur 
son passage: un fait remarquable c'est que plusieurs arbres furent réduits en cendre par 
la foudre. La grêle devrait être attribuée dans les régions déboisées, à l'évaporation 
trop rapide que subirait la pluie en traversant des couches d'air très sèches, lequel lui 
enlèverait tout calorique latent et en amènerait la congélation. Dans les régions 
boisées l'air étant toujours humide, l'évaporation de la pluie se fait plus lentement. 
Tant que la destruction des forêts ne dépassa pas certaines limites, les effets qui en 
dérivèrent se bornèrent aux proportions des localités qui en furent frappées; mais, 
quand la destruction des forêts devint presque générale, c'est-à-dire quand elle frappa 
tous les continents de l'hémisphère Nord, les dommages furent énormes et offrirent un 
accroissement géométrique épouvantable. L'homme, en dépouillant ces continents de 
leur manteau végétal, se constitua un facteur négatif, capable d'apporter des perturba- 
tions météorologiques, et par conséquent climatériques et sanitaires, d'une grande im- 
portance. En effet, c'est de nos propres yeux que nous assistons au spectacle de la suc- 136 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cession des deux saisons extrêmes (été et hiver) sans les deux moyennes de passage 
(printemps et automne) comme jadis. Aujourd'hui on passe de la chaleur extrême à 
un froid extrême, avec une rapidité surprenante, ce qui cause le plus grand mal à l'éco- 
nomie humaine, qui n'est plus à même de résister à de puissants ennemis opposés 
entre eux. Aujourd'hui on passe de la sécheresse la plus absolue, aux pluies torren- 
tielles, aux brouillards les plus épais, aux giboulées de neige, qui désolent les pauvres 
campagnes. 
Il ne se passe pas un mois sans que le Bureau météorologique de New York (Ar. F. 
Herald) ne signale une forte dépression atmosphérique avec un cyclone épouvantable. 
Arago affirmait que les orages étaient inconnus dans les régions arctiques, tandis que de 
nos jours ils sont si fréquents !-A la suite de notices exactes recueillies dans les Obser- 
vatoires météorologiques étrangers des différents pays de l'Europe, le Dr. Walikof a pu 
remarquer que les régions occidentales du monde ancien, avec leurs nombreuses forêts, 
ont une influence marquée sur la température des localités environnantes, et que l'ac- 
croissement normal de la température des rives de l'Océan atlantique à l'intérieur des 
continents en a été sensiblement modifié.-Les chaleurs de l'été sont plus intenses à 
l'intérieur des terres qu'au bord de la mer. Selon Walikof les forêts exerceraient une 
influence qui ne s'arrêteraient pas à leurs limites naturelles, mais qui s'étend tout 
autour d'elles, en raison de leur position, des essences des arbres qui les composent, 
et de la façon dont elles sont orientées. Il en résulte que l'homme, en déboisant 
certains points, et en en reboisant d'autres, modifie certainement un milieu climaté- 
rique. 
Il y a plus encore. 
Un déboisement très-étendu est la cause d'accidents sanitaires et économiques très 
importants. En effet, les changements brusques de l'atmosphère comme les chaleurs 
extrêmes qui succèdent au froid intense, la grande humidité et la sécheresse excessive, 
les courants d'air violents, etc. ont tous été cause de refroidissements et de nombreuses 
maladies. De même, les brusques dépressions atmosphériques agissant avec les ten- 
sions électriques extrêmes, sont une cause puissante de stimulations nevro-organiques. 
Et que dirons nous du trouble survenu dans l'échange des gaz qui devrait se faire dans 
l'équilibre établi par la nature? Non-seulement ici la production de l'oxygène a dimi- 
nué, mais de cet oxygène naissant, qui prend le nom d'ozone, qui possède tant de ver- 
tus oxydantes, et qui, vraisemblablement, est un puissant obstacle à la vie parasitique. 
Quant aux dommages économiques, il suffirait de consulter les régistres des différentes 
Administrations de l'Italie, pays qui en Europe est des premiers à déplorer les maux 
causés par le déboisement, qui s'est accompli sur les Alpes et sur les Apennins dans un 
si court espace de temps, pour en rester atterrés ! Un document très-récent publié 
par le Directeur de la Statistique du Royaume, Mr. le Comm. L. Bodio estime à 4,156,- 
401 hectares la surface boisée actuelle en Italie, sur 286,588 kilom. carrés de la surface 
totale. De sorte que les terrains boisés seraient à ceux qui ne le sont pas, comme 
1.69 !.. Il ne se passe pas une seule année que quelque région de l'Italie ne soit 
désolée par des inondations qui mettent souvent en danger l'existence de populations 
laborieuses, et pèsent lourdement sur le bilan de l'Etat. Il nous suffira de rappeler ici 
qu'en 1882, la surface inondée s'éleva, rien que dans les provinces de la Vénétie et de la 
Lombardie, à 234,016 hectares ; les dommages soufferts par les particuliers, montèrent 
à 130,000,000 de francs, et les dépenses soutenues par l'Etat pour les travaux les plus 
importants de réparations de routes, d'endiguements, etc. dépassèrent 20,100,000 francs. 
Au moment où nous traçons ces lignes (28 Mai 1887), il y a eu, dans toute l'Europe un 
abaissement très rapide de la température, accompagnée de neige, de grêle, de brouil- 
lards épais, de pluies torrentielles et d'inondations. Un télégramme de la Hongrie 
porte : " Entre Gross-Varadino, Karlsburg et Temeser toute la région est inondée. A SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
137 
Gross-Varadino, dans la partie basse de la ville, l'eau est montée jusqu'au second étage, 
en causant la ruine de beaucoup de maisons et en ensevelissant bien du monde ; les 
chemins de fer sont interrompus ; quatre-vingt villages sont détruits ; les récoltes sont 
perdues et avec elles, une grande quantité de bétail a péri ; les victimes humaines 
sont nombreuses, la misère est épouvantable ! " 
Dans les provinces méridionales la destruction inconsciente des forêts, faite en toute 
hâte et avec une précipitation aveugle, surtout pour la construction de 3240 kilom. de 
chemin de fer, a été la cause principale de l'accroissement de la muZaria, depuis une 
trentaine d'années, dans les localités renommées jadis pour leur salubrité. 
Oui, Messieurs, les maux, et les dommages d'ordre économique et sanitaire que les 
ditférentes Administrations de l'Etat et les particuliers ont à déplorer, comme consé- 
quence du déboisement, sont énormes, incalculables ! 
Une autre conséquence du déboisement, c'est la disparition de plusieurs espèces de 
quadrupèdes et de beaucoup d'oiseaux, lesquels, s'alimentant principalement de ces 
innombrables essaims de petits insectes qui pullulent dans la nature, garantissaient de 
l'attaque de ces parasites, une infinité de graines, et de tendres végétaux, ainsi que les 
écorces, et les feuilles des arbres, les bourgéons, les fleurs et les fruits. 
Il y a des contrées en Italie, où jadis de vastes terrains couverts de vignobles et 
d'arbres fruitiers étalaient des plantes prospères et d'un rendement abondant ; aujour- 
d'hui, ces contrées un peu à cause des chenilles, et des nombreux parasites, un peu par 
suite des intempéries, ne sont plus que des landes désertes et désolées. 
Il est inutile d'ajouter que, par la destruction des forêts un des principaux éléments 
de la vie, le bois, s'épuise rapidement ; peu à peu les pâturages en souffriront, aussi 
bien que les élevages des animaux à la glandée ; beaucoup de terres basses devi- 
ennent stériles par suite de fréquents es alluvions; et, non-seulement les cours des fleuves 
et des rivières feront défaut soit à l'arrosage des campagnes, soit, à la navigation, soit 
aux besoins domestiques, mais encore ils priveront de leur secours de nombreuses 
industries qui trouvent dans l'eau une immense force motrice à bon marché. Je ne 
craindrai pas, enfin, d'affirmer que le bilan des Etats sera éternellement compromis par 
les dommages incalculables que cause le déboisement. 
Illustres Collègues : 
En exposant à votre examen les idées qui précèdent, j'aime à croire que nous pour- 
rons nous accorder sur les conclusions suivantes, qui, selon moi, découleraient de ces 
idées mêmes :- 
I. Les forêts ont une importance climatérique et sanitaire indiscutable et de premier 
ordre. 
II. La progression arithmétique des maux qui ont succédé au déboisement rapide et 
inconsidéré, que nous déplorons aujourd'hui, ne tardera pas à prendre des proportions 
géométriques irréparables, si des mesures promptes et énergiques ne viennent y mettre 
obstacle. 
III. La Section de Climatologie et de Démographie du neuvième Congrès médical inter- 
national fait des vœux pour que tous les Etats civilisés se mettent d'accord afin d'arrêter 
l'aveugle destruction des forêts et quant au but de presser l'œuvre du reboisement. 
C'est par ces moyens là que la sentence des économistes pourra avoir sa solution : 
La civilisation en mettant le pied dans un pays détruit les forêts; arrivée à sa maturité elle 
les rétablit. 138 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CLIMATE AND MALARIA. 
CLIMAT ET FIÈVRE PALUDEENNE. 
ÜBER KLIMA UND MALARIA. 
BY JOSEPH PARRISH, M.D., 
Of Burlington, New Jersey. 
The use of the word malaria, as a cause of disease, and, indeed, sometimes as a dis- 
ease, is so common, and yet so inexpressive of the meaning intended to be conveyed by 
it. that I am prompted to suggest for your consideration certain inquiries, and offer 
statements, the tendency of which is to surround the dogma of the paludal origin of 
intermittent autumnal fevers with grave doubts as to its verity. 
The word is commonly employed, as you know, in connection with the disorders 
that occur in the autumn, which assume the type of intermittence, and are usually 
called ague, or chills and fever. In addition to this limited application of the word, 
it is nowadays fashionable with the profession to use it to designate complicated forms 
of intermittent disease, as malarial gout, malarial rheumatism, malarial neuralgia, etc. 
And, as we shall presently see, there is frequently a unity of cause, or it may be a 
vicarious transference of symptoms from one to another. 
In answer to the question: What is malaria? one practitioner, or author, informs 
us that it is a poisonous vapor which is exhaled from decaying vegetable matter. 
Another calls it a specific spore, or microbe, that is peculiar to swamps or marshy 
lands, and which, under certain degrees of heat, is set free, and poisons the atmos- 
phere. Another prefers to define it as an impalpable virus, which cannot yet be 
accurately described, but continues to occupy the realm of mystery, and must so remain 
until some future microscopist, or yet unborn chemist, shall succeed in eliminating 
the toxic element, whatever it may prove to be, and expose it for inspection and 
credence. 
These malarial disorders are prevalent in hot climates, or that season of the year, 
in any climate, when the change of temperature from hot to cold is the most decided 
both as to suddenness and intensity. Some observers amuse themselves by describing 
isothermal zones, which correspond in their boundaries with geographical districts that 
are supposed to be malarial, and thus imagine that they have discovered a correspond- 
ence between marsh and disease which they take to be final and conclusive in confirma- 
tion of the theory that marsh poison is the chief factor of periodical fevers. 
Assuming now that we may look elsewhere for the source of intermittents than 
among swamps, marshy meadows and the muddy shores of creeks and rivers, the fol- 
lowing inquiry seems to be in place:- 
"If it can be shown that the characteristic chill, fever and sweat prevail in moun- 
tainous, rocky and arid places, may not the marsh theory be excluded even from local- 
ities where marsh is the prevailing type. ' ' * This is a pertinent inquiry. It opens the 
way to a very wide field, which may be explored with profit by the careful and patient 
student. He will not belong in discovering that the focus of the (so-called) malaria is 
located in the tropics, and that its career is as erratic and uncertain as are its various 
definitions and descriptions. It will also be found that there are other diseases com- 
plicated with what we recognize as malarial fevers which may occur at the same time, 
in the same locality and not infrequently in the same person. 
Mr. Haspel observes the frequent association of intermittent fever with dysentery 
* Transactions of New Jersey Medical Society for 1886. Presidential address, p. 39. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
139 
and affections of the liver. ' ' The transformation of these three morbid states, one into 
the other, and their alternate succession-are these not proofs that they depend upon 
the same cause ? One cannot refuse to recognize between these maladies, so unlike in 
appearance, a very great affinity-points of contact, intimate and numerous-and, in 
short, a family connection." * 
14 Bronchitis is a common accompaniment of remittent fevers in India, and in the 
hospital at Bombay pneumonia is the most usual of all the inflammatory complications 
in asthenic subjects." f Of the fevers which occurred during the American war, Robert 
Jackson observes as follows : "Indeed, the intermittent, the dysentery, and even the 
dropsical swellings, so alternated with one another as evidently showed that they all 
depend upon the same general cause." J Blane says of fever and dysentery-"The two 
diseases may be considered vicarious." § Dr. Oldham, author of "What is Malaria? " 
from whose valuable book these extracts are taken, says, that 4 4 Malarious fevers, dys- 
entery and hepatitis may appear at the same time and under the same circumstances 
of exposure, and that any two of them may appear at once in the same individual." 
A. K. Johnson declares that "the circumstance of intermittent passing into remittent, 
and remittent into malarious yellow fever, often terminating in intermittent-facts 
observed not only in the East and West Indies, but on the continent of America and of 
Africa, demonstrate a unity of cause as firmly as the best established facts in medicine. " || 
Admitting this identity of cause, is it not logical and consistent to accept as true an 
identity of type ? If the fever is due to an organic poison, why may not the pleurisy, 
bronchitis, and other diseases be attributed to the same cause? Reversing the question, 
if these disorders are due to cold-to chill, which is the common belief, why not assume 
that they are caused by miasmatic poison, and not by chill ? 
So much concerning causation. 
We now approach a most interesting feature of intermittents, namely, their period- 
icity. A common opinion seems to prevail within the profession that this periodicity 
is in consequence of a peculiar element or quality of the poison, imparting to the con- 
stitution an impression which becomes permanent, and giving to other diseases which 
may appear from time to time in the same individual the same intermittent feature; 
but it seems to me that this view is singularly hypothetical, and is used without any 
warrant drawn from nature or experience. It is certain that the human constitution is 
subject to the law of periodicity in very many of its evolutions. From the dentition of 
infancy, through all the changes of puberty, manhood, and the decline of functional 
activity in advanced life, there are periods, well marked as to time and condition, which 
display the growth and development of the race with a regularity and certainty that 
may be considered characteristic. And if such law governs the normal state, why may 
it not respond to morbid impressions and become as rhythmical as any other vital 
movement. 
Salter says that " There are three kinds of periodicity in disease. One in which it 
is produced by the periodical return of its cause, as the recurrence of hay fever every 
summer, the morning expectoration after a night's rest, indigestion every day at a 
certain hour after dinner. Another, in which the periodicity seems to depend upon 
that rhythmical impress which is stamped on the functions ; that sort of diurnal oscil- 
lation in which the body is swung by the constant recurrence of one unvarying daily 
interval of the habitual actions and passions of the body." He thinks that "ague 
acquires its periodicity from the diurnal heat into which the body falls." 
* Oldham's " What is Malaria ? " p. 183. 
f "Diseases in India," v. 73, taken from Oldham's "What is Malaria?" p. 183. Dr. More- 
head. J "On Fevers," p. 303. 
£ " Disease of Seamen," p. 449. || See Aitken, Vol. n, p. 1048. 140 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
C. H. Jones says, " It seems to me that periodicity has no relation to the cause of the 
disorder. Malarious disorders are very commonly periodic, but are also very often not; 
and other painful maladies which have nothing to do with malaria, but depend on 
organic lesion, are sometimes typically periodic." 
Other forms of disease occur in place of chills at regular periods, notably asthma, 
neuralgia, etc. Salter calls attention to the periodicity of asthma. He says: "It is 
one of the few diseases that can be strictly pronounced periodic. It is not merely par- 
oxysmal, it is periodic; the paroxysms occur at regular and definite periods. In others, 
however, the regularity is more curious; as the period characteristic of the particular 
case recurs, the attack is predicted with the greatest certainty, and never fails to appear 
at the right time-never misses, never anticipates, never postpones." Spitka describes 
a periodical insanity and epilepsy. Folsom and Mann do likewise. Migraine is another 
affection which takes on the periodic type. Dr. Wharton Sinkler has seen a number 
of cases where attacks occurred on Sunday and at no other time. 
As to treatment, but little need be said. Quinine and arsenic are the principal drugs 
that are used; and by a curious coincidence quinine seems to be equally efficient in 
curing the paroxysms, whether used by the advocates of marsh poison to antidote the 
poison, or by the advocates of cold or chill as the cause, to give tone and resisting energy 
to the nervous system. Both sides have an equal claim to the drug as a final cure of 
the intermittent seizure. Of course there are other remedies which are employed, as the 
practitioner may determine. 
One feature in the treatment may be referred to as sometimes equally efficient in its 
use, but without any pretension to legitimate medicine. I refer to charms, amulets, 
incantations, prayers, and such shocks as are produced by fright, grief, or any 
similar impression. These have all been used with good effect upon a certain class of 
patients, bat they certainly have no antiseptic or antidotal properties, acting, as they do, 
psychologically, and making no pretension to legitimate medicine. 
To conclude the subject in a few words, the following may be summarized :- 
1. It is admitted that the cause of the diseases that are complications with mala- 
rious fevers is exposure to cold. 
2. That by the rapid evaporation from the body, which means the withdrawal of 
animal heat, all the symptoms which are said to be due to local emanations from the 
soil may be produced, without the presence of a specific poison. 
3. There seems to be no locality called malarious where fever may not occur from 
cold or chill, the very conditions being present which are productive of chill. 
4. Inasmuch as excessive heat depresses vital energy and predisposes to chill, it is 
important to protect the body from sudden change of temperature to a lower degree, and 
thus avoid chill. 
These thoughts and conclusions seem especially in place at this time, from the fact 
that the tendency of the profession is to overlook conditions and causes of disease that 
are near at hand, and patent to the senses, and to penetrate the domain of the unknown, 
seeking for influences in the microscopic world to discover invisible and impalpable 
essences, of whose existence nothing is known. While I would not discourage scientific 
investigations to the remotest realm of observation for the advancement of science and 
the benefit of mankind, I would not overlook what is at hand nor be carried away by 
a germicidal wave that is just now sweeping through college halls and private offices 
of the profession, lest it may be said, as Dr. Dewy has put it- 
' Hepatic doctors now are seen no more, 
1 \e hunt for bile has long been given o'er, 
Whoever would a reputation make, 
Deserts the bile-the bugs to overtake." 141 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
MEDICAL TOPOGRAPHY OF CALIFORNIA. 
TOPOGRAPHIE MÉDICALE DE CALIFORNIE. 
DIE MEDICINISCHE TOPOGRAPHIE CALIFORNIENS. 
JOHN WORCESTER ROBERTSON, A.B., M.D., 
Of Napa, California. 
California, because of its equable temperature, its mineral springs, its beautifully 
located health resorts and its scenery, is attracting invalids from all over the world, 
and their reports are so favorable, such wonderful cures have been recorded, and so 
strong is the testimony as to the efficacy of its climate in the arrest of consumption 
and the restoration to health of those afflicted with other chronic diseases, as to attract 
the attention of sanitarians and to develop a widespread interest among all who are 
investigating the influence of climate over disease. 
Many statements have been made, and much credit given, that are not strictly war- 
ranted by existing facts. While our climates are delightful, an'd so varied as to suit all 
diseases that climate can benefit, yet it must be confessed that the majority of patients 
come but to die, and that many receive not the slightest amelioration of their symptoms. 
There is much ignorance among physicians in regard to our various climates and their 
probable therapeutic effect, and, for this reason, it seems well, for their better guidance, 
to place before this Congress such information relative to the location and topography 
as will explain the temperature, humidity and other climatic features common to the 
greater portion of California, as well as to point out the local and varied attractions 
which render it so peculiarly delightful to the invalid. 
GEOLOGY. 
The geology of California is extremely interesting, differing, as it does, from the 
region east, and presenting certain features rarely met with elsewhere. America was 
upheaved from east to west. The Appalachian, Rocky, Sierra Nevada, and, lastly, the 
Coast Range of mountains, successively emerged from the ocean. 
The Sierra Nevada dates no further back than the cretaceous period, and on its 
western slope, as well as over the intervening valleys, and composing the whole of the 
Coast Range, are vast cretaceous beds. This was all raised during the tertiary period, 
the majority of it being miocene, while in certain places it dates as recent as the post- 
pliocene. It is not rich in fossils, and certain portions are so barren as not to furnish 
satisfactory data by which the age can be determined. 
It differs from tertiary found elsewhere, in that metamorphic rock is abundant. 
In Northern California the majority of the high mountains are but cones of extinct 
volcanoes. Mount Shasta, which rises to a height of fourteen thousand four hundred 
feet, out of a plain two thousand feet high, is of this character. A most remarkable 
example of this is a peak known as Goose Nest, also in Northern California, and but a 
few miles from Shasta. The upper third of the mountain is covered by a mass of 
scoriae, while on the top of the old crater are flues descending into the mountain, in as 
perfect condition as if the fires had died but yesterday. All of this country, as well as 
the region surrounding, is covered by débris, and there is every indication of recent 
volcanic action. The tertiary strata, while not violently displaced, show many fissures 
and much local disturbance. 
In the extreme north of the State, and covering hundreds of square miles, are the 
' ' lava beds " ; as the name indicates, they are composed of cooled masses of la vatic 
overflow. 142 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Through the Shasta and Sacramento valleys are found volcanic products and masses 
of metamorphic rock, gneiss and the various schists being extremely abundant, while 
obsidian and other rocks which have undergone vitrification are of frequent occur- 
rence. Along the coast serpentine forms a great portion of the bed rock. The Coast 
Range, in Central California, presents many interesting features. 
Though mineral springs are found both on the mountains and in the plains, they 
are here in the greatest numbers. Having been formerly an ocean bed, the various 
salts occur in great abundance, and every stratum is largely composed of and satu- 
rated with them. Probably because of recent volcanic action, and the still uncooled 
masses of lava, earthquakes are of most frequent occurrence, and through fissures thus 
formed water flows; in its passage upward it becomes impregnated with the minerals 
contained in the broken strata. Either because of the depth of origin, or heated by 
local masses of uncooled lava, very many of these are warm-in a few instances boiling. 
In one canyon alone over three hundred have been counted, and in the radius of a few 
miles there are probably a thousand. They contain the greatest variety of mineral 
salts. Many have been analyzed, but the great majority are either unanalyzable or the 
analysis given cannot, for many reasons, be considered accurate. 
Geologically, Southern California is not attractive. The mountains near the coast 
are of the tertiary period, while the vast country inland, having so recently been the 
bed either of the ocean or brackish lakes, is covered with alkaline deposits. 
TOPOGRAPHY. 
Situated midway of the north temperate zone, between latitude 42° on the north 
and between 32° and 33° south, California stretches seven hundred and fifty miles 
north and south, with an average width of two hundred and fifty miles. Its western 
boundary borders on the Pacific Ocean, while the eastern, conforming to this line, so 
bends as to appear angular. The topography of California deserves a careful study, for 
on it depends the climate of the inland valleys. 
The northern half is much more diversified by mountain and valley than is the 
southern. Prof. Whitney has traced five distinct belts running north and south, at an 
average distance from each other of fifty-five miles. For our purpose no subdivision of 
the Coast Range will be recognized, thus leaving four well-defined chains, which, by 
their conformation, so affect the country adjacent as to greatly modify the climate. 
This they may do either by reason of their height, shutting off the coast winds, or, by 
a break, allowing it to have a tempering influence. The Sierra Nevada, on the eastern 
border, rises abruptly from ten to twelve thousand feet. 
The Siskiyou range, separating from the Sierra-with which, further north, it is 
identified-breaks through the middle of Northern California, and, stretching due 
south, ends in the coast range near Cape Mendocino. It has an average height of six 
thousand feet and its lowest pass is five thousand feet. Between the Siskiyou and Sierra 
Nevada lie the Shasta and Scott valleys, the former containing, probably, fifteen hundred 
square miles, the latter not over six hundred. 
The Coast Range parallels the shore of the Pacific and stretches the entire length of 
California. Few of its peaks rise above five thousand feet. The hills composing it are 
not, as a rule, precipitous, and are evidently the result of but a moderate upheaval. 
The range is from thirty to seventy miles in width, and there are many sculpturings 
due to aqueous erosion. The foot-hills are but a few miles from the shore, and gradually 
rise, in many places becoming a part of the Coast Range. Between the foot-hills and 
the Coast Range, and also between the various ridges of the Coast Range, are found 
California's most beautiful valleys. 
Near Cape Mendocino the foot-hills, Coast Range and Siskiyous meet. They extend 
back a hundred miles, but break within a few miles of the Sierras. From this point 143 
the Coast Range and Sierras separate, and, to the south, include the great Sacramento 
and San Joaquin valleys. The outlet of these valleys, and of the Sacramento and San 
Joaquin rivers, which drain them, is the Bay of San Francisco. The San Joaquin 
valley is but a continuation of the Sacramento, being bounded by the Coast Range on 
the west and the Sierras on the east. These chains separate still more as they go south, 
leaving a broad, gradually-rising valley, which finally reaches its southern limit at the 
Tehachapai mountains, an offshoot of the Sierras. Through the Tehachapai Pass access 
to the lowlands of Southern California is gained. A large part of the eastern portion 
is a desert, spreading out in low-lying alkali plains-unwatered, and, therefore, unin- 
habitable. There are "sinks" found here which are below the level of the ocean. 
The central portion, more elevated, has a regular rainfall and produces bountifully 
where irrigation is possible. 
The Coast Range breaks as it reaches Southern California, and is smoothed off into 
low-lying hills which allow cultivation to their summits. Directly along the coast and 
extending twenty and thirty miles inland there is a most pleasant country, delightful 
by reason of climate, scenery and many natural advantages. Here, man has done 
much to assist nature in the production of a most useful sanitarium. 
DRY SUMMERS AND WINTER RAINS. 
From the middle of May till the middle of September rain seldom falls. The 
winter rains, as a rule, do not commence before October or November. 
Where, within the tropics, the northeastern and southeastern trade winds meet, is a 
region of calms and rains. This belt moves northward and southward with the sun's 
declination. Where, within the temperate zone, the northern and northwesterly winds 
from the polar regions meet the westerly return trade winds, is a region of storms and 
rains. These belts also follow the sun's declination north and south. Applying these 
laws to this coast: At our midsummer the vertical sun would be on the tropic of Cancer, 
and, in that vicinity, the northeasterly and southeasterly trade winds would meet, 
create ascending currents, consequently calms; this air, laden with moisture, would 
rise into cooler regions, when a portion of its moisture would be precipitated, making 
tropical rains; it would then flow north and south toward the poles. Confining our 
attention to that portion which would flow toward the north pole, the larger part of it 
must descend to the earth within 30° of latitude, under the law, as stated by Professor 
Henry; as in going north it continually has to pass over a portion of the earth which is 
moving less rapidly than the portion it has left, it is deflected and becomes a southwest 
wind. The greater part of this upper current having descended to the earth within 
30° and returned to join the trade wind, the remainder would flow toward the pole, 
portions descending in its course at all points where the rarefaction of the air near the 
earth's surface would permit. These descending currents cause the local variable winds 
of our temperate zone, but the aggregate of all of them is the prevailing southwest 
return trade wind. The descending currents cannot give rain, as they only fall to the 
earth when they become colder than the air near the earth's surface. In falling they 
are constantly arriving at places of warmer temperature than those they have left; 
therefore, they change to a condition of taking up moisture rather than of parting with 
it. Where the great body of the descending return trade wind reaches the earth, 
between latitudes 28° and 35° must, therefore, on this coast, be comparatively a rainless 
region. Other lessening portions of the upper current would pass on until they met 
the prevailing northerly wind from the polar regions, when their temperature would be 
lowered and their moisture condensed and fall as rain. The conflict of this descending 
current with the polar wind would create storms and give rise to electrical phenomena. 
The prevailing northerly polar wind reaches to about latitude 60°, varied by the 
declination of the sun. 
SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 144 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The cause of this dry season is supposed to be the return trade winds, deprived of 
their moisture, which prevail during the summer months. 
On the other hand, beginning in September, the wind currents are from the south. 
These winds are saturated with moisture from the Gulf of California and other south- 
ern tropical seas. They lose but little moisture passing over the hot deserts and valley 
of Southern California, and it is only as they reach the cool coast, from Santa Barbara 
northward, that they deposit much rain. The further north they go the more are they 
affected by the coolness incident to a higher latitude. 
For the same reasons it has been supposed that moisture-bearing west winds would 
deposit more rain in the northern than in the southern part of California. It is not 
probable that this increased rainfall is due altogether to a colder latitude. The tem- 
perature is not such as to be a powerful condenser. The mercury seldom falls below 
50° F., and, if it were this temperature that condensed the moisture of the west wind, 
the condensation should take place in the summer as well as the winter, the variation 
in temperature between these seasons being slight. During the months of October, 
November and December, 1885, an unusually large amount of rain fell on the northern 
coast, but during this time the temperature did not fall below 60° F., and no snow 
fell either on the Coast Range or in the Siskiyou mountains. 
Beside the moisture-bearing south and southwest winds, are the west winds, which, 
in their course with the Japan current, absorb much moisture, and certainly aid power- 
fully in giving the northern coast a large rainfall. 
Paucity of observations forbids precision in locating storm centres. However, much 
valuable information can be gleamed from the official report of the masters of coasting 
vessels, as well as the eminently scientific researches of Professor Davidson. The fact 
is well established, that the storm centres of nearly all tornadoes which visit the 
Pacific coast originate far north and travel southward at the rate of about 150 miles a 
■day. Many of these go no further south than Cape Mendocino, latitude 40° 20'. 
Crescent City, latitude 42°, has an annual rainfall of 80 inches. . San Francisco, lati- 
tude 38°, has only 25 inches. 
DISTRIBUTION OF RAIN. 
During the wet season the clouds are from the west and southwest, and are satu- 
rated with moisture. They flow over the lowlands of Southern California and deposit 
but little of their moisture. San Diego, directly on the coast, receives but ten inches. 
Los Angeles, higher up in the foot-hills, has seventeen. San Bernardino, still further 
westward, has sixteen. Beyond, in the eastern portion of Southern California, the rain- 
fall is not over two or three inches. As the country is level, hot and without vegeta- 
tion, it exerts no power of condensation. The moisture-bearing winds following the 
coast impinge against the Coast Range and deposit a greater amount of moisture on the 
western than the eastern slope. A cooler latitude and the greater altitude of the range 
cause an increased rainfall as they go further north. Those clouds passing further 
inland are but little influenced till they reach the Tehachapai mountains; these cause 
a sudden rise of rainfall. From two to three inches at Mohave it increases to fifteen 
inches at Tehachapai, on the top of the mountain. Just beyond, the low, hot, sandy 
valley of the San Joaquin again causes a decrease of moisture. There is an average of but 
three inches at Bakersfield ; this gradually rises to six at Tulare, nine at Fresno, eleven 
at Merced, and thirteen at Stockton. Passing into the Sacramento Valley, there are ten 
at Sacramento, fifteen at Colusa and twenty-seven at Red Bluff. The stations mentioned 
are on a line with the centre of the valley. 
Going west or east from this central line the rainfall increases because of altitude. 
This increase is much greater on the east. The western slopes of the Sierras have a 
largely increased rainfall. This is well illustrated by comparing the rainfall of Sacra- 
mento, which is twelve inches, with that of Placerville, twenty-five miles due east, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
145 
where the rainfall is forty-six inches ; or Marysville, having sixteen inches, with Nevada 
City, which is about thirty miles east, on the slope of the Sierras, where the rainfall is 
fifty-six inches. As the highlands in the northern Sacramento valley are reached, the 
rainfall increases, and at Shasta, where the Siskiyous, Coast Range and Sierras meet, 
there is the heaviest rainfall in the State-excepting only the adjacent coast. From 
twenty-seven at Red Bluff the rise is rapid, reaching seventy or eighty inches at Shasta, 
but forty miles north. 
TEMPERATURE AND CLIMATES. 
The great Japan current which, leaving the Indian Ocean, flows along the eastern 
coast of Asia until, touching the western continent, it is deflected southward, closely 
hugs the western shore of North America. Although, leaving the Indian Ocean as a 
warm current, it becomes cooled rapidly on its way north. 
According to the report of Prof. Davidson, who has made a careful study of this 
stream, it reaches the coast of California with a temperature of 14° C., which gradually 
increases to 17° C. off San Francisco. From this point southward it rises more rapidly, 
owing to hotter latitudes. It may roughly be said to increase 1° to 2° C. for every 
degree of latitude south. 
The width of the current is seven hundred miles. The westerly winds of summer 
and the southwesterly winds of winter bear with them the uniformity of temperature 
of this large mass of water, rendering the coast warmer in winter and cooler in summer 
than it would otherwise be. It also equalizes the temperature, giving Santa Barbara, 
latitude 34°, almost as cool a climate as has San Francisco, latitude 38°, or Crescent 
City, latitude 42°. The temperature along the coast seldom rises above 21° C. or falls 
below 5° C. The lowest average is 11° C. for the month of January, the highest 17° C. 
for September. The average temperature of the months vary from 12° C. to 14° C., the 
mean annual temperature being 13° C. The mean isotherm of 11° C. which passes 
through New York, latitude 41°, bears northward as it crosses the continent, touching 
the Pacific at Vancouver's Island, latitude 49°. Nature also draws isotherms in her 
distribution of trees and plants. While, on the eastern coast, latitude 60° is the northern 
limit of coniferæ, they are found as high as latitudes 68° and 70° in regions adjoining 
the Pacific. It is thus evident that the climate of Northern California is much more 
temperate than that of the Eastern States which are situated in the same latitudes. 
This does not hold true of Central and Southern California. San Francisco and Wash- 
ington, in the same latitude, and having the same mean annual temperature, have 
climates very dissimilar, owing to the great difference between the mean summer and 
winter temperatures of Washington, which amounts to 22° C., and the small difference 
in San Francisco being not over 6° C. San Diego, in the same latitude as Charleston, 
is 5° C. cooler. 
Isothermal lines, which normally run east and west, are, as they near the coast, so 
deflected as to run north and south and define three distinct climatic belts. These may 
be named coast, valley and mountain, and while they resemble each other in having 
only two seasons, they are dissimilar in other respects, each presenting peculiar attrac- 
tions for different classes of invalids. These differences depend upon the topography 
of the country and are of degree rather than kind, altitude, distance from the ocean, 
and situation with reference to mountain chains giving to each region its characteristic 
climate. That of the coast extends only a few miles inland, but stretches five hundred 
miles north and south. It is characterized by a mild temperature, which varies little 
summer or winter, a fresh sea breeze during the warm part of the day, fog in summer, 
and an abundant downpour of rain in winter. Here perpetual spring is found ; the 
trees being principally fir, spruce and redwood, and the grass always green, the vege- 
tation presents both summer and winter, a pleasing contrast to that prevailing in the 
valleys and mountains of the interior. 
Vol. V-10 146 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
While, strictly speaking, the coast belt extends but a few miles inland, there is a 
modified coast climate reaching many miles from the ocean, embracing the valleys of 
the foot-hills and the western slope of the Coast Range. It also includes the coast region 
of Southern California. It possesses a climate in some respects superior to that of the 
more bracing coast ; the heat of the interior valleys, modifying the rawness of the coast 
breeze, raises the temperature and produces an agreeable balminess that has given these 
regions their great climatic reputation. Here the thermometer may rise during the 
hottest days to 30° C., or during the coldest winter nights may fall to 5° C. Taking 
Los Angeles as a type, the mean temperature of the hottest month is 20° C., that of 
the coldest 12° C., while the mean annual temperature is 16° C. The valley belt, 
beginning with Shasta on the north, extends down through the Sacramento and San 
Joaquin valleys into the Mojave Desert and plains of San Bernardino. While the Coast 
Range protects to a certain extent, there are certain breaks through which the sea breeze 
has access to the heated plains and acts powerfully in moderating their temperature. 
Wherever these passes occur, the coast breeze, sucked in with great force because of the 
vacuum formed by the heated air rising from the valleys, bears with it fog and moisture. 
This is more especially noticeable at San Francisco. The two great valleys of California, 
the Sacramento and the San Joaquin, here meet, and the Golden Gate presenting no 
barrier, allows the breeze to pass unimpeded. Those places first reached by this breeze 
have their climates decidedly influenced, but as it flows north and south they gradually 
lose their power to modify. 
Sacramento, eighty miles east, has a climate that compares favorably with that of 
Los Angeles, being but little warmer in summer or cooler in winter. Further north 
the heat becomes greater, the thermometer ranging from 28° C. to 33° C. At times 
during the hottest days it rises over 38° C., and has reached 46° C. Because of the 
dryness of the atmosphere and the constant breeze, the heat is easily borne, evaporation 
from the surface of the body taking place with great rapidity. The temperature of the 
southern portion of the San Joaquin valley is very much the same as is that of the 
northern Sacramento, the same conditions being present. While the summer tempera- 
ture of the Shasta valley resembles that of northern Sacramento, the winter temperatures 
differ widely. The Siskiyou mountains absolutely shut off Shasta valley from the 
coast wind, and the modifying influence which it would exert is lost. Here there is a 
regular succession of the four seasons, and they are well pronounced. 
During the winter the warm coast breeze exerts a marked influence over the whole 
of the Sacramento and San Joaquin valleys. The average of the mean temperature for 
the six winter months is 10° C. While the moderation is probably due to the coast 
breeze, much also depends on their location, with reference to the Sierra Nevada range. 
This, rising rapidly, protects the valley from the cold polar winds. While the western 
slope is covered with green grass, and flowers bloom and fruit ripens in the open air, 
the eastern is barren, cold and often buried in snow. 
The valley belt may be said to include the western slope of the Sierras up to five 
thousand feet. Above this line both the summer and winter temperatures become less. 
No observations have been taken that will allow any trustworthy statement. It is well 
known that the climate is temperate, and that the atmosphere is dry, bracing, and during 
the summer, mild. 
THERAPEUTICS. 
Unfortunately there is but little trustworthy testimony to be collected from the vast 
number of invalids who annually visit here. They go from place to place, restless and 
despondent, because too often they receive no benefit. They but seldom seek medical 
advice, using mineral waters that may happen to be near them, or selecting a location 
for reasons not always medical. Experience has taught physicians that certain diseases 
originate on the coast while others are more prevalent in the valleys, and it is hoped SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
147 
that when the various facts now being collected are properly tabulated, much valuable 
statistical information will be at our command. 
At present but a brief summary can be made. 
It is well known that certain diseases select their location, and under the favoring 
influence of moisture, heat, filth and lack of drainage, so readily develop as to be called 
epidemic. These cannot be properly claimed to belong to any one climate or locality, 
depending, as they do, on removable causes. Even these diseases are powerfully 
influenced by the coast climate and cold ocean breeze. San Francisco, poorly quaran- 
tined and exposed to infectious diseases because of its connection with Asiatic ports, 
is practically free from epidemics. Though smallpox is monthly imported, it seldom 
spreads beyond the pest-house. While the seaport towns of Mexico and South America 
are ravaged by cholera, it has never appeared here. There are certain diseases which 
the location of the country, its temperature, its moisture or its dryness, its heat or cold, 
and other climatic conditions peculiar to it render endemic. The more pronounced the 
climate, the more likely are these types to be well defined. The coast climate is peculiar 
in that the mean temperature of no month materially differs from the mean annual 
temperature ; that during the summer fog is almost daily present, while in winter the 
rain is abundant, giving during both seasons a cool, moist atmosphere. Another most 
important factor of our climate is the constant west wind blowing from the Japan cur- 
rent, with a temperature of 12° C. Because of these climatic surroundings, rheumatism 
and neuralgia are most frequently developed, and all such cases are unfavorably influ- 
enced by the climate. Bronchitis and catarrh are also prevalent. Consumption seldom 
developes, and in the early stages, when uncomplicated by bronchial lesions, a residence 
here is beneficial. 
Idiopathic erysipelas is of extreme frequency, while puerperal fever is almost 
unknown. The winds undoubtedly act as a germicide. Diseases which are supposed 
to be caused by germs are of rare occurrence. Diphtheria, typhoid fever, smallpox 
and cholera are unknown. Measles and scarlatina come only as light rashes with little 
or no fever. Malaria never originates here, and, when brought from the interior, 
rapidly assumes a remittent type and recovers without the aid of medicine. 
In San Francisco and other centres of population the incident impurities are suffi- 
cient to overcome the sanitary influence of the wind. Filth and lack of drainage pro- 
duce epidemics of diphtheria and the malarial fevers, especially in certain low-lying 
wards of San Francisco, where the ground is made by filling in old marshes. 
In those localities somewhat removed from the coast, but still influenced by the 
ocean breeze, a similar class of cases are found, but in a modified form. The winds do 
not exert so profound an influence, either in cooling or purifying the atmosphere. 
Typhoid and other continued fevers not unfrequently occur, but as a whole the climate 
is salubrious. 
The Valley Belt presents but few attractive features and does not call for more than 
passing notice. During the summer the heat is intense at mid-day, but pleasant at 
night. Evaporation is rapid, both from the body and respiratory organs. This dries 
the mucous membranes and parches nose, throat and bronchial tubes, producing catarrhs 
and bronchial irritation. 
In certain localities, where irrigation is practiced and large tracts of land are over- 
flowed, there is a prevalence of malarial diseases. Collections of filth and improper 
drainage are here followed by swift retribution. There are no extraneous sanitary 
influences which prevent germ development, and the surroundings are such as to render 
it prolific of disease. In winter, however, it is a popular resort for invalids, because 
of the mildness of its climate. 
The temperature of the mountain being cooler than that of the valley, and the 148 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
atmosphere being dry, bracing and invigorating, are hopeful signs that much thera- 
peutic benefit is to be derived from a residence here. 
Because of the rainless summers and cool nights, camp life can be indulged in. 
The streams abound in fish, and the mountains are the homes of many kinds of wild 
game, thus furnishing a pleasant occupation for those who desire sport, and inducing 
that amount of exercise necessary to vigorous health. 
But few locations have been made, and the country is sparsely inhabited. No sta- 
tistics have been gathered as to prevalent diseases. Experience teaches that pneumonia 
is of most frequent occurrence, as well as certain of the continued fevers, one, known 
as mountain fever, being peculiar to this region. It closely resembles typho-malarial, 
but presents certain features which differentiate it from all other recognized fevers. 
So far, consumption has been but lightly touched. Inasmuch as the great majority 
of all invalids who seek a home here have this disease, more than a passing notice should 
be given it. Roughly stated, the majority of those who are suffering from this disease 
die ; some few recover, and in many the disease seems to make but slight progress. 
The universal complaint is that consumptives arrive in the last stages, when recovery 
is hopeless. It is far better that all such should remain at home. If they will come, 
Southern California should be selected for a home. The mildness of the climate assures 
freedom from disagreeable weather, and it is claimed that death is retarded. Incipient 
consumptives and those who, by reason of heredity, are predisposed to this disease, 
receive the greatest benefit. The coast, the modified coast, or the mountain climates 
should be selected. Those only who are still strong and vigorous, and who suffer from 
no bronchial lesion, should reside on the coast; providing that the constitution be 
sufficiently rugged to react from the cold fogs and bracing winds, it is the climate par 
excellence. For those in whom the disease is more advanced, or whose constitution is 
feeble, benefit follows a residence in either the mountain or modified coast climate. 
There are many localities in the Sierra Nevada range, with an altitude of eight to 
twelve thousand feet, which possess all features necessary to a health resort. Such an 
elevation, like the pneumonic cabinet, acts mechanically in forcing lung expansion and 
causing an increased lung development. 
Whatever be the cause, whether it be the out-door life, the pure air uncontaminated 
by civilization, altitude forcibly distending the lungs in order to gain the required 
oxygen, or these influences combined, certainly the results claimed by' those who have 
lived there are encouraging. 
Probably residence should be limited to the four or five months of summer, not 
alone because of the rigorous winter. After a few months' residence in these high 
altitudes the lung tissues, because of expansion, become attenuated, and, on the return 
to places where the atmospheric pressure is greater, hemorrhages are of frequent occur- 
rence. The mountains in summer and the valleys of central and southern California 
in winter, will probably be an excellent combination. 
Some observers claim that in the valleys of northern and central California, 
especially in the Santa Clara, Napa and others adjacent to San Francisco, consumption 
is not at all retarded in those cases far advanced. This may be due to the fact that 
these patients will drink the water and bathe in the hot mud of the many mineral 
springs which are here so abundant. 
There is a class of nervous diseases peculiar to California, or rather an intensified 
form of " American nervousness." The aetiology is not well understood. Whether it 
be the bracing climate, hurried eating, fast living, atmospheric influence, or a combina- 
tion of all these, certainly nervous diseases have assumed great prominence. Possibly 
the long dry season and the fact that the electrical discharges are rare, may be a suffi- 
cient explanation. It has been well established that in those localities where the warm SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
149 
winds blow, a powerful electrical influence is exerted by them over both vegetable and 
animal life. These nervous diseases are manifested principally as neuralgias, spinal 
irritation, hysteria, nervous prostration and the various forms of insanity. 
A study of the last class seems to prove that the nationality of the inhabitants is a 
powerful factor. With a population of but little over a million, there are near three 
thousand patients in the insane asylums, while there are many kept at private insti- 
tutions. While those bom in foreign countries compose one-third of the population, 
they furnish two-thirds of the insane. 
•In this brief review of the therapeutics no mention has been made of the many and 
valuable mineral springs which are found in such abundance. This was not because 
of any doubt regarding their therapeutic importance. They have obtained so great a 
reputation, «nd when properly analyzed and classified they promise to be of so much 
value in the treatment of kidney, liver and other chronic visceral diseases, and more 
especially in rheumatism, that it has been thought best that they be given special and 
separate notice. 150 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FOURTH DAY. 
The Section re-assembled at 11.30 A.M., for the discussion of papers. 
DISCUSSION. 
Dr. A. AV. Leighton, of New Haven, Connecticut, said the subject of Dr. 
Bryce's paper is of vast importance to the majority, both sick and well, who cannot 
travel. Dwelling-houses certainly exhibit all kinds of winter climates-hot, cold, 
sunny, gloomy, still or draughty, dry, damp or musty ; in fact, various degrees of 
absolute and relative humidity-all susceptible of intelligent control. The speaker 
desired to emphasize a few suggestive points. 1. A winter dwelling-room is gener- 
ally a condenser, not unlike Liebig's in its action, and this phase of the question is 
particularly suggestive. Warm air may enter the room charged with only a small 
degree of moisture, but excessively dry, as it usually is, the exposed walls and par- 
ticularly the windows are cold enough to chill a thin layer of air down to or quite 
below the dew-point ; and the result is a constant downward draught, along these 
surfaces, of damp cold air, which is as dangerous and uncomfortable as one entering 
an open window. He inferred from this that, instead of huddling stoves, fireplaces 
and hot-air flues along the protected walls of rooms, on the score of economy, the 
reverse should be the case ; that hot-air flues should discharge under the coldest 
window, and that radiators and other sources of heat should be similarly placed. 
2. Evaporating pans in contact with the fire-pots of furnaces are in one sense a 
delusive safeguard. The evaporation of several gallons of water daily does not 
sensibly affect the relative humidity. Sensitive persons suffer when this evaporation 
ceases, and immediately experience a relief when the pan is refilled, but this is not 
due to any alteration in the desiccating power of the air, but rather to the prevention 
of the irritating effects of the burnt organic element of air, and to unknown causes. 
The lesson here is to prevent desiccation of mucous membranes by controlling 
temperature, not by furnishing moisture. 
3. Few are conscious of the powerful draught that rushes from basement to 
garret in winter, especially in tall city dwellings. Let the cook burn a steak in the 
basement, however, and in spite of all known precautions, you will almost instantly 
smell the characteristic odor away off in the attic. While this indicates a source of 
dangerous draughts, it is also a source of safety as supplying an inevitable ventilation. 
Sanitarians often make unnecessary pleas for special openings in rooms as exits for 
foul air, without reflecting that for every cubic foot of warm air introduced into a 
room, an equivalent must escape, in spite of closed windows and tight joints. Let 
the fresh air supply be increased fourfold, and the question of exit may be left to 
take care of itself. 
Dr. Kretzschmar, speaking to the paper of Dr. Wise on Swiss climate, desired to 
state that the latter omitted to mention any contraindications of those places. He SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY 
151 
thought it should not be overlooked that patients with extensive pulmonary disease, 
with tendency to diarrhoea, nervous irritability or high fever are never benefited in 
the high regions of the Swiss Alps. He objected strongly to the tendency, becoming 
so pronounced at St. Moritz and Davos, to create a Saratoga-a place of amusement 
among the mountains. Imagine for an instant a consumptive attending one evening 
a ball, the next evening a fair, then a card party, then a masquerade. But Dr. 
Wise says the out-door amusements are especially to be recommended. Now 
imagine a consumptive sleighing, skating, tobogganing, etc., and then arriving 
home over-tired, suffering probably from an attack of hemorrhage as a result of the 
imprudence. The supervision and control of a responsible and conscientious physi- 
cian are absolutely necessary for consumptives, and it is not beneficial for them to live 
together with those who visit these beautiful Alpine health resorts. Dr. Wise has 
fallen into the habit of most resident physicians, of recommending the Engadine 
without stating its disadvantages. 
Dr. J. W. Jones, of North Carolina, spoke briefly of the special climatic advan- 
tages of his own home, Tarboro, Edgecombe county, phthisis being almost an 
unknown disease. 
Dr. T. M. Coan, of New York city, said that the first duty of the specialist in 
springs and climate was to understand the counter-indications as well as the indica- 
tions of the given place. Patients were continually going to famous springs, or 
were even sent there by physicians, simply because the springs were famous, without 
regard to their fitness to the individual case. He had known a prominent statesman 
worn down by political troubles, who was sent to Carlsbad, a reducing spring, and 
was injured. Had he gone to Rozart or Ems he would have been restored to health. 
In no specialty is the patient more in need of advice, and more careless in obtaining 
it, than in this matter of the springs and climate cures. 
Vice-President, Director Körösi, of Budapest, Hungary, in the chair ; the Presi- 
dent read on behalf of the author, who was unavoidably prevented from attending, 
an abstract of a paper on collective investigation, entitled- 
PRELIMINARY INQUIRY INTO THE GEOGRAPHICAL DISTRIBU- 
TION OF ACUTE RHEUMATISM, CANCER, RICKETS, 
CHOREA AND URINARY CALCULUS. 
ENQUÊTE PRÉLIMINAIRE DANS LA DISTRIBUTION GÉOGRAPHIQUE DU RHU- 
MATISME INFLAMMATOIRE, DU CANCER, DU RACHITISME, DE LA 
CHOREE ET DU CALCULUS URINAIRE. 
VORLÄUFIGE UNTERSUCHUNG ÜBER DIE GEOGRAPHISCHE VERTHEILUNG DES AKUTEN 
RHEUMATISMUS, KREBSES, DER RHACHITIS, CHOREA UND HARNSTEINE. 
BY ISAMBARD OWEN, M.D., F.R.C.P., 
Of London, England. 
In accordance with the request of the International Collective Investigation Com- 
mittee the following memorandum and inquiry paper were sent by post to every mem- 
ber of the medical profession residing in the United Kingdom of Great Britain and 
Ireland, in the months of January, February and March, 1866:- 152 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
INTERNATIONAL MEDICAL CONGRESS-COMMITTEE FOR COLLECTIVE INVESTIGATION. 
Preliminary Inquiry into the Prevalence of Rickets, Acute Rheumatism, Chorea, Can- 
cer and Urinary Calculus in Different Regions.-The International Committee for Collective 
Investigation, desiring to make inquiry into the Geographical Distribution and Ætiology of the above 
diseases, will be greatly obliged by your answering the following Preliminary Questions, and return- 
ing the paper within a fortnight to the address printed on the other side. 
Are The Following Diseases, or any of them, Common In Your District; that is, would a medical 
man in average practice in it be likely to meet with, on the average, a case a year? 
Answer. 
Rickets:-Bent Bones, usually the Leg Bones,accompanied often with enlarge-) 
ment of the lower end of the Radius and the Sternal ends of the RibsJ 
Acute Rheumatism:-Including the so-called "sub-acute" variety 
Chorea 
Cancer:-Including the several forms of Malignant Disease 
Also;-Should you say that urinary calculus (renal, vesical, or urethral,) 
is prevalent in your District?) 
Observer's Name 
Professional Title 
Date Residence 
The Committee will, further, be much obliged if you will give them information respecting the gen- 
eral features of the locality by underlining any of the following terms that may apply to it:- 
Town. 
High. 
Partly high. 
Open. 
Country. 
Low. < 
Partly low. j 
Shut in by trees,-by hills. 
Densely peopled. 
On a height,-in a hollow,-level 
Damp soil. 
Thinly peopled. 
Dry soil. 
Also, for information on any special feature of the Dietary of children and of adults in the district. 
INTERNATIONAL MEDICAL CONGRESS. COMMITTEE FOR COLLECTIVE INVESTIGATION. 
memorandum on the inquiry instituted by the above committee into the geographical 
DISTRIBUTION AND ÆTIOLOGY OF CERTAIN DISEASES. 
Dear Sir :-At a General Meeting of the International Medical Congress held last year in Copen- 
hagen, it was resolved to appoint a committee to carry on, in an international manner, the system of 
Collective Investigation initiated in England by the British Medical Association. We, the undersigned, 
had the honor of being appointed representatives of the various countries expected to take part in this 
important movement. 
Our aim is, to institute collective inquiries with reference to some broad and simple aspects of disease, 
upon which information, extending over as wide an area as possible, is very desirable. 
The first subject into which we have undertaken to make an inquiry, and for which we trust to have 
your cooperation, is the general aetiology of the following well-known diseases :- 
Rickets, 
Acute Rheumatism. 
Chorea, 
Cancer, 
Urinary Calculus. 
In reference to Acute Rheumatism, Chorea and Cancer, much of the work desired has already been 
done, or is at present being done, by the members of the British Medical Association. We are anxious 
that the work already done by them should not only be supplemented, but especially that it should be 
extended over a wider area. 
The first object at which we aim is to be able to lay down, as accurately as possible, the outlines of 
the Geographical Distribution of the above affections, with a view to deduce the relation, if any, which 
these affections bear to peculiarities of soil, climate, dietary and local habits. 
The question enclosed with this note, to which we earnestly beg that you will accord an answer, is of 
a simple and general character; and we trust that a sufficient number of replies will be given to enable 
us to trace from them the first outlines of a map of these diseases with confidence and correctness. 
We are, dear Sir, yours faithfully, 
Bernhardt, Bouchard, Bull, Davis, D'Espine, Duckworth, Ewald, Fayrer, Gull, Humphry, 
Jacobi, Axel Key, Korânyi, Lange, Lépine, Gutiérrez-Ponce, Pribram, Rauchfuss, Rune- 
berg, Schnitzler, Trier; Isambard Owen, Secretary-General. 
*** The British Medical Association has courteously volunteered to forward our undertaking by cir- 
culating this inquiry among the members of its body. It will be sent to every registered medical prac- 
titioner in the United Kingdom. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
153 
The number sent out was upward of twenty thousand. 
Of this number three thousand and twenty were returned duly filled up. 
The returns were then sorted according to the localities from which they respectively 
came; the information contained in them tabulated and transferred, in the form of color, 
to the series of maps which accompany this report. 
The following is the mode in which the information in question is placed upon the 
maps :- 
1. A separate series of maps is taken for each disease which was the subject of 
inquiry. 
2. Localities in which the reports state that the disease in question is common, or in 
which, if there is more than one report, a majority of two-thirds state the disease to be 
common, have been marked with a Blue spot. 
3. Localities in which the reports state the disease in question not to be common, 
or in which, if there is more than one report, a majority of two-thirds state the disease 
not to be common, have been marked with a Red spot. 
4. Localities as to which a discrepancy of evidence exists, and as to which the 
majority, in either sense, is less than two-thirds, have been marked with a Purple 
spot. 
But it will be understood that in the case of cities or considerable towns, the reports 
affect the towns alone. In the case of small country towns or villages, the reports 
refer to a larger or smaller country district surrounding the seat of practice. 
In estimating the results of these returns, we must be cautious to interpret them in 
a broad and general sense, and not to press conclusions too hard. In respect to country 
districts especially, the prevalence or non-prevalence of a disease, in the experience of a 
reporter, may be due simply to chance and not to the working of any especial physical 
cause. The maps must, therefore, be studied as a whole, and conclusions arrived at 
from the broad results of the distribution of each disease. With this proviso we can 
proceed to an inspection of the maps. 
ACUTE AND SUBACUTE RHEUMATISM. 
Acute and subacute rheumatism appear to be pretty nearly universal throughout 
the whole of the British Isles. There is scarcely a place marked upon the maps in 
any color but blue. 
The exceptions appear to be-for the most part, at least-mere chance exceptions, 
there being, as far as can be seen at present, no common bond of situation, soil or cir- 
cumstances connecting them. 
The most important places in which the disease is said to be uncommon in England 
and Wales are Sedbergh, Pontefract and Pateley Bridge (industrial), in Yorkshire ; 
Lymm and West Kirby (industrial), in Cheshire ; Buxton (the well-known health 
resort), in Derbyshire; Worksop (industrial), in Notts ; Clevedon (seaside resort), in 
Somersetshire; Teignmouth (seaside resort), in Devon ; St. Ives (fishing village), in 
Cornwall; Woodstock (country town), in Oxfordshire; Littlehampton (seaside resort), 
in Sussex; Beckenham (London suburb), in Kent; and Llandrindod Wells (health 
resort), in Radnorshire. 
The remaining places are little more than villages, with their surrounding districts. 
In Scotland the prevalence is much the same, the only important places that are 
marked as exceptions being North Berwick (seaport), in Haddingtonshire, and Cromarty 
(seaport), in the shire of that name. 
In Ireland there is no important exception. 
And all the places marked on the islands are in blue. 
It may be noticed, however, that the exceptions include two Spas standing on high 
ground, viz., Buxton and Llandrindod Wells, and several seaside places. 154 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CANCER. 
Cancer, also, is very generally spread throughout the British Isles, though less uni- 
versally so than acute or subacute rheumatism. 
No general condition of situation, geology or circumstance appears to attach to the 
exceptional places marked in red on the cancer maps. Some are towns, some village 
districts; some lie high, some on the plains; some in river valleys; some are on the 
coast, some inland ; some are industrial centres, some agricultural or pastoral regions. 
The general result obtained, on close inspection of the maps, appears to be that 
cancer is common in all parts of the British Islands, but only just so common that the 
chances of distribution may leave about one place in three or four free from the disease 
for some years in succession. 
The more important towns in which cancer is stated to be uncommon are the 
following:- 
In Northumberland, Morpeth, on the coal field and in a river valley. 
In Durham, Seaham, a colliery port on the coast, and Barnard Castle (industrial), 
on the Tees. 
In Lancashire, the great manufacturing town of Salford, with two suburbs, one to 
the north, on hilly ground, one to the south, on flat ground, and the manufacturing 
town of Kirkby, Lonsdale. 
In Yorkshire, the manufacturing town of Richmond, the industrial towns of Sed- 
bergh and Pateley Bridge, in river valleys, and of Pontefract, on plain ground, and 
the Spa of Harrogate. 
In Cheshire, the towns of Middlewick and Lymm, one on a river, the other on a 
stream. 
In Derbyshire, the health resorts of Buxton and Mattock, the former standing 
high. 
In Worcestershire, the manufacturing town of Kidderminster; also Bromsgrove and 
Droitwick (salt-making town). 
In Somersetshire, Taunton and Bridgwater, both on rivers in flat ground, and partly 
industrial, and the seaside resort of Clevedon. 
In Wilts, the towns of Chippenham and Devizes, partly industrial. 
In Hampshire, the seaside resort of Bournemouth. 
In Dorset, the seaport of Swanage. 
In Staffordshire, the manufacturing town of Rugeley. 
In Sussex, the seaside resort of Worthing. 
In Kent, the suburbs of Beckenham and Bromley. 
In Scotland, the seaports of Cromarty and Nairn, in the counties of those names ; 
the industrial town of Dunkeld, in Perthshire; a few places in the coal-mining country 
around Glasgow and in the neighboring county of Ayr. 
In Ireland, Athlone, on the Shannon ; Drogheda, Navan and Kells, in county 
Meath; and Sligo, in the county of that name; none with any important industries. 
In the islands, the seaport of Castletown, in the Isle of Man, and that of Stornoway, 
in Lewis ; in Kirkwall and Lerwick, in Orkney and Shetland, and several similar 
places. 
RICKETS. 
When we come to deal with rickets the condition of the maps is very different, and 
a definite principle of distribution is at once obvious. 
Rickets is by no means so universally distributed a disease as acute rheumatism 
and cancer. In the country districts the red spots considerably outnumber the blue ; 
but, with few exceptions, wherever a large industrial population is gathered together, 
both town and village districts show the latter color. 
In Northumberland the blue appears in the southeast corner, in Newcastle and its SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
155 
dependencies upon the Tyne ; Morpeth, another large town in the coal field, appearing 
purple. 
In Cumberland and Westmoreland the towns of Kendal (industrial) and Whitehaven 
(a seaport on the coal field) are blue, though Carlisle (partly industrial) exceptionally 
is red. 
In the coal fields of Durham the blue is thickly scattered, the blue spots in this 
county exceeding the red by two to one. It should be noticed, however, that the large 
manufacturing towns of Stockton and Darlington are colored red. 
In the coal fields of Lancashire, again, the blue spots are thickly accumulated, no 
important town appearing as red. 
In the North and East Riding of Yorkshire, which are not industrial for the most 
part, the blue spots are few ; but the seaport of Hull and the neighboring town of 
Beverley, as well as the great manufacturing town of Middlesboro, show that color. 
The important city of York itself, which has many industries, as well as the manu- 
facturing town of Richmond, which lies high, appear as red. 
In the West Riding of Yorkshire, which is chiefly coal field, the blue is as thickly 
scattered as in Lancashire. 
In Cheshire the red is considerably in excess, but none of the larger industrial centres 
are of that color. Birkenhead, Stockport and Chester are blue, and Macclesfield purple. 
In Derbyshire, again, the blue clusters about the important industrial town of 
Derby. Glossop, which is properly a suburb of Manchester, is also blue. The health 
resorts of Buxton and Matlock, and many other places are red, but no industrial centres 
appear of that color. 
In Notts, again, an industrial county, all the large towns, except Worksop, from 
which reports have come, are blue. 
In Lincolnshire the large city of Lincoln and the seaport of Grimsby, which are the 
most important industrial centres, are blue. 
In Shropshire, again, Shrewsbury, Wellington and Broseley, on the coal field, appear 
as blue ; Ironbridge is purple. No industrial centre is colored red. 
Herefordshire has no industrial centre ; the blue color appears only in the county 
town, which has some minor manufactures. 
In Monmouthshire the blue and purple spots are in excess, appearing thickly on the 
coal field in the west of the county, in the busy seaport of Newport, and also in the 
county town of Monmouth. 
In Worcestershire the blue centres again upon the coal fields, Dudley, Kidder- 
minster and Halesowen being of that color, though Stourbridge and its neighborhood 
are red. 
In Gloucestershire, Bristol and Stroud, both manufacturing places, are blue ; 
Gloucester, also in part a manufacturing town, is purple, and Cinderford, the centre of 
the Dean Forest coal field, appears as blue. 
Yeovil, in Somersetshire, the centre of a glove manufacture, is blue, as also is the 
large but somewhat decayed pleasure city of Bath. 
Wilts has no manufactures of importance. 
In Hampshire we find the important seaports of Portsmouth and Gosport blue, as 
well as the city of Winchester. 
The Isle of Wight, which has no manufactures, shows an exceptional amount of blue. 
From Dorset westward, in what is called the "West of England," we find a con- 
siderable amount of blue, but it still tends to the larger towns. In Dorset itself, Poole 
and Dorchester, the two largest towns, are blue. In Devon we find the great centre 
formed by the adjacent towns of Plymouth, Stonehouse and Devonport, of the same 
color, and the city of Exeter purple ; and in Cornwall two out of the three largest towns 
reported on are also blue. 156 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In Staffordshire and Warwickshire we see all the large towns of the " Black Country " 
marked in bine-Birmingham, Wolverhampton, Wednesbury, Walsall, Bilston and 
West Bromwich. From Stafford itself we have no information, nor from Stoke-on- 
Trent, but the suburbs of Stoke are marked in blue. Coventry, though a considerable 
industrial town and situated on a coal field, is red, but Tamworth, on the same coal 
field, is blue. Burton-on-Trent, the seat of the great breweries, is red. The well- 
known Spa of Leamington, again, a somewhat decayed town, on the other hand, is 
blue. 
In Leicestershire, Leicester and some neighboring towns are blue. So is the manu- 
facturing town of Northampton, in Northamptonshire. 
In Bedfordshire, Bedford itself, though an industrial town, is purple only. Luton, 
one of the seats of the straw manufacture, is blue, but Dunstable, another seat, is red. 
Cambridge and Huntingdon, the only considerable towns in the counties of those 
names, are marked in blue. 
In Norfolk we have all the important towns blue, viz., Norwich, Lynn and Yar- 
mouth. Norwich has manufactures ; the other two are busy seaports. 
Ipswich, the only large town in Suffolk, is purple. 
In Essex, Chelmsford and Colchester, the only towns of any size, are blue. 
In Oxfordshire, Oxford and Banbury, the only large towns, are blue. 
In Buckinghamshire, Buckingham, a town of less importance, is red. 
In Berkshire, Reading, the only industrial centre, is again blue. 
So are Hertford and Hitchin, the only towns of any industrial importance in 
Hertfordshire. 
Every district of London comes out blue, and many of the surrounding suburbs. 
The populous district of Greenwich is blue, though the neighboring towTn of Woolwich 
is red. 
In the Southeast of England there are few industrial centres. 
In Sussex the three largest towns, Brighton, Lewes and Hastings with St. Leonards, 
appear in blue, while Dover, Folkestone, Canterbury, Maidstone, Faversham, Chat- 
ham and Gravesend, the most important towns, industrially speaking, in Kent, are of 
the same color. The large seaside health resorts of Margate and Ramsgate are red. 
In Wales there seems a tendency to rickets in Montgomeryshire, in which, however, 
there are no industrial centres of any importance. 
The town of Haverfordwest in Pembrokeshire appears in blue, as do nearly all the 
chief centres of the coal and iron district of Glamorgan, viz., Cardiff, Merthyr-Tydfil, 
Mountain-Ash, Swansea, Morristown and Briton Ferry. The copper smelting tow'ns of 
Llanelly and Kidwelly, somewhat scattered places, are marked, however, in red. 
In Scotland, as in England, the locality of rickets is chiefly in the great industrial 
centres. On the whole, the disease appears less prevalent in Scotland than in England 
and Wales. In Scotland there are two chief localities in which the blue marks 
abound. 
The first is the neighborhood of the Firth of Forth, where we find Edinburgh, 
Leith, Dalkeith, Falkirk and Grangemouth marked in blue, and Portobello in purple. 
In the rest of the southeast of Scotland the marks are chiefly red ; but among a 
few places of lesser importance Haddington appears in blue, and Dunbar in purple. 
The important towns of Berwick on Tweed and North Berwick are in red. 
The second great locality of rickets in Scotland is the industrial neighborhood of 
the Clyde, where we find Glasgow, Paisley, Greenock and Dumbarton marked in blue, 
besides a number of similar places in the neighborhood of the river, a little higher up 
than Glasgow, and upon the Glasgow coal field. 
The region of the blue marks extends into Ayrshire as far as Kilmarnock, but 
Ayr itself is in red, and no other blue mark appears in the southwest of Scotland, SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
157 
except at Wigtown, in the shire of that name. Off the coal field there are few indus- 
tries in this part. 
The highlands appear almost free from rickets, the only blue marks being at the 
important seaport of Aberdeen, at Rothsay in Argyle, in the Isle of Coll, and at a 
small place in the Mull of Cantire. The town of Inverness is marked in red. 
On the east coast we get the industrial town of Dundee, the town of Forfar and the 
seaport of Bervie, with some places of smaller importance in Perthshire, Fife and 
Kinross. The towns of Perth and St. Andrews, the former a manufacturing centre, 
the latter a university town, are in red. 
Ireland appears as free from rickets as Scotland. There are but three industrial 
towns of importance in Ireland, and the two most important, Dublin and Belfast, are 
marked in blue. Cork, the third, is red, but the report from Cork is from one man 
only. Otherwise the few blue marks are scattered over the map without any apparent 
principle. 
All the chief towns of the Isle of Man and the Channel Islands are marked in red; 
one small place in Shetland appears in blue. 
CHOREA. 
Chorea follows to a very great extent the distribution of rickets and, like it, accu- 
mulates in the great industrial centres. On the whole, however, it appears in rather a 
larger proportion of places than rickets. 
In Northumberland, Cumberland, and Westmoreland it appears in nearly every 
place in which rickets is common and is scattered about in rather more of the smaller 
centres. Carlisle, Penrith and Keswick, in which rickets is uncommon, are marked in 
blue on the chorea maps, but Whitehaven, which is blue in rickets, appears red in 
chorea. 
In Durham and Lancashire the distribution is again almost identical, but Stockton 
and Darlington, which are red in rickets, appear, the one blue, the other purple in 
chorea, and chorea appears to prevail rather more in the north of Lancashire than 
rickets. On the other hand, Salford, which, like Manchester, is blue on the rickets 
map, appears read in chorea. 
York and Richmond are as free from chorea as from rickets. Middlesboro is pur- 
ple only in the chorea map. 
In the West Riding of Yorkshire, and in Cheshire, the distribution of the two 
diseases is again almost identical, but Birkenhead, in the latter county, is marked as 
being/ree from chorea, while rickets is prevalent in it. 
In Derbyshire the blue appears more frequently than in rickets, but as before, 
Glossop and Derby, and its suburbs, are blue, Buxton and Matlock red. Chesterfield, 
which is blue in the rickets map, is red in chorea. 
In Nottingham and Lincoln the same identity occurs for all the large centres, except 
that Boston, in the chorea map, appears in purple. 
In the Severn Valley chorea appears more frequently than rickets; but, as in the 
case of the former, all the chief industrial centres appear in blue. 
Worcester is blue in chorea though red in rickets. Droitwich is red in both. 
In the great South Wales coal field of Monmouthshire and Glamorgan the blue 
appears even more constantly for chorea than it did for rickets. The town of Mon- 
mouth again appears blue. 
Gloucester is again purple; Bristol, Clifton, Stroud and Cinderford blue. The Spa 
of Cheltenham, a flourishing but not industrial town, with many schools, is blue in 
chorea, though red in rickets. 
The same general correspondence extends to Somerset and Wiltshire, Salisbury 
(cathedral city) and Marlborough (public school) are blue. 158 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In Hampshire, Southampton is blue and Winchester red, the contrary having pre- 
vailed in rickets. The Isle of Wight shows the same tendency to the one disease that it 
did to the other. 
In Dorset the blues are strengthened by the addition of the seaside resort of Wey- 
mouth and the Isle of Portland. 
In Devon, Plymouth and Stonehouse are purple only, and Exeter is marked in red. 
Teignmouth is still red, and otherwise the correspondence is tolerably close. 
It is rather less close in Cornwall, where Redruth is purple instead of blue, but 
Penzance and St. Ives here become purple also. 
The "Black Country" is still studded with blue at all the important centres. 
Leamington is still blue and Coventry red ; Leicester and Northampton are still blue; 
Bedford again purple; Luton blue, and Dunstable red; Huntingdon remains blue, but 
Cambridge is red. 
Norwich, Lynn and Yarmouth are again blue, and Ipswich, Chelmsford and Col- 
chester are blue. 
So are Oxford, Buckingham, Reading, Hertford, and Hitchin. 
In London there is a discrepancy. The southwest and the southeast districts, com- 
prising Westminster, South Kensington, Chelsea, Hammersmith, Fulham, Wandsworth, 
Clapham, Vauxhall, Southwark, Camberwell, and Deptford are red, and the city 
purple, all the rest of the Metropolitan area being blue. Greenwich is again blue and 
Woolwich red. 
Hastings now appears as red, but Brighton and Lewes, the two most important 
towns of Sussex, are purple. 
Dover is purple; Folkestone, Maidstone, Faversham, Gravesend, and Bromley are 
blue; Chatham is purple only. 
Montgomery again shows a number of blue marks, and the blue appears in Breck- 
nock. Haverfordwest is red instead of blue, while Llanelly and Kidwelly are still 
red. 
Chorea, like rickets, has its two great centres of distribution in Scotland. Edin- 
burgh and Leith are still blue; Falkirk and Grangemouth purple; Musselboro is blue 
for chorea, though red for rickets. 
Berwick on Tweed and Galashiels, which are red for rickets, are blue for chorea. 
As in the case of rickets, Dumbarton, Greenock, and Glasgow, and a group of 
smaller places on the upper Clyde, are blue, but Paisley is red for chorea. 
The blue marks are fewer in Ayr, and in no case correspond with those of rickets. 
Two other small places are marked blue in southwestern Scotland, but Wigtown 
is red. 
In the Highlands the blue appears again at Rothsay, and at the towns of Forres and 
Elgin, and the seaport of Lossiemouth, which three are red for rickets. 
Also at three places in the county of Banff, and two in Aberdeen, which are red for 
rickets. The town of Aberdeen is blue as before. 
On the Eastern coast Stonehaven and Bervie change colors; and blue and purple 
preponderate in Forfarshire, Dundee and Forfar being again of that color. 
Perth is blue for chorea, and the distribution in this county is not the same as that 
for rickets. St. Andrews is still red, but Cupar is blue. 
In Ireland, again, chorea is rather more prevalent than rickets. All three industrial 
towns, Dublin, Belfast, and Cork, are blue for chorea, and Limerick, an industrial town 
of less importance, is purple. 
In the Islands the blue appears in one small place in Jersey, and in the towns of 
Kirkwall and Lerwick in Shetland, but not elsewhere. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
159 
The distribution of urinary calculus is on quite different lines. Many of the great 
centres of population-London, Manchester, Liverpool, Birmingham, Leeds, Sheffield, 
Derby, Northampton, Bristol, Cardiff, the three towns of Devon, Newcastle, Edinburgh, 
Glasgow and Dublin being among them-are reported as not being commonly liable to 
the disease. 
The great centre of the disease is the eastern half of the county of Norfolk; to speak 
more accurately, the Northern and Southern Parliamentary Divisions-in which but 
one red mark appears to fourteen blue ones, the red mark, indeed, being at a small 
village. 
This eastern half of Norfolk comprises several geological formations. The chief 
part of it is on the Norfolk Crag, but the western portion is on chalk marl, and the 
eastern edge, upon which Yarmouth stands, consists of London clay covering Norfolk 
Crag. 
In the western part of the county, comprising the Western Parliamentary Division, 
we get two blue marks and three purple-the purple including Lynn-to seven red 
ones. Two of the purple stand upon the chalk or chalk marl; Lynn is situated on 
the Kimeridge clay, Downham on the upper green sand, and Upwell on a reclaimed 
marsh. 
In Suffolk we get fourteen blue and purple to thirteen red marks, some standing on 
the Norfolk Crag, some on London clay and some on chalk or chalk marl. 
The neighboring counties of Cambridge and Huntingdon exhibit a great many blue 
spots, but few of them are placed upon any of the formations that appear in East Nor- 
folk or Suffolk. 
Proceeding northward from Norfolk, we find a considerable proportion of blue in 
Lincolnshire, viz., seven, and one purple, to twenty-six red; but though the chalk (or 
chalk marl) occurs again in Lincoln, the purple spot only, and none of the blue, appear 
upon it. 
Three out of the four blue spots in Northeast Yorkshire, viz., Hull, Hornsea and 
Bridlington, are upon this formation. 
Isolated spots of blue appear in many other parts of the country, but nowhere with 
sufficient frequency to attract attention, except in the "Black Country" coal field, 
which is thickly dotted with blue-Wolverhampton, Dudley, West Bromwick, Stour- 
bridge, Halesowen, Hagley and Aldridge being of that color, and Wednesbury purple, 
though the town of Birmingham is red. 
It is difficult to say that in any other part of England than in East Anglia and 
Lincolnshire and the 1 ' Black Country ' ' is stone markedly prevalent. The chalk and 
chalk marls elsewhere than in Norfolk and Suffolk do not show any particular propor- 
tion of calculus. 
The South Wales coal field has also a sufficient number of blue spots to attract 
attention, but this is not the case with any other of the coal fields in South or North 
Britain. 
Cornwall shows rather a tendency to calculus, there being four purple spots to 
seventeen red. 
In all districts of London stone is said to be rare. 
Little stone appears in Scotland, the eastern portion, between the Moray Firth and 
the Firth of Forth, containing nearly all the blue spots to be found. Nairn, Forres, 
Keith, Aberdeen and Kircaldy are the chief places thus distinguished. 
In Ireland, also, calculus rarely appears, and is chiefly limited to the eastern parts. 
Blue marks occur at Clonmell and Carrick on Suir; at Kilmore, on the coast of Wex- 
ford; at Arklow, on the coast of Wicklow; at Skerries, on the coast of Dublin county; 
at Ballynahinch, in Down, and at Bushmills, on the coast of Antrim. 
URINARY CALCULUS. 160 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The accumulation of calculus on the eastern coasts of all three kingdoms, and the 
general immunity of the western coasts, is remarkable. It is also to be noted, as before 
observed, in how very few of the large towns calculus is common. Lincoln, Norwich, 
Ipswich, Hull, Nottingham, Wolverhampton and Salford are the only towns of any 
considerable size marked in blue or purple, and most of these are situated in the east 
of England. 
On the whole, then, we gather from the results of this inquiry :- 
1. That no part of the British Isles can be said to be free from acute or subacute 
rheumatism, and very few from cancer. No definite reason for the immunity (if it 
exists) of certain places from cancer can be traced by the inquiry. 
2. That rickets and chorea are diseases mainly affecting large town populations, 
especially industrial town populations, and that they are generally found together. 
3. That urinary calculus chiefly affects certain well-defined regions on the east 
coast of Great Britain, and is pretty well limited to the east coast of Ireland. That 
these special regions are the eastern parts of Norfolk, Suffolk and Lincolnshire, and the 
part of Scotland between the Moray Firth and the Firth of Forth. That it is excep- 
tionally prevalent in the " Black Country," and possibly in the South Wales coal fields 
also, but that no geological principle of distribution can be traced at present. 
THE INFLUENCE OF METEOROLOGICAL CHANGES ON THE PRE- 
VALENCE AND SEVERITY OF DISEASES AT CLEVE- 
LAND, OHIO, IN THE YEAR 1886. 
L'INFLUENCE DES CHANGEMENTS METEOROLOGIQUES SUR LE DÉVELOPPE- 
MENT ET LA RIGUEUR DES MALADIES A CLEVELAND, OHIO, 
EN L'AN 1886. 
ÜBER DEN EINFLUSS METEOROLOGISCHER VERÄNDERUNGEN AUF VORHERRSCHEN UND 
HEFTIGKEIT DER KRANKHEITEN IN CLEVELAND, OHIO, IM JAHRE 1886. 
BY HENRY Z. GILL, A.M., M.D., LL.D. 
Of El Dorado, Kansas. 
Since the beginning of the " Collective Investigation of Disease " in Europe and in 
America, many observers and State medical societies have turned their attention to the 
subject of the relation of meteorological conditions and changes to prevalent diseases. 
And it seems to be attracting the study of more men in the general practice of medi- 
cine than ever before. 
It is evident that the collection of facts must be extensive and accurate before valu- 
able and safe conclusions can be drawn on the relation of cause or condition and 
results. 
For some years past I have been working on this subject and recommending it to 
the attention of others, believing that the accumulation of facts is the first step to any 
investigation of this character. 
The Signal Service has been very prompt in furnishing reports from stations, giving 
the local meteorological conditions, and, where the necessary means have been fur- 
nished by societies or individuals, the tests for ozone have been made also. 
The data of this report cover the year 1886, and are, we believe, as nearly correct 
as statistics generally; at least, great care has been taken to make them so. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
161 
The city of Cleveland, Ohio, is situated on the southeastern shore of Lake Erie, in 
latitude 41° 30z N., longitude 81° 27 z W., and has an elevation of 690 feet. The popu- 
lation is 205,973 (the weekly report of the health board, ending July 9th, 1887, gave 
the population as 210,000). The soil is sandy, thus greatly facilitating percolation. In 
the more thickly populated portions of the city wells have been mostly abandoned. 
The water supply is from the lake, is abundant, and, thus far, generally speaking, pure, 
though improvement is needed respecting the locality of the intake. The city covers 
a large territory, and cannot be said, with few exceptions, to be crowded, but the con- 
trary. The mortality rate for 1885 was 17.43; while reckoning on the same basis of 
population it is, for 1886, 17.11 per 1000; the other basis gives only 16.78. 
The following table, No. 1, exhibits deaths from diseases, including cholera infantum, 
diphtheria and croup, measles, scarlet fever, typhoid fever, and whooping cough, for 
the years 1884, '85, '86, in Cleveland. The comparative numbers are*interesting. 
Table No. 1.-comparative statement of deaths from six prevalent 
DISEASES. 
1884. 
1885. 
1886. 
Sum. 
Cholera infantum 
278 
325 
252 
855 
Diphtheria and croup 
196 
184 
178 
558 
Measles 
197 
31 
21 
249 
Scarlet fever 
18 
32 
20 
70 
Typhoid fever . 
121 
71 
115 
307 
Whooping cough 
37 
23 
37 
97 
Total 
847 
666 
623 
2136 
The following table, No. 2, shows a comparison of deaths, in Cleveland, from 
cholera infantum, for the months of June, July, August and September, for the same 
years. 
Table No. 2.-cholera infantum. 
Average 
Total 
June 
July 
August 
September 
Months. 
68.2 
05 O 05 05 
CO C5 CD 
05 b 05 CO 
Relative 
Humidity. 
1884. 
68.2° 
05 05 05 05 
00 CD 00 
co io b b 
o o o o 
Tempera- 
ture. 
to 
05 O <! 
cn io co <? 
Deaths. 
00 
• 
74.4 
78.8 
84.0 
77.4 
Relative. 
Humidity. 
1885. 
05 
p 
00 
O 
05 05 05 
H-i Qi hi 
b ôo b b 
o o o o 
Tempera- 
ture. 
299 
K) b-1 CH 
Qi 4 W 
Deaths. 
05 -1 -1 -I 
CD CO O ÇJI 
b CO CD b 
Relative 
Humidity. 
1886. 
3 
o 
05 05 05 05 
CD CD CH 
ôo b b b 
o o o o 
Tempera- 
ture. 
239 
o W CD 
Deaths. 
œ 
I-1 to w 
to CO w to 
01 O «5 
Total Deaths. 
The following Diagram, 1, exhibits the daily range of thermometer and death-rate 
for the month of Jnly. 
Vol. V-11 162 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Diagram 1. 
(Volera infantum ««J ol/iei' fiiieasts vf this citas fer Jüfy Cffw/afai, ûfc 
6 9o //■ 
Ttrtf Choiera lujaiifum. lEiiiero-coiifa fi Wher h'fa fatcues ft Total 
- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
163 
The relation of scarlet fever and diphtheria in the number of cases reported to the 
City Board of Health for 1886. The previous year showed (see Jour. Am. Med. Assoc., 
Vol. vil, p. 456) almost the same relationship. See, also, Report of Michigan State 
Board of Health, 1882, p. 543, Diagram 2. 
High temperature is an important element in the production of intestinal disorders. 
Another is high relative humidity. When these two coincide-act as conjoint factors- 
the result in fatal cases seems to be well marked,' especially so when following a con- 
siderable number of warm days. On this point September, 1884, is a conspicuous 
example. 
Diagram 2. 
C/cte/ccneD; 
Chic. 
i88( 
Ce nïaji 7os u ises. n 'porfa j Jcid~ß< weï yf /; Ça ZZ j, 
<Jan. yck \june Dec. 
cScai/almce... 
DipnthemC 
(Scaâ'aTaicc. case.<t f7e<c7}}j. Z<> 
Diphtheric;case.î. dea-Chs 13.0 
High temperature, of itself depressing to the tone of the system, is very much so 
to infants and children, who are frequently not able to remove from heated localities in 
which they may be placed, or to cool themselves in case of being overheated. Again, 
it promotes fermentation of food, souring of milk before taken and decomposition after- 
ward ; thus, the septic condition of the ingesta is favored, and the formation of 
ptomaines, which, it is believed by many, are the cause of the sudden and violent 
symptoms in many of the cases of cholera infantum. (Silas A. Potter, M.D., in ad- 
dress at Annual Meeting, Mass. Med. Soc., June 8th, 1887.) Months. 
Mean Barometer. 
Mean Temperature. 
Mean Relative Humidity. 
Wind. 
dear. I J 
ATH 
'S 
fr 
ER. 
'S 
S 
O 
Q 
Precipitation. 
Range of Temperature. 
Total Deaths. 
Dipht 
8 
i 
« 
SERIA. 
8 
G 
O 
Q 
Cholera Infantum. 
U 
ARR1 
)ISEA 
g 
c 
Q 
ô 
O 
W 
Other Like g g 
Diseases. " ► 
Total this Class. | 
Typi 
Fev 
■ 
8 
■ 
öS 
O 
IOID 
rER. 
ce 
S 
G 
Cases. K 
► 
g 
Deaths. S 
SCAI 
Fea 
QQ 
8 
s 
Q 
ILET 
ŒR. 
ce 
8 
A 
Whooping Cough. 
Acute Lung Disease 
(Pneumonia). 
00 
a 
ce 
ce 
January 
30.032 
30.093 
29.964 
30.061 
29.925 
29.954 
29.933 
29.973 
30.071 
29.432 
30.002 
30.122 
23.1° 
25.4° 
34.9° 
49.1° 
57.4° 
65.5° 
69.9° 
69.5° 
64.8° 
53 9° 
38.9° 
25.3° 
83.0 
79.5 
79.1 
76.2 
80.0 
75.4 
70.8 
73.3 
69.5 
69.7 
68.7 
76.0 
w. 
s. 
w. 
N. E. 
N. 
N. 
N. E. 
N. E. 
8. E. 
8. E. 
W. 
w. 
3 
2 
6 
11 
11 
13 
16 
13 
12 
11 
5 
7 
12 
17 
16 
11 
14 
11 
12 
11 
14 
11 
12 
10 
16 
9 
9 
8 
6 
6 
3 
7 
4 
9 
13 
14 
3.35 
1.55 
2.00 
1.78 
1.68 
1.01 
2.64 
1.36 
4.04 
.47 
3.89 
3.57 
62.6° 
62.5° 
66.4° 
58.2° 
43.9° 
46.0° 
40.9° 
38.5° 
45.1° 
44.9° 
51.4° 
52.3° 
281 
287 
391 
317 
270 
288 
473 
401 
406 
296 
310 
320 
22 
16 
29 
24 
20 
19 
16 
15 
37 
41 
55 
35 
9 
1 
11 
12 
4 
7 
12 
7 
10 
13 
18 
16 
6 
5 
9 
8 
7 
10 
5 
4 
1 
3 
1 
1 
1 
1 
19 
103 
77 
40 
6 
3 
1 
2 
3 
6 
15 
22 
20 
3 
1 
2 
6 
6 
7 
2 
5 
15 
38 
27 
12 
7 
3 
4 
8 
7 
9 
6 
6 
40 
156 
126 
72 
16 
7 
6 
6 
7 
7 
1 
3 
3 
13 
49 
28 
36 
8 
6 
5 
10 
4 
3 
2 
7 
5 
27 
20* 
9 
17 
3 
3 
3 
11 
19 
7 
2 
2 
55 
64 
2 
1 
2 
1 
5 
2 
4 
4 
41 
29 
44 
27 
29 
22 
17 
19 
16 
25 
34 
42 
1 
5 
1 
2 
1 
2 
1 
2 
2 
3 
3 
8 
8 
2 
2 
3 
3 
1 
4 
1 
2 
27 
33 
20 
40 
27 
14 
8 
14 
3 
7 
3 
7 
11 
February 
March 
April 
May 
June 
July 
August 
September 
October 
November 
December 
29.281 
48.2° 
75.1 
N. E. 
110 
151 
104 
27.34 
Max., 92.0°; 
Min., 9.0°. 
3525 
329 
120 
58 
252 
75 
132 
459 
161 
115 
160 
21 
345 
20 
37 
183j 
31 
* Including seven cases of typhoid pneumonia and typho-malarial fevers, 
t " Annual Report of Health Department of Cleveland, Ohio." 
TABLE NO. 3.-A MONTHLY PRESENTATION OF THE METEOROLOGICAL CONDITIONS, AND THE DEATHS FOR THE YEAR 1886. 
164 SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
165 
If, then, microorganisms and the products of their action be the causal relation of 
many of the intestinal disorders of children, and a high degree of heat and moisture, 
■which are favorable conditions to their action and development, prevail, a cooler and 
drier atmosphere and antiseptic measures are clearly indicated. These, in one or in 
many forms, are found to produce the best results thus far known. The medicines 
most efficient are either generally or specially antiseptic. As Dr. Potter has pointed 
out, some of the measures adopted which might not at first have been thought to be 
antiseptic are, in fact, decidedly so. 
The state of the barometer, as shown in these examinations, does not seem to indi- 
cate much influence ; yet it may, in conjunction with other conditions, play its part, 
favorable or unfavorable. 
The examination of ozonic conditions has been commenced in several parts of the 
State of Ohio ; but the reports which have come to hand up to this date (examinations 
have been made about a year) have not been available for this report. In Michigan, 
the examinations have been conducted for a number of years, and interesting results 
published by the State Board of Health of that State, of which our colleague in the 
Section, Dr. Henry B. Baker, is the efficient secretary. 
Preventive measures, whether referring to conditions which are unfavorable or abso- 
lutely opposed to the development and spread of diseases, or antidotal and destructive 
of the agency producing the condition -which we call disease, are of the highest pos- 
sible importance, and cannot be placed in too high estimate. To this end we may be 
permitted to repeat, all the facts and conditions should be collected, arranged, analyzed, 
and their bearing on results carefully weighed, that each may receive its exact value 
and no more, and that the resultant influence of certain combinations may be clearly 
ascertained. Thus may the supposed influence of drugs be corrected when over-esti- 
mated, and a degree of scientific accuracy be reached unattainable by any other method. 
With this view I have been urging medical societies and boards of health to appoint 
observers in different sections to make observations, and report annually not only the 
meteorological changes, but the prevalence of diseases and the relation of said changes 
to them. 
DIE SCHÄDLICHEN WIRKUNGEN DES GEDRÄNGTEN BEISAMMEN- 
LEBENS IN STÄDTEN. 
THE INJURIOUS EFFECTS OF OVERCROWDING IN CITIES. 
LES PERNICIEUX EFFETS D'UNE TROP GRANDE AFFLUENCE D'HABITANTS DANS 
LES VILLES. 
DR. AGATHON WERNICH, 
Cöslin, Pommern. 
Seitdem, durch eine exacte Bevölkerungsstatistik die höhere Durchschnittssterblich- 
keit bei den grossstädtischen Bevölkerungen im Vergleiche zu den Bewohnerschaften 
des platten Landes nachgewiesen ist, sind die Bestrebungen, den eigentlichen Grund 
dieser Erscheinung zu ermitteln, nicht zur Ruhe gekommen. Die Thatsache als solche 
prägt sich in der Berichterstattung sämmtlicher Culturstaaten so grell aus, dass in 
Europa die Hygieniker sich zuweilen vor die Frage gestellt sahen, ob das gedrängte 
Leben in den Städten und seine unaufhaltsame Zunahme mit der gesundheitlichen 
Wohlfahrt noch vereinbar sei, ob es nicht zu den vornehmsten Rücksichten auf die 166 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Gesundheit der kommenden Geschlechter gehöre, den Zudrang nach den städtischen 
Brennpunkten auf irgend eine Weise einzudämmen. 
Die öffentliche Gesundheitspflege würde jedoch ihre Aufgaben verkennen und ihre 
Mittel überschätzen, wollte sie auf anderem Wege, als durch Klarlegung des Begriffes 
der ' ' Bevölkerungsdichte, ' ' ihren bezüglichen Zielen und Aufgaben entgegengehen. 
Es erscheint zunächst kaum fraglich, dass ein Fehler darin liegt, mit dem Begriffe der 
Bevölkerungsdichte, des blossen städtischen, d. h. gedrängteren Beisammenlebens, alle 
sichtbaren Folgen dieser Art von Lebensführung zu umfassen. Eine Scheidung 
zwischen den Lebens- und Gesundheitsbedrohungen, welche erweislich nur auf das 
räumliche Gedrängtsein der Menschen zurückzuführen sind, von denen, die aus ander- 
weitigen Eigenheiten der städtischen Existenz erwachsen, scheint unbedingt noth- 
wendig. Hierbei ist es praktisch vom grössten Werthe, die einzelnen Unterarten der 
gedrängten Existenz zu analysiren, denn für jede Art von Zusammenhäufung wird 
sich als natürliches Gegenmittel ein System der Decentralisation, wenn auch nicht 
immer durchführen, so doch ersinnen lassen. 
Um diese Analyse vorzunehmen, wird man nicht von den complicirtesten, sondern 
von den einfacheren und einfachsten Beispielen für die Bevölkerungsdichte der Städte 
ausgehen müssen. Ursprünglich waren es die Sterblichkeitszahlen der Grossstädte, 
an denen zuerst die Erscheinung der Ungunst im Vergleiche mit dem platten Lande 
in ihrer ganzen Schwere ersichtlich gemacht wurde. Noch jetzt gilt als ein schlagendes 
Beispiel die Sterblichkeit mancher grossen englischen Städte, welche die der ländlichen 
Umgegenden um fünf pro Mille und mehr überragt; für Preussen ergiebt sich im 
ganzen Staate zu Ungunsten der Städte ein Sterblichkeitsplus von gegen drei pro Mille, 
während dieses Verhältniss zwischen Berlin und der Provinz Brandenburg noch Ende 
der 70er Jahre 5.2 auf das Tausend betrug. 
Mit der wachsenden Einsicht in den Grund der Erscheinung hat man dort wie hier 
mit Erfolg den einzelnen Uebelständen entgegen gearbeitet. Die' Erkenntniss des 
Zusammenhanges zwischen dem verunreinigten und doch immer wieder bebauten 
Boden und einer erschreckend hohen Typhusmortalität wurde der mächtigste Hebel 
zu dem grossen hygienischen Werke der Berliner Canalisation. Und ähnlich wie hier 
das AVheneinandergedrängtsein in der Fläche in seiner fatalen Bedeutung gewürdigt 
wurde, so wandte sich später die Aufmerksamkeit einer anderen Art von Bedrängniss 
zu : dem Abdrängen vom Boden, von der Fläche, in die Tiefe und in die Höhe, wie es 
in den Kellerwohnungen und in den hohen Stockwerken seinen Ausdruck findet. Man 
lernte ermessen, dass, wie in jenen der Mangel an Luft und Licht, so in diesen ein 
eigen th ümliches Sonderklima seine verderblichen Folgen entfalten muss; weitere Nach- 
forschungen stellten es äusser Zweifel, dass die intensive Sonnenstrahlung, der natür- 
liche Gang der erwärmten Luft nach oben, der Mangel der Entwärmung bei Nacht in 
den höchsten Stockwerken noch schlimmere Krankheitseinflüsse hervorbringt, als die 
Mängel der Kellerwohnungen ; und dass durch dieses künstlich ungesunde Sonderklima 
gerade die ärmlichsten Bevölkerungsschichten am heftigsten betroffen werden, für 
deren Kinder und unbehülfliche Personen es an Transportmitteln mangelt, um auch 
nur für Stunden der krankmachenden Hitze zu entrinnen und eine zeitweise Ent- 
wärmung möglich zu machen. Als weitere ungünstige Seiten der grossstädtischen 
Bevölkerungsdichtigkeit sind am häufigsten hervorgehoben worden : die Wohnungsnoth 
in der Form, dass ganze zahlreiche Familien oft nur einen geheizten Raum innehaben 
(jeweilig auch wohl gar keinen heizbaren Raum), -das Elend des Schlafstellen- oder 
Schlafburschenwesens, - die Zusammenpferchung der Arbeiter und ganz besonders 
auch der Arbeiterinnen in Industriewerkstätten und Fabriken, - die Ueberfüllung 
vieler öffentlichen Anstalten, so mancher Krankenhäuser und Gefängnisse, Schulen 
und Asyle. 
Von diesen Verhältnissen, soweit sie Berlin, die auf dem alten Continent im schnell- SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
167 
sten Wachsthum begriffene Stadt, betreffen, haben sich die verschiedenen neueren amt- 
lichen Berichte ein Bild zu geben bemüht. Genehmigen Sie die Vorlage eines dieser 
sogenannten Generalberichte, den ich vor meiner Versetzung in meinen jetzigen amt- 
lichen Wirkungskreis, den Sitz der Regierung im pommerischen Flachlande, zu erstat- 
ten berufen war. 
Grundverschieden von den grossstädtischen Zahlen erscheinen auf den ersten Blick 
die demographischen Verhältnisse, wie sie sich in dem Sanitätsbericht über den 
Regierungsbezirk Cöslin, welchen ich als eigene Arbeit gleichfalls vorlege, verzeichnet 
finden. Alle Complicationen der Lebensführung stellen sich hier sehr viel einfacher 
dar ; ja man wäre hinsichtlich des Gegensatzes zwischen städtischer und plattländischer 
Existenz versucht, zu glauben, dass diese Gegensätze bei den Mittelstädten von etwa 
20,000 Einwohnern vielleicht noch eben angedeutet, bei den Städtchen von 6000 oder 
10,000 Einwohnern überhaupt nicht mehr nachweisbar sein könnten. 
Jedenfalls überzeugt man sich, dass man hier Vergleichsansätze von allereinfachster 
Art, gleichsam die Uranfänge jener Contraste vor sich hat, wie sie die Grossstädte dar- 
bieten, wenn man die äusserliche Aehnlichkeit der beiderseitigen Arbeiter- und Tage- 
löhnerwohnungen, die Gleichförmigkeit der städtischen und ländlichen Hauseinthei- 
lung, das Uebereinstimmende in der Lebens- und Beschäftigungsweise hier wie dort 
berücksichtigt. In jenen Städtchen, wie sie sich im zweiten Berichte geschildert 
finden, fehlen Kellerwohnungen ebenso wie vierte und dritte Stockwerke ; es scheint 
von Mangel an Bodenfläche nicht die Rede ; es fällt das Gedrängtsein in engen Arbeits- 
räumen bei Tage fort, ebenso das Herbergs- und Schlafstellenwesen : also das Zusammen- 
gedrängtsein zur Nachtzeit. Noch absoluter entfallen andere Schädlichkeiten der 
grossstädtischen Existenz, - so die nervenaufregende und nervenzerrüttende Erwerbs- 
concurrenz, mit ihr die Ueberanstrengung als Ursache früh zum Tode führender Herz- 
krankheiten, und mit der Bedrohung durch anderweitige Verfälschungen der Lebens- 
rnittel, besonders auch die fatale Beschaffenheit der Kindermilch. Thatsächlich 
verschwinden auch - mit manchen entsprechenden anderweitigen Todesursachen - 
aus den Sterblichkeitstabellen der kleinen Städte fast ganz die Ziffern für die Sommer- 
sterblichkeit der Säuglinge in Folge von Brechdurchfall ; auch die Tuberculose- 
Mortalität tritt erheblich zurück : -jene dem Wegfall des verderblichen heissen Haus- 
klimas und der Darmerkrankungen, - diese dem Zurücktreten der industriellen 
Lungenerkrankungen entsprechend. * 
Um so mehr befremdet es, feststellen zu müssen, dass trotz alledem ein starkes 
Ueberwiegen der städtischen Sterblichkeit auch hier, und zwar bis zum ausgeprägten 
Gegensatz, sich geltend macht. Der Sterblichkeitssatz ist für den Durchschnitt der 
gesammten Bevölkerung 25.5 pro Mille, - und hinter ihm bleibt die Landbevölkerung 
mit 2.6 zurück, während er durch das Sterblichkeitsverhältniss der Städte und Städt- 
* Die Schwindsuchtsverhältnisse.-Absolut mit den 34 übrigen Regierungsbezirken ver- 
glichen in Bezug auf seine Volksdichtigkeit steht Cöslin mit 39 Einwohnern auf den km. fast 
genau an dem nämlichen Platze (34), welcher ihm vermöge seiner Tuberculosesterbezilfer von 185 
zufallen würde: xxxn.1 Unter den Kreisen hat der Kreis Cöslin mit der Bevölkerungsdichtig- 
keit von 58 pro km. auch die höchste, der Kreis Rummelsburg, in welchem nur 29 Menschen 
auf den km. entfallen, auch die niedrigste Tuberculoseziffer, nämlich 222, resp. 181. 
Diese Verhältnisse lassen sich in der Schwindsuchtssterblichkeit der Berichtsjahre ohne Zwang 
wiederfinden. Nur scheint es nach den in der Sterblichkeitstabelle 2 verzeichneten Ziffern, die 
nach den Altersgruppen getrennt sind, als ob überall auf dem Lande die höhere Altersstufe 
(über 50 Jahre), in den Städten dagegen die Altersgruppen zwischen 15 und 50 Jahren an der 
1 Schlockow, "Die Verbreitung der Tuberculose in Deutschland," etc.,etc. Zeitschrift des Kgl. Statist. 
Bureaus, 1883. Heft in, IV, S. 245. 
2 Sc. in der Tabellarischen Anlage No. III. 168 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
eben um 2.7 auf das Tausend überschritten wird. (Siehe Tabelle, S. 171.) Das an- 
scheinend Unerklärliche dieser Erscheinung hat mich zu verschiedenen Berechnungen 
und Untersuchungen veranlasst, die wenigstens hier und da dem uns beschäftigenden 
Gegensatz eine neue Seite abgewonnen haben. 
Ist es gestattet, auch das Nebensächliche mit wenigen Worten zu berühren, so 
greifen die Ursachen des Contrastes zum Theil schon in das Leben vor der Geburt zurück. 
♦ Auf S. 118 findet sich eine Zusammenstellung der in der Geburt abgestorbenen ehe- 
lichen und unehelichen Früchte. Während die Zahl der unehelichen Geburten an 
sich auf dem Lande noch etwas höher ist, als in den Städten, auch die Zahl der sämmt- 
lichen Todtgeborenen - wahrscheinlich wegen Mangels an rechtzeitiger Kunsthülfe - 
sich so vertheilt, dass verhältnissmässig mehr Todtgeburten ehelicher und unehelicher 
Kinder zusammen auf dem Lande vorkommen, ändert sich dies Verhältniss merklich 
zu Ungunsten der Städte, wenn die todtgeborenen unehelichen Kinder beider Kategorien 
verglichen werden. Der Wunsch, die illegitime Frucht zu beseitigen, tritt in der 
Stärke hervor und wird mit so viel Raffinement und Erfolg ausgef ührt, dass in den 
Städten diese Gruppe einen Vorsprung von 92% gewinnt ; in den etwas grösseren, 
besonders den mit Garnisonen belegten uud den vom Fremdenverkehr berührten 
Städten nimmt dieses Verhältniss nach angedeuteter Richtung noch beträchtlich zu. * 
Ein weiterer Antheil des Ueberwiegens der städtischen Sterblichkeit schreibt sich 
aus den ansteckenden Kinder- und Schulkrankheiten her. Man hat in anderweitigen Zu- 
Schwindsuchtssterblichkeit vorwiegend betheiligt seien. In entschiedener Abnahme begriffen 
zeigt sich die Schwindsuchtssterblichkeit (Stadt und Land) im Kreise Colberg : 
1883: 33 + 19 - 1884: 39 + 10 - 1885: 20 + 9 f in der Stadt und 
1883: 29 + 18 - 1884: 19 + 18 - 1885: 16 + 24 f auf dem Lande, 
so dass die Gesammtsterblichkeitsziffern lauten : 
für 1883 : 99 - für 1884: 86 - für 1885 : 69. 
Auch für Neustettin ergiebt sich eine deutliche Reduction, nämlich : 
1883: 27 + 17 - 1884: 19 4- 13 - 1885: 30 + 12 in der Stadt und 
1883: 47 + 66 - 1884: 43 + 54 - 1885: 42 + 53 auf dem Lande, 
insgesammt für 1883 : 157 - für 1884: 129 - für 1885 : 137. 
Geringere Abnahmen sind bei Belgard, Schivelbein, Schlawe und Stolp sichtbar. 
Dagegen zeigt sich in den Kreisen Dramburg und Lauenburg 
(mit 1883: 19 + 14 - 1884: 21 + 19 - 1885 : 24 + 34 in der Stadt, 
1883: 12 + 18 - 1884: 10 + 10 - 1885: 9 + 6 auf dem Lande, 
zusammen für 1883: 63 - für 1884: 60 -für 1885: 73 - resp. 
mit 1883: 16 + 8 - 1884: 12 + 7 - 1885: 14 + 8 in der Stadt, 
" 1883: 13 + 28 - 1884: 18 + 16 - 1885: 23 + 30 auf dem Lande, 
zusammen für 1883 : 65 - für 1884: 50 - für 1885 : 75) 
eine Zunahme, die in Dramburg mehr die Städte als das Land betrifft, während sie in Lauenburg 
mehr den Plattlandbewohnern zukommt. Mit einem geringen Plus betheiligt sich auch der 
Kreis Rummelsburg, in welchem 1883: 44 - 1884: 50 - 1885: 54 Personen beider Alters- 
kategorien an Tuberculose starben. - Die communalärztlichen Berichte aus Falkenburg deuten 
mit Recht darauf hin, dass die Industrie der Tuchfabrikation sehr wohl zur Erklärung für ein 
allmähliges Ansteigen der Tuberculose-Sterblichkeit herangezogen werden könne. 
* Das Verhalten der städtischen und ländlichen Todtgeburten, unehelichen Ge- 
burten UND UNEHELICHEN TODTGEBURTEN.- 
Von 2225 unehelichen Geburten hätten auf die Städte nach Maassgabe des 
Verhältnisses der Einwohnerzahlen zu entfallen 582; - 
Die factisch ermittelte Zahl ist jedoch 579; - 
Die Städte behalten also hier ein Minus von 1.8 ä 
Von 876 Todtgeborenen hätten nach obiger Maassgabe auf die Städte zu 
entfallen 225 ; - 
Die factisch ermittelte Zahl ist 220 ; - 
Die Städte bleiben also hier im Rückstände mit 5.7 ao SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
169 
sammenstellungen ermittelt, dass bei Masern und Scharlach die ländliche und städtische 
Jugend sich mit annähernd gleicher Mortalität betheiligen. Dies trifft jedoch für unser 
Material nur in Bezug auf die Masern zu, während für Scharlachepidemieen sowohl die 
Ausbreitung als die Tödtlichkeit in den städtischen Bevölkerungen durchweg die viel 
schlimmere war ; die Scharlachsterblichkeit ist es besonders, welche mit dem städtischen 
Gedrängtleben in der Fläche eine nahezu vollkommene Parallele innehält. In etwas 
anderer Form äussert sich der verderbliche Einfluss, welchen die Diphtherie zu 
Ungunsten der Städte entfaltet. Der ganze Norden Europa's und mit ihm die nörd- 
lichsten preussischen Provinzen kennt seit anderthalb Jahrzehnten verheerende 
Diphtherie-Epidemieen auch auf dem platten Lande. Allein, während hier die zeitliche 
Dauer dieses Krankheitseinflusses als eine begrenzte erscheint, haben unsere kleinen 
und Mittelstädte nicht nur monatelang, nein, über mehrere Jahre hinaus an Diphtherie 
ihren jungen Nachwuchs verloren, sind trotz aller sanitätspolizeilichen Maassnahmen 
immer wieder und mit immer neuen Heerden der Verseuchung anheimgefallen. 
Mehrfach macht in perennirender Form sich innerhalb der Städte auch der 
Abdominaltyphus geltend, während er auf dem platten Lande vorwiegend in schnell 
vorübergehenden Hausepidemieen (oft in der ausgesprochenen Form des Nahrungs- 
Dagegen hätten von 98 unehelichen Todtgeborenen nach obiger Maassgabe 
auf die Städte zu entfallen 25 ; - 
Die factisch ermittelte Zahl ist jedoch 34; - 
Hier gewinnen also die Städte ein Plus von 92 
Von nicht geringem Interesse ist hiernach noch die Vergleichung obiger allgemeinerer Ver- 
hältnisszahlen mit den betreffenden Ziffern für die drei grössten Städte-Cöslin, Colberg und Stolp. 
Es lässt sich aus denselben folgende kleine Tabelle zusammenstellen : 
Ueberh. Geb., 
t 
Leb. geb., 
Unebel., Ebel, geb., 
Unebel. f 
C'öslin, Stadt : 
582 
19 
563 
64 
518 
3 
„ Land: 
1043 
31 
1012 
120 
923 
3 
Von 1625 überhaupt Geborenen würden auf die Stadt : 606 
das Land: 1019 
582 
entfallen ; factische Zahlen 
also • 
- 24 = 39 p. M. im Rückstände. 
+ 24 = 24 „ im Ueberschuss. 
Von 184 Unehelichen würden auf die Stadt: 68 
das Land: 116 
- 4 = 58 p. M. im Rückstände. 
+ 4 = 34 „ im Ueberschuss. 
entfallen; factische Zahlen 
Von 50 Todtgeborenen würden auf die Stadt: 19 ) 
das Land: 31J 
also 
19 
entfallen; factische Zahlen 
Von 6 unehelichen Todtgeburten würden auf die Stadt: 2.2 
das Land: 3.8 
, 3 
► entfallen ; factische Zahlen 
also 
+ 0.8 = 363 p. M. im Ueberschuss. 
- 0.8 - 216 „ im Rückstände. 
Ueberh. Geb., 
t 
Leb. geb. 
Unehel., Ebel, geb., 
Unebel, t 
Colberg, Stadt : 686 
44 
642 
99 
587 
10 
„ Land: 1221 
49 
1172 
128 
1093 
4 
Von 1907 überhaupt Geborenen würden auf die Stadt: 717 
das Land : 1190 
entfallen ; factische Zahlen 
also J 
- 31 = 43 p. M. im Rückstände. 
+ 31 = 30 ,, im Ueberschuss. 
Von 227 Unehelichen würden auf die Stadt: 85 
das Land: 142 
99 
entfallen; factische Zahlen p-,g 
also 
+ 14 = 164 p. M. im Ueberschuss. 
- 14 = 98 „ im Rückstände. 
Von 93 Todtgeborenen würden auf die Stadt: 35 1 
das Land: 58 J 
+ 9 = 257 p. M. im Ueberschuss. 
- 9 = 152 „ im Rückstände. 
44 
entfallen ; factische Zahlen 
Von 14 unehelichen Todtgeborenen würden auf die Stadt: 5.3 1 
das Land : 8.7 J 
also 
entfallen; factische Zahlen 
also 
+ 4.7 = 1886 p. M. im Ueberschuss. 
- 4.7 = 540 „ im Rückstände. 170 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
typhoids), oder ganz vereinzelt beobachtet wird. Gilt dies für die Art der Typhus- 
erkrankungen, so betheiligen sich an der Steigerung der städtischen Typhusniortahïâï 
mit sichtlicher Präponderanz jene Fälle, in denen vom Lande in die Städte über- 
siedelnde Personen jugendlichen Alters oft schon in den ersten Wochen des ungewohn- 
ten Aufenthaltes von Typhoid befallen und hingerafft werden. 
Die Ursachen der zuletzt geschilderten verderblichen Einflüsse finde ich nun in der 
Bebauungsart des Bodens unserer Städte, wobei nicht die Grösse und nicht das absolute 
Gedrängtleben das Entscheidende ist, und bringe f ür diese keineswegs neue Hypothese 
folgende aus dem vorliegenden Material hergenommene Begründung bei : 
Die Bauanlage der hinterpommerischen Städte führt sich bei etwa der Hälfte der- 
selben auf den Uebergang aus den wendischen Staatsverhältnjssen - der Kastellanei- 
Verfassung- in die deutsche Verwaltung (14. Jahrhundert) zurück. Denn wenn auch 
die damaligen den Landesherren Kriegshülfe und Steuern direct leistenden (sogenannten 
Immédiat-) Städte nicht unmittelbar aus den alten wendischen " Castris " entstanden, 
so lag doch das mit diesen gleichzeitig errichtete "Forum" derartig unweit der 
Kastellauei-Baulichkeiten, dass die deutschen Einwanderer des 14. Jahrhunderts in 
dem Forum und seinen nächsten Umgebungen einen geeigneten Stütz- und Mittelpunkt 
zur Gründung ihrer Handelscolonien, der neugebildeten Städte, erblicken mussten. 
Nach der Umwallung der letzteren wurden die ehemaligen Castra meistens aufgehoben; 
doch bestanden sie hin und wieder als Mittelpunkte wendischer Burgflecken neben den 
neuangelegten deutschen Städten fort. Dagegen nahmen die übrigen, später entstan- 
denen Städte ihre Entwickelung von der Dor/anlage, der langen Reihe dicht an die 
Heerstrasse gesetzter Häuschen her, aus welcher Neben- und Parallelstrassen nur lang- 
sam herauswachsen, und deren späterer " Markt" nirgends den Character des Ringes 
oder Forums, sondern stets den des etwas umgewandelten Kirchplatzes zeigt. 
Es ergiebt sich nun, dass fast der nämliche Gegensatz, wie zwischen Stadt und Land, 
besteht zwischen den aus wilden politischen Gründungszeiten herstammenden und den 
von jeher offenen Städten. Jene waren es, die, ursprünglich umwallt, ummauert und 
von Gräben umzogen, ihre Bevölkerungen auf einen gegebenen Raum zusammen- 
pressten. In ihren engen Gassen sind Luft und Sonnenschein noch heute seltene Gäste, 
und wenn in diese schlechten Strassen, in diese back-to-back houses, durch Niederreissen 
einmal Breschen gelegt werden, so pflanzt sich der Schmutz und die Unreinlichkeit dei' 
Jahrhunderte in einer neuen Gestalt oft noch ferner fort. Denn diese Plätze sind es 
auch vornehmlich, aus deren altem, mit den Abfällen der Zeit imprägnirtem, aber 
anscheinend noch benutzbarem Baumaterial angeblich neue Häuser aufgebaut werden, 
und ebenso wird der ungereinigte oder mit altem Bauschutt locker aufgefüllte Boden 
zur Errichtung neuer, aber von vornherein ungesunder Strassen und Viertel missbraucht. 
Ueberh. Geb,, 
t 
Leb. geb., 
Unehel., 
Ehel. geb., 
■Unehel. f 
Stolp, Stadt : 800 
19 
781 
103 
697 
4 
„ Land: 2977 
102 
2875 
338 
2439 
12 
Von 3777 überhaupt Geborenen würden auf die Stadt: 835 
das Land: 2942 
entfallen ; factische Zahlen .n)-~ 
also 
- 35 = 42 p. M. im Rückstände. 
+ 35 = 12 ,, im Ueberschuss. 
Von 441 Unehelichen würden auf die Stadt: 97 
das Land: 344 
entfallen ; factische Zahlen 
also 
+ 6 = 60 p. M. im Ueberschuss. 
- 6 = 18 „ im Rückstände. 
Von 121 Todtgeborenen würden auf die Stadt: 27 
das Land: 94 
also • 
- 8 = 292 p. M. im Rückstände. 
+ 8 = 85 „ im Ueberschuss. 
19 
entfallen ; factische Zahlen 
Von 16 unehelichen Todtgeborenen würden auf dieStadt: 3.5 
das Land: 12.5 
entfallen ; factische Zahlen 
also 
+ 0.5 = 143 p. M. iin Ueberschuss. 
- 0.5 = 40 „ im Rückstände. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
171 
Es sei mir zum Schluss gestattet, die gewonnenen Anschauungen in den folgenden 
kurzen Thesen zusammen zu fassen : 
1. Es lässt sich beweisen, dass kleine Städte, welche für ihre Flächenausdehnung 
keineswegs übervölkert sind, aber aus Mangel an Fortschritt und Gedeihen ihre mittel- 
alterliche Anlage beibehalten haben und selbst bei Neubauten und Erweiterungen alte 
verbrauchte Baumaterialien verwenden, eine ebenso grosse Sterblichkeitsziffer haben 
und in ebenso ungünstigem Gegensatz zu dem platten Lande stehen, wie viele Gross- 
städte, deren Bewohner auf einen relativ viel kleineren Flächenraum angewiesen sind. 
2. Jede Form des Gedrängtlebens in Städten verlangt ihre eigene Begriffsbestim- 
mung, muss specifisch nachgewiesen und auf ihren factischen schädlichen Einfluss 
geprüft werden. 
3. Da sich für jede Form des Zusammendrängens und der Anhäufung von Menschen 
auch ein System der Zerstreuung erfinden lässt, haftet die höhere städtische Sterblich- 
keit keineswegs unbedingt dem Gedrängtleben als solchem an, - noch weniger aber 
erhöht sie sich nothwendig mit der Grösse und dem Wachsthum der Städte. 
DIE STERBLICHKEIT IN DEN POMMERSCHEN STÄDTEN UND AUF DEM PLATTEN 
LANDE. 
Kreise. 
Jahrgang. 
Städte. 
Plattes Land. 
§ 
K Z 
«S 
5 O 
H 
"5 
ES STARBEN 
AUF 1000 
M. 
W. 
d 
s 
N 
M. 
W. 
d 
8 
g 
3 
■ 
B 
Städter. 
Land- 
bewohner. 
1883 
168 
144 
312 
426 
388 
814 
1,126 
25.5 
24.5 
Belgard J 
1884 
196 
188 
384 
444 
360 
804 
1,188 
31.2 
24.2 
1885 
150 
135 
285 
398 
330 
728 
1,013 
23.5 
21.9 
1883 
62 
62 
124 
208 
174 
382 
506 
26.6 
22.8 
Bublitz 
1884 
80 
65 
145 
200 
180 
380 
30.9 
22.7 
1885 
100 
96 
196 
261 
200 
461 
657 
41.7 
28.8 
1883 
58 
69 
127 
255 
243 
498 
625 
25.7 
19.9 
Bütow I 
1884 
105 
95 
200 
258 
232 
490 
690 
40.4 
19.4 
1885 
60 
72 
132 
328 
275 
603 
735 
26.7 
23.5 
1883 
218 
190 
408 
325 
288 
613 
1,021 
23.9 
21.7 
CÖSLIN. 
1884 
219 
190 
409 
333 
327 
660 
1,069 
23.9 
23.4 
1885 
204 
180 
384 
323 
282 
605 
989 
22.5 
21.5 
1883 
289 
247 
536 
360 
325 
685 
1,221 
27.4 
21.3 
Colberg 
1884 
353 
335 
688 
430 
417 
847 
1,535 
35.0 
26.6 
1885 
227 
281 
508 
482 
431 
913 
1,421 
26.0 
285 
1883 
196 
187 
383 
238 
250 
488 
871 
28.5 
21.1 
Dramburg 
1884 
165 
156 
321 
207 
219 
426 
747 
24.6 
18.3 
1885 
240 
221 
461 
293 
264 
557 
1,018 
34.3 
24.1 
1883 
105 
85 
190 
379 
348 
727 
927 
20.3 
21.2 
Lauenburg 
1884 
122 
123 
245 
406 
392 
798 
1,043 
26.2 
23.2 
1885 
106 
87 
193 
434 
334 
768 
961 
20.7 
22.3 
1883 
271 
236 
507 
736 
646 
1,382 
1,889 
28.5 
23.8 
Neustettin 
1884 
309 
277 
586 
958 
899 
1,857 
2,443 
31 1 
31.8 
1885 
297 
188 
485 
794 
717 
1*511 
L996 
27.3 
25.9 
1883 
62 
62 
124 
397 
336 
733 
857 
23.7 
24.2 
Rummelsburg 
1884 
78 
96 
174 
481 
440 
921 
1,095 
33.3 
31.5 
1885 
75 
75 
150 
410 
349 
759 
909 
28.7 
26.0 
1883 
87 
65 
1'62 
161 
156 
317 
469 
25.6 
23.3 
Schivelbein 
1884 
79 
58 
137 
138 
302 
439 
23 1 
22 2 
1885 
87 
70 
157 
125 
118 
243 
400 
26.5 
18.0 
1883 
258 
240 
498 
788 
781 
1,569 
2,067 
32.2 
24.1 
SCHLAWE 
1884 
278 
260 
538 
1 330 
1 868 
33 0 
22 0 
1885 
200 
194 
394 
637 
626 
1,263 
1,657 
25.0 
20.7 
Stolp J 
1883 
298 
283 
581 
928 
771 
1,699 
2,280 
23.4 
22.0 
1884 
415 
390 
805 
589 
432 
1,021 
1,82'. 
36.6 
13.2 
1885 
411 
407 
818 
730 
666 
1,396 
2,214 
37.1 
18.1 
6,628 -f 
6,109 : 
12,737 
15,556 + 13,994 : 
29,550 
42,287 
28.2 
22.9 
22,184 
25.5 
20,103 
: 42,287 172 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE THERMOMETER AS A CLIMATOLOGICAL INSTRUMENT. 
LE THERMOMÈTRE COMME UN INSTRUMENT CLIMATOLOGIQUE. 
DAS THERMOMETER ALS KLIMATOLOGISCHES INSTRUMENT. 
CHARLES SMART, M. B., C. M. 
The thermometer is a valuable meteorological instrument. In cold weather it gives 
expression to the degree of coldness and in hot weather to the degree of heat, and we 
learn a good deal from that. When it indicates 30° Fahr, we expect ice-films on the 
pools, and when it mounts high into the nineties we anticipate a list of sunstruck cases 
in the evening papers. But the dead or absolute temperature which the thermometer 
gives us is a most imperfect indication of the call made upon the heat-regulating func- 
tion of the human system by the degree recorded. At 30° Fahr, the weather may be 
pleasant, provided there is no wind, and at 90° Fahr, it may not be unpleasant if there 
is a breeze and the atmosphere is dry and disposed to promote evaporation from the 
skin. 
The range of atmospheric temperatures above the normal of the animal heat is 
limited, that of temperatures below the normal is extensive, so that what we, as medical 
climatologists, desire is a thermometer which will indicate not the dead or absolute 
temperature, but how cold it is to the feel-what demand is made for protective cover- 
ing, or on the heat-producing powers of the system ; in other words, how rapidly a 
certain climatic exposure carries off the animal heat. 
There are three principal factors which make up the sum of that which we call 
climate-the absolute temperature of the air, its motion and its moisture. Any attempt 
to simulate by an apparatus the conditions of the living body, and to note the change 
produced in it by the influence of these factors, is out of the question, on account of 
the complexity of the conditions ; hence some simpler method must be adopted to show 
the calls made by climatic influences on the animal heat and the consequent strain upon 
the energies of the human organism. The thermometer will answer our purpose in an 
inquiry of this nature, for when the mercurial column has been raised by artificial 
means to a given point, the rapidity with which it falls from that point in a given time 
under exposure to the influence of certain climatic factors will give the means of 
expressing the relative value of such climatic influences. The same thermometer when 
raised to 98.4°, the normal human temperature, will always fall to the same point when 
exposed in the calm for the same length of time to the same temperature lower than 
98.4°. Suppose the distance from 98.4° to the given temperature be expressed as unity, 
the fall in the calm for a given temperature below 98.4° will always be a certain frac- 
tional part of that unity-say, for example, two-tenths. If, now, this thermometer, 
which falls, when exposed in the calm to a given temperature, two-tenths of the distance 
from 98.4° to that temperature, be exposed for the given time to the same temperature 
pZus wind and moisture, and it is found that instead of falling two-tenths of the distance 
it falls three or four or five-tenths, we are warranted in saying that of this fall, all which 
is in excess of two-tenths, or the fall in the calm, is due to the influence of the motion 
and moisture of the atmosphere. And as this is true for all given temperatures, it 
follows that were a thermometer so graduated as to show on its scale the point to which 
exposure to each degree of temperature in the calm would depress the column in a given 
time, that thermometer, when its fall for the given time was noted under exposure, would 
show in degrees of calm cold the equivalent of the exposure to which it had been 
subjected. 
The graduation of a thermometer in this way calls for much patient and intelligent 
labor on the part of the maker ; but the grand objection to its use is the necessity for SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
173 
a warm mercury bath to raise its temperature above 98.4° prior to taking an obser- 
vation. The heat of the mouth will not do, for when the column is thus raised, dis- 
cordant results are obtained on account of the varying quantities of moisture attaching 
to the bulb. It therefore appears that if any practical benefit is to accrue from this 
idea it is by the preparation of reference tables, based on the results of a series of re- 
liable observations. 
Some years ago, when stationed at a Western post, I had favorable opportunities for 
making such observations. First I determined the fall of my thermometers in the 
calm. I had four of them, each an all-glass instrument, i. e. with no brass or other 
metallic mounting about it. Calm days were selected for the observations and a room 
that .was perfectly free from draughts ; and to cut off the thermic influence of the 
observer the thermometer-stand was placed in a roomy box, open at the top and with 
its sides rising a foot above the level of the bulb. Observations were made through a 
hole bored at a proper level in one of the sides. The stand supported the all-glass ther- 
mometer, which was specially selected on account of the slowness of its fall, a second 
very sensitive thermometer to indicate the dead temperature during the period of the 
observation, and a watch to give the time of exposure. The all-glass thermometer was 
raised a few degrees, above the human temperature in a mercurial bath and immediately 
transferred to the stand for the observation of the fall of the mercurial column. 
Observations were made with all four of the thermometers and for varying times, as 
one, one and a half, two, three and four minutes, and the results agreed with each 
other ; but it was found that, although the same thermometer always fell from 98.4° 
to the same point when exposed for the same time to the same temperature, it did not 
fall the same fractional part of the distance for all temperatures, but increased in its 
fall as the distance to be fallen increased, that is, if the thermometer fell two-tenths 
of the distance when the given temperature was 40°, it fell less than two-tenths when 
the given temperature was higher than 40°, and more than two-tenths when the given 
temperature was lower, this depending, no doubt, upon the increased energy of the con- 
vective or displacement current established by an increase in the difference of tempera- 
ture between the heated bulb and surrounding air. Taking one of the four thermometers 
by way of example, it was found that with one minute's exposure to- 
88.4° making a distance of 10° the fall was .180 
78.4° " " 20° " " .200 
68.4° " " 30° " " .207 
58.4° " " 40° « .215 
48.4° " " 50° " " .220 
38.4° " " 60° " " .230 
28.4° " " 70° " " .235 
18.4° " " 80° " " .240 
As it was found impossible to determine by experiment the fall in the calm for every 
degree of temperature required in this investigation, and as a close approximation to 
the fall for many degrees below zero was necessary, such observations as the above 
were made the basis of a calculation by which the fall for.all the other degrees was 
reached. The laws governing the motion of currents established by differences of 
temperature were considered in this calculation, which is given in full in the appended 
note.* That its results approximate closely to fact is shown by the correspondence of 
the calculated numbers with those yielded by observation. 
«- When a body is placed in a gaseous medium possessing a temperature lower than its own, 
it loses heathy radiation and convection. We know that the loss by convection is proportionally 
more rapid the greater the difference between the two temperatures ; and if this increased rapidity 174 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Thus for a- 
Distance of 10° the calculated fall is .186, the observed .180 
" 20° " " " .198, " .200 
« 30° " " « .207, " .207 
" 40° " " " .214, " .215 
« 50° " " " .222, " .220 
" 60° " " " .228, " .230 
" 70° " " " .234, " .235 
" 80° " " " .240, " .240 
Having thus determined along the scale of this thermometer the various points to 
which the mercurial column would fall when exposed in the calm to any given degree 
of loss by convection be determined for every degree of temperature, a sufficiently accurate 
approximation will be made for all the purposes of this inquiry. 
As the rapidity of loss must depend on, and be proportionate to, the increased activity of the 
convection currents, a determination of the energy of these currents at their inception will furnish 
the required information. 
We have, for the determination of this point, certain observations made on the mercurial fall 
of a given thermometer-for instance, those stated in the text of this paper ; and as the size and 
shape of the given thermometer are always the same, any differences in the velocity of the con- 
vective currents will depend solely on difference of temperature. 
Taking as the rate of expansion of gases for every degree above zero, and of contraction 
for every degree below that point, and making t represent the temperature of the air and T the 
difference between the air temperature and 98.4°, or the temperature of the heated thermometer 
T . 
bulb, will give a relative expression of the height to be fallen to yield a velocity corres- 
ponding to that of the current established between the air and the bulb. Then, as the velocity 
is nearly equal to eight times the square root of the height, 8 "j/t wiB give a relative 
expression of the velocity itself : For 1° the expression will be .3384 ; for 10°, 1.08; for 20°, 1.5424; 
for 40°, 2.2224; for 80°, 3.2712 ; for 98.4°, 3.7 ; and so for all other degrees of difference. If, now, 
the relative expression of the velocity of the current for a difference of 98.4° between the tempera- 
tures of the air and bulb-to wit, 3.7-be called unity, the expression for 1° will be .09 of that 
unity; for 10°, .29; for 20°, .42; for 30°, .52; for 40°, .60; for 80°, .88; for 98.4°, 1, and so for 
all other degrees of difference. 
Now, to determine the real value of these relative figures we have any two of the actual 
observations made. The two selected were those with 80° and 30° of difference, the former as 
being the largest, and the latter the smallest, as it was conceived that those under 30° were liable 
to inaccuracy from the smallness of the fall. A distance to be fallen of 80° gave a fall of 19.2°, 
or .240 of the distance, while a distance of 30° gave a fall of 6.2°, or .207 of the distance, thus 
showing a difference of (.240-.207), or .033 of the distance for the fifty degrees of temperature 
lying between the two observations. But we have already seen that the relative expression of 
the velocity for 80° of difference is .88 of the velocity for 98.4°, while the expression for 30° is .52 
of the same unity, thus showing the velocity for the fifty degrees of temperature lying bptween 
the two observations to be ,88-.52 = .36 of the velocity for 98.4.°. It follows that a velocity of 
.36 of the unity causes a fall of .033 of the distance to be fallen, and that the unity itself (the 
velocity occasioned by a difference of 98.4°) causes a fall of .092 of the distance. 
Now, the effect of convection for 30° of difference we have seen to be .52 of the effect for 98.4°, 
i. e., .52 of .092, or .048 of the 30°; but as we know that the fall caused by 30° of difference is 
.207 of the distance, all of the .207 in excess of .048-that is, .159-must be due to radiation. 
And again, the effect of convection for 80° of difference we have seen to be .88 of the effect 
for 98.4°, i. e., .88 of .092, or .081 of the 80° ; but as we know that the fall caused by 80° of dif- 
ference is .240 of the distance, all of the .240 in excess of .081-that is, .159-must be due to 
radiation. 
Knowing, then, that the fall from radiation in this given thermometer is .159 of the distance 
to be fallen, and that the unity in the table of relative velocities of convection currents is .092 
of the distance to be fallen, the fall in the calm for any and all degrees may be obtained. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
175 
of cold, I was prepared to observe the influence of the other climatic 
factors. This thermometer, when raised to 98.4 by artificial means, 
and exposed to the influence of cold, wind and moisture for one minute, 
would show, by its fall at the end of that time, the degree of calm cold 
which would carry off its heat with the same rapidity as was effected 
by the cold, wind and moisture to which it had been exposed, i. e., it 
would enable me to state definitely the influence of the climatic factors 
independent of the cooling influence of evaporation from the cutaneous 
and pulmonaiy surfaces. Instead of recording the absolute temperature 
as so many degrees, the wind as so many feet per second or miles per 
hour, and the relative humidity as so much, I would be enabled to say 
that the climatic influences, at the time of the observation, were equal 
to so many degrees of calm cold, or, in other words, that they made as 
much demand on the powers of the system as an exposure to so many 
degrees of a calm, dry cold. 
In making the subsequent observations a stand was used which 
carried this thermometer, along with a watch, a delicate thermometer 
to indicate the dead temperature during the period of observation, and 
Casella's air-meter, No. 350, to give the velocity of the air currents. 
The bulb of the special thermometer was immersed to a given point 
on the stem in the mercurial bath, and its column raised to a few 
degrees above 98.4° Fahr.-to 105° or 110°-depending on the cooling 
influence of the intended exposure-sufficiently high, in fact, to enable 
the observer to place it in position and have his finger on the catch of 
the air-meter and his eyes on the falling column and watch-dial before 
it reached the level of 98.4.° On the instant it reached that level, time 
was noted and the index of the meter liberated ; then the other ther- 
mometer was watched, and if stationary for the minute, at the expira- 
tion of that time the height of the falling column was noted, while the 
finger checked the index of the air-meter. 
If the temperature varied during the minute of exposure, the 
observation was rejected. 
At the beginning, middle and end of each day's series of observa- 
tions, the dew-point was recorded ; but the heated bulb of the falling 
thermometer being dry, evaporation from its surface failed to enter into 
the experiment as a cooling agency, and the resultant of the observa- 
tions gave expression only to the influence of the wind as modified by 
the amount of moisture with which it was charged. No note was taken 
of the height of the barometer during the observations, as the meteoro- 
logical register of the post showed an air pressure of twenty-five and a 
half inches, with little variation from day to day or from month to 
month. It was therefore assumed that the atmospheric pressure did 
not enter into the observations as an element of variation. 
Over one thousand observations (1064) were placed on record before 
proceeding to figure up the conclusions to which they might point, yet 
so generally consistent were the results, that long before the series was 
concluded the observer was able to determine the air movement from 
the fall of the mercurial column-that is, to him the fall of the mercury 
became an anemometer. When the series was completed, the individual 
observations were massed together in accordance with the velocity of 
the wind ; all those, for instance, with the wind ranging from 484 to 
572 feet per minute, averaging 528 feet per minute, or six miles per hour, being thrown 176 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
together that the average might be struck and the extremes more readily appreciated. 
The following table gives the results :- 
RATIOS BORNE BY THE FALL WHEN EXPOSED, TO THE FALL IN THE CALM, THE LATTER BEING 
UNITY. 
Calm 1 
i mile per hour 1.42 
i " 1.54 
i " 1.66 
1 " 1.71 
li " 1.88 
2 " 2.03 
2| " 2.14 
3 " 2.21 
3| " 2.39 
4 " 2.43 
4J " 2.54 
5 miles per hour 2.63 
5J " 2.75 
6 " 2.81 
7 " 2.93 
8 " 3.01 
9 « 3.08 
10 " 3.18 
12 " 3.27 
14 " 3.39 
16 " 3.47 
18 " 3.53 
20 " 3.60 
In summing up these results toward the close of the series of observations, an inter- 
esting discovery was made. Previous to commencing, while all care was devoted to 
the selection and graduation of the thermometers, but little thought was given to the 
record of the air-meter. It was now noted, however, that although the meter measured 
the velocity of the current with accuracy when it passed in a line parallel to the axis 
of the wheel, any obliquity in the direction of the current caused a corresponding loss 
of power over the revolution of the wheel, so that less wind was recorded than actually 
passed. Robinson's cups should have been used instead of Casella's air-meter. The 
wind, particularly when high and blustering, is seldom steady from one point, but 
veers a few degrees on either side of it, and in proportion to its degree of obliquity was 
its unrecorded passage. The ratios recorded are, therefore, a little too high, particularly 
with the higher velocities. Assuming, however, these ratios to be as close an approxi- 
mation to the truth as this flaw in the observations will permit, the use of such a table 
may be indicated. 
Suppose the absolute temperature in a given case to be 68.4°, a distance to be fallen 
of 30°, and the velocity of the wind eight miles per hour, the ratio for which is 3.01. 
The thermometer when exposed to an air current of eight miles at 68.4° falls 3.01 times 
the distance which it falls for 30° of difference in the calm ; but it falls for 30° in the 
calm .207 of 30° ; for the wind exposure it therefore falls .207 X 3 01 = -623 of 30°, or 
18.7°-that is, from 98.4° to 79.7°. But as 79.7° of the absolute scale is equal to 20° 
of the sensitive scale, we are warranted in saying that a temperature of 68.4° w ith eight 
miles per hour of wind is equal in its cooling effect to a temperature of 20° in the calm. 
And so of all other temperatures and velocities of the air. 
In conclusion, I submit a table calculated on this basis, giving in degrees of calm 
cold the equivalent of temperatures down to 20° below zero, in conjunction with winds 
ranging from calm to twenty miles an hour. This table, of course, carries with it the 
error of the observations on which it is based. The ratios being greater than they 
should be, give a larger fall for the given wind, and a lowrer temperature as the result. 
It is respectfully submitted, however, not as embodying the actuality, but as an approxi- 
mation thereto, and as a step in the direction of greater precision in our ideas with 
regard to the climatological influence of air currents, and particularly as they bear 
upon our views of climate, based, as these generally are, on statements of the maximum, 
minimum and mean temperatures of the locality. »- 
o 
Calm. 
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12 Miles Per Hour. 
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177 
Vol. V.-12 I «... 
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3% Miles Per Hour. 
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Miles Per Hour. 
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7 Miles Per Hour. 
sgS.çiBsssigâÀàââiâisssiààgèià 
8 Miles Per Hour. 
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12 Miles Per Hour. 
14 Miles Per Hour. 
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16 Miles Per Hour. 
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178 SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
179 
[Abstract.] 
VITAL STATISTICS AND MEDICAL GEOGRAPHY. 
STATISTIQUES VITALES ET GÉOGRAPHIE MÉDICALE. 
STERBLICHKEITSSTATISTIK UND MEDICINISCHE GEOGRAPHIE. 
ALFRED HAVILAND, M.R.C.S., 
Of London, England. 
The author commenced by giving a brief history of Medical Geography from its 
earliest introduction by the Hippocratic School of Medicine to the time when the work 
of Dr. William Farr rendered this branch of medical science possible in England. 
He then described the plan of three decennial supplements to the Registrar-General's 
Reports which Dr. Farr had initiated and succeeded in carrying out for the years 1851- 
1860 and 1861-1870. 
Dr. Farr's great aim in tabulating the deaths from the several causes selected, occur- 
ring in the 630 Registration Districts into which England and, Wales are divided, was 
to keep the sexes entirely separate, so as to enable the Medical Geographer to show the 
effect of sex upon the mortality from certain diseases-cancer, for instance. Again, 
well knowing the effect of age, he considered it important that the mean number of 
males and females living at different periods of life, in each district, should be ascer- 
tained and given, as far as the Census Returns would admit, and that the number of 
males and females dying from certain causes should be given for each age period, with 
the view of ascertaining the relative mortality among the males and females living 
during the decennial periods reported on. The advantage of such a system is obvious, 
for no investigation bearing upon the natural history of this case could be undertaken 
without its adoption. Nevertheless, the present Registrar-General of England has so 
far departed from Dr. Farr's plan as to render his supplement to his 45th Annual 
Report (1871-1880) not only useless but misleading. 
The author then proceeded to illustrate his remarks by reference to maps showing 
the geographical distribution of several diseases, especially of cancers, among males 
and females separately. 
In conclusion, he urged upon the Congress the necessity of its pointing out to the 
different Governments of the civilized world the importance of their adopting an uni- 
form mode of collecting Vital Statistics and tabulating them according to sex and age, 
in accordance with some definite plan based upon the principles laid down by the late 
Dr. William Farr, c.B., F.N.S., D.c.s. 180 
NINTH INTERNATIONAL MEDICAL CONGRESS 
A CONTRIBUTION TO THE STUDY OF THE CLIMATIC AND OTHER 
PECULIARITIES OF LOCALITIES WHICH DETERMINE EXEMP- 
TION FROM PREVALENCE OF ENDEMIC PLAGUES. 
UNE CONTRIBUTION À L'ÉTUDE DU CLIMAT ET D'AUTRES PARTICULARITES 
DES LOCALITÉS QUI PRÉVIENNENT LES FLÉAUX ENDÉMIQUES. 
EIN BEITRAG ZUM STUDIUM DER KLIMATISCHEN UND SONSTIGEN LOKALEN EIGEN- 
THÜMLICHKEITEN, WELCHE BEFREIUNG VON ENDEMISCHEN SEUCHEN BEDINGEN. 
BY RICHARD J. NUNN, M. D., 
Of Savannah, Georgia. 
In medicine the investigation of negative phenomena is scarcely less important, 
from a scientific point of view, than is the careful examination of the positive condi- 
tions which exercise a controlling power upon the origin and spread of diseases. 
There is a fascination in chasing a disease to its home. There is somewhat of excite- 
ment in the constantly recurring scientific skirmishes which unavoidably attend such 
an investigation ; and great pestilences, like great wars, are blazoned forth in history, 
and the heroes of the one, like the heroes of the other, ride into fame and notoriety on 
the crest of the great waves of destruction and death. So it is not astonishing that the 
causes which produce the exemptions from diseases of one kind or another should have 
received at the hands of scientists but very little attention. Such observations do not 
seem to lead to fame or wealth, they require the concurrent work of a number of observ- 
ers at different localities, and, for a long time, the visible results would only be an 
array of curious scientific facts, with not one life saved, and, apparently, not a human 
being benefited, by all that labor. Apparently, yes ; but, in reality, the results might 
be most valuable, as leading us up to a knowledge which would enable us to exclude 
disease, a power which sanitarians will tell us is far more valuable than is the ability 
to cure it. 
Every locality seems to enjoy immunity from certain diseases, while certain other 
maladies seem to make their habitat in each. • 
In common with other places, Savannah, Georgia, can claim an entire exemption 
from certain maladies, while others appear there only in a very mild or modified form. 
It is proposed in this paper to lay before you such a topographical description of the 
city of Savannah, Georgia, and such a history of its sanitation, as will enable you to 
judge how far these can be credited with the very extraordinary exemptions from 
certain diseases, and the modified type of others, which are manifested in that locality. 
TOPOGRAPHY. 
The Savannah river, a deep, broad stream, strongly charged with the red clay of the 
Georgia hills, flows (subject to the tides) in a southeasterly course to the Atlantic. 
On the south bank of this river, about fifteen miles from the ocean, by the course of 
the river, but about twelve in an air line, rises a steep sand bluff, running about a mile 
along the river, with a maximum height of about forty-five feet above mean low 
water. Upon this bluff is situated the city of Savannah, in latitude 32° 4' 9/z N., 
longitude 8° 7Z W. 
This bluff is but the northern extremity of a ridge of high ground which extends 
several miles to the south, gradually sinking to the level of the surrounding land, SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
181 
while for fifty miles around (except seaward) the country is mainly composed of large 
bodies of swamps, interspersed occasionally with high land. 
Wide streets, unpaved, with four or five exceptions, and with sandy, porous soil, 
divide the city, which is some two miles square, into rectangular blocks of about 300 
by 200 feet, these blocks being again subdivided by longitudinal lanes, while scattered 
through the city at regular intervals are twenty-five open squares of one to one and 
one-half acres, and the number of open spaces is still further increased by a park and 
parade ground of about thirty acres, and an old cemetery which has been unused for 
over thirty years. It will thus be seen that the city is amply supplied with breath- 
ing spaces, and shade has been provided by profusely planting the squares and streets 
with trees. 
WATER SUPPLY. 
In the history of Savannah there have been four sources of water supply-surface 
wells, river water, driven wells, and artesian wells. 
Before the year 1853 the inhabitants derived their supply of water from surface 
wells, public wells being sunk in the squares or at the intersections of streets, but 
many of the householders had wells upon their lots, often within a few feet of the 
privy vaults. The depth of the wells seldom exceeded twenty feet, and the water was 
drawn through pumps, principally of wood. 
From the character of the soil it will be observed that the water of these surface 
wells must have been largely contaminated with sewage, and it is of record that the 
existence of chemical evidence of this fact, so far as the wells in the older portions of 
the city are concerned was laid before the scientific section of The Georgia Historical 
Society and the public. More recently this statement was confirmed by the accidental 
leaking of a naphtha pipe connected with the gas works, by which all the wells in the 
neighborhood were affected. 
There is further confirmation of this statement in the fact that when the sewers 
were built, some of them were laid deeper than the wells had been dug, and in these 
localities the wells went dry, the drainage being from the well to the sewers. This 
necessitated the deepening of the wells and the consequent reversal of the drainage. 
From this it will be evident that for a long period of the city's existence the in- 
habitants were in reality drinking filtered sewage more or less diluted. 
The observations just made touching surface wells are equally applicable to the 
driven wells, which were only forced down to the stratum of water from which the 
surface wells drew their supply. 
The saline constituents of the water from the different wells varied much, some of 
them being rich in salts, others containing but little; potash, soda, magnesia, lime and 
iron were found in varying proportions. 
In 1853 water-works were constructed, a system of pipes laid, and water taken from 
the river was supplied to the citizens, and from this time the river water slowly, to a 
great extent, but never entirely, supplanted the use of the water from the surface 
wells as a beverage; apart from the clay held in suspension, analysis and experience 
have shown this to be a water of remarkable purity, and its fine keeping qualities have 
long made it a favorite among seafaring men. 
The present year has witnessed the inauguration of a system of artesian wells 
which have been sunk in the lowlands to the west of the city, near the river at the 
site of the present water-works. The wells are between four and five hundred feet 
deep, give a rise above the surface at the works of twenty-eight feet, or forty-one feet 
above mean low-water mark, and a flow of seven million gallons per diem, equal to 
one hundred and fifty gallons per diem to each inhabitant, and even this unusually 
large proportion will be shortly increased. 182 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FORESTS. 
The forest growth of the surrounding country is chiefly the long leaf pine (Pinus 
palustris) and oaks on the high lands ; cypress (Cupressus disticha) and other swamp 
trees in the lowlands. 
RICE CULTURE 
Is prohibited within a mile of the city limits, but beyond that it is extensively carried 
on on the lowlands. 
GEOLOGICAL. 
The ridge upon which Savannah is built consists entirely of sand, with a substratum 
of clay at varying depths, even coming to the surface in some places. 
I am indebted to Dr. G. H. Stone for the following description of the geological 
stratification of the Savannah plateau, as found by him in boring his artesian well to a 
depth of 991 feet, over double the depth of any yet bored in his locality. 
" The erosion of the primal ocean cut away three thousand feet of the base of the 
Appalachian range, and, according to geology, everything for that distance is vesicular 
carbonate of lime, of tertiary formation. 
"We actually find hard and soft layers alternating from 250 feet to 991 in my well, 
and in the deep well at St. Augustine the same to 1400 feet, where the drill broke. 
Thus:- 
Sand 30 feet. 
Surface water and quicksand 50 " = 80 feet. 
Marl 35 " = 115 " 
Rock 4 " = 119 " 
Marl 81 " = 200 " 
Rock 6 " = 206 " 
Marl and sand 44 " =250 " 
Hard rock. 
Soft rock. 
Hard rock. Water strata. 
Soft rock L50 " = 400 " 
Hard rock. 
Same without water 591 " = 991 " 
SEWERAGE. 
Up to 1853 there were no water-closets in the city ; privies being used, and the 
cleaning of the vaults was accomplished by burying the contents in pits dug in the 
streets; while slop water was either thrown into the vaults, to soak from them into the 
ground, or else was scattered upon the streets and lands. 
After 1853, that being the year when a system of water supply was adopted, water- 
closets were introduced, and dry wells were dug, into which they were discharged. 
It will be observed that, although convenient, this arrangement made matters 
worse from a sanitary point of view ; for now not only did the excrementitious matters 
find their way into the soil, as before, but, in addition, the gases pent up in the dry 
wells forced their way through the soil-pipes back into the houses. 
About 1870 sewers were built with which the water closets were connected, dry 
wells Were prohibited, and the contents of vaults were henceforth to be carried beyond 
the city limits. 
SUBURBAN DRAINAGE. 
Within the last few years the drainage of the surrounding country is being system- 
atically carried out, with the result of greatly lessening the virulence of malarial 
diseases and vastly diminishing their fatality. 
CLIMATE. 
The climate of Savannah is mild, and although one year may be found to difler 
greatly from another in extremes of temperature, it is rarely that the thermometer SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
183 
rises to 100° F. in summer or falls below 20° F. in winter; indeed, it might be fairly 
said that between 80° F. and 90° F. would be an average summer heat, and between 
30° F. and 40° F. a fair record for winter. 
BAINFALL. 
The rainfall is somewhere in the neighborhood of fifty inches a year. 
DISEASES. 
Hydrophobia is unknown. Dogs sometimes have heat strokes, accompanied with 
convulsions, but a sousing in cold water will cure them. 
Vesical Calculus, as a disease, does not exist among the residents of the city, but 
many cases have come there from the surrounding country for treatment. 
Renal Calculus is exceedingly rare. 
Cholera Asiatica has on several occasions severely visited the plantations sur- 
rounding Savannah, but has never appeared in the city proper, except ' ' when brought 
from New York by United States troops in 1866. Deaths-whites 85, blacks 211; 
1867, deaths-whites 12, colored 17; 1868, deaths-whites 13, blacks 18." (Report 
of Dr. T. J. McFarland, Health Officer, 1887.) The disproportion between the ratio 
of deaths among the whites and blacks will be more apparent upon learning the number 
of each class of population during these years, which was as follows : 1866, whites 
14,316, blacks 12,189; 1867, whites 14,470, blacks 12,458; 1868, whites 14,624, 
blacks 12,727, so that in a population of 27,000 the whites exceeded the blacks by 
2000. The greater immunity of the whites is very striking, and among them the dis- 
ease was almost entirely confined to the poorer classes and strangers. 
Typhoid Fever has no home in Savannah. Once in a while, at long intervals, a 
sporadic case has occurred resembling it very much, and showing at the post-mortem 
the characteristic bowel lesions; but in the view of the recent discovery by Dr. Van- 
dyke Carter touching the non-typhoid ulceration of the glands of Peyer ( Lancet and 
Medical Record, July 10th, 1887, p. 146), it may be doubted that these were genuine 
cases; but, undoubtedly, typhoid fever has been introduced, on more than one occasion, 
and has not spread. In 1851, '2 and '3, numbers of immigrants landed in Savannah 
from Ireland. Some of these brought with them typhoid fever. The cases were treated 
in the hospital, in the general ward, without any sanitary precautions whatever, but no 
new cases developed. During the war typhoid fever prevailed among the troops from 
other parts of the country then quartered in or around Savannah, but with the departure 
of the troops the disease went too, and now such cases are as rare as ever. 
Typhus Fever.-It is almost unnecessary, but it may be well to mention that typhus 
(spotted, ship or prison) fever is absolutely unknown. 
Exanthemata.-All of the eruptive fevers are of an exceedingly mild type, and trou- 
blesome cases are usually the result of the transgressions of ordinary hygienic rules. 
Diphtheria was scarcely known until within the last twenty years, and although 
occasionally somewhat prevalent, it does not present itself with the extraordinary viru- 
lence of type to be witnessed in other localities. It was noticed by the health authori- 
ties that houses adjacent to dry wells were most liable to be infected with this disease, 
and hence the wells were ordered to be filled, and no more are permitted to be built. 
Dr. J. S. Morel, the only living physician having any practical experience before 
1849, distinctly asserts thjt the putrid sore throat of that early date, which has been 
supposed to be identical with diphtheria, was not at all the same disease. 
Membranous Croup is fortunately an exceedingly rare disease. 
Cholera Infantum-Summer Complaints of Children.-On several occasions speakers at 
the meetings of the Georgia Medical Society have directed the attention of the profession 
to the comparatively small mortality among children during the hot months of the 184 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
year. This the profession has endeavored to account for by 1, the relative coolness of 
the season; 2, by the plan of the city giving ample air spaces; 3, by the quantity of 
shade trees; 4, by the almost constant breeze enjoyed by this city, in common with 
other localities upon the sea-coast; and 5, by the almost entire absence from the city of 
malarial diseases during the summer months. 
. The mildness and rarity of this class of complaints is really one of the most remark- 
able in the whole series, as presenting a state of facts exactly the opposite of what 
might be supposed would be the result when arguing from the semi-tropical location 
of the city. That the subject has been so frequently discussed by the local profession 
is evidence that it is a matter of curiosity to the doctors themselves ; but however 
unaccountable it may be, the fact remains that for the number, health and beauty of 
its young children Savannah is, and has long been, celebrated ; and it has been more 
than once suggested that this city should be brought prominently before the public as 
a summer residence for children. 
Cerebro-spinal Meningitis paid us but one visit, and then we had about fifty or a 
hundred cases. It was imported, as was cholera Asiatica, just after the war, and quickly 
died out. It never was in Savannah before, and has not been since, and during its 
visit its victims were chiefly non-residents and negroes. 
Puerperal Fever.-The oldest physicians have no recollection of any epidemic of 
puerperal fever ; nay, more, they fail to recall any cases which could be so classified. 
There are, it is true, now and then cases of peritonitis following delivery, but it is 
simple, or what might be called traumatic, peritonitis ; but of the infectious or epidemic 
form of puerperal peritonitis we have no cases. It may be well supposed that this is 
not the result of any hygienic precautions, for the majority of physicians do not hesi- 
tate to attend labor cases when attending other contagious diseases, and many cases 
among the poorer classes are attended by midwives, who are often very ignorant and 
quite unacquainted with anything like sanitary laws. As a safe lying-in station 
Savannah cannot be excelled. 
Sunstroke.-Although work goes on in summer just the same as in winter, and men 
often spend days in situations exposed to the full force of the sun, as on the tops of 
buildings, etc., sunstrokes are very unusual. 
Erysipelas is far from common; occasionally cutaneous erysipelas (exanthematicum) 
is met with, but phlegmonous erysipelas is remarkable for its rarity. 
Yellow Fever.-A glance at the following table will show that Savannah is among 
those ports having had the fewest epidemics, taking her place along with Boston, Mass., 
and Providence, R. I., having had but four years of epidemic.* 
Yellow fever has been carried into the following Atlantic and Gulf ports :- 
Boston, Mass during four years. 
Providence, R. Iduring four years. 
New York Cityduring twenty-one years. 
Philadelphia, Paduring seventeen years. 
Baltimore, Mdduring seven years. 
Norfolk, Vaduring ten years. 
Wilmington. N. Cduring six years. 
Charleston, S. Cduring forty-four years. 
Savannah, Gaduring four years. 
Mobile, Ala... during sixteen years. 
Pensacola, Fladuring twenty-two years. 
New Orleans, Laduring forty-»ne years. 
Galveston, Texduring nine years. 
This refers simply to years in which the disease obtained some epidemic foothold at 
* From the "Annual Report of the Board of Health of the State of Georgia." SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
185 
the ports named. How many times infected vessels arrived at the quarantine of each 
port, it is impracticable to determine. 
Dengue.-Savannah has been visited with this disease about three times, but it is 
unimportant, as not being attended with any fatal results. 
In the remarks just made no distinction is made between the white race and the 
aegroes, who live side by side in the locality with which this paper deals, because the 
.observations are equally applicable to both races. It would be different were we dis- 
cussing the question of general mortality, for, from causes not necessary to be considered 
in this paper, the mortality among the negroes is much greater than among the whites, 
and the statistics of each race is separately kept. Some statisticians, by an unscien- 
tific jumbling of race statistics, would make it appear that the death rate of our 
southern cities is high. Whether this is done through ignorance, inadvertence or from 
interested motives, makes no difference ; it is scientifically incorrect ; it is simply mis- 
leading and untrue. 
Whenever two distinct races are thus placed in juxtaposition the statistics should 
always be, as with us, kept apart, or at least should be made so as to show the race 
peculiarities, that is, if truth is the object to be attained. Thus the mortality of the 
English in India in no way influences, or is influenced by, that of the Hindoos. The 
death rate of negroes in the army in the West Indies has been reported as proportion- 
ally greater than that of the white soldiers. The death rate of the negroes in New 
York is far in excess of that of the whites; and so it is in Savannah, but that no more 
proves that our climate is unhealthy for the white race than does the traditional fatality 
of the climate of Ireland to snakes, and certain other vermin, argue that the same 
climate would be fatal to human beings; on the contrary, the Irish people are remark- 
ably healthy and prolific. In this connection it is interesting to note the extraordinary 
effects produced by changed social conditions upon a population or a portion of a pop- 
ulation, especially when made up of distinctly different races. In the five years pre- 
ceding the war (from 1856 to 1860) the mortality among the blacks never equaled that 
of the whites. Now the mortality of the blacks is double what it then was, while 
that of the whites has diminished one-half. 
Up to 1854 the negroes were known to be proof against yellow fever, but in the 
epidemic of 1876 many of them died with that affection. What has brought about 
these changes ? 
It has long been known that malarial diseases affect the negroes but little; but, 
although the effects upon individuals may apparently be slight, it does react upon the 
race in some ways. Instance the following : In the early part of this century, there 
died a rice planter, whose plantation was on the Savannah river; his negroes were 
divided equally between two heirs, one-half was retained on the rice plantation, the 
other was taken to a cotton plantation on the high land; many years after, it became 
necessary to count the negroes on both places, none having been bought or sold in the 
meantime. It was found that the negroes on the cotton place had nearly doubled their 
while those on the rice place numbered exactly the same as at the time of the 
division. 
Another exemption which could formerly be claimed for the negroes is consump- 
tion ; now it sweeps whole families out of existence in a few years. 
Under the old régime the negroes were remarkably free from specific disease, in all 
its phases; now its constitutional effects are widespread. Insanity in various forms 
has wonderfully increased, and among diseases affecting morality, kleptomania seems 
to have made wonderful strides. 
From this it will be seen that it is important that the statistics of races should 
always be kept distinct, more especially as it is the policy of the South to promote the 
settlement there of persons from other localities, and, as these cannot be of the African 186 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
race, statistics based upon observations made upon a race having such marked peculiari- 
ties as the negro, would be valueless, untrustworthy, erroneous and misleading. 
Prevalent Diseases.-With such an array of facts as is here presented, it may be 
asked if we have any diseases whatever. It is not within the scope of this paper to 
deal with that portion of the subject in detail ; it will be sufficient here to observe that 
the prevailing diseases are affections of the lungs, gastro-intestinal disorders, and 
paludal diseases of various types. 
Lung Affections, among which is included pneumonia, are the most fatal and fre- 
quent diseases to be met with in this locality, and, as proof of this, the fall and spring 
months are those in which medical men are most in request, while the midsummer 
months are by far the healthiest. 
Malarial Diseases.-Since the adoption of a thorough system of drainage, diseases 
of a malarial type have undergone a remarkable amelioration, the virulent forms so 
often met with a couple of decades ago are now rarely, if ever, seen, and as a conse- 
quence, the rate of mortality has decreased in the city nearly fifty per cent. 
DEATH RATE. 
In view of the remarkable facts presented in this brief synopsis it will be readily 
supposed that the rate of mortality is exceedingly low; in 1884-'86 the ratio per 
thousand was 17.9; 13.7; 17.1 for whites. 
The mortality among the blacks is large in Savannah, in common with all other 
cities where they congregate, but there are known causes at work to account for this 
large death rate among them, the discussion of which is entirely beyond the scope of 
this paper. 
CONCLUSION. 
There is no surely known cause upon which to build a theory to account for the 
remarkable exemptions from certain diseases enjoyed by the people of Savannah. Cer- 
tainly it cannot be found in the quality of the water supplied, for the results were the 
same when the people drank filtered sewage as since they drank river water. It can- 
not be the result of drainage; for the exemptions were the same when there was no 
drainage. But it has been suggested that the city is protected by the high bluff upon 
the river front, and by the forest growth upon the other sides; this, however, would 
only apply to malarial diseases, the result of emanations from the surrounding sWamps, 
and this class of diseases has certainly been materially modified, nay, well nigh exter- 
minated, by prohibiting rice culture within a mile of the city, and by the inauguration 
of a thorough system of suburban drainage. Again, the unpaved wide streets, and 
numerous squares, have, by some, been supposed to have much to do with the absence 
of infectious diseases, the loose sand rapidly drinking in all fluids from the surface, 
and thoroughly filtering and purifying them from all disease germs. And to the cool- 
ing and purifying effect of our abundance of shade trees, and to an almost constant sea 
breeze, has been attributed the absence of heat diseases. There may be some truth in 
each of these suggestions, but the whole truth has not yet been attained, though it may 
be attainable. 
It is already well known that certain diseases, such as smallpox and typhoid fever, 
may be almost styled cold weather diseases, while another class is peculiar to hot 
climates, and it may with some little reason be conjectured that this city is so happily 
situated as to be a little too far south, and therefore a little too warm, for the cold 
weather disorders, and a little too far north, and therefore a little too cool, for the trop- 
ical diseases; but it may also be that there is an antagonism between the paludal 
atmosphere by which the city is environed and the diseases in question, which effect- 
ually excludes, or destroys, the latter. 
There will probably, during the coming generation, be ample opportunity to judge SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
187 
as to what extent the immunity from disease enjoyed by Savannah has been the result 
of her porous soil, wide, unpaved streets, profuse forest growth and numerous squares. 
For in the march of improvement, it is in contemplation to pave the streets, and pav- 
ing the streets has, so far, carried with it the total, unsparing, destruction of the shade 
trees. Then, too, some of the citizens loudly denounce what they are pleased to call 
the waste of ground given up to wide streets and open squares, and would willingly 
see buildings located in the squares and some of the streets closed up and appropriated 
to the same purpose; in fact, so great has been the pressure brought to bear, that the 
municipal authorities, in laying out an extension of the city, felt forced to abandon the 
old plan which has provèd so good, and have adopted a more compact design. Whether 
or not this is best, the irrefutable logic of events must determine; the facts of the future 
will be the basis of the verdict; but, unfortunately, should it be on the wrong side, 
there will then be no redress, it will be too late to retrace the steps taken or undo 
the injury inflicted. How much wiser would it have been to have adhered to the 
plan which has already borne the test of time, and been found to be all that could be 
desired. • 
Finally, whatever may be the cause of the exemptions, the fact remains that Savan- 
nah is situated upon a medically neutral territory, where the virulent malarial disease 
of the extreme south cannot find a suitable home, and which seems to be equally as 
unsuited to the no less intractable forms of disease which are peculiar to more northern 
latitudes. 
It is no part of the plan of this paper to enumerate all the diseases to which Savan- 
nah is a stranger, and which immunity is shared by many other places, but rather to 
mention such diseases as are, to a great extent, characterized by their universality, yet 
from which Savannah is exceptionally free; and the better to understand this subject, 
a classified table of the diseases mentioned in this paper is here submitted:- 
DISEASES ABSOLUTELY UNKNOWN IN SAVANNAH. 
Hydrophobia, 
Puerperal fever, 
Typhus fever, 
Vesical calculus. 
DISEASES NOT EXISTING AND WHICH, WHEN INTRODUCED, HAVE DIED OUT. 
Typhoid fever, Cholera Asiatica, Cerebro-spinal meningitis. 
DISEASES RARELY MET WITH. 
Erysipelas, 
Sunstroke, 
Membranous croup, 
Renal calculus. 
Diphtheria, 
DISEASES EXISTING IN A MILD OR MODIFIED FORM. 
The exanthemata, 
Cholera infantum. 
DISEASES WHICH HAVE BEEN EPIDEMIC AT LONG INTERVALS. 
Yellow fever, Dengue. 
DISEASES THE RESULT OF LOCAL CAUSES NOW MUCH MODIFIED BY SANITATION. 
Malarial diseases. 
DISEASES USUAL IN SAVANNAH IN COMMON WITH OTHER CITIES ON THIS CONTI- 
NENT IN NORTHERN LATITUDES. 
Gastro-intestinal disorders 
Diseases of the lungs. NINTH INTERNATIONAL MEDICAL CONGRESS. 
188 
These statistics have the endorsement of Dr. James S. Morel, who has been a prac- 
titioner in Savannah since 1832, and of Dr. James B. Read, whose experience dates 
from 1849, while the observations of the writer began in 1851. and, in addition, a num- 
ber of more recent practitioners have expressed their approval as concurring with our 
own experience. 
■i EXTRACT FROM LETTER OF DR. J. S. MOREL. 
August 16th, 1887. 
"Neither from the thirties nor the forties does my memory bring forward epidemics of any 
nature referred to by you. No typhoid, none of the exanthemata, only measles seemed to ap- 
proach an epidemic. Scarlet fever never. As for the disease known as diphtheria, it was not 
known in those years. . , . Savannah seems to be highly favored in her exemption from all epi- 
demic diseases indigenous to our climate; even our bilious remittent fever has declined; this 
disease in the twenties, thirties and forties became less and less formidable, even endemically. 
Our exemption may be due to our deep, sandy soil, and those luxuriant air purifiers, the trees, 
that ornament our streets." 
It is not claimed that this subject has*been treated as elaborately as could have been 
wished, but a sufficient number of facts, it is hoped, have been advanced to demon- 
strate that there exists in this locality an interesting immunity from certain diseases, 
and that there is a probability that other places would show similar exemptions if their 
medical history were closely scrutinized. 
It is a trite and homely proverb that " an ounce of prevention is worth a pound of 
cure," but it contains a most valuable truth, and one which the medical profession has 
always most unselfishly recognized ; and many life-saving truths have been discovered 
through the careful scientific studies bravely carried on in the presence of the enemy 
and after the battle, of the causes which tempted and made successful his assault; but 
I believe that an equally careful scientific study of the natural causes that have pre- 
vented his assault would be equally, if not more, fruitful in beneficial results, for 
defences which will deter are better even than those which may repel attacks, and it is 
with the hope of inducing other and abler minds to work for the good of our common 
humanity in this neglected direction, and for that purpose alone, that I have endeavored 
to excite an interest in a course of observation full of promise for the race though not 
of fame for the student; and the hope is further cherished that enough has been done 
to induce others to pursue this most interesting and valuable inquiry. 
IN THE HEART OF THE ALLEGHANIES.-THE CLIMATE AND 
SANITARY QUALITIES OF WESTERN NORTH CAROLINA. 
AU CŒUR DES ALLEGHANIES.-LE CLIMAT ET LES QUALITES SANITAIRES DE 
LA CAROLINE DU NORD OCCIDENTALE. 
IM MITTELPUNKT DES ALLEGHANYGERIRGES.-DAS KLIMA UND DIE SANITÄREN EIGEN- 
SCHAFTEN DES WESTLICHEN NORD-KARO LIN AS. 
BY HENRY O. MARCY, A.M., M.D., LL.D., 
Of Boston, Mass. 
Some notice of the climatological factorage of the United States, as influenced by the 
great Appalachian chain of mountains, in their southerly extent, should be taken in 
this Section of the Congress. Geologically of the oldest formation, in their immense 
range, they extend from Canada on the north far down into Alabama. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
189 
Broken in the north into every diversity of pattern, they carry on their broad slopes, 
in their central portion, the great coal measures of Pennsylvania, separating Virginia 
from her western division, under the name of the Blue Ridge, and it is not until the 
border of North Carolina is reached that they assume their grander proportions. Here 
they separate into radiating lines, traversing the entire State, stretching down into 
South Carolina and Georgia, and are intimately connected by irregular cross ranges, so 
that the whole section, as viewed from some of the greater elevations, presents, as far 
as the eye can reach, in every direction, an extremely rough sea of billowy mountains, 
and within a limit of fifty miles there are twenty or more peaks that are over six thou- 
sand feet in altitude. This territory comprises about ten thousand square miles. The 
valleys, for the most part, have an elevation above the sea level of two thousand feet 
and upward. 
The Blue Ridge on the east is the ■water-shed, although the Smoky Range on the 
west is of the greater altitude. Through this the streams have cut their way, often by 
extremely wild and picturesque gorges, sometimes traversed with great difficulty and 
even danger. 
These mountain ranges present many features of scientific interest, chief of w7hich 
is found in the composition of the granite. The decomposition of the rocks is most 
extraordinary, railroad cuts often extending fifty feet through the ledges, requiring only 
the use of the pick and shovel. The explanation is found in the fact that the feldspar 
is by far the largest factor of the granite ; often it with the mica and quartz lie in 
separate layers, and to this peculiarity is due the exceptional purity and extent of the 
mica veins here found of greater size than elsewhere in the world. To the decomposed 
feldspar, setting free potash salts, is also due the marvelous tree growth which covers 
this entire territory, nine-tenths of which is yet the primeval forest. These forests con- 
sist chiefly of deciduous trees in great variety, oak and chestnut predominating. Under 
their broad arches, spreading out in leafy shade, eighty to one hundred feet above the 
traveler, one may ride on horseback almost anywhere, except along the streams, which 
are thickly hedged by an almost impenetrable jungle of kalmia and rhododendron, 
whose waxy leaves, in June and July, are almost hidden by the great bunches of pink 
and white bloom. 
Pearly streams of the purest water make laughing music through every valley, and 
from the hillsides gush forth in endless number cool springs, often impregnated with 
iron, sulphur and other minerals. In a few places lithia springs are reported and 
claimed to possess much medicinal value. 
The smaller streams abound in trout ; the larger game is still found in the forest 
depths, holding attractions for the sportsman, while the seeming endless variety of plant 
growth furnishes interest to the botanist, and the lover of nature never tires of the 
kaleidoscopic pattern of landscape picture, on every hand, domed by the clear blue 
vault of heaven, which is itself often the panorama of cloud and storm rarely seen out- 
side these mountains. 
The great variety of forest and plant growth is found in the fact that these elevated 
ranges extend into a southern latitude. In climbing the sides of some great mountain, 
the different tree growth of two thousand miles in latitude may be met, until near the 
summit one wanders under the impenetrable shade of the balsams and firs peculiar to 
the great stretches north of Canada and to Northern Europe. 
From the above description, ready inference will be made of a scant population, 
which is found, indeed, in a class of hardy mountaineers, simple and uncultivated in 
taste and habit, whose chief wealth lies in broad acreage of small monetary value, 
interspersed with little patches of com and grain along the larger streams, and also in 
herds of cattle, sometimes of considerable size, which roam through the forest at will, 
and are often found grazing upon the highest tops of the mountains. 190 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
On account of the inaccessibility of this section until recently, it has been less 
known to the outside world than perhaps any other of equal size in the United States 
east of the Rocky Mountains. Before the late war, a few of the more wealthy planters 
upon the coast of the Carolinas and Georgia took refuge upon the easterly and southern 
slopes from the summer heat, and during the four years of conflict many families found 
safety tiere from the warlike incursions which sooner or later spread over nearly every 
other portion of the Confederacy. 
When first known to the whites, this region was the central home of the Cherokee 
Indians, and in this tribe was found a civilization superior to any other of the races 
east of the Mississippi. When visited by William Bartram in 1772 (see his most inter- 
esting book published in London in 1778), he found them dwelling in houses made of 
logs, much as now seen occupied by the natives, and separated in families, living a 
peaceful life, cultivating their corn and beans in well kept fields. He repeatedly 
expressed his wonderment at the physical strength and beauty of the natives. 
• In these valleys may yet be seen in good preservation the great mounds of a prehis- 
toric race, and following many a vein of mica has been traced the cuts and tunnels from 
whence were obtained the splendid specimens found in the tombs of these extinct races 
extending through the valleys of the Ohio and Mississippi. 
Among the first of the railroad projects of the South, now more than forty years ago, 
was the plan to cross these mountain ranges, uniting the sea with the then early 
developing West. This was earnestly advocated, among others, by John C. Calhoun 
and Robert S. Hayne, then the two leading political economists of the South, the latter 
of whom died in Asheville, N. C., in the furtherance of this object. Owing to the dis- 
asters following the recent conflict and the engineering difficulties to be overcome, it is 
only very recently that this territory has been rendered by any means fairly accessible 
to travel. The invalid seeking health in this region, has also been met with the extraor- 
dinary disadvantage of not finding, even in moderate degree, the home comforts so 
essential to his welfare. However, the advantages offered to invalids, in considerable 
variety of disease, were so apparent that many have braved the discomforts attending 
such evils, and results have been attained of a character sufficiently marked to warrant 
the further study of the climatic conditions of this wide extent of country. 
Asheville, the central metropolis of this region, has grown, within a short period, from 
a small village to a city of about nine thousand inhabitants. At first it was simply a 
summer resort for the residents of the low country south, and, until very recently, 
almost without winter visitors. Now a considerable percentage of the inhabitants con- 
sists of invalids from the North, many of whom have found such marked improvement 
that they have made it a place of permanent abode. Some of the residences are homes 
of wealth and comfort, and a number of excellent hotels offer good accommodation. 
The largest are the Swannanoa and the Battery Park. The latter, recently erected by 
Col. Coxe, of Philadelphia, is a model of excellence rarely surpassed anywhere. This 
was nearly as full last winter as during the more fashionable summer season. Dr. Battle, 
a resident of the hotel, who has had the opportunity of observing several hundred cases, 
assures me that he has rarely seen a patient whom he thought had made a mistake in 
selecting Asheville as a health resort. I saw several physicians who not only were enthusi- 
astic in the belief that this section was one of great healthfulness, especially to be com- 
mended in pulmonary diseases, but said they themselves were compelled by disease to 
leave other localities, while here they were able to endure the fatigues of the active 
practice of their profession. One who four years ago had had frequent haemoptysis and 
a supposed cavity was now nearly free from cough, had been actively at work, and cer- 
tainly gave every appearance of recovery. From Dr. Watson we received a confirmatory 
report in his exceptionally large and varied experience. I have sent about fifty patients SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
191 
to Asheville and vicinity within a few years, and, for the most part, with very satis- 
factory result. 
The town has not been entirely free from diarrhoeal diseases and typhoid, but great 
improvement has been made within two years in the introduction of pure water from a 
distance, and a system of good sewerage has been also inaugurated. The location is 
excellent, upon a plateau, with a beautiful outlook over an amphitheatre twenty miles 
in diameter, surrounded by mountains, yet clothed for the most part by forest. 
Asheville is twenty-three hundred feet above the sea, and from its southern location 
possesses advantages in climate which, for mildness, is not unlike Southern France. 
From observations now made for a number of years, the mean average temperature of 
Asheville is: Spring 52.3°, summer 71.3°, autumn 55.3°, winter 37.2°, year 55.3° F. 
During a period of eight years the thermometer but twice rose above 88°, and only three 
times fell below zero. 
I here append a carefully-kept record, tabulated by Mr. D. S. Watson, of Asheville, 
for the first four months of 1886. The cold wave of January will be remembered as 
having passed over the entire South, and was of a severity beyond that in the experience 
of " the oldest inhabitant." 
I copy the following tables from a reprint of Dr. H. T. Gatchell :- 
TABLE A. 
Table of deaths from consumption in 10,000 of white population, excepting in 
Western North Carolina, where the estimate is for whites and blacks :- 
Four counties in Western North Carolina , 6.5 
Three counties in South Carolina, with Aiken as central point 10.2 
Minnesota 10.7 
Four adjoining counties in Georgia, with Thomasville as central point 11.3 
Peninsula of Florida 13.0 
Mainland of Florida 18.0 
Plains of Colorado (excluding Denver) 21.6 
Maine 28.0 
Los Angeles County, California 29.0 
Massachusetts 29.0 
New Orleans 30.0 
District of Columbia 30.0 
Charleston, South Carolina 31.4 
TABLE B. 
Table of deaths from pneumonia in 10,000 of white population, excepting in Western 
North Carolina, where the estimate is for whites and blacks :- 
Western North Carolina 4.5 
Los Angeles County, California 5.3 
Four counties in Georgia, with Thomasville as central point 5.5 
Florida...' 5.7 
Minnesota 6.0 
Michigan 8.0 
Charleston, South Carolina 9.0 
Maine ; 9.0 
New Orleans 9.3» 
District of Columbia 10.0 
Massachusetts 14.0 
Plains of Colorado (excluding Denver) 17.0 
The late Dr. H. T. Gatchell, of Asheville, was a careful student of the section of 
country adjacent to Asheville for many years, and his observations, first published 
nearly twenty years since, are of much value. His son, Dr. E. A. Gatchell, writes me 
his experiences are confirmatory of those of his father. The elder wrote : " In a series 192 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of nine years the mercury did not rise above 90° F. any day in summer, the nights are 
always cool, permitting refreshing sleep. In winter it is seldom that a zero tempera- 
ture is reached, while the air is comfortable, dry, clear and invigorating. . . . 
' ' The following table gives the ratio of consumption in several sections of the country. 
The figures indicate the number of deaths from this disease in every thousand :- 
New England (nearly) 250 
Minnesota and California 150 
Kentucky and Tennessee 100 
Western North Carolina 30 
To any who seek entrance to the mountain region from the east, Asheville will be 
the central point of interest and, if actuated by the restlessness of most of our country- 
men, the first stopping place. There can be no doubt but many localities upon the 
easterly and southerly slopes of the Blue Ridge present great attractions for invalids. 
A number of my medical correspondents write that some of these localities are 
especially desirable because of the dryness of the atmosphere and freedom from fog, 
■which, at certain seasons of the year, prevail to a considerable extent through the 
mountains. 
Unfortunately, no records of temperature, sunshine, rainfall, etc., from other locali- 
ties have come under notice. The same general features of the landscape and climate 
here prevail. Along some of the southerly slopes the " no-frost line " is clearly per- 
ceptible, and sanitaria, well selected at such localities, would offer certain marked 
advantages. It is greatly to be regretted that careful observations have not been made 
at some of these places as to the equability of heat, amount of sunshine, rainfall, etc., 
as well as to the absence of severe cold, a fact so abundantly substantiated that it can- 
not be doubted, although a little distance away frost and ice are of common occurrence. 
On the Western North Carolina Railroad, at Morganton, is located the State Asylum 
for the Insane, selected because of the healthfulness and beauty of surroundings. 
The Piedmont Springs, fifteen miles north of Morganton, have been a favorite 
resort for a generation, and a long, rambling hotel, venerable in service, offers attrac- 
tions of quiet and rest. The springs are sulphur, not unlike the White Sulphur of 
Virginia, and a short distance away is a fine chalybeate spring, entirely free of sulphur. 
The surroundings are wildly mountainous, picturesque, of a rugged Swiss type. 
A few miles south of Marion, at Glen Alpine, is a large hotel, long a favorite resort 
of the residents of the southeast. Here are said to be good springs of iron and sul- 
phur. Lithia springs are reported at several places on the southeasterly slopes of the 
Blue Ridge, but little, however, is known of the medicinal value of the waters. 
The railroad crossing the Blue Ridge is an engineering feat worthy of modern science, 
and compares favorably with the difficulties overcome in the famous Soemmering Pass 
of Europe. To the north, in the range known as the Black, towers Mount Mitchell, 
the highest peak of the entire region, 6711 feet above the sea level. In a broken, 
undulating line runs the chain of the Blue Ridge to the Grandfather, fertile farms 
dotting its slopes here and there ; a region intersected by valley and mountain, pic- 
turesque, wild gorges, rippling streams, tumbling cascades, forests, deep jungles of 
rhododendron, with a mean annual temperature of 45° F., quite similar to that of 
Vermont. From this point, the Grandfather, diverges the Smoky Range, called by the 
Indians Unaka or White, which forms the boundary line of Tennessee. Its grandest 
representative is found at its very beginning, in the Roan, 6390 feet in height, and the 
beautiful peak called the "Yellow," a little less high than either, is the massive gate 
forever locked between these magnificent representative pillars of the splendid ranges 
of the Blue Ridge and Unaka mountains. Near the top of the Roan a large and com- 
fortable hotel has been erected by General John P. Wilder as a sanitarium, open during 
four months of the year. It is the highest inhabitable spot east of the Rocky moun- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
193 
tains. The difficulties encountered in the ascent make the journey a severe one for the 
invalid, although the railroad from Johnson City to Cranberry passes at the base of the 
mountain. The station called Roan is the point of leaving the rail. There is in con- 
templation the speedy completion of an elevated railway to the top. The Signal Service 
station on the mountain has furnished interesting and important data for climatic study. 
The equability of the temperature has far exceeded expectation, and the electric pheno- 
mena are very interesting. It has long been claimed that the Roan offered an asylum 
to the victim of hay fever unequaled, but the irony of Fate has in it another illus- 
tration. Now that the recluse here can be surrounded by the comforts of modern life, 
the old enemy continues in attendance, for hay fever has been reported in the entire 
locality the last two years, including also the region about the Grandfather. 
A new avenue has been opened through the mountains from the south to Asheville, 
via Hendersonville from Spartansburg. Ten miles south of Asheville, amid pleasant 
surroundings, is the Arden Park Hotel, situated halfway to Hendersonville ; also a 
town with good hotels, and the entire section one of beauty and interest. A little 
south from here is Cæsar's Head, an abrupt "fault" in the mountain on the South 
Carolina border. Much is claimed for this locality on account of its dryness, but I 
know of no reports of actual observations. The landscape views are extremely varied 
and interesting. The elevation is about four thousand feet. The hotel is well kept 
and a popular resort in summer. The air is pure and bracing, and many attractions 
are found in the immediate vicinity to interest the invalid. 
West is Cashier's Valley, a high table land about 3400 feet above the sea. It is of 
repute as a resort for consumptives. Still further west is the Highlands, a hamlet 
widely advertised as a health resort. It is reached with great difficulty, indeed to the 
confirmed invalid inaccessible, long distance from the rail on either side, over roads of 
the worst sort. Here the average rainfall has been found to be seventy inches annually, 
and, judging from the configuration of the abrupt mountain ranges bordering the low- 
lands lying south, it is presumable the rainfall of the entire region is excessive. 
Down the French Broad river one easily reaches, by rail, the Hot Springs, which are 
becoming justly celebrated. The hotel accommodations are modern and excellent, 
while the baths are numerous and ample. The effect of the water appears not unlike 
the famous hot springs of Arkansas. 
Westward from Asheville about thirty miles is the enterprising little town of 
Waynesville. In the Richland valley, one mile away, is situated the Hayward White 
Sulphur Springs. The proprietor, Major W. W. Stringfield, is justly popular and his 
new hotel has been well filled with guests. The elevation is over twenty-seven hun- 
dred feet. The valley is very lovely, and the view of the broad meadows and lofty 
mountain ranges as seen from the hotel is beautiful beyond description. The waters of 
the creek rush along with great rapidity over the whitest pebbles, and their gentle mur- 
muring is sweet music to the troubled heart and weary brain. Much curative effect is 
claimed for the sulphur water, which wells up pure and cool into a marble basin at the 
edge of the valley. Westward from Waynesville the railroad climbs the Balsam range 
to a height, at the divide, of nearly thirty-five hundred feet. The dry, pure, bracing 
air has attracted hither invalids, who reported to me great benefit from a few weeks' 
residence, although the hotel is limited and designed only as a station for dining pas- 
sengers. Beyond lie the beautiful broad valleys of the Luckaseegee and Little Tennes- 
see rivers, rapid streams of considerable size, only recently reached by rail; still further 
westward tower the splendid ranges of the Cowee, Mantehaleh and Valley River moun- 
tains, irregularly dividing the wide space of the base of the triangle made by the Blue 
Ridge and Smoky ranges. These are almost without exception clothed to the very top 
with the primeval forest, which yet covers nine-tenths of the entire territory. The 
Vol. V-13 194 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
country beyond the iron ways is of yet greater interest to the invalid able to * ' rough 
it ' ' somewhat. The roads are, of course, poor, the hotels intended as hostelries only, but 
the quaint, old-time manners and customs of a rude but always hospitable, honest peo- 
ple, are a never-failing source of interest, and often of profit, to the student of men as 
well as nature. 
The valley of the Mantehaleh is of interest as a broad plateau between the ranges, 
watered by the loveliest of rivers. Its banks are thickly hedged with kalmia and 
rhododendrons which in June present a mass of bloom never seen outside these 
mountains. The delicate branches of the graceful birches gently sway in the breeze, 
the music of the laughing waters fills the air ; all else is the unbroken silence of the 
primitive forest. Mr. L. R. Fint, who resides on a cattle ranch in the Mantehaleh val- 
ley, has sent me a daily record of the weather during the past summer. The rainfall 
has been large and the variations in temperature considerable. On the 13th of June 
there was a frost and a temperature record of 30° F. I found the two weeks which I 
spent here during August of the present year very agreeable, although a fire morning 
and evening was a comfort. Frost was reported about the 20th of the month. 
The Valley River valley surpasses all the others in beauty and picturesqueness; 
broad and fertile, a landscape rarely equaled, set in a mountain frame of living green, 
of which the eye. never tires. The small hotel is ever full, and when proper accommo- 
dations can be reached by rail it will become a popular resort. 
Surrounded by a medium from which there is even momentarily no escape and which 
we must ever breathe, atmospheric impurities must be of the first consideration in the 
climatic elements. These are both chemical and atomic ; while the relative amount of 
oxygen varies but little in a given weight of air taken from sea or mountain, its changes 
even in very slight amount are important. When deficient it is usually replaced by 
carbonic acid. The last is undoubtedly deleterious : nausea and headache are common 
in close rooms containing only one per centum of carbonic acid. These changes are also 
important as indices of an atmospheric contamination in a particulate way by the pres- 
ence of foreign material, chiefly of a fermentative type. Since these are usually of the 
lowest origin of spore plant life, the general name of germ contamination has been 
given to it. 
The value of recent investigations upon this subject, as a cause of disease, is one of 
the triumphs of modern science, and invests the study of climate with new interest. 
Since these minute growths develop under conditions of the atmosphere usually 
marked by the lessening of the oxygen and increase of carbonic acid, such changes 
assume an importance greater than earlier supposed. 
The organic material exhaled with the breath is molecular and is disseminated by 
atmospheric currents. The odor from the decomposition of these organic elements is 
generally perceptible when the carbonic acid reaches seven parts in ten thousand, and is 
strong when it amounts to ten parts. One of the chief causes of lung diseases in cities 
arises from the atmospheric contamination by myriads of microscopic cell growths. 
One danger, by no means hypothetical, from the consumptive lies in the material 
expectorated. This very commonly dries where it is carelessly lodged, is pulverized 
and distributed as dust. In the inspiration of the atmosphere thus infected, the bacilli 
are lodged upon the mucous membrane of the air passages, and, if these are inflamed 
or broken, may find a suitable soil for generation. In this sense certainly consumption 
is a contagious or rather an infectious disease. Organic material in the air is ever to 
be looked upon as injurious. We can have no chemical test for discriminating between 
hurtful and harmless organic matter, since the poisonous infection is vital. 
The mechanical admixture of water with the atmosphere in the form of vapor is a 
constantly varying factor, dependent upon a number of conditions, and although rarely SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
195 
entirely absent is an element of itself comparatively unimportant; however, in combi- 
nation with heat, albuminoids and the omnipresent microscopic cell plants, it renders 
possible changes of the highest importance. 
Atmospheric moisture has a marked influence upon the skin and its glandular 
functions, as well as upon the respiratory tract. Its presence also lessens, in a consid- 
erable degree, the permeability of the atmosphere by the sun's rays, diminishing 
thereby the oxidizing power of sunlight. 
Ozone, although we know far too little of it as yet, as an agent, from its admitted 
powers, is an important atmospheric factor in its bearing upon climate and health. It 
is an allotropic form of oxygen which has attained new properties of an intensely active 
character, supposed to have been produced chiefly by electricity. 
Ozone owes its great value as a disinfecting agent to its exceedingly powerful oxid- 
izing qualities. The compounds of ammonia, phosphorus and sulphur are acted upon 
with great rapidity, and the odors resulting from decomposition are removed instantly. 
It is probably destructive to all the minute vegetable organisms. Under the direction 
of a committee from the American Medical Association, a series of continuous studies 
in various sections of the country have been conducted for a number of years to deter- 
mine if any relation exists between the development of acute epidemic diseases and 
changes of atmospheric character. 
Ozone tests are being continually and carefully made. It exists in larger quantities 
in the atmosphere of mountains and forest country than elsewhere, and is increased 
most of all after severe thunder storms. To this, more than any other agent, is to be 
attributed the so-called "clearing eflect upon the air" after a thunder shower, giving 
a delightful, exhilarating feeling in respiration never experienced after a long rain. 
Temperature is an important climatic consideration. The remarkable results obtained 
from a winter residence at elevated localities in the Alps has demonstrated the possi- 
bility of great gain, although the cold is intense. Under such conditions, the atmos- 
phere is nearly free from moisture and impurities, and the cold in the sunshine is 
seeming rather than real, since the diathermancy of the air is so great at considerable 
elevations that the sun's rays make it comfortable to remain out of doors when the 
ordinary thermometer registers a temperature of 20° or 30° F. The experience in our 
own country, of invalids at elevated regions of the North in winter, has been limited, 
and generally not favorable. 
Patients have braved the winter in the Adirondacks, some with good results ; but 
out-of-door exercise is limited, and the elevation of one thousand feet too little to 
make the rarefaction of the atmosphere important. This is also true in the White 
Hills of New Hampshire. A warmer climate, with elevation, is important, and one of 
the great climatic advantages of the elevated regions of Western North Carolina con- 
sists in the latitude, which is south of 36°, between 33° 53z and 36° 33'. The winter 
temperature here is not unlike Southern France, while the elevation is from 2000 to 
3000 feet. The invalid can comfortably be out of doors in winter here most of the 
pleasant days. One of the very best commendations of any climate is found in the 
largest number of hours and days suitable for exercise out of doors. This, of course, 
applies to rain and storm as well as cold. 
The barometric changes occurring in the great aerial ocean in which we live are of 
the greatest interest. From their study, in large degree, has arisen the new science of 
' ' Probabilities " as to weather, which already governs so great a part of the civilized 
world in its movements. Air currents are created, with changes of temperature, moist- 
ure, etc., many hundreds of miles in length. 
In elevated localities, broken by high mountains there is a more or less fixed cloud 
region, where the chilling of the moisture-laden atmosphere causes condensation ; espe- 
cially is this true during the summer months. During the day the surface of the lower 196 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
valleys is much heated, and the lower atmospheric stratum becomes rarefied and rises 
along the slopes, producing the breezes of the early part of the day. After sunset, the 
higher peaks and sides radiate the heat more rapidly than the base, and the cold, con- 
densed air descends, causing often an evening wind. These air currents vary greatly 
with the configuration of the locality, and should be studied in relation to the selection 
of sanitaria. 
The formation of clouds about the mountain tops is different. The warm, damp 
winds blow across the ranges, the air is suddenly cooled, and most of the moisture 
is precipitated in the form of mist, rain or snow. The air currents that cross the 
summits sink in various directions, condense and become warmer in descending, and, 
as a consequent, relatively drier. In a country intersected by diversified ranges this 
modification of the temperature of the air currents gives great variety to the cloud 
formation and rainfall. Often the wind blowing steadily in one direction will give 
abundant rain on the first range of mountains, while beyond it is clear and dry. These 
influences greatly modify the climate of the valleys, which is widely variable, according 
as they are sheltered from the winds and open to the sunlight. The extreme tempera- 
ture between day and night is also more marked in the valley. Upon the side toward 
the sun, under the direct influence of its rays, the heat is increased by radiation during 
the day and diminished during the night. On the contrary, the differences in tempera- 
ture between the heated and cold seasons is less marked in the valleys. Locations 
for residences in valleys should be selected that will furnish the greatest number 
of hours of sunshine. 
When the atmospheric humidity is considerable, the morning and evening extremes 
of temperature in the valleys produce condensation of the moisture in the form of mist 
or fog, while the upper slopes may be entirely exempt from these. 
An important climatic element of any country exists in the character of its surface. 
Its ability to absorb and retain moisture governs in large share its temperature, and the 
temperature of the soil in a marked degree governs the temperature of the air. They 
are usually alike. A loose, porous soil covered by a heavy tree growth furnishes the 
best surface for equalization of evaporation and uniformity of temperature. The earth's 
surface is charged with negative and the overlying atmosphere with positive electricity. 
The latter is much more marked in elevated regions broken in sharp mountain ranges. 
This produces in regions of considerable elevation, during the heated season, thunder 
storms of great intensity. 
A mountain or elevated climate is advantageous to a variety of diseases influenced 
by a change of circulation. The lessening of the atmospheric pressure causes the dimi- 
nution of the blood flow in the brain and central organs and increases it in the cutaneous 
surfaces. Imperfect nutrition, as exhibited in anæmia, indigestion, loss of appetite, 
etc., is greatly benefited by the pure, bracing air and exercise. 
Neuralgia, nervous prostration, loss of sleep, headache, hypochondria, etc., lessen 
under the stimulus of a better nerve nutrition. The improved circulation and nutrition 
of the respiratory organs give relief in most cases of asthma dependent upon changes 
of the bronchial mucous membrane as well as upon innervation. Bronchial inflamma- 
tions are usually benefited, and the increased respiratory function lessens the conditions 
favoring consumption, and often the disease itself in its incipiency is arrested. 
The invalid suffering from extreme weakness induced by any cause had better not 
attempt a residence in an elevated region unless by the advice of a competent physician, 
for, while an elevated climate is stimulating and has a powerful therapeutic action on 
most functions, it requires a certain integrity and resisting power, which the patient 
may not possess. 
Organic diseases of the heart and great vessels are, almost without exception, made 
worse by the over-work demanded of the circulatory apparatus. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
197 
Perhaps the most important of all conditions to be considered is that of the mental 
state of the invalid when directed to any locality for the benefit of his health. They 
should not only be guarded against extremes of exposure, exercise, care as to diet, etc., 
but above all be given, as far as possible, a bright, hopeful, happy state of mind. All 
these prerequisites to improvement are so essential that the invalid does well to place 
himself under the care of a resident physician. Occupation to direct the attention from 
self should, as far as possible, be obtained. The sportsman finds recreative pleasure in 
the rod and gun, the botanist in the wide diversification of plant life, the geologist and 
mineralogist in the ever-interesting outcropping minerals about him. Indeed, Western 
North Carolina abounds in mineral wealth. Here are found the richest corundum mines 
of the world, rich ores of various kinds-gold, iron and copper-mica blocks, from six 
inches square to two feet, and marbles of most exquisite beauty, from pure white, pale 
flesh color to coal black, variegated by seams and stripes of every color. To one actu- 
ated by the need or pleasure, the rearing of flocks and herds, or the cultivation of the 
fertile fields, gives occupation and a healthful happiness. 
"The bliss of a spirit is action," is the unwritten law of life, and he who seeks the 
renewal of its pulses must come under its universal requirement. To the invalid resting 
under condemnation from the violation of nature's laws, a wise selection of residence 
in the mountain regions of the great Appalachian chain holds out a hope often denied 
to the dweller in the cities of the plain. Everywhere mountains and streams, cliffs and 
valleys, gaps and glens, add charm to the scene and inspire delight in the lover of the 
beautiful and sublime, and while health is borne upon the breeze, beauty and grandeur 
fill the soul. 198 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
RECORD OF WEATHER AT ASHEVILLE, N. C., FOR JANUARY, 1883. (l). S. WATSON.) 199 
SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
to O Cn P) m 
o o Q o o 
RECORD OF WEATHER AT ASHEVILLE, N. C., FOR FEBRUARY, 1886. (D. S. WATSON.) 200 
NINTH INTERNATIONAL MEDICAL CONGRESS 
RECORD OF WEATHER AT ASHEVILLE, N. C., FOR MARCH, 1886. (D. S. WATSON.) SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
201 
RECORD OF WEATHER AT ASHEVILLE, N. C., FOR APRIL, 1886. (D. S. WATSON.) 202 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIFTH DAY. 
The Section met at 3 P. M., when the following paper was read :- 
THE DEMOGRAPHIC EFFECTS OF INTRODUCED DISEASES, AND 
ESPECIALLY LEPROSY, UPON THE HAWAIIAN PEOPLE. 
LES EFFETS DÉMOGRAPHIQUES DES MALADIES INTRODUITES, LA LÈPRE 
SURTOUT, CHEZ LE PEUPLE HAVAÏEN. 
DIE DEMOGRAPHISCHEN WIRKUNGEN EINGEFÜHRTER KRANKHEITEN UND INSBESON- 
DERE DES AUSSATZES, AUF DIE BEWOHNER DER SANDWICH-INSELN. 
BY GEORGE W. WOODS, M.D. 
The eight islands forming the Hawaiian Kingdom were undoubtedly sighted and 
probably visited by the early Portuguese navigators as early as the middle of the six- 
teenth century; but they cannot be said to have been actually discovered until Captain 
Cook visited the group, in 1778. 
The descriptions of Cook and his associate, Vancouver, represent a tropical country, 
with its heat mitigated by the constant "trades" into a most salubrious and perfect 
climate, and inhabited by a people ethnologically belonging to the great Malay family, 
in a state of primeval savagism, not yet emerged from the " Stone Age." Their gov- 
ernment was a despotism of chiefs, to whom their subjects rendered a servile homage; 
their religion the worship of idols and savage divinities, under the auspices of a priest- 
hood, which made use of the powerful weapon termed tabu. By means of this tabu 
the poor and weak were denied luxuries-though not necessities-which were reserved 
for the rich and powerful, and certain springs, fields, trees, animals and various foods 
were thus reserved for the privileged classes. There was no marriage ceremony and 
no bar to separation, while the husband had power over the lives of wife and children. 
With this freedom of cohabitation the male parentage became uncertain, and, in con- 
sequence, children took family rank from the mother. 
Physically and mentally the Hawaiians were considered to be superior to all other 
Polynesian races. They are described as tall, broad-chested, sinewy rather than mus- 
cular, with lively, expressive faces, noses slightly flat and often aquiline, mouth and 
lips large, splendid teeth, and with bodies tattooed. No mention is made of imperfec- 
tions or chronic diseases marring the physical type. The women are referred to as 
being of slightly inferior stature, and as possessed of remarkably small and well- 
formed hands and feet. The chiefs and higher classes were distinguished as being 
taller than the common people and remarkably obese after middle life. All were intel- 
ligent, energetic, kind, simple and hospitable. Their dwellings were palm thatched 
houses framed with the wood of the cocoanut palm ; their dress only the maro, to which 
the chiefs and warriors added mantles of feathers ; their furniture, tapa mats and uten- 
sils fashioned from the cocoanut and gourd. They were an industrious people, culti- 
vating the taro in large, irrigated fields, and rearing fish in artificial ponds admirably 
constructed of coral rock. They did not weave or make pottery, but constructed beau- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
203 
tiful tapa mats from the inner bark of a native tree, on which they painted fancLul 
designs. Fishing and war were their chief occupations, and for these purposes tney 
fashioned canoes, many of them of enormous size, from the trunks of trees. Their 
food consisted of poi, or fermented taro (the root of the Tarum esculentum), the bread 
fruit and cocoanut, fish-generally eaten raw and often in a putrid condition-various 
Crustacea and esculent sea-weeds. Their only intoxicant was the ava (Piper methysti- 
cum), which, when abused, developed a constitutional dyscrasia analogous to scor- 
butus, when the body was covered with a scaly eruption and the eyes became inflamed. 
Their great recreation was swimming, in which they were very expert, and hours were 
passed daily among the breakers in this amphibian sport. They were a happy, simple, 
contented people, save when their passions were aroused by inter-island strife, and sub- 
ject to none of the grave maladies of civilization. The only record we have of any 
disease peculiar to this people is the prevalence among all classes of the pupu, or native 
scabies, and varieties of eczema. At this period of discovery, 1778-1779, the Hawaiian 
people are said to have numbered 400,000, and we have no reason to doubt that this 
estimate was approximately correct. 
Now comes civilization, represented principally by the Anglo-Saxon race, to change 
or modify the ancient conditions and ways, to impress upon this peculiar people their 
laws, religion, manners, customs, language, government, opinions and vices. 
Their climate, soil and general environment remained practically the same, and we 
must therefore look to the altered conditions in their new mode of life, and implanted 
germs of disease, for an explanation of the astonishing demographic changes which a 
century has wrought in the Hawaiian race. 
First came voyages of discovery ; next, whalers ; then missionaries ; lastly, mer- 
chants and colonizers. The people then threw away their idols, embraced, at least out- 
wardly, the Christian religion, and thrust their Kahuwas from them ; they clothed 
themselves, and built better homes; submitted to education and learned various indus- 
tries ; built towns ; established a representative government and j udiciary ; later were 
given a constitution; and, in short-all with foreign aid and dictation-builded a nation 
after European and American models. 
But this simple people could not so far alter their nature as to do more than provide 
for their own primitive wants, after the manner of their forefathers, and were naturally 
opposed to continuous labor, either in the field or elsewhere, when the earth and the 
sea offered to them, with slight exertion, nearly all that their bodies demanded. So, 
when household service and the cultivation of the soil on a large scale, in the interests 
of foreigners, demanded earnest, hard-working laborers, the Chinese flocked to the 
islands, at first voluntarily, and later as coolies, under contract. 
The first effect of contact with civilization was the inoculation of the race with the 
poison of syphilis, presumably during Cook's stay at Hawaii ; and with a people so 
loose in ideas of sexual morals-a condition which Christianity, represented by the mis- 
sionaries, found it difficult to contend against, even having to use the ancient weapon 
of tabu in protection of female purity-the disease soon became widely spread, and has 
ever since been so constantly recognized in its demographic effects, that the statement 
of a recent writer, that " the great majority of the adult Hawaiian population is con- 
taminated," is not to be considered as a mere figure of speech. 
Later succeeded epidemics of scarlatina, rubeola, pertussis, influenza and variola, 
which slaughtered thousands, and the native population, which, in 1778, had been 
estimated at about 400,000, was, in 1836, reduced to nearly one-fourth that number, 
and in 1850, to nearly one-fifth.* 
* The necessity for a " Board of Health " was now so apparent that an organization was 
effected in December of this year. 204 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The extraordinary mortality of these epidemics-all, save smallpox, rarely assuming 
so fatal a form in other lands-has been attributed to an aggregation of causes, viz., 
to cachectic conditions, and impaired vitality, through venereal disease and poverty ; 
sensitiveness to changes of temperature, engendered by the use of clothing ; voluntary 
exposure to sudden changes of temperature, principally by sea-bathing when in a febrile 
condition; imperfect nutritive character of food in cases of debility from prolonged dis- 
ease, and perhaps, often, an insufficiency ; and lastly, every form of licentious and 
vicious indulgence, including ava drinking, opium smoking and the excessive use of 
intoxicating liquors. 
Syphilis had, undoubtedly, produced its worst effects on this race. 
The Reverend Charles Stewart, an eminent missionary, writing as early as May, 
1823, says : " Nor to mention the frequent and hideous mark of a scourge which, more 
clearly than any other, proclaims the curse of a God of Purity, and which, while it 
annually consigns hundreds of this people to the tomb, converts thousands while living 
into walking sepulchres. The inhabitants generally are subject to many disorders of 
the skin. The majority are more or less disfigured by eruptions and sores, and many 
are unsightly as lepers. The number of either sex, or of any age who are free from 
blemishes of this kind, is very small, so much so, that a smooth and unbroken skin 
is far more uncommon here, than the reverse is at home." Again, in July of the same 
year he says : "We seldom walk abroad without meeting many whose appearance of 
misery and disease is appalling, and some so remediless and disgusting that we are 
compelled to close our eyes against a sight that fills us with horror. Cases of oph- 
thalmic scrofula and elephantiasis are very common." 
Dr. Arthur Mowritz thinks that these may have been lepers ; but it seems much 
more likely that these pitiable objects were sufferers from advanced venereal disease, 
which the good clergyman chose to mention in terms better suited to the family and 
secular readers of his diary, leprosy being symbolical of everything unclean. Certainly 
there were, at this period, many excellent medical observers in Honolulu, and they 
have made use of no such terms. 
Thus was prepared a degenerated and markedly unprolific race, with an impetus 
toward extinction, at a period coinciding with the establishment of the coolie trade, now 
to be, in consequence of this Asiatic emigration, exposed to a still greater evil in the 
form of enthetic disease. At this period the Chinese commenced to enter the kingdom, 
to form an integral and important element of the population, to mingle and inter- 
marry with the native race, bringing with them that great mystery among diseases, 
Asiatic leprosy, or Elephantiasis Græcorum. In this highly receptive condition for 
disease, the natives welcomed the new comers cordially, and either married or cohabited 
with them, and the seeds of disease thus implanted found a congenial soil in which to 
germinate.* 
The mode of life and characteristics of the Hawaiians furnished every desired condi- 
tion for the extension of leprosy. Extreme good nature, social tastes and hospitality; 
no fear of the disease, even in its most repulsive form ; eating from the same dish, and 
passing the pipe or ava cup from mouth to mouth, even when ulcerated surfaces bathed 
with pus were apparent; living with and cohabiting with the diseased, in receiving from 
them attentions and services at every age, but especially in childhood, as nurses and 
servants. Another potent factor in the spreading of leprosy was promiscuous and com- 
pulsory vaccination during epidemics of smallpox, when it was necessary to use human 
virus. 
* The history of the introduction of leprosy into Surinam, through an importation of African 
negroes, corresponds closely with that of its introduction into the Hawaiian islands by the 
Chinese. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
205 
The first native leper was recognized in 1848, eight years after the inauguration of 
the coolie emigration, but it was not until 1859 that leprosy was accepted as being 
deeply rooted in the native race, this recognition being due to the investigations of Dr 
Hillebrand. The natives termed it Maipaké, or " Chinese disease," and there is little 
doubt that their decision as to its source was the true one. 
The genesis of leprosy has been discovered by various observers and writers in the 
following causes, viz., in syphilis, it being considered a quaternary form of that disease; 
in malarial poison; in the exclusive or excessive use of salted meats; in the consumption 
of raw and putrid fish; in the eating of certain grains, as the dahl in India; in filthy 
• habits, and especially neglect of bathing. All of these causes have their origin in local 
observation of the disease, which exists where there is no malaria, no rotten fish as an 
habitual or occasional diet, no excessive use of salted meats, no feeding on dahl or dis- 
eased cereals, and where people are scrupulously attentive to the bath. For unknown 
centuries the Hawaiian had cultivated his taro patch, constantly exposed to paludal 
poison, and his diet was largely composed of fish, generally raw and often putrid, 
without developing the disease. In the later period during which he has been under 
observation, he has not eaten largely of salted fish or meat, while he has been accustomed 
to an almost daily bath in the sea. As to its origin in venereal disease, and the declara- 
tion that it is an advanced form of that malady, the assumption is remarkable, as lep- 
rosy antedates this sexual disease by untold epochs. 
The same diversity of opinion is expressed as to whether it is contagious or heredi- 
tary. The celebrated Committee of the Royal College of Surgeons decided against the 
contagious character of the disease, and directions were issued to the Colonial govern- 
ments that "the liberty of lepers was not to be restricted." This decision was based 
on the evidence of observers in Jamaica, Barbadoes, Mauritius, New Brunswick, India, 
Burmah, Crete, Mitylene, etc., and the carrying out of this recommendation seems, 
through statistical reports, to have been productive of no increase, though many of the 
original reporters have changed their opinions. Dr. Baelz, of the University of Tokio, 
Japan, is a non-believer in contagion, as are those eminent observers, Drs. Danielssen 
and Boeck, of Norway, who express themselves in the most positive terms. Dr. G. L. 
Fitch, in charge of the Hawaiian leper settlement in 1884, endorses this view, and sup- 
ports his opinion by a series of cases, observations and references. He also believes 
that "heredity plays but little figure in the spread of the disease." He cites cases of 
autopsie inoculation without development of the disease, and declares that it is abso- 
lutely non-contagious and non-inoculable. In opposition to the opinions of Dr. Fitch 
are those of G-. Trousseau, M. d., and J. S. McGrew, M. D., long residents of the islands, 
supported by J. Brodie, M. D., N. B. Emerson, M. D., and M. Hagan, M. D., who pro- 
nounce leprosy to be eminently contagious. At a later date Dr. Edward Arning, who 
has made most careful bacterial researches at Molokai, expresses the same opinion, as 
does Dr. Arthur Mowritz, who considers the case as " positively proven;" and pon- 
derous evidence is adduced in support of this view, which is further accredited by most 
of the respondents to interrogatories propounded by the Hawaiian government to the 
authorities and distinguished medical men of all countries where leprosy now exists. 
(" Leprosy in Foreign Countries," Honolulu, H. I., 1886.) 
All agree, likewise, that leprosy is hereditary, but that this cannot account alone for 
its rapid dissemination, as the Hawaiian race is notoriously unprolific, and sterility the 
rule among lepers. * All cases not hereditary are almost invariably traceable to leprous 
contact, no so-called sporadic case having been reported that would bear the test of 
careful investigation ; and the special case of Father Damien, the heroic priest who has 
administered to the spiritual and temporal wants of the lepers of Molokai since 1873, 
* There are many exceptions to this rule, but offspring have little vitality. 206 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and who developed the tubercular form of the disease in 1885, is worth volumes of even 
convincing native evidence in support of the view of contagion. A minority undoubt- 
edly resist the disease, but the great majority, under close contact, become lepers. A 
remarkable case is told of an Hawaiian with positively no family history of leprosy or 
close contact with lepers, who, as bearer of a coffin at the funeral of a leper, had an abra- 
sion of the shoulder bathed with liquid exudations from the decomposing body during 
the journey to the cemetery. On his return he cleansed the abrasion carefully; but it 
was too late, and in a few months he was a pronounced leper. 
Dr. Mowritz concludes that about eighteen per centum of the Hawaiian race resist 
leprosy; that seventy per centum of the cases have been due to contagion, twenty-eight 
per centum to heredity and two per centum to vaccination. 
The latter cause is probably a more potent factor than this small percentage would 
indicate. Professor Gairdner, of Glasgow, recently reports in the Medical Journal 
the case of a young boy who seemed to have contracted leprosy through vaccination. A 
physician in an "island of the tropics" vaccinated his own son with virus obtained 
from a native child belonging to a leprous family. From his son he took virus with 
which he vaccinated the boy whose case is reported. The native child developed 
leprosy later in life ; the physician's son was subsequently affected with the disease, and 
the third boy was the victim of leprosy in its worst form, ending fatally. It is noted 
that the physician's son had the disease more mildly than the boy inoculated from him, 
and there could, therefore, have been no attenuation of the poison. 
In other countries these views in support of contagion are sustained by a host of 
authorities, including Dr. Hansen, of Norway, Dr. Allen, of Corea, Dr. Dight, of Beirut, 
Syria, Dr. Wong, of Canton, China, and Surgeon-General Cockburn, of the Indian 
Army. 
In view of the undoubted importation of leprosy into the Hawaiian Kingdom from 
China, the views of Dr. F. Wong, a Chinaman by birth, but a graduate of a European 
medical school and a practitioner of marked ability, are of the greatest importance and 
interest. In a> paper entitled * ' Memorandum on Leprosy, ' ' addressed to the Inspector- 
General of the "Chinese Customs Service," he states the general belief that it arises 
in some local endemic cause, possibly malaria, and declares it to be both hereditary and 
contagious. This belief is universal among the Chinese, and that the disease is not 
more widespread is due to a universal horror of the disease, with separation of lepers 
from the rest of the community. The leprous only marry with those similarly affected, 
save in cases where the disease is undeveloped or the hereditary taint unknown, and 
Dr. Wong thinks there is a tendency to gradual extinction of the disease, though all 
children of lepers manifest it up to the fourth generation, when it is considered safe to 
marry with them. Cohabitation is the great spreader of the disease, and females in 
disguise are the chief agents in its dissemination, offering their persons for prostitution, 
thereby hoping to rid themselves, or " sell off," as it is termed, their leprosy. A course 
of prostitution is recommended by the native Chinese faculty as a potent remedy. 
{Medical Customs Report, 1873. ) 
This weight of evidence is not simply in favor of the contagious and hereditary 
character of leprosy, but the case seems absolutely proven, if preponderance of testimony 
is to determine the decision. In Asiatic lands leprosy is a disease of remote and ancient 
date; in Europe it is an inheritance from the period of the Crusades to us modern 
observers, and everywhere, save among the native races of Hawaii, the lepers are 
shunned, segregated, admitted to no social and few civil relations-only allowed to 
consort with fellow-sufferers, and generally cared for by government philanthropy. 
But in these islands we can fix the date when the first leper reached their shores. He, 
and probably other companions, sowed the seeds of this disease, and when they had 
germinated we find no dread manifested, but the developed leper, in all his ugliness, SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
207 
deformity and corruption, is in no wise treated differently from the native brother, 
clean and free from all bodily imperfections, but is permitted to share house, food, 
clothing, bed and pipe; to intermarry with the uninfected, and beget children-no 
relation of life being denied to him. And so the sowing of the germs went on unim- 
peded until public attention was called to the matter, public feeling aroused, and the 
government instructed its Board of Health to assemble the lepers. These orders were 
earnestly obeyed, but the natives offered a stem opposition to the enforcement of the 
act, and are still far from being reconciled to this wise and paternal policy. 
Leprosy in the Hawaiian islands in no way differs from that of other lands, manifest- 
ing itself in both its anæsthetic and tubercular forms, though at least one observer deems 
anæsthetic leprosy to be the predominant variety. Here, as in Europe, the contagium 
of the disease has been demonstrated to reside in the bacillus lepræ, so carefully studied 
in Northern Europe by Virchow, Neisser and M. Comil, and at the Hawaiian leper 
settlement by Dr. Arning. The latter has made a complete study of the bacillus, 
demonstrating it in all of the discharges-purulent, mucous, salivary and intestinal ; 
in all the tubercular and nodular formations, and, in anæsthetic cases, in association 
with the nerves supplying the surfaces deprived of sensation, but not in the blood or 
urine.* 
In these discharges, loaded with bacilli, we have the materies morbi ; in the domestic 
and social relations of life vve have the opportunities for inoculation ; in abraded sur- 
faces, or highly vascular mucous membranes, we have the conditions favoring facile 
reception ; and in the records of hundreds of reported cases we have the evidence that 
thus the disease is most generally propagated, that it is contagious throughout its whole 
course, and that it is hereditary. 
Dr. Aming believes that exhalations from ulcerated surfaces of lepers are most fre- 
quently the carriers of the bacillus or contagium, and that it enters the system through 
the mucous membrane of the bronchi and alimentary canal. The common presence of 
scabies, eczema and parasitic affections among the affected affords another means of 
distribution. 
We have seen that the native race-through disease and lessening of reproductive 
power-has been reduced from a population of 400,000, in 1778, to one-fifth of that 
number in the year 1850, or, in accurate figures, 82,203. 
In 1860, the year succeeding that in which leprosy was positively diagnosed, the 
census reported the native population at 66,984, a decrease in ten years of 15,219. 
At this period, the disease showing rapid increase, legislation was demanded "to 
save the native race from extinction and in 1865 "an act to prevent the spread of 
leprosy ' ' was passed, which, put in force by the ' ' Board of Health, ' ' established a leper 
hospital at Kalihi, near Honolulu, to which all suspected lepers were brought and 
subjected to examination. The second act of the board was to secure a portion of the 
island of Molokai for a leper settlement, where the infected could be segregated ; and 
here, after due preparation, the lepers were first transferred in the early part of Janu- 
ary, 1866. In this year, 1866, the population was enumerated, and the native race 
found to have diminished in six years by 8219. Six years later, 1872, we have another 
enumeration, and we find the natives numbering 49,044, showing a loss of 9721. 
* The bacillus lepree is found in the form of fine, slender rods, occasionally tapering at both 
ends, about half the diameter of a blood corpuscle, and in width one-quarter of their length, are 
either rectilinear or slightly curved, and resemble Koch's bacillus of septicaemia in the mouse. 
Sometimes they have bulbous or lance-shaped extremities, and often exhibit unstained transverse 
lines. They are found generally packed in " lepra cells," which seem to be modified white cor- 
puscles, and the lymphatic system is the channel of their progress. Granular particles may be 
associated with the bacilli, which are probably spores.-Neissek. 208 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Again, six years brings us to 1878, and we have only 44,088, a further dwindling of 
4966. This year was the Hawaiian Centennial, dating from Captain Cook's landing, 
and we see the results of a century of civilization in the pure-blooded native race being 
reduced four-fifths iù number. The latest census is that of 1884, which reports the 
number of pure natives at 40,014, and we record a loss of 4064. Other statistics of this 
most recent census show unmistakably that immigration is rapidly supplanting the 
native Hawaiian, and amalgamation of these foreign races is taking place, as the half- 
castes show an increase in the six years of 798. We see that the Chinese, who in 1878 
only numbered 5916, have increased in 1884 to 17,931 ; Americans, from 1276 to 2066 ; 
British subjects, from 883 to 1282 ; Germans, 272 to 1600 ; and Portuguese laborers, 
from 436 to 9377. The total population had increased through immigration and births 
from 57,985 to 80,578, which included 2048 children of foreign parents, and the half- 
castes had increased by twenty per centum. 
Next to the continued diminution of the native race, the most noticeable and 
alarming feature of this census is the great increase of Chinese coolies, who may still be 
bringing leprosy in its latent form. The same fear may be expressed in regard to the 
Portuguese, leprosy being prevalent in the Azores and other colonies of Portugal. 
An analysis of these various censuses of the Hawaiian Kingdom shows that, though 
the native race is still diminishing with lamentable rapidity, there has been a marked 
diminution in the percentage of decrease since 1860. In the period extending from 
1850 to 1860 it was 18.40 per centum, an annual average of 1.84 per centum ; but in 
the period of six years, from 1878 to 1884, it had fallen to 9.19 per centum, an annual 
average of 1.53 per centum, an improvement which we must conclude to be due to 
wise sanitary legislation, in which the segregation of lepers is included. 
Tabular records of the leper settlement at Molokai show that up to, and inclusive 
of, 1885, 3076 lepers have been received, thus enumerated:- 
Total Hawaiians 2997 
Mixed Hawaiian blood 37 
Chinese 22 
Whites 16 
Other nationalities 4 
3076 
In consequence of native opposition, great difficulties are encountered in securing 
the persons of lepers, and up to 1876 it was estimated that a greater number was at 
large than had been brought within the boundaries of the settlement. The largest 
leper commitment was 487 in the year 1873, and the smallest 51 in the year 1880. 
The natural deductions from the above table are, that the white race is both resist- 
ant of leprosy and by its habits opposed to those close associations with lepers which 
are necessary for the transfer of the contagium; that the mixed Hawaiians are approxi- 
mately to be classed as the whites with reference to resistance and modes of life; and 
that, while we owe the introduction of leprosy to the Chinese, the small number of 
commitments to Molokai is amply explained by the wholesome horror this people have 
of those who are afflicted, by the outcast life of lepers in China and the selection by the 
various companies and agencies having control of coolie labor of none but the vigor- 
ous and apparently healthy, in which vast crowd a leper may occasionally be intro- 
duced as an accident, the disease being persistent in its latent, and, therefore, unde- 
terminable form. (We assume these cases to have originated in China.) 
Of the enumerated whites, six were Germans, four Americans, four British, one 
Pole, one Portuguese, and of this number four only are stated to have lived in other 
countries where leprosy was endemic. The four of other nationalities were all cases of 
preexistent disease. SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
209 
As regards treatment in leprosy, the experience of the world is that no drug has yet 
proven to be curative; and as regards prophylaxis, we can only separate the infected 
from the well, and can go no further until we know how and in what medium the 
bacillus has its birth. The drainage of marshes and cultivation of the soil does not 
eradicate, nor the removal of communities from marshy districts influence the disease. 
It is independent of food, surroundings, topographical features and climate ; prevail- 
ing under all peculiarities of diet, vegetable, animal or ichthyophagous, salt or fresh, 
plain or varied, near the shore and on table lands, in river bottoms and interior plains, 
in the cold north and sunny south. It may, however, be kept in abeyance-perhaps, 
never to manifest itself-by generous living, good nourishment and absence of all care, 
hard labor, or exposure to vicissitudes of temperature. 
The only constitutional remedies which have proven of any value are mercury and 
arsenic, and the former may eventually be so used as to prove a positive bactericide to 
the bacillus lepræ. 
The lesson we derive from the " Middle Ages " should not be wasted upon us, and 
the advocates of the non-contagious character of leprosy should be denied a hearing. 
The tide of emigration which swept over Europe after the fall of the Roman Empire, 
sowed the seeds of leprosy from the Arctic shores to the Mediterranean; from the 
Caucasus to the Atlantic shores of Europe, and even to distant Iceland. No country 
escaped, and the care of lepers became the one great public charity, until the number of 
leprous communities scattered over the continent was estimated at nearly twenty 
thousand. 
And how was the European leprosy eradicated? By laws of church and state 
declaring the leper a pariah; by depriving him of all civil rights; by separation-shut- 
ting him off from all the rest of mankind, and so letting the infected and the disease 
die out together; and by making a public opinion which should consider this work of 
ostracism a religious and civil duty. 
The results show the wisdom of this policy; for, from a widespread disease it became 
practically annihilated-so concentrated and reduced as to be no longer a public terror- 
and, in the seventeenth century, had almost ceased to exist, lepers only being heard of 
here and there, more especially in the north and in isolated spots along the Mediter- 
ranean. 
Methods of dealing with the leper have been a vital consideration in the Hawaiian 
Kingdom for thirty years, and may become so to the people of the United States, as the 
disease is present among us in Louisiana and the eastern provinces of Canada, and has 
followed Chinese emigration to the Pacific coast, where prostitution brings this people 
into close relation with the white race, as well as that from the Scandinavian provinces 
of Europe to our northwestern territory. 
In the Hawaiian islands the lessons of history are accepted, and but for the opposi- 
tion of the natives themselves the disease ere this would have been confined to the 
boundaries of the leper settlement. But they are still as unwilling to deliver up 
infected relatives as when the law of segregation was first promulgated, and it is prob- 
able, as previously stated, that a vast number of lepers are still in concealment. Such 
opposition must prevent the law, to a great degree, from fulfilling its purpose, and may 
defeat entirely its ultimate aim. 
The eradication of leprosy can only be effected, then, by bringing the lepers together 
into an isolated community. Here-if the law can be enforced-the disease must be 
eventually eradicated, as the generative powers of the leper are feeble, and births com- 
paratively few, children being commonly still-born. The bodies of lepers should be 
cremated as well as the clothing of the dead, and, so far as possible, all discharges, 
morbid and fecal, as well as the clothing and bedding of the living, and the walls, 
floors and utensils, should be submitted to the action of some germicide, so that the few 
Vol. V-14 210 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
non-lepers, who must control intercourse with the outside world, may be, if possible, 
secured from being carriers of contagion. 
Eventually the cultivation of the bacillus lepræ and inoculation, after the manner of 
Pasteur, may receive consideration as a means of staying the destructive progress of 
leprosy, which is surely to be enumerated with the other devitalizing agencies so steadily 
hastening the native race of the Hawaiian Kingdom toward annihilation. 
DEMOGRAPHIC CONSIDERATION OF THE EVILS OF ARTIFICIAL 
METHODS OF PREVENTING FECUNDATION, AND OF 
ABORTION PRODUCTION, IN MODERN TIMES. 
CONSIDÉRATION DEMOGRAPHIQUE DES MAUX DES METHODES ARTIFICIELLES 
POUR PRÉVENIR LA FÉCONDATION ET PROCURER L'ABORTION 
DANS LES TEMPS MODERNES. 
DEMOGRAPHISCHE ERWÄGUNGEN DER ÜBEL KÜNSTLICHER METHODEN ZUR VERHIN- 
DERUNG DER BEFRUCHTUNG UND DER HERVORBRINGUNG DES 
ABORTS IM JETZIGEN ZEITALTER. 
BY THOMAS M. DOLAN, M.D., F.R.C.S. ED., 
Of Halifax, England. 
Ever since Hippocrates drew up that oath which, amid all the changing centuries, 
stands out to us to-day as binding and as true in its precepts as any law of the Chris- 
tian Dispensation, the medical profession has faithfully fulfilled that part of the 
injunction relating to the administration of deleterious drugs to women. 
The oath thus runs: " I will give no deadly medicine to any one if asked, nor suggest 
any such counsel, nor will I conspire with a woman to destroy her unborn child." 
What the father of Medicine laid down as the moral law in a pagan age, surely we 
who live in a century dignified by another name ought more strictly to follow, and in 
action and by word carry on the teaching of the school of Hippocrates. 
As a profession, I am convinced we discountenance in private the acts included 
under the title of this paper; but is this enough ? 
There are occasions when to be silent is to connive, and I believe we have now 
reached a crisis in the history of medicine, a crisis affecting all civilized countries, when 
it has become necessary for members of the profession to speak out, and declare that 
faith that is in them. 
Our rôle as physicians would indeed be limited if it were simply confined to the 
cure of disease; we aspire to something higher; we aim at making people healthier, 
consequently happier, and, I hope, better. 
Of late years we have gained a new title to respect by our exertions on behalf of 
State medicine. In the whole domain of State medicine no question can be raised so 
important as one affecting the perpetuation of our species; it is the initial question; it 
is a far reaching one. 
It may be considered in its purely religious aspect, a side upon which I need say 
very little, because so much has been written on this side, and so well, by the teachers 
of Christianity, that I could not add anything new; moreover, I could not hope to con- 
vince any who deny teaching which rests on faith; those who believe require no argu- 
ments to confirm them in their acceptance of the dogmatic laws laid down by the SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
211 
Christian churches on the sanctity of marriage, on the ends for which marriage was 
instituted, and on the sin incurred by the practice of preventive checks. 
I leave this side to the ministers of religion, and shall confine myself to what I 
deem the medical aspects, in the hope of eliciting opinions from others on these prac- 
tices. I unreservedly accept the proposition laid down by the doctors of the universal 
church: "Peccant conjuges si in usu matrimonii vel post usum, aliquid faciant 
quo impediatur generatio, vel quo semen rectum rejiciatum, quia agunt contra finem 
matrimonii." 
What are the practices to which I allude ? Of late years we have been confronted 
by a revival of some of the doctrines of Malthus, though not expressed with the same 
refinement or ability with which Malthus introduced his views. One word on Malthus. 
Malthus' law may be formulated as follows :- 
Population, when unchecked, goes on doubling itself every twenty-five years, or 
increases in geometrical ratio, while the means of subsistence, under circumstances 
most favorable to human industry, cannot be made possibly to increase faster than in 
arithmetical ratio. This law rests on assumptions. (1) It presupposes that genera- 
tive power will be equal in all. (2) It leaves out the increasing industry of man and 
his inventions; it forgets the powers brought to man's aid; the steam engine enables 
man to multiply his production tenfold. (3) The stern logic of facts oppose the law; 
in France wealth increases and population decreases, reminding us of the warning of 
Goldsmith :- 
"Ill fares the land to hastening ills a prey, 
Where wealth accumulates and men decay." 
In England population increases and wealth also increases, so that the law of Mal- 
thus might be almost reversed. Malthus made another general statement : "Popula- 
tion invariably increases when the means of subsistence increases, unless prevented by 
powerful and obvious checks; these checks, and the checks which keep the population 
down to the level of the means of subsistence, are moral restraint, vice and misery." 
The history of Ireland negatives this statement; the means of subsistence have been of 
the most limited kind, so much so that we might venture to formulate a rival law, 
that poverty and increase of population went together. The word subsistence admits 
of different interpretations. The law of Malthus will not stand examination. The 
neo-Malthusians have struck out a programme of their own. Education by the press 
is now recognized, and the neo-Malthusians have brought to their aid the printing 
press and commenced an active propaganda. We have had a flood of literature scat- 
tered amidst our English-speaking population, openly teaching how fecundation may 
be prevented ; and, worse still, means are provided, in the shape of medicated tampons, 
syringes and sheathings, by means of which it may be arrested. This is the first evil 
we have to meet openly. I may here briefly allude to the justification for these 
procedures. 
Those who support this creed, in place of the natural law to which it appeals in 
other parts of its programme, accept as a basis the artificial legislation of civilized coun- 
tries, which makes the struggle for existence so keen as to interfere with provision for 
the inhabitants of those countries. "Large families," they say, "are injurious to a 
nation; diminish the number and there will be room enough for all." If we admit 
such a doctrine, why not resort to more thorough measures, and remove all who do not 
themselves contribute to their own maintenance, such as the old, the insane, the 
incurably sick, the blind, the deformed. We shall thus clear the ground effectually. 
Society would at once revolt against such a proposal. I do not accept the Malthusian 
doctrine as offered in its modern guise; I hold that the world is, or should be, large 
enough for all who may be born into it. I maintain this neo-Malthus creed to be a 
weak excuse to shift the responsibility for the world's ills upon man's imperfect gov- 212 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ernment of this globe of ours. What, though progress and poverty go hand in hand, 
must the blame be laid on large families ? Must we not rather probe to the bottom 
and seek for other causes ? in the relation of capital and labor, in the unequal distri- 
bution of wealth, in defective landlords, and in other politico-economical parts of our 
social system. Should not this earth be sufficient to supply the wants of all ? Do net 
the sea and the rivers give us fish in abundance ? Are there not fertile lands in every 
country from which we can draw food supplies? Is there not more wealth than is 
needed ? Before the worm on the leaf turns, or the worm in the dust, before political 
economists of this school can say population is excessive, only such a number shall be 
born, families must be kept within a certain limit, they must first answer these 
questions. 
In this republic of yours one of your citizens, George, has dared to ask these 
questions. Whatever may be said of his teaching, he does not ask for people to rise 
to better things by the practice of arts which lower women to the level of prostitutes, 
nay, even lower than the brutes we deem our inferiors, or induce men to imitate the 
action of the man whose name has been handed down in connection with a vice which 
has ever been held to be disgraceful. Historically we have it on evidence that the vice 
of to-day is simply a copy of what was known in the early days of the world. We read 
in Genesis thatOnan, " semen fundebat in terram, ne liberi fratris nomini nascerentur. " 
Speaking plainly, we have to deal with onanism ; though we may call it by fashionable 
names, as preventive checks, control of population, it here stands out in all its hideous 
nakedness. Those who believe in revelation will accept this history of the punishment 
of Onan : "And, therefore, the Lord slew him, because he did a detestable thing." 
Onan's name has lived, and believer and unbeliever have ever since associated his name 
with a vice which has only to be mentioned in secret. We have made progress since 
those days. We dignify onanism by another name. Those who commend the arrest 
of fecundation call one of their plans the method of retraction : as here the act is com- 
pleted extra vas, the vice is the same. With great ingenuity some of the methods are 
so devised that the act is completed intra vas ; but who will say that there is any 
difference in the two actions save in the methods? Onan's intention is still carried out. 
Onanism is to be condemned on the following grounds : (1) Because it offends against 
the natural law ; (2) because it is detrimental to the interests of society ; (3) because 
it is physiologically injurious. 
I. What do I mean by natural law ? I may define it as the light of natural reason 
by which we distinguish what is right and what is wrong. Now, this natural law is 
one and in itself identical for all mankind ; in fact, the different races of mankind, 
civilized and uncivilized, are guided by the same general principles-I may call them 
precepts of morality-which spring from the natural law. We are told by Quatrefages 
that races far removed from our ideas of civilization have certain moral characteristics 
shown by the modesty of their women, by their punishment for adultery, by their 
marriage customs, etc. 
Herbert Spencer, in his "Sociology," also gives us instances of the same kind occur- 
ring in savage tribes, and he gives us instances how, in the process of man's evolution, 
the moral law so'far perfected itself, that in place of indefinite, incoherent marital 
relations we have definite, coherent ones. If, however far back, we pursue the subject, 
we find that natural law has exerted itself, and the sexual instincts, however gratified, 
by rapture of women, by their purchase, or by consented association, have been so in 
accordance with the natural customs which rule the whole animal world. Whatever 
practices we find prevailing among the rudest tribes, say even infanticide, yet we cannot 
attribute to these tribes the arts which are prevalent to-day in civilized communities, 
and which would appear to have their growth in civilization. Just as sodomy, forni- 
cation, and other forms of sexual crime are condemned by the universal consent of man- SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
213 
kind, and are against the natural law, so I maintain that onanism, extra or intra vas, 
is also against natural law and should be condemned. 
You will, I trust, admit that the question is not one of marriage alone ; it is more 
fundamental; it regards the proper use of sex itself. Reasoning more closely from the 
moral side, I say that onanism then is to be condemned because- 
1. It is a crime against the law of reason or natural law. 
The reason is simple. It is a crime to divert what we use from its intrinsic end. 
The intrinsic end of copulation is generation ; therefore, onanism, which diverts copu- 
lation from this end, is a crime. 
2. It is a grievous crime. 
Crime is light or grievous according to the matter which it disordinates. The matter 
disordinated by onanism, or rather undone by it, is the most important good of the 
human race, viz., its continuance. It cannot under any circumstances lose its guilt ; 
the contract of marriage cannot remove or lessen it ; it is indifferent in what way it is 
performed, because there is always the same element of guilt, viz., the distortion of 
copulation from its end. The above charges are confirmed and promulgated by revela- 
tion, though they do not depend upon it, and can only be questioned by the utter sub- 
version of all morality. If we look at the consequences and signs of the opposition of 
onanism to the natural law, we find them in the following :- 
1. Onanism is contrary to natural instincts ; it is only resorted to by calculation. 
2. It is against the common voice of mankind. 
II. Herbert Spencer tells us that the future of domestic evolution is almost secured. 
After tracing the progress of the sexual relations through all its phases, he says (1 ' Prin- 
ciples of Sociology," Vol. I, p. 787) : "The monogamie form of the sexual relation is 
manifestly the ultimate form, and any changes to be anticipated must be in the direc- 
tion of completion and extension of it. . . . There may, too, be anticipated a strength- 
ening of that ancillary bond constituted by joint interests in children. In all societies 
this is an important factor, and has sometimes great effect even among rude peoples. 
Falkner remarks, although the Patagonian marriages are at will, yet when once the 
parties are agreed and have children, they seldom forsake each other, even in extreme 
old age. And this factor must have become more efficient in proportion as the solicitude 
for children becomes greater and more prolonged, as we have seen what it does with 
progressing civilization, and must continue to do so." 
Herbert Spencer is well known in the States. He has paid a high tribute to 
American women and the way the Americans bring up their children, so that what he 
has to say comes from one favorable to your institutions. If what he says be true, 
then must the whispers which come across the Atlantic, that preventive checks are 
the order of the day in America (as well as in other countries), be taken to mean that 
you are not advancing on the lines of true civilization. 
Herbert Spencer writes as a political economist, and he could not entertain in his 
programme speculations of this kind, because the primary scope of political economy 
is the good of society, and the primary good of society is its continuance. I suppose 
we are all agreed on certain principles of social morality, and that we have some defi- 
nite ideas on the institution of marriage, and that it was intended to put an end to 
promiscuity, and that one of its chief ends was the conservation of the species. The 
conjugal relation is one of choice and is composed of many elements. 
It bears a relation to the individual and to the State. Family life has ever been 
associated in its greatest perfection with the happy voices of children, and the prolific 
mother has been ever the type of ideal happiness, because the family makes the State 
and because each State wants her citizens. The real wealth of the nation lies not in gold 
or in temporal possessions alone, but the number of well-ordered, well-fed and contented 
inhabitants she can support. America is not over-populated when so much land yet 214 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lies uncultivated, nor, looking at other countries, can I consent to the proposition that 
they are over-populated. In France the population does not increase so fast as in Ger- 
many or England; the question comes home to her, how far artificial restraint is 
accountable for this? Looking at the subject from the family side, I say that conjugal 
onanism is to be condemned. It prostitutes woman. No doubt woman has the hard- 
est lot, but she does not make her condition better by adding to her already great 
burden the burden of sin, and, as I shall presently show, of disease. I am willing to 
concede to woman all she asks for in the way of social status. If she desires to come 
down from the high pedestal on which she now stands, and from being the object of 
man's admiration, and shall I say, too, of his adoration, prefers to enter into the fierce 
arena of life and become his competitor, by all means let her. For many women the 
professions are the most suitable vocations, and I do not dispute woman's capacity in 
many fields on which she has entered. But woman cannot change her nature as easily 
as she can change her garb or occupation. Though she may enter on the duties 
hitherto assigned to man, aud though she may do man's work, yet she cannot divorce 
herself from her higher instincts and what I may call her higher duties. If she enters 
on the married state of her own free will, she should accept the responsibilities entailed 
upon her sex and by her duties to society. Celibacy is open to her if she has an objec- 
tion to children. Thousands of women are compelled to lead celibate lives, and do so 
with purity. Women may say, " we are meant for better things than child-bearing. 
Children hinder us from taking our due part in society, and prevent us from elevating 
ourselves." This is a strange justification. Is she willing to be simply a man's play- 
thing, to minister purely to passions expended licentiously, and in methods which 
offend against ordinary decency ? Is it true she is willing to give up what has ever 
been, in almost every age, the crowning glory of women, that of motherhood, in order 
to throw herself into the business of life ? In the old and decaying civilizations sexual 
vice was the prelude of their downfall, and though I do not believe we have reached 
such a degree of degraded voluptuousness as marked the decline of some of the older 
civilizations, yet I think we have entered on the first stage, and here the axiom of Ovid 
has force-principiis obsta. 
I trust the higher education of women does not consist in learning how to prevent 
fecundation ? Her elevation in the social state should not be purchased by degradation 
personal to herself. Without woman's help we cannot check these frauds, and unless 
we can awaken the conscience of women and make them feel that these acts are sinful, 
hateful, and that each fraud is an indirect infanticide, we shall not put an end to the 
evil. 
In the old civilizations, in the days of their youth conjugal love was ever associated 
with children. Juno tempted Æolus to let loose the pent-up winds on the Trojan 
ships by the offer of a beautiful nymph Deiopea, whom she promised to bind to him in 
the stable bonds of wedlock and to call his own, and who could make him the father 
of a beautiful offspring. Virgil spoke for his time. In a play of Sophocles called 
Œdipus, the King, the citizens tell of their sufferings in the following words:- 
" The nurslings of the genial earth 
Wane fast away ; 
The children, blighted ere their birth, 
See not the day, 
And the sad mother bows her head."; 
With a difference we may apply these lines-the nurslings are blighted ere their 
birth, but the mothers do not weep; nay, they glory in the destruction they are the 
means of causing. 
Sophocles speaks for his time. In another play of this old teacher of morality, the SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
215 
Antigone, occur some lines which are applicable to this question. Across the lapse of 
some thousand years the voice of Antigone speaks to us, trumpet-tongued, a truth- 
" No ordinance of man shall override 
The settled laws of nature and of God ; 
Not written these in pages of a book, 
Nor were they framed to-day or yesterday ; 
We know not whence they are ; but this we know, 
That they from all eternity have been, 
, And shall to all eternity endure." 
This Pagan sister s words, the word# of a woman who suffered, who lamented her 
fate, "cut off from marriage bed and marriage song, untasting wife's true joys or 
mother's bliss, ' ' may perchance teach some erring sister now, and so, from the dead 
past Antigone's voice teaching morality, may blossom into life some little being. 
III. We are interested as moralists, political economists, and still more as physi- 
cians. It is impossible that onanism should be entertained in our science, because 
medical science is subordinate both to the moral law and political economy. Gentle- 
men, onanism is opposed to the entire scope of medical science. What are the objects 
of our art ? The supreme scope of medicine is to assist the moralist and the economist; 
the supreme direct scope to secure the healthy fulfillment of physiological functions, 
while the immediate scopes are to prevent disease in particular, and to remedy disease 
already contracted. Onanism offers us patients, and so far it does concern us more 
immediately, perhaps ; in all other respects it is irreconcilable with medicine. 
The physiological aspects may be said by some to concern us more particularly. I 
need not detain you with a recapitulation of the physiology of the sexual organs in man 
and woman; all the parts concerned are most wonderfully structured, no less so in man 
than in woman. What concerns us most is the nervous supply of these organs, because 
it is in this part men and women suffer by the artificial checks in vogue. I shall take 
them in order, and shall first speak of the effect of some artifices on man. 
The method of retraction I find is very common. I speak from my professional 
experience of cases wherein this practice, followed for years, has been attended by the 
most injurious consequences. I need not give cases ; the symptoms in the male may 
be divided into neuropathic, vascular and pulmonary, the nervous predominating. We 
are all familiar with the symptoms in the solitary onanist ; they are not so accentuated 
in the conjugal onanist; we need not be surprised at the presence of neurotic symptoms. 
Retraction is the most inj urious of all the methods to the male. I need not describe in 
detail what the various plans are, but the next, one derived from a Dr. Condom, who 
has achieved a notoriety equal to that of Onan himself, is also injurious to the male, 
apart altogether from the pollution it leads to. It interferes with the natural gratifica- 
tion ; it taxes also the nervous system, because the dual action is not suspended, for 
there is always the fear that the condom may not be impervious. 
2. The injurious effects on the female of the various methods are well recognized. 
The method of retraction and of Condom interfere with the sexual acts to the greatest 
extent, as the semen is not distributed over the vas intended for it by nature. There is 
not completion of the act. This denial brings on a number of well-defined symptoms, 
which may be divided into neuropathic, vascular, pulmonary, besides local affections 
of those organs which are so intimately connected with the sexual act, the uterus and 
its appendages. I could bring forward numerous cases to bear out these statements, 
but I abstain, for the reason advanced by Doctor Mayer, who has so ably treated the 
subject. All practitioners must have observed them more or less, and it is sufficient to 
evoke their recollection to supply for our silence. French writers have dealt with this 
unpleasant subject, and as the French language lends itself better than ours to an NINTH INTERNATIONAL MEDICAL CONGRESS. 
216 
explanation of delicate subjects, I quote from a French author why conjugal onanism 
should be attended by such general and local affections. 
Francis Devay says : "Il n'est point difficile de concevoir le degré de perturbation 
qu'un semblable pratique doit exercer sur le système génital de la femme. En provo- 
quant les désirs qui ne sont point satisfaits, une stimulation profonde retentit dans tout 
l'appareil ; l'utérus, les trompes, et les ovaries entrent dans un état d'orgasme ; l'o- 
rage n'est point apaisé par la crise naturelle ; une sur excitation nerveuse persiste. Il 
se passe alors ce qui aurait lieu, si présentant des aliments à un homme affamé, on les 
retrait brusquement de la bouche, après avoir ainsi violenté son appétit. La sensibilité 
de la matrice et tout l'appareil de la reproduction sont tirailles en sens contraire. C'est à 
cette cause trop souvent mise en action que l'<i doit attribuer ces nerveuses multiples 
ces bizarres affections, qui ont pour point de départ le système génital de la femme." 
Dr. Mayer also says: "Il est vrai semblable que l'éjaculation et le contact du 
sperme avec le col utérin constituent pour la femme la crise de la fonction génitale, en 
apaisant l'orgasme vénérien, en calmant les convulsions de la volupté, sous lesquelles 
s'agitait frémissante l'économie toute entière." 
It has often been said, " que l'utérus est la femme if this be true, then we can 
understand why in these days uterine diseases are on the increase. I do not iavor the 
view that all diseases of the generative tract in women are to be attributed to conjugal 
frauds ; but I cannot at the same time shut my eyes to facts which clearly point to 
sexual abuse as the cause of many of the lesions we meet with in the sexual and repro- 
ductive organs of women. It is a subject which has yet to be cleared up, and it is well 
worthy of the attention of the profession. 
I have said sufficient on this point of the question, and before proceeding to the de- 
structive measures adopted, I may in conclusion say that the conjugal frauds complained 
of are practiced, not by those we term the lower classes, but by those who would like 
to be included, and who do include themselves, under the title of the higher classes. If 
education brings about such results, we may expect that the custom will be more uni- 
versally adopted. Selfishness is at the root of the evil ; men and women are unwilling 
to put forth too great an effort ; they have an ambition to give their children a position 
equal to their own ; in other words, the child has to begin where the father left off. 
This is not good for a child or a country. We are too ambitious and aim at too much 
comfort, and comfort is but another name for luxury. Guyot says there are two ways 
in which this comfort may be gained and preserved : either by redoubling one's efforts 
or by reducing one's burdens to a minimum. Most Frenchmen prefer the latter course. 
We blame the imprudence of the spendthrift who brings children into the world with- 
out having the means of maintaining them in it ; but the prudence which refuses to 
undertake the duties of maternity for fear of the burdens which they entail is a grave 
symptom of moral inertia. The spring of life and energy is broken in a man who, in- 
stead of action, makes it his aim to avoid action. " Every child you don't have," says 
M. de Lalalisse, "is one man the less, and that man might have been a Papin, a 
Watt, a Stephenson ; the increase of population forces progress on every people. The 
exaggerated application of the Malthusian principle threatens little by little to destroy 
the population. If this should extend to other races which form the front ranks of 
civilization, they will run the risk of some day being supplanted by the less civilized 
people." * 
With truth I said this question was one of the most important in connection with 
State medicine. It concerns the individual, the family, society. We, as medical men, 
with all those interests at stake, cannot longer be silent, and I believe a good deal rests 
* Guyot. " Principles of Social Economy." London, 1884. pp. 134-140. SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
217 
with us toward checking these evils. Individuals cannot do much, but a united pro- 
fession can accomplish a good deal. I appeal to the profession-not of one country, 
but of the world-to let it go forth from this great Congress that, in the interests of the 
individual, the family and society, you condemn these conjugal frauds, on the grounds 
of social morality and social economy, in the true interests of the nations you represent. 
Abortion production need not detain us very long. It is a crime recognized by the 
laws of all civilized countries; it requires no argument to show why such a practice is 
immoral and criminal. I use the word abortion in its broadest sense; criminal abortion 
includes all attempts made at any time to destroy the fecundated ovum, the embryo or 
the foetus. A differentiation has been made between the living and the inanimate 
fœtus, fixed by the number of days that have been passed, and there has been endless 
discussion as to the period at which life is manifest. As soon as impregnation has taken 
place a being is in process of formation, and that being has rights, and those rights 
must be safely guarded. This is the only logical position we can take. 
Though the laws of different countries punish those who induce or submit to abor- 
tion, and though the medical profession, as a body, supports the teaching of Hippocrates, 
yet we have evidence that abortion production is on the increase in countries which 
claim to be civilized ; in fact, it would appear that we have almost reached the state 
which distinguished the last days of the Roman Empire. This remark applies to 
America, England, France, Germany. 
I make this statement on the authority of such experts in medico-legal studies as 
Casper and Tardieu. These writers furnish us with statistics on infanticide which are 
appalling, but they do not reveal the actual extent of the evil ; they only furnish us 
with the number of cases found out, or the number of autopsies made, or public inqui- 
ries held relative to infantile deaths. 
We are told that in your country the abortionist, male or female, practices the art 
almost openly, and that it is a very lucrative trade; we are told that some of your 
women, who are too refined to adopt the other preventive checks, have no hesitation in 
resorting to practices more heinous still and more criminal. We are told that it is not 
the ignorant, but your educated, refined and fashionable women who are the worst 
sinners. 
I hope, for the honor of your American women, the imputation on their fair name 
will be denied. If it cannot, then may they hang their heads in shame, and stand 
confessed as Herod's successors. He killed the infants after birth, it is true, but the 
crime is none the less because committed before birth. As to the prevalence of the 
fashion in England, we have but too much proof. The opinion of Dr. Braxton Hicks, 
Consulting Physician to Guy's Hospital, should satisfy us. "Production of abortion," 
he says, "is, I regret, rather extensively regarded by the married public as not only 
venial, but ordinary and proper, if pregnancy should interfere with their arrangements. 
One is coolly asked to induce abortion for the veriest trifle-because it interferes with 
the autumn holiday or the season, because of the disagreeables of pregnancy and labor, 
for trifling sickness, or because the husband, or both, do not like children." 
The instincts of nature, one would think, would guard against this crime. All the 
perfumes of Arabia could not sweeten Lady Macbeth's hands, nor could they the hands 
of her sisters imbued in infants' blood. Think of the crime as if performed on the 
living child whose prattle amuses and delights us. Think how one would feel to see 
it dashed against a wall or to see some rude instrument pushed into its tender flesh ; 
think of the gaping wounds and its little life cruelly crushed out. No mother could 
stand by and see such cruel things done. 
What is the difference ? Until we can make women see that the crimes are identical, 
we shall not stop abortion. Women have the key to the position. Abortion procured 218 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by the married woman is even more heinous than when induced by some frenzied girl 
who wishes to conceal her shame; if any defence could be raised, it might be for the 
victim of man's passion. 
What is the cause of this change of feeling on the subject ? Dr. Hicks lays the 
blame, as I do, to the literature with which we have been flooded. He says: 
' ' This tone of mind is the natural outcome of such teachings as are conveyed in 
works like 'The Fruits of Philosophy.' But I think I only speak from my own 
experience, that in many instances it has, in a measure, undermined the health and 
moral tone which was formerly the characteristic of the English women. At all events, 
I hold that a considerable amount of the disturbance and diseases of the uterus and its 
appendages results from the practical application of the modern so-called philosophy. 
But surely he must be a very clever philosopher who can, while interfering with the 
laws of nature, avoid the consequences of the disarrangements by his own contrivance; 
even if he could avoid bodily injury, he cannot stave off its moral or mental effects." 
I need not bring any further evidence as to the existence of this crime in modern 
times; we all know of it. I call upon the profession to make a united stand against it. 
We may be the saviours of our country. 
Our choice lies between two philosophies: on the one hand we have a philosophy 
which has been called by Sir Isaac Newton "sublime;" of which Rousseau said "that 
if it had been the invention of man, the invention would have been greater than that 
of the greatest heroes." A philosophy which has stood the test of time and been 
accepted by the greatest minds of our own and past ages-a philosophy which teaches 
us a morality conducive to the best interests of the individual, the family, society. It 
is the old revelation to man. On the other hand we are offered a philosophy which 
lowers and degrades, and is of the earth earthy, and which, as we know, too frequently 
ends in crime. We are offered for the philosophy of the Scriptures and the Gospels 
the newer philosophy of the sponge, the tampon and the vaginal douche, of which 
these are the fruits. The choice is before you. 
THE NATIVE TREATMENT OF DISEASE IN SYRIA. 
LE TRAITEMENT NATIF DES MALADIES EN SYRIE. 
DIE BEHANDLUNG DER KRANKHEITEN UNTER DEN EINGEBORENEN SYRIENS. 
BY THOMAS W. KAY, M. D., 
Of Beyrout, Turkey. 
It is my object in this paper to present to you the people of this country from a 
medical standpoint, by giving a general idea of the ways in which they treat disease. 
By Syria is to be understood that section of country situated on the eastern shore 
of the Mediterranean, and extending from about Acre on the south to the Taurus 
mountains on the north, or that included between the parallels 32° 5Z and 36° 5Z north 
latitude. 
This country, containing a population of some two millions, extends eastward and 
ends in the Syrian desert. Though inhabited by a people whose ancestors were, and SECTION XVI-MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
219 
whose religions are, widely different, yet their treatment of disease is generally uniform. 
Nor must it be supposed that the treatment pursued in Syria differs essentially from 
that of Palestine and Asia Minor, for such is not the case, there being a greater- or less 
uniformity in the manners and customs of all the inhabitants of Turkey in Europe or 
in Asia, and also of those inhabiting those northern countries of Africa which border on 
the Mediterranean. 
The medical and surgical needs of this people are supplied by not more than one 
hundred and fifty physicians and surgeons, many of whom are American, English, 
French and German, but most are natives who have been educated in the government 
colleges at Cairo and Constantinople, or by the Mission Colleges at Beirût and Aintab. 
Thus we see not more than one physician to every thirteen thousand or fourteen thou- 
sand persons, were they equally distributed ; but it is even worse than this, for most of 
these physicians are located in the large cities, with the exception of the graduates of 
Constantinople, who have charge of the medical department of the Turkish army. In 
consequence, there are thousands of people without any educated physician to minister 
to their wants. It is this class of people to which I wish to call your attention. They 
are probably more subject to disease, on the whole, than the inhabitants of the cities, 
for though they have purer air, yet their food is of the coarsest kind ; they are poorly 
protected from the elements, and their houses are anything but sanitary, man and the 
lower animals frequently inhabiting the same dwelling and the same room. 
This need for medical attention among such a large class has caused many native 
"hakims," or doctors, to appear, whose sole claim to the healing art may rest upon 
inheritance, upon the fact of their possessing the whole or a part of some medical book, 
or upon age, position or experience ; and not infrequently we see them treating disease 
in accordance with some scientific principles, though they are arrived at by a far different 
train of reasoning from that used by educated physicians. 
In many cases even these physicians are absent, so the heads of the family have to 
do what they can, depending on popular beliefs taught by the hakims. 
The medical books that I have mentioned are in Arabic, most of them being trans- 
lated from the Greek, or, at least, setting forth the doctrines of the old Greek school. 
In many cases these books are so vague in their teachings that nothing can be under- 
stood ; e. y., medicines are said to act in four ways, viz., materially, actively, consti- 
tutionally and energetically, and in not a few cases some spiritual efficiency is ascribed 
to the drugs. 
The first book in the Arabic materia medica was written by Mohammed, son of 
Zacharia Er-Râzi, who was followed by Ibu-Sina (Avicenna), Abu-Hanifah, Yiurgius- 
Ibu-Yuhanna, Ibu-il-Bitar, and others. 
Some of their best known works are Munhaji-el-Bayän, Ghayet-el-Itquan, Rahmet, 
Quanûn-Ibu-Sina, and Mufradât-el-Hashayish. 
A firm belief, among the natives, in spirits of all kinds exists, and the same being 
taught by their medical books has caused the treatment of all diseases to take a spiritual 
turn, and many look upon medicine as wholly secondary. This has given rise to what 
may be termed the faith-cure school, who claim, by their prayers to saints, to effect 
marvelous cures. There is a saint for nearly every disease. Saint Kushaia cures 
insanity and hysterical affections, but the patient must be confined in a dark cave, 
with an iron ring about the neck, while bread and water is all that is allowed, for food. 
Saint Adna is the patron saint of the ear, while Saint Nahia looks after the eye. 
Should a patient fail to be cured, it is a sign that he has offended the saint in some 
way, or it may be that he is not a favorite. 
Closely connected with this kind of treatment are many rites not of a religious 
nature. The atlas bone of a wolf is worn around the neck of children subject to croup, 220 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to prevent paroxysms. In infantile convulsions a sword must be drawn across the 
forehead and laid by the side of the little sufferer till the paroxysm is broken. The 
child is supposed to be in a state of ecstasy, and must not be touched with the hands, 
nor should the sword be touched before the child recovers, for fear of the transmission 
of the affection to others. 
Besides these two classes of doctors may be mentioned the bone-setters. It is con- 
ceded by all that the best bone-setters are found among the sheep- and goat-herds. They 
frequently have to set broken limbs among their flocks, and becoming quite expert at 
the business, apply the knowledge thus gained to the relief of their fellow-beings. For- 
merly, traveling surgeons used to come from Algeria, but being so poorly patronized, they 
have ceased their visits. 
The ideas held by the natives on the pathology of disease are crude, antiquated and 
confused. They speak of the sanguineous, phlegmatic, bilious and melancholic temper- 
aments; the simple and compound organs and humors of the body; the animal, cor- 
poreal and mental powers of life; the heart and the spirit, which are the hottest parts of 
the body, and the skin, which is the coldest part of the body. These are all affected 
more or less by the earth, air, climate, water, age, sex, emotions, etc., producing health 
or disease according as equilibrium is kept up among the various factors. Diseases, foods, 
and medicines are divided into two classes, viz., cold and hot, or dry and moist, and in 
all cases they carry out the old allopathic practice, on the principle of contraries curing. 
Thus we see hot diseases treated by cold medicines, and vice versa. Most painful dis- 
eases are supposed to be due to gas in some part of the body, and are classed with the 
cold diseases. These must be treated by aromatics and carminatives, or by saccharine 
and starchy foods, which are classified as hot. Animal food cools, and thus we find that 
it is never used in rheumatism, a cold disease. 
To attempt a description of their modes of treatment in all diseases cannot be thought 
of in a paper of this length, nor can they be classified scientifically, so it only remains 
to treat them as may appear to be most instructive. 
Exanthematous diseases are found at all seasons of the year, and variola is never 
absent; in fact, the people have become so accustomed to its presence that they have 
little fear of it, though the percentage of deaths from it is large. The only exception 
to the contagious diseases is scarlatina, which, so far as I am able to learn, has never 
appeared in this country except as sporadic cases, which were imported and failed to 
spread. The treatment of all exanthemata is alike, the patient being confined to a 
closed room and kept as warm as possible, while all fresh air is excluded, so that the 
disease may "ripen" rapidly. In order to destroy the germs of the disease, branches 
of the myrtus communis are hung about the room, while the floor is sprinkled with 
camphor, aqua rosæ, and vinegar; and cow dung with the skins of pomegranates are 
burned in front of the door. 
An interesting fact to note here is the firm belief in the contagiousness of consump- 
tion. This belief has been held for many years, and it is so strong that after a death 
from this cause, all the clothing and furniture used by the deceased during the sickness 
are gotten rid of, and the room in which the death took place is left vacant for a longer 
or a shorter period. 
Blood-letting is practiced in all acute inflammatory diseases, usually before the fourth 
day, with the idea of cutting short the malady by drawing away the germs with the 
blood. An exception to this rule, however, must be observed in the treatment of inflam- 
matory affections of the respiratory organs. Here the humors of the chest are said to 
be thick, and the administration of expectorants or emetics is considered better. Should 
the symptoms point toward the alimentary canal, emetics and purgatives are adminis- 
tered. Their favorite emetic is ant. et pot. tart., which is given in large doses, but SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
221 
infusion of tobacco or a strong solution of salt in water is not unfrequently employed. 
The most common laxatives and purgatives used are confect, rosæ, tamarindus, sennæ 
fol., magnes, sulphat., cassia fistula, colocynthis, scammonium, aloes, and the juice of 
a species of euphorbia. 
When a fever has become well established, warm drinks of a soothing character are 
about the only treatment. Some of these drinks are hot infusions of flores tiliæ 
Europææ, flor, viclæ odoratæ, malva rotundifolia, eryngium creticum, micromeria thea 
Sinensis, adiantum capillus veneris, flor, sambuci nig., fruct. ceratoniæ siliquæ, 
fruct. zizyph. vulgaris, erythræa ramosissima, etc., which are sweetened by the addi- 
tion of dried pears, tamarinds, raisins or figs. For the cerebral symptoms attending 
fevers or for inflammatory affections of the meninges a pumpkin is cut open and made 
to fit the head as a cap. Should the vital powers be very much depressed, the patient 
can be wrapped up in the skin removed from a freshly-killed sheep. This treatment is 
also used for all cases of severe shock following accidents. 
Some curious ideas are entertained concerning sick persons being visited. Should 
two persons be sick in the same room it matters not, but under no conditions should 
one sick person be allowed to enter the room of another, nor is it considered safe for a 
patient to be visited by a woman who is having her menses. Blood-letting is also 
practiced in local troubles, and the point from which the blood is drawn is supposed to 
affect seriously the subsequent course of the disease. The blood must be drawn from 
the hand for the head, and from the foot for the womb. 
A favorite plan of treatment for icterus is cutting the frænum linguæ. Cups and 
leeches are frequently used in place of the lancet, and their most common use is prob- 
ably in eye and ear affections, the favorite seat of application being behind the ear. 
And now I will call your attention to their most common and most potent agent in 
the treatment of disease. It is the actual cautery or one of its modifications. Its use 
is so common that it is rare to find a native who does not bear its marks. Red-hot 
nails, and knitting needles, spoons filled with hot ashes, and pieces of rope dipped in 
boiling oil, are all variously used in the different diseases. Diseases of the stomach, 
liver, or spleen, tonsillitis and diphtheria, inflammations of the respiratory organs, boils, 
abscesses, hernia, articular rheumatism, the many forms of paralysis, and many other 
diseases are cauterized ad libitum. In most of these the cautery is applied directly 
over the affected part, but in gastric troubles a painful spot is sought over the spinal 
column, and it is here that the cautery is applied. In hernia a radical cure is occasion- 
ally effected by this method. In hemiplegia the cautery is applied over the parietal 
bones or at the base of the skull, extending for a distance of six or seven inches down 
the spine. Poultices may be substituted for the cautery in milder troubles, and the 
most common ingredient of these is fresh cow dung, which may be mixed with flax- 
seed, bran, bread and oil, mal va or some other native plant. In some cases a pigeon is 
split open down the back and immediately applied to the part. This is especially used 
in exostoses. The use of the cautery in articular rheumatism has been mentioned, but 
more frequently the skin is scarified and warm applications made. The Turkish bath 
is also used, and the hot sulphur baths at Tiberias have become quite a place of resort 
for all rheumatics in the surrounding country. 
Hot baths are also used in syphilis, but the treatment resolves itself chiefly into 
dietetic and medicinal. Spices and condiments of all kinds are forbidden for forty days 
or more, while the patient eats only unleavened bread, which is frequently made with 
an infusion of sarsaparilla, and he drinks milk or water. Iodide of potash is some- 
times used in the late stages of the disease, but more frequently fumigations of cup. 
sulph., fol. oleæ Europææ, fol. cupressi, fol. lansoniæ inermis, and either hyd. chl. 
mit., or hyd. sulphuret, mixed by means of saliva, arc employed. 222 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A strict diet is also enforced in gonorrhoea, while the ashes of date seed are admin- 
istered internally. 
Malarial diseases are common along watercourses, and are effectively treated by 
decoctions of the root bark of the salix, of the root bark of the populus alba, and of 
fol. oleæ Europææ. 
For diarrhoea and dysentery they use infusions of many native aromatic umbelli- 
ferous plants, to which opium may or may not be added, and in cases of colic or intes- 
tinal obstruction, tobacco smoke is introduced into the rectum by means of the long 
stem of a smoking pipe. This mode of treatment is also used for strangulated hernia, 
but taxis, cold applications and holding the patient up by the feet are more common. 
To resuscitate the drowned, inversion of the body is also used, but more frequently 
they lay the body on its back and turn the heels over the head, thus compressing the 
thorax, while the position of the body favors the flow of water from the lungs. 
Menstrual disorders are not very common as compared with the more civilized 
countries, and ovarian tumors are almost unknown. When amenorrhoea exists it is 
treated by purgatives and decoctions of spices and aromatics ; also, the adiantum 
capillus veneris is a favorite remedy. 
As diuretics in the suppression of urine or in dropsical effusions they use the root of 
the arundo donax, of the pistacia terebinthus, or of petroselinum sativum, also fol. 
thym, vulgaris, and stigmata of yellow zea mays. A different form of diuretic is 
used to prevent hydrophobia after a person has been bitten. It is an infusion made 
from the cetonia aurata, a kind of beetle, which, they. say, makes the patient pass 
wasps and hornets in his urine, and if he can be kept awake so as to see the sun rise 
on the fortieth morning after the bite, he is considered safe. The wound must also be 
cauterized and the dog killed. 
In poisonous wounds, inflicted by scorpions and serpents, the limb is bandaged above 
the bite, the wound freely incised, the blood sucked out and the cautery applied. 
Finally, the person is made to drink an infusion of eryngium creticum. 
Leprosy is a common disease of this country, and the state of the leper is hard, for, 
as the disease is considered contagious, the leper is exiled from friends and village. All 
forms of treatment have demonstrated themselves to the natives as useless, except 
poultices of the roots of cyclamen heteræfolium, which, they claim, are of service in 
ameliorating the disease. 
Intestinal parasites of all kinds are very common, with exception of the tænia 
solium, the tænia mediocanellata being most common. This fact is due to the small 
consumption of hog meat, none but Christians using it. To get rid of these, they give 
soap, emulsion of pumpkin seeds or decoction of cort. rad. punicæ granati. To remove 
the oxyuris vermicularis they pass a piece of the peritoneum of a sheep up the rectum, 
and when removed several hours after, the worms are said to be attached to it. 
Parasitic skin diseases of both animal and vegetable origin are as common as those 
of intestinal parasites. Favus is treated by cutting the hair and applying a mixture of 
galls and oil to the head, or for this may be substituted hot pitch and hot olive oil. 
A creasotic substance is also applied to the shaven head. This substance is obtained 
by sealing up wheat in a porous earthen vessel, burying it just below the surface of the 
ground, and keeping a fire burning over it for several hours. For scabies, a favorite 
application is composed of hyd. bichlor., cup. sulph., sulph. subi., acid, citricum, 
semen, sesam. orient, and ol. olivæ. 
Probably no people are more liable to eye diseases than the Syrians, and, strange to 
say, their remedies are comparatively few. Pannus is sometimes markedly benefited 
by the use of dry collyria, composed chiefly of ant. oxid. or zinc. oxid. 
For trachoma, the retrotarsal conjunctival fold is hooked up on small hooks and SECTION XVI MEDICAL CLIMATOLOGY AND DEMOGRAPHY. 
223 
excised, causing sometimes marked benefit. Trichiasis is treated by pinching up a 
piece of the superior palpebral integument and fastening it between clamps composed 
of thin pieces of reed, after which the projecting fold of skin is removed. When suffi- 
cient time has been allowed to prevent bleeding, the clamps are removed and the 
wound allowed to heal by granulation. 
The only treatment for cataract is by couching, this being done by common sewing- 
needles fitted into handles. The operation does not differ essentially from that described in 
our text-books, but the prognosis is not very good, only moderate success being attained. 
The removal of the uvula as a cure or as a preventive of throat trouble is a common 
practice, as is also the rupture of the tonsils. The former operation is done with scissors, 
the latter by passing the thumbs of both hands into the mouth, and as the fingers are 
placed behind the angles of the lower maxilla, the thumbs are placed over the tonsils, 
and sufficient force applied to disorganize the structure of the gland. Wounds, whether 
incised, punctured or lacerated, are treated alike. Cobwebs, ground coffee, dry earth, 
soot and wine are one or all applied so as to arrest the hemorrhage, after which pitch, 
resin, wax and olive oil are melted together and poured into the wound, it having been 
previously cleansed from the styptic substances. Granulating wounds are treated by 
various ointments composed of wax and olive oil, to which is added the lisæa Syriaca, 
the saponaria officinalis or resin, pistaciæ terebinth. 
Burns are treated by dusting burned goat's hair or powdered wood charcoal over 
the denuded surface. 
Circumcision is practiced by all except the Christians. The operation is done by 
drawing the prepuce well out with the fingers or a pair of forceps, and removing it with 
one cut of a razor. No stitches are used after the operation, but an astringent powder 
is dusted over the surface, and the wound allowed to heal by granulation. 
Luxations of all kinds, except those of the lower maxilla, are comparatively rare. 
Having little or no knowledge of the anatomy of the parts, damage is frequently caused 
by the great force applied in reduction, and not unfrequently it remains unreduced. 
Luxation of the lower jaw is supposed to be due to some evil spirit, so the sufferer has 
to go to the head religious man of the village, who essays to expel the spirit by taking 
off his shoe and striking the patient sharply with it on either side of the jaw. Reduc- 
tion is said to be the rule after this treatment. 
Fractures are treated for five days by cold applications, after which, if situated in 
one of the limbs, the fractured part is surrounded with small, flat pieces of reeds, and 
the whole covered by a mixture of barley flour and white of egg, which hardens and 
makes an immovable apparatus. This is usually applied very tightly, and is, in some 
cases, followed by disastrous results. Should amputation of a limb be necessary, it is 
performed by first binding the limb tightly above the seat of injury or disease with a 
cord or a piece of strong cloth, after which the limb is removed by means of a razor 
and a common saw, no flaps being formed and no ligatures being used, but the stump 
is immersed in a vessel of boiling oil or pitch. Recovery is said to be the rule. 
Vesical calculi are common, and especially among the poorer classes, and apparently 
in the limestone districts. The operation for this, as regards life, is very successful, 
though urinary fistulæ are a frequent result. The only instrument used is a razor, or 
some other sort of cutting instrument. After the patient has been put into the lithot- 
omy position, the operator passes his left index finger well up the rectum, while the 
fingers of the right hand are pressed deeply into the hypogastric region, so that the 
stone can be brought between the left index finger and the neck of the bladder. The 
right hand is now withdrawn, and the stone is made to force well out the perineum, 
when a bold cut is made in the median line at the most prominent part and down to 
the stone. If the incision is not large enough, it is enlarged till the stone can be forced NINTH INTERNATIONAL MEDICAL CONGRESS. 
224 
out by the finger. Fortunately, the operation lasts only a few minutes, as the use of 
anæsthetics is not known by the natives. 
In closing, I wish to express my indebtedness for many new facts, and corroboration 
of my own observations, to the following gentlemen: Drs. Geo. E. Post, W. T. Van 
Dyck and Habib Tubbaji, of Beyrout ; Bishârah Manassah, of Brumânah ; Jurgius 
Kefrfini, of Hums; S. Baddoor, of Batroun; Yûsuf Abu Suleiman, of Zahleh; Shakir 
U1 Quirm, of Hebron, and Elias Saba, of Es-Salt. 
After a vote of thanks to the President, the Section, at 5.45 P.M., adjourned 
sme die. 
The non-attendance of a stenographic reporter and the neglect by speakers, especially during the 
later sessions, to comply with the request to hand the Secretary memoranda of their remarks, have made 
it impossible for him to preserve a full record, in the minutes, of the interesting discussions which 
occupied the morning hours. 
Charles Denison, m.d., 
Secretary. SECTION XVII-PSYCHOLOGICAL MEDICINE AND NERVOUS 
DISEASES. 
OFFICERS. 
President: JUDSON B. ANDREWS, A.M., M.D., Buffalo, N. Y. 
VICE-PRESIDENTS. 
Prof. Rudolf Arndt, m.d., Griefswald, Germany. 
Wm. Wilberforce Baldwin, m. d., Florence, 
Italy. 
Prof. D. Binswanger, m.d., Jena, Germany. 
George Fielding Blandford, m. d., f. r. c. p., 
London, England. 
Sir James Crichton Browne, m.d., ll.d., f.r.s., 
London, England. 
Peter Bryce, m.d., Tuscaloosa, Ala. 
R. H. Chase, a.m., m.d., Norristown, Pa. 
Daniel Clark, m.d., Toronto, Canada. 
J. Langdon Down, m.d., f. r. c. p., London, 
England. 
Edward East, m.d., m. r. c. s., l. s. a., London, 
England. 
Prof. A. Eulenberg, m.d., Berlin, Prussia. 
Orpheus Evarts, m.d., College Hill, Ohio. 
Theodore W. Fisher, m.d., Boston, Mass. 
Prof. August Foret, m.d., Zurich, Switzerland. 
Prof. Luigi Frigerio, m.d., Alexandria, Italy. 
W. W. Godding, m.d., Washington, D. C. 
Prof. E. T. Girtstrom, m.d., Hernosands, Sweden. 
Eugene Grissom, m.d., ll.d., Raleigh, N. C. 
John C. Hall, m.d., Philadelphia, Pa. 
Prof. V. Hinze, m.d., St. Petersburg, Russia. 
Prof. E. Hitzig, m.d., Halle, Prussia. 
Prof. E. A. Homen, m.d., Hensingfors, Finland. 
C. H. Hughes, m.d., St. Louis, Mo. 
H. M. Hurd, a.m., m.d., Pontiac, Mich. 
Hans Laehr, m.d., Schweizerhof, Germany. 
Megalhaes Lemos, m.d., Oporto, Portugal. 
H. Rooke Ley, m. d., m. r. c. s., Manchester, 
England. 
William Julius Mickle, m.d., f.r.c.p., London, 
England. 
Arthur Mitchell, m.d., ll. d., Edinburgh, 
Scotland. 
Prof. 0. Müller, m.d., Blankenburg, Germany. 
C. H. Nichols, m.d., New York City, N. Y. 
M. le Dr. A. Pitres, Bordeaux, France. 
M. le Dr. Emanuel Regis, Castel d'Andorte, 
France. 
Prof. M. Rosenthal, m.d. , Vienna, Austria. 
Geo. H. Savage, m.d., f.r.c.p., London, England. 
S. S. Schultz, m.d., Danville, Pa. 
Seymour J. Sharkey, m.d., London, England. 
E. C. Spitzka, m.d., New York City, N. Y. 
Henry P. Stearns, a.m., m.d., Hartford, Conn. 
Prof. Valdemar Steenberg, m. d., Roskilde, 
Denmark. 
Prof. E. Tebaldi, m.d., Padua, Italy. 
John Batty Tuke, m.d., f.r.c.p., Edinburgh, 
Scotland. 
D. Hack Tuke, m.d., f.r.c.p., London, England. 
Walter H. Walshe, m. d., f. r. c. p., London, 
England. 
Prof. H. A. Wildermuth, m. d., Wurtemberg, 
Germany. 
Prof. L. Wille, m.d., Basel, Switzerland. 
SECRETARIES. 
G. A. Blumer, m.d., Utica, N. Y. | E. D. Ferguson, m.d., Troy, N. Y, 
Prof. E. Mendel, m.d., Berlin, Prussia. 
COUNCIL. 
E. N. Brush, m.d., Philadelphia, Pa. 
Floyd S. Crego, m.d., Buffalo, N. Y. 
Richard Dewey, m.d., Kankakee, Ill. 
Gustavus Eliot, a.m., m.d., New Haven, Conn. 
G. Stanley Hall, a.m., m.d., Baltimore, Md. 
Walter Hay, m.d., Chicago, Ill. 
Gershom II. Hill, m.d., Independence, Iowa. 
Harold N. Moyer, m.d., Chicago, Ill. 
C. F. MacDonald, m.d., Auburn, N Y. 
R. J. Patterson, m.d., Batavia, Ill. 
P. M. Wise, m.d., Willard, N. Y. 
Philip Zenner, m.d , Cincinnati, Ohio. 
Vol V-15 
225 226 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met at the Congregational Church on Monday, September 5th, at 
3 p.m. The President, Judson B. Andrews, a.m., m.d., delivered the following 
address :- 
THE DISTRIBUTION AND CARE OF THE INSANE IN THE UNITED 
STATES. 
LA RÉPARTITION ET LE SOIN DES ALIENES DANS LES ÉTATS-UNIS. 
ÜBER DIE VERTHEILUNG UND VERSORGUNG DER IRREN IN DEN VEREINIGTEN 
STAATEN. 
Gentlemen :-The pleasant duty devolves upon me to welcome you to the ses- 
sions of this Section of the Ninth International Medical Congress, and invite you to 
participate in the exercises of the occasion. It is a hearty welcome I give you, 
though clouded with sadness as we mourn the absence of one who was chosen to 
stand in this place and receive the honors of this position. 
To many of us the death of Dr. Gray is a personal grief, and to all a cause of sad 
regret. This is not the time for any extended remarks or for a eulogy upon his life 
and character ; but I should be recreant to my feelings did I fail to place on record 
an expression of appreciation of his services, and the loss sustained by his death. 
H is life was devoted to the care of the insane and to the advancement of the specialty 
of his choice. The wide reputation he gained in both fields of labor furnishes ample 
proof of the success of his life work. 
The death of such a man is a grievous loss to humanity, in whose behalf he 
wrought ; to the profession he honored, and to the specialty he loved. The Section 
lias lost the benefit of the wise direction and judicious counsel of one who by experi- 
ence and ability was eminently fitted for the position he held. A great man, a rep- 
resentative leader in American psychiatry, has fallen. 
DISTRIBUTION AND CARE OF THE INSANE IN THE UNITED STATES. 
A brief statement regarding the distribution and care of the insane in the United 
States will, we think, prove of interest to all, and especially to the residents of other 
countries, who are our guests upon this occasion. To present in the most concise 
manner the statistics of the insane, and the methods employed in their care, is the 
simple purpose of this paper. 
As there is no annual enumeration of the insane in the United States, we are 
compelled to refer to the last decennial census for the record of numbers. This shows 
that in 1880, of a total population of 50,155,000, there were 91,997 insane, a pro- 
portion of one insane person to every 545 of the inhabitants. Considering the dis- 
tribution of the insane as to locality or divisions of the country, the general principle 
is established that the amount of insanity bears a close relation to the duration of the SECTION XVII-PSYCHOLOGICAL MEDICINE 
227 
social and governmental life of the people. This is well illustrated in the arrange- 
ment of the States by sections.* 
Dividing the country into two great belts of north and South, there is an almost 
regular proportionate decrease of lunacy as we leave the older settled parts of the 
country along the Atlantic coast, till we reach the extreme western slope. 
In the northern belt, the New England States take the lead with one insane per- 
son to every 359 of the inhabitants. This decreases till we reach the newer States 
and Territories, with one insane person to every 1263 inhabitants. In the southern 
belt we have the seaboard States with one insane person to every 610 of the inhabit- 
ants, and the extreme southern States with one insane person to every 935 of the 
population. These figures emphasize the statement that the pioneers of our newer 
settlements are the more hardy and vigorous citizens, and that the feeble and depen- 
dent are left in their former homes, to enjoy the comforts of the hospitals and asylums, 
which are the special growth of the older civilization. 
Further divisions of the total insane population of the country are naturally made 
by nationalities and by race and color. The native whites number 36,828,698, with 
59,581 insane, or a proportion of one insane person to every 618 of the inhabitants; 
while the foreign whites, with 6,574,330, furnish 26,259 insane, or one insane person 
to every 250. The causes productive of the larger percentage of insanity in our 
immigrant population do not at present concern us ; we but note the fact of the 
mixed character of our people as in marked contrast with the homogeneousness of 
other countries as represented in the great centres. New York is the first Irish city 
in the world, and Berlin and Hamburg are the only cities which contain as many 
Germans as our own metropolis. In London there is only one and six-tenths of one 
per cent, of the foreign element, and the same characteristics are observed in Paris, 
Berlin, Vienna, and the other European capitals.f The colored class of our popula- 
tion consists of negroes, Indians, Chinese and Japanese. Of the former there is a 
total of 6,580,735, with 5996 insane, or one insane person to every 1097. In the 
negro race the proportionate increase of insanity is far greater than in any other 
division of the population. From 1870 to 1880 there was increase in the census of 
the colored race of 34.85 per cent., while for the same period there was an increase 
of 258 per cent, of the insane. * This large multiplication has occurred since eman- 
cipation from slavery and the consequent changes in conditions and life. The causes 
are briefly told : enlarged freedom, too often ending in license ; excessive use of stimu- 
lants ; excitement of the emotions, already unduly developed ; the unaccustomed 
strife for means of subsistence ; educational strain and poverty. The total census of 
the other colored races is 172,020, with 105 insane, or one insane person to every 
1638. The small percentage of insane among the aborigines and Chinese is fully in 
accord with the observations of writers upon the causes productive of mental disease. 
There is much less of the refinement of civilization ; less competition and struggle 
for place, power, or wealth, and as a consequence, less tendency to mental deterio- 
ration. 
As a supplement to these figures from returns of the tenth census, I have 
prepared the appended table, which gives the number of insane in the asylums of 
the country in 1880, and at the close of the last fiscal year, and also the number of 
medical officers. The table contains all of the more important institutions in exist- 
» Prof. A. 0. Wright, of Wisconsin. "Proceedings of Conference of Charities and Correc- 
tions." f See Andover Review, 1887. 
J Roberts, of North Carolina. "Report of Eastern Asylum, 1883." 228 
NINTH INTERNATIONAL MEDICAL CONGRESS. * 
ence at that time, as well as those erected since that date. The comparison shows 
the increase in number under care during the six intervening years. One hundred 
and twenty-one asylums are represented in this list, and of these 106 existed in 1880 ; 
while fifteen State institutions have been added since. In 1880 there were in the 
asylums here enumerated 39,093 patients, and in 1886 the number had increased to a 
total of 61,411 patients, making a gain in accommodation of 22,318. Of this num- 
ber the new institutions contain 5890, leaving an increase of accommodation in the 
older asylums of 16,428. The total increase is 55 per cent, of the number provided 
for in 1880, or an annual increase of more than nine per cent. Should this continue 
during the rest of the decade there will be more than 75,000 patients in the asylums 
of the country in 1890, at the time of the next decennial census. It is impossible, 
with any degree of accuracy, to estimate the whole number of the insane at that- 
time, but it is probable that this large increase of accommodation will lead to a 
decrease in the number of the insane in private care as compared with the figures of 
the last census. To care for this large number of patients there are 377 medical 
officers, or a proportion of one physician to every 160 patients; and if the small pri- 
vate asylums were included it would swell the number to 400, or one to every 150 
patients. 
The methods employed in the care of this large dependent class are an interest- 
ing subject for study, and to these your attention is next directed. These methods 
can only be enumerated rather than described in full detail in the short time 
allotted. 
It must be borne in mind that in this country there is no central authority in 
lunacy matters, and that all of our thirty-eight States and ten Territories are free to 
regulate their own internal affairs without supervision from the general government. 
This gives the greatest diversity to lunacy regulations, in respect to the law of com- 
mitment, and the organization and management of asylums, with, however, that 
agreement which the purpose to be accomplished, the care of the insane, necessarily 
produces. 
The institutions are varied in name and character according to the power which 
organizes and controls them. They are respectively State, county, municipal, private 
and incorporated asylums. The latter class consist of the insane departments of some 
of the old established general hospitals. The State asylums are under the charge of 
boards of trustees or managers, who report directly to the legislature which creates 
them. The county and municipal asylums are controlled by committees appointed 
by the county or city officials, while the incorporated institutions are responsible to 
their several hospital boards. Additional supervision is provided in the State of New 
York by the appointment of a commissioner in lunacy, whose powers correspond 
with those of the English commission. In several of the States visitorial and some- 
times supervisory power is conferred upon the State Board of Charities, but in the 
greater number there is no authority intervening between the managers or trustees 
and the legislature. 
State institutions now exist in all of the States of the Union except two,* and pro- 
vide accommodation for the larger number of patients that are under public charge. 
Separate provision is made for the convict and criminal insane in two States, New 
* Delaware and Vermont. The insane of the former are sent to the institutions of some other 
State, while those from Vermont are cared for in the private asylum at Brattleboro. The Terri- 
tories of Arizona, New Mexico and Wyoming contract with the asylums of neighboring States for 
the care of their insane. SECTION XVII PSYCHOLOGICAL MEDICINE. 
229 
York and Michigan, an example which will in time be followed in the other more 
populous States. 
The asylums* generally receive all classes of the insane, but in the States of Massa- 
chusetts, Rhode Island, New York and California, the policy of separating the 
acute and chronic insane has been adopted. The Willard Asylum, in the State of 
New York, was the first one organized for the special care of the chronic class, and 
has now a population of nearly 2000 patients, taken largely from the county re- 
ceptacles. 
Although the theory that the insane are the wards of the State, and that it is the 
duty of the State to provide for all of its insane, has been adopted throughout the 
Union, and the people have supplied the money with a generous and even prodigal 
hand, there are few of the States which have kept pace in the supply of accommoda- 
tion with the ever-increasing demand. This arises in part from the accumulation 
of chronic lunacy due to the prolongation of life from the better care and treatment 
of the insane, but more from the phenomenal growth of our population and the 
consequent increase of the number of the insane. However good the intentions, the 
growth of charitable institutions is proverbially slow and rarely equals the needs of 
the dependent class, even among the most generous and sympathetic people. 
Up to twenty years ago there was little diversity in the plans of asylums through- 
out the country. They were all constructed upon the compact linear design, introduced 
by the late Dr. Kirkbride, with which all are familiar, from its frequent reproduction. 
The first essential departure from this plan was made at the Willard Asylum in New 
York, where a system of separate structures was designed by the superintendent, 
Dr. Chapin. These were located in different parts of the large farm, in such relation 
to the central asylum buildings as to be within easy control of the administrative 
authority. 
A separate provision for the more able-bodied workers, and for those who required 
for their care the facilities of the hospital structure, was the first division made. This 
has since been extended by the erection of special buildings for the more feeble and 
helpless class of patients. This departure from the established usage provoked 
discussion and called forth prognostications of failure. Experience, however, proved 
the practicability of the plan, and familiarity with its details showed its advantages 
for the purposes for which it was originated. The principle of separate structures 
has been adopted and extended in other institutions, and divisions and subdivisions 
have been made until in some there are nearly as many separate buildings as there 
are classifications of patients. In carrying out of the plan to its legitimate conclusion 
we now have separate buildings for congregate dining halls, for bathing and other 
services. The latest hospital plan upon this segregate theory resembles a village 
with streets, sewered, lighted, lined with trees, and built up with neat and tasteful 
cottages. In all of these structures the resources of the architect have been invoked 
to give variety of form and to break up the monotony of former styles. 
Another departure from the compact linear plan is found in what may be called 
the congregate-segregate plan, in which the buildings, separate and complete, are 
joined by connecting fire-proof corridors. This combines to a great extent the 
* It should be understood that our remarks apply to the State asylums of the country, the 
method of care for the dependent insane which has the approval of the medical profession and 
the confidence of the public. Most of the criticisms made against our asylum system have origi- 
nated in the defects of county or municipal asylums, when other than strictly medical considera- 
tions have controlled their erection and conduct. 230 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
advantages of the close and segregate systems ; as it separates the buildings, gives 
the fullest opportunity for light and air, makes the classification more distinct, and 
still brings all within ready reach for administration and control. The plan is a 
flexible one and admits of indefinite expansion and of addition in various directions. 
Besides .new buildings upon the plans described there is great activity in the 
improvement of existing structures, by additions to the original buildings, or by the 
erection of others upon the grounds. The additions are mostly infirmary wards for 
the sick and feeble, and wards for the filthy and demented, or for the most disturbed 
and maniacal classes. All of the plans and arrangements give evidence of careful 
thought bestowed upon the subject, as well as of progressive views entertained of 
what is needed for convenience and care, and for the comfort of different classes of 
patients. The best type of these infirmary buildings consist of one, or at most of 
two stories. Exteriorly they are surrounded by broad verandas for exercise and 
protection from heat and storms. Interiorly, there are regular hospital wards with 
rooms for attendants, for friends visiting patients and for the seclusion and separa- 
tion of special cases. Every facility which the home, or general hospital can fur- 
nish, for the best medical care of patients, is provided in these asylum wards. 
The separate buildings for the quiet and demented class are usually of two 
stories, arranged with day rooms, dining and service rooms on the first floor, and 
sleeping apartments above. These generally consist of large associate dormitories, 
with a small number of single rooms for such patients as may suddenly become dis- 
turbed or violent. 
In a few instances, seaside and country residences have been prepared as homes 
for the convalescent, and for such as may be benefited by the change of air and 
removal from the asylum and its associations. Farm houses. already existing on 
asylum sites have been utilized for patients of the agricultural class whose surround- 
ings are thus made to approximate their former condition. The limit of variety as 
well as of simplicity and economy in asylum construction was reached when tents 
were occupied by patients during the summer months while waiting for the comple- 
tion of permanent buildings. They served a good purpose, and were said to be 
satisfactory for the temporary use of the patients assigned to them. 
As showing the probable direction of changes it is proposed by one of the State 
asylums to erect a series of buildings, as a colony, some miles from the hospital 
proper, where patients can be employed in cultivating land purchased for the pur- 
pose. The profits of labor thus employed in raising farm products it is believed will 
materially reduce the per capita cost of maintenance, and at the same time improve 
the health and increase the happiness of such patients as can be trusted with the 
enlarged freedom. 
Another proposed change is to attach to the present asylums for the acute insane, 
buildings erected at less cost and scattered about the grounds, for the chronic insane, 
thus bringing the two classes under the same management. When a case becomes 
chronic, it is to be transferred from the hospital proper to one of the cottages, where 
opportunity for occupation in agricultural or mechanical pursuits is provided. 
These changes in the construction and arrangements have been followed by others 
in the modes of heating and ventilation which accomplish the purposes with greater 
perfection and economy. Boilers adapted to extremely low steam pressure are 
taking the places of the former high-pressure boilers, and direct radiation is now 
employed in various apartments with the advantage of increased comfort and more 
ready control. The large blower fans which force air through conduits and base- 
ment passages have in many places been superseded by natural ventilation through SECTION XVII PSYCHOLOGICAL MEDICINE. 
231 
windows and open fireplaces, or by suction fans, which give a more direct and posi- 
tive current in the exit flues from the wards. By the use of these the whole volume 
of air in the building can be changed as often as three times an hour ; even in those 
having an air space of 4000 cubic feet per patient. Electricity is being introduced 
in the new asylums and many of the older ones are substituting it for gas for illumi- 
nation, from motives of safety, cleanliness and economy. In all directions, so far as 
relates to plans of construction and arrangements for the health and comfort of 
patients, there has been during the past few years marked progress in American 
asylums. This has resulted in economy of expenditure in the original structures, in 
increased facility for classification and in greater regard for the needs of the indi- 
vidual patient, which is the highest good attainable in asylum care. 
For the medical care and successful treatment of patients, the institutions of the 
country were never so well prepared as at present. A larger number of medical 
officers is provided and a higher standard of qualifications is sought, the effect of 
which is to reduce the influence of politics and favoritism in appointments. 
In the State of New York the enforcement of a civil service examination gives a 
guarantee of good medical attainments in the successful applicant. The teaching of 
psychology in the medical schools has largely increased the interest in the subject. It 
has directed the attention of many of the younger men to the specialty, and led them 
to seek the advantages offered in asylums for practical experience, and has made the 
general practitioner more competent for the duty of examiner in lunacy, now so gen- 
erally required by the laws for commitment to asylums. The knowledge thus acquired 
often enables him to make a diagnosis of the individual case and to form an intelli- 
gent opinion of the necessity of transfer to an asylum, or of the propriety of treat- 
ment at home, and in the latter case of conducting it correctly. The unparalleled 
progress in neurology, cerebral anatomy, physiology, pathology and localization of 
function has enlarged the horizon of our knowledge of disease and of the action of 
causes, and furnished a scientific and positive basis for treatment in many cases of 
insanity which before was unattainable, and has rendered possible those most brilliant 
operations in brain surgery by which epilepsy has been cured and brain tumors suc- 
cessfully located and removed. Insanity dependent upon disease of the reproductive 
system is yielding to the operation for the removal of ovaries, and oophorectomy is 
recognized as a legitimate mode of treatment, and castration, in appropriate cases, 
has now some able advocates. Electricity, for many years a plaything and experi- 
ment in the hands of physicians, is now being used with more intelligent knowledge 
of its powers and of the class of cases in which it may prove useful. Its handmaid, 
massage, less powerful and less mysterious, but not less practical, has gained a posi- 
tion of prominence in the treatment of insanity in many institutions for the insane. 
The experiments in mesmerism, mind reading and the faith cure have led to a closer 
investigation into the relation between mind and body, with a result of finding in 
expectant attention a valuable and legitimate help in the treatment of mental disease. 
In the strictly therapeutic treatment of insanity, the statement of Dr. Tuke in 
his notes on the insane in the United States : "I am afraid we have neither anything 
to teach nor to learn from each other in the therapeutics of insanity, " is as true to-day 
as when written. The advances in the discovery of new remedies, and improve- 
ments in the pharmacist's art, have been as readily received and subjected to the 
crucial test 6f experiment in the United States as in other countries. The large 
number of new drugs, new preparations, and active principles which have been pre- 
sented to the profession within the last few years have produced an embarrassment of 
riches in this field which has, we believe, had a good effect in practice. 232 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It has led to differentiation in the use of remedies and promoted greater accuracy 
in prescribing. With a closer study of symptoms there has been a more intelligent 
and rational employment of the remedy best adapted to the individual case. Another 
result has been a marked tendency to break up a pernicious routine of practice which 
had its origin in a more limited supply of remedies. This better knowledge of drugs 
and of the limitation of their use has reduced the amount given, and to-day less 
medicine is prescribed and more reliance placed on other remedial measures. 
In what may be called the moral as distinguished from the therapeutic treatment 
of insanity, there has been a great change of practice in the asylums of the country. 
The old-time prejudices have largely given way to the more intelligent and less con- 
servative methods of care. In this, as in hospital construction, the demands of the 
individual, as distinguished from the mass, receive more attention, and this is the 
key-note of progress. It is seen in every direction in which the care or the interests 
of the patient are involved. 
In the way of amusements there is the greatest variety, adapted to the tastes of 
the individual. In all the asylums the time, patience, and ingenuity of the officers 
are taxed to increase the means of relieving the tedium and monotony of life in 
the wards. In some institutions this is carried to the point of filling out every evening 
with some gathering of patients for instruction or pleasure. 
The occupation of patients fills a prominent place in treatment, in the estimation 
of all who have charge of our institutions, and one will find in the different asylums 
nearly all the methods of employment which have been found useful in other coun- 
tries. Here, as elsewhere, nothing equals the benefit of agricultural pursuits for 
men, and sewing, laundry and housework for women. But, for the large number of 
patients who are not accustomed to these forms of work, other means are made use 
of, as spinning, weaving, embroidery, drawing, painting, and fancy work. The cloth- 
ing and bedding for the house are made by patients, brushes, mattresses, rugs, and 
other household articles are manufactured, and in all departments of asylum work 
patients render willing assistance. 
Schools are being revived in American asylums as a means of occupation and 
moral treatment. Although not employed so generally, as in the Richmond asylum 
under the late Dr. Lalor and his successor, or formerly in the Utica asylum under 
Dr. Brigham, they are found a valuable addition to other remedial agencies. 
The benefit derived from systematic instruction in arousing attention, increasing 
mental strength, and diverting the mind from the various delusive ideas which con- 
trol it, renders a full return for the outlay of labor in conducting a school, and should 
lead to its introduction in all asylums. 
As showing the amount and variety of occupation among patients, we present 
from the report of the Buffalo State Asylum the table of work for the last current 
year. (See Appendix. ) This is but a repetition of what is done in other asylums, 
and is not presented as anything peculiar or unusual in amount or variety. Although 
the labor of patients has always been utilized, the real value of occupation as a 
remedial agent in the treatment of insanity, after the subsidence of the acute symp- 
toms, has not been appreciated until a comparatively recent date. It is, however, 
at the present time, receiving the attention which its importance demands. 
In tracing the influence of occupation we are compelled to note its fourfold effect : 
First, in the improvement of the general health and mental vigor of the patient ; 
second, in arresting tendencies to dementia ; third, in the reduction of violence and 
disturbance in the refractory wards, and lastly, in the decrease of mechanical 
restraint. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
233 
This introduces the vexed question which has been so often and thoroughly dis- 
cussed since the days of Conolly and Gardiner Hill. Of the former attitude of 
American alienists I need not speak. The world moves, and with it the views and 
practice of our profession regarding the use of mechanical restraint. While the 
non-restraint system has not become a universally accepted dictum, there is but a 
minimum amount of restraint employed, and then only under the personal super- 
vision of a medical officer. 
There are some American superintendents who have openly avowed their 
adherence to the absolute non-restraint system, and many who virtually practice it 
without being willing to proclaim themselves its advocates. The position of the 
profession in America, as I interpret it, is, that the employment of some form of 
mechanical restraint in certain cases is legitimate, and its members are unwilling to 
deprive themselves of its advantages, when in their deliberate judgment it is 
necessary or preferable to other modes of treatment in the individual case. While 
it is not ruled out by the tyranny of public or official opinion, which may overcome 
the judgment of the physician who is responsible for the proper care of the patient, 
it is only prescribed like any other medical or moral treatment. 
In American asylums seclusion is usually resorted to for short periods only, and 
during the paroxysms of excitement. It is controlled by strict rules and continued 
only under the positive direction of the medical authorities. 
The tendency in American institutions is toward enlarged freedom and liberty for 
the individual patient. This follows as a necessary sequence the general introduction 
of occupation for all who are able and can be induced to employ themselves in out- 
of-door work. It is further promoted by the now common practice of leaving the 
doors of some of the wards open during certain hours of the day, for the unrestricted 
egress of patients. This has met with favor, and has been successfully employed to 
a degree that could not have been anticipated, or even dreamed of as possible, a few 
years since. It has subverted the former idea that none of the insane could be 
trusted save when safely secured behind bolts and bars. This tendency is further 
shown in the granting of paroles, either general or restricted to the asylum grounds, 
to such patients as show sufficient self-control to inspire confidence in their ability to 
restrain themselves within the prescribed limits. 
Another evidence of enlarged freedom is shown in the change of feeling in regard 
to the necessity or even value of airing courts. In many of the newer asylums 
no provision is made for them and in others their use has been discontinued. Patients 
are sent out to walk or to spend their time under the care of attendants. The result 
is highly satisfactory, as the watchfulness and supervision exercised over them is in 
marked contrast to the carelessness and indifference engendered by the high barriers 
of the court-yard. The patients appreciate the greater liberty allowed, and efforts 
to escape are not more frequent or successful than under the former conditions. 
Those who have had experience with both systems could not be induced to place 
their patients within the confined limits of enclosures. In still another direction is 
increased liberty of action manifest. In the convalescent and more quiet wards 
the doors of the rooms are left unlocked at night. This gives free access to the 
service rooms of the wards, removes the feeling of close confinement, allays fears of 
danger from fire, and inspires confidence by the trust reposed. Although an experi- 
ment, after a trial of some months we are able to commend the change. 
Wherever the unpleasant and disagreeable features of restraint and confinement 
can be removed or alleviated the result is beneficial to the patient and to the medical 
officers. Liberty under proper discipline and restrictions, and not the license of 234 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
undisciplined and unrestricted freedom is to be advocated. Paroles for patients to 
visit their homes on trial are given in some institutions, but their use is not universal, 
nor indeed so frequent, as in other countries. This custom varies, as it depends 
entirely upon the laws -existing in different States, in some of which no provision has 
been made for the exercise of this power. 
In the management of asylums no subject is of more vital importance than the 
character of the attendants employed. A good corps of competent attendants, 
well qualified, and imbued with a proper spirit and interest in their work, will more 
than counterbalance defects of construction, or even minor errors of administration. 
How to obtain this desirable result has always been the study of superintendents of 
asylums. The low rate of wages necessarily paid in the public institutions compared 
with what can be earned in other vocations, the small chance of promotion, the strict 
discipline enforced, the trying character of the work, and the further fact that the 
experience gained is of but little value in any other position of life, all tend to make 
the tenure of place but temporary. Another powerful element operating in this 
direction is the fact that the entire absence of classes in America opens wide every 
avenue of employment to both sexes, and that every one aspires to better his or her 
condition in life. To overcome these difficulties in part an effort is being made in 
this country to instruct and train attendants for their duties, and thus give asylum 
work the prominence and position of a skilled vocation. After systematic training 
there is an increase of wages, which, with the advantages indicated, it is hoped will 
give greater permanency in place, and effect the desired improvement in the service. 
Spasmodic efforts to train attendants have been made from time to time in 
different localities, but it is only within the last three years, and in American 
asylums, that training schools have been established, which require a course of 
instruction, and grant, after a satisfactory examination, a diploma, setting forth the 
special fitness of the possessor for the position of attendant upon the insane. There 
are now a number of schools in full operation in connection -with asylums in different 
States, and in other institutions instruction is given, in a less formal manner, in the 
rules and regulations and in the duties and responsibilities of attendants. 
.Of the full benefits of this progressive step it is too early to speak; time and 
experience are needed for their development. It is not too much to say that the 
movement receives the unqualified praise of those in the best position to form an 
intelligent judgment. We believe there is no exaggeration in the predictions of Dr. 
Stephan Smith, the Commissioner in Lunacy of the State of New York, that 
" within a decade no attendants will be employedin the State who have not their 
certificates of graduation from a training school." This effort to improve the quali- 
fication of those in immediate attendance and care of patients promises great benefit 
to the insane and marks an era in progress. 
Since the establishment of training schools, the advisability of uniforming attend- 
ants has attracted more attention than ever before. The practice has been introduced 
to a limited extent, and wherever employed has met with favor. Its advantages are 
more marked in the case of women attendants, as it largely reduces the cost of 
clothing and prevents a tendency to display and the unnecessary expenditure of 
money. The uniform becomes a distinctive mark of position, and carries with it a 
degree of authority recognized by the patients and the community, and arouses 
a certain esprit de corps among the attendants themselves. It will, we think, 
win its place here, where distinctions of this character have not received general 
favor. The use of it in the public service and by private corporations is gradually 
overcoming the prejudice against it. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
235 
In the State of New York, attendants and all other employes in public asylums 
have been placed upon the civil service list and are subject to examination before a 
board organized for the purpose. This makes them State appointments and renders 
them entirely independent of political influence, both in appointment and continuance 
in place. An extension of this system would do away with the present evil existing 
in some States, which arises from the positions of attendants being considered 
places of patronage for the party in power, and would increase the efficiency of the 
service. 
In looking over the ground which we have thus cursorily traversed, the first 
thought which occurs to all, undoubtedly, is that nothing new or original is presented 
in this summary. This might have been expected, as the same problem is before us 
all, to care for and treat the same form of disease existing in the same type of humanity, 
and while the details may and do differ, the underlying principles and methods remain 
the same. The greatest credit we can claim is that we have not neglected to avail 
ourselves of the experience which time and labor have wrought out, and that we have 
applied it to the ever-changing conditions which exist among us. How well this has 
been done we leave you to judge, promising that, so far as you avail yourselves of the 
opportunity to visit the asylums of the country, you will cheerfully have accorded you 
every facility for forming an intelligent opinion. 
APPENDIX NO. I. 
The following is the list of new State Asylums organized since 1880 : - 
No. of Patients. 
Little Rock, Arkansas 369 
Jamestown, Dakota 136 
Blackfoot, Idaho 50 
Traverse City, Michigan 429 
Ionia, Michigan 95 
Meridian, Mississippi 213 
Reno, Nevada 161 
Binghamton, New York 936 
Buffalo, New York 398 
Goldsboro, North Carolina 169 
Morganton, North Carolina 307 
Norristown, Pennsylvania 1496 
Warren, Pennsylvania 658 
Knoxville, Tennessee 206 
Terrell, Texas 267 
Number of patients accommodated at the close of 
the fiscal year for 1886 5890 236 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
APPENDIX NO. II. 
NUMBER OF PATIENTS. 
Institutions. 
Census 
1880. 
Date of 
Last 
Report. 
Num her 
of Medical 
Officers. 
Institutions. 
Census 
1880. 
I Date of 
Last 
| Report. 
| Number 
of Medical 
1 Officers. 
Tuscaloosa, Ala 
373 
733 
3 
Totals brought forward 
20,371 
35,271 
204 
Little Rock, Ark 
369 
3 
Middletown, N. Y 
185 
411 
3 
Napa, Cal 
770 
1,436 
3 
Bloomingdale City, N. Y 
202 
272 
6 
Stockton, Cal 
1,081 
1,486 
3 
Ward's Island, New York City, 
1,149 
1,691 
*Pacific Asylum, Cal 
159 
159 
2 
N. Y 
12 
Hartford, Conn 
145 
134 
3 
Emigrant Asylum, N. Y 
114 
20 
1 
Cromwell, Conn 
5 
11 
1 
Hudson River Hospital, Pough- 
Middletown, Conn 
505 
1,146 
5 
keepsie, N. Y 
246 
425 
4 
Spring Hill, Conn 
15 
18 
1 
Erie County Asylum, Buffalo, 
270 
371 
Pueblo, Col 
34 
138 
1 
N. Y 
1 
Jamestown, Dakota 
136 
2 
Monroe Co. Asylum, Rochester, 
Yankton, Dakota 
28 
144 
2 
N. Y 
210 
258 
2 
Chattahooche, Florida 
76 
192 
2 
Onondaga County Asylum, 
Milledgeville, Ga 
626 
1,238 
5 
Syracuse, N. Y 
111 
114 
1 
Anna, Hl 
477 
634 
3 
Marshall Infirmary, Troy, N.Y. 
98 
86 
1 
Batavia, Hl 
17 
26 
2 
Queen's County, Asylum, N. 
Elgin, I'll 
513 
539 
3 
Y 
104 
115 
1 
Jacksonville, Ill 
620 
926 
4 
Utica, N. Y 
595 
574 
5 
Cook County Asylum, 111 
Kankakee, Ill 
470 
833 
4 
Sanford Hall, Flushing, N. Y.. 
32 
22 
1 
88 
1,515 
5 
Willard, N. Y 
1,513 
1,818 
8 
Indianapolis, Ind 
929 
1,587 
7 
Providence Asylum, Buffalo, 
150 
Independence, Iowa 
450 
694 
4 
N. Y 
90 
1 
Osawatomie, Kansas 
Mount Pleasant, Iowa 
197 
400 
3 
Blackwells' Island, New York 
454 
544 
4 
City, N. Y 
1,294 
1,709 
10 
Blackfoot, Idaho Ter 
50 
1 
Hart's Island City, N. Y 
301 
600 
3 
Topeka, Kas 
122 
5 8 
3 
Homœop. Hosp. City, N. Y 
150 
150 
1 
Anchorage, Ky 
377 
713 
3 
Randall's Island, New York 
126 
132 
Hopkinsville, Ky 
438 
576 
3 
City, N. Y 
3 
Lexington, Ky 
589 
599 
3 
Goldsboro, N. C 
169 
0 
Jackson, La 
210 
597 
2 
Morganton, N. C 
307 
2 
*New Orleans, La 
145 
145 
1 
Raleigh, N. C 
269 
248 
3 
Augusta, Maine 
403 
528 
3 
Longview, Carthage, Ohio 
637 
734 
3 
Catonsville, Md 
343 
418 
2 
Sanitarium, Cincinnati, Ohio... 
45 
54 
2 
Mt. Hope, Balto., Md 
352 
484 
2 
Cleveland, Ohio 
624 
625 
4 
Bay View, Md 
199 
250 
1 
N. W. Asylum, Toledo. O 
129 
125 
1 
Boston, Mass 
Essex Co. Receptacle, Mass 
169 
231 
4 
Columbus, O 
871 
904 
5 
59 
54 
1 
Dayton, Ohio 
583 
592 
4 
Danvers, Mass 
598 
763 
5 
Oxford Retreat, Ohio 
"262 
25 
0 
Northampton, Mass 
439 
491 
4 
Salem, Oregon 
437 
3 
Somerville (McLean), Mass 
155 
167 
3 
Danville, Petina 
454 
846 
4 
Taunton, Mass 
564 
663 
5 
Dixmont, Penna 
549 
587 
4 
Worcester, Mass., (Acute,) 
489 
758 
6 
Harrisburg, P<-nna 
413 
461 
5 
Worcester, Mass., (Chronic,) 
337 
398 
2 
Norristown, Penna 
Friends' Asylum, Philadelphia, 
1,496 
6 
Ionia, (Crim.) Mich 
95 
2 
Kalamazoo, Mich. 
658 
790 
5 
Penna 
90 
102 
2 
Pontiac, Mich 
410 
637 
5 
Penna. Hospital, Philadelphia, 
378 
Traverse City, Mich 
429 
4 
Penna 
370 
5 
Rochester, Minn 
82 
605 
3 
Phila. Hospital, Philadelphia, 
268 
St. Peter, Minn 
626 
874 
3 
Penna 
973 
3 
*Deer Lodge City, Mon. Ter 
44 
44 
1 
Warren, Penna 
658 
3 
Tewksbury, Mass 
226 
367 
2 
Butler Asylum, Providence, 
Jackson, Miss 
387 
417 
2 
R. I 
164 
168 
3 
Meridian, Miss 
213 
2 
Cranston, R. I 
228 
425 
2 
Fulton, Mo 
507 
552 
4 
Columbia, S. C 
420 
647 
3 
St. Joseph, Mo 
195 
397 
3 
Knoxville, Tenn 
206 
2 
St. Louis, Mo 
366 
523 
3 
Nashville, Tenn 
385 
402 
2 
*St. Vincent, Mo 
132 
132 
1 
Austin, Texas 
350 
594 
3 
Lincoln, Neb 
160 
374 
3 
Terrell, Texas 
454 
267 
2 
Reno, Nev 
161 
1 
Brattleboro, Vt 
450 
3 
Concord, N. H 
288 
328 
3 
Petersburg, Va 
267 
436 
3 
Keene, N. H 
4 
1 
Staunton, Va 
463 
627 
4 
Essex Co. Asylum, N. J 
243 
383 
3 
Williamsburg, Va 
323 
402 
3 
Morristown, N. J 
549 
856 
5 
Government Asylum, Wash- 
Trenton, N. J 
502 
646 
3 
ington, D. C 
860 
1,267 
6 
Auburn, Crim., N. Y 
141 
201 
3 
Fort Steilacoom, Washington 
Binghamton, N. Y 
936 
3 
Territory 
91 
164 
1 
Buffalo, N. Y 
398 
3 
Weston, West Ya 
394 
676 
4 
Brigham Hall, Canandaigua, 
Mendota, Wis 
533 
531 
3 
N. Y 
62 
62 
3 
Winnebago, Wis 
473 
669 
4 
King's County, Flatbush, N.Y. 
773 
1,416 
4 
Milwaukee, Wis 
208 
325 
2 
Totals carried forward 
20,371 
35,271 
204 
Totals (Asylums 121) 
39,093 
61,411 
377 
(Enlarged and perfected from table in the " International Record of Charities 
and Corrections for 
April, 1887.") 
♦No returns for 188G. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
237 
APPENDIX NO. III. 
TABLE SHOWING NUMBER OF DAYS WOMEN WERE EMPLOYED, KIND OF WORK DONE, 
AND AVERAGE PER CENT. DAILY, IN EACH MONTH FROM SEPTEMBER 
30th, 1885, TO SEPTEMBER 30th, 1886. 
LABOR. 
Total 
1886. 
January 
February 
March 
April 
June 
July 
September" 
1885. 
October 
November 
December 
Month. 
4- 
SIS 
Ward work. 
'i 
misissi 
ssa 
Dining room. 
•g 
Laund ry. 
GO 
m 
Sewing. 
§ 
sis 
Mending. 
t 
ftg.smm 
Knitting. 
i 
isi 
Embroidery. 
s 
: 82 
School. 
s 
Sä8£Sä?28 
CO O iS 
In centre. 
m 
Care of room and 
person only. 
I 
SiiiSiifS 
st 
Total days' work. 
g 
g 
iii» 
tit 
Total days of patients 
per month. 
233288323 
383 
Per cent, employed. 
TABLE SHOWING NUMBER OF DAYS MEN WERE EMPLOYED, KIND OF WORK DONE, AND 
AVERAGE PER CENT. DAILY, IN EACH MONTH, FROM SEPTEMBER 
30th, 1885, TO SEPTEMBER 30th, 1886. 
Month. 
Barn, farm and lawn. 
Engineer and firemen. 
Carpenter. 
Painting. 
:hen and laun- 
with laundry 
office boy and 
•visor. 
Tailor and shoe shop. 
Ward work. 
Dining room. 
Unclassified out-door 
work. 
Unclassified in-door 
work. 
School. 
Care of room and 
person only. 
Total days' work. 
Total days of patients 
per month. 
| Per cent, employed. 
fl 
>-< 
dry, 
cart, 
supei 
1885. 
October 
1,162 
86 
15 
60 
500 
26 
517 
340 
526 
245 
22 
26 
3,499 
4,783 
73 
November 
624 
104 
36 
66 
450 
18 
594 
330 
681 
231 
2 
24 
3,136 
4,421 
70 
December 
568 
117 
45 
62 
476 
32 
971 
531 
558 
399 
27 
3,759 
4 501 
83 
1886. 
January 
277 
127 
41 
40 
472 
20 
942 
526 
486 
481 
82 
26 
3,494 
4,611 
75 
February 
268 
83 
22 
60 
338 
20 
801 
446 
461 
472 
174 
98 
3,145 
4,193 
75 
March 
481 
104 
20 
52 
451 
15 
928 
540 
403 
551 
190 
107 
3 735 
4,683 
78 
April 
883 
94 
12 
59 
428 
16 
1,025 
518 
432 
375 
123 
69 
3,915 
4,583 
85 
May 
957 
53 
20 
63 
425 
3 
1,196 
614 
437 
168 
76 
47 
4,012 
4,757 
84 
June 
1,054 
51 
22 
72 
448 
16 
903 
601 
564 
89 
38 
24 
3.858 
4,649 
83 
July 
936 
55 
78 
484 
5 
1,057 
562 
438 
102 
27 
3.717 
4.687 
70 
August 
939 
56 
37 
64 
475 
20 
1,049 
516 
557 
141 
39 
3,854 
4,826 
79 
September 
497 
51 
44 
60 
500 
22 
875 
526 
420 
217 
36 
3,212 
4,745 
67 
Total 
8,596 
981 
314 
736 
5,447 
213 
10,858 
6,050 
5,963 
3,471 
707 
550 
43,336 
55,439 
78 
Sundays are omitted. In figuring percentage employed, " care of room and persons " is deducted. 
LABOR. 238 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ON THE VARIOUS MODES OF PROVIDING FOR THE INSANE AND 
IDIOTS IN THE UNITED STATES AND GREAT BRITAIN, AND ON 
THE RAPPROCHEMENT BETWEEN AMERICAN AND BRITISH 
ALIENISTS IN REGARD TO THE EMPLOYMENT OF MECHANICAL 
RESTRAINT. 
SUR LES DIVERSES METHODES DE POURVOIR AUX BESOINS DES ALIENES 
AUX ÉTATS-UNIS ET DANS LA GRANDE BRETAGNE, ET SUR LE RAPPROCHE- 
MENT ENTRE LES ALIENISTES AMÉRICAINS ET ANGLAIS EU ÉGARD A 
L'EMPLOI DES MOYENS MÉCANIQUES DE CONTRAINTE. 
ÜBER DIE VERSCHIEDENEN METHODEN ZUR VERSORGUNG DER IRREN UND IDIOTEN 
IN ENGLAND UND DEN VEREINIGTEN STAATEN, UND ÜBER DAS "RAPPROCHEMENT" 
UNTER AMERIKANISCHEN UND BRITISCHEN IRRENÄRZTEN HINSICHTLICH DER 
ANWENDUNG MECHANISCHER ZWANGSMITTEL. 
D. HACK TUKE, M.D., F.R.C.P., 
London, England. 
Gentlemen:-I count much upon your indulgence in presuming that you are will- 
ing to listen to the somewhat desultory remarks I desire to make in response to your 
invitation to contribute a paper to the Psychology Section of the International Con- 
gress. What I propose to do is to resume, after an absence of three years, the friendly 
converse with my co-alienists in the United States on certain subjects of common inter- 
est which we discussed when I had the pleasure of visiting your institutions. I have 
not failed to watch since then what has been done and written in your country as to the 
best way of providing accommodation for the insane, and also as to the best way of 
restraining them from doing injury to themselves or others ; and my observations are 
made chiefly in reference to these aspects of our department of medicine. 
I have thought that in connection with the former subject it might be interesting 
and agreeable to you to know the exact distribution of the insane and idiots of Great 
Britain, and to compare this, as far as possible, with your own. 
I do not suppose for a moment that our own allocation of the insane classes is by 
any means perfect, or that we have succeeded in fully solving the problem which arises 
in view of the enormous accumulation of lunatics, but our experience and practice 
may not be without their use in the consideration of the vast question which you, like 
ourselves, have been for some years anxiously considering, and are considering at the 
present moment, and if I may be allowed to prophesy, will consider for some time 
to come. Taking first the number of the insane and idiots in England and Wales as 
reported in the last available Lunacy Blue Book, we have a total of about 80,000 
patients. (Table I. ) Of these about 8000 belong to the private, and about 72,000, the 
great majority, to the indigent or pauper class. I must premise that the numbers I 
have given do not include the insane or idiotic who reside in their own homes and are not 
under the supervision of the Lunacy Commissioners. Although the census of 1881 attempts 
to furnish returns of the lunatics and idiots in England and Wales, it does not distin- 
guish between those who are at home and those in asylums. Moreover, these cannot 
be considered as sufficiently trustworthy to be included in any scientific statistics. 
Now, of the total number which I have given, about 71 per cent, are confined in 
public asylums, in which term I include our county, borough and metropolitan district 
asylums, as also our State asylums and registered (or endowed) hospitals. (Table II.) 
I may state that our county asylums correspond in their appointment to your State 
asylums, but differ from them in this, that they provide for the indigent classes, while 
yours receive patients of various social positions. This our endowed hospitals do. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
239 
Our metropolitan district asylums are exclusively for the pauper class who are demented 
or idiotic. In our proprietary asylums or licensed houses, there are 5 per cent, of the 
gross number of patients. As we usually call these institutions ' ' private asylums, ' ' it 
is important that they should not be confounded with those hospitals for the insane in 
the United States which you call " private " in common with proprietary asylums, in 
order to distinguish them from your State and Government institutions. We have 
about 8 per cent, residing in private dwellings, most of them being paupers, while a 
small fraction are single patients of the well-to-do class residing in lodgings or the 
families of medical men and others. Lastly, there are rather more than 14 per cent, 
cared for in workhouses, and, I believe, fairly well cared for. In some there are very 
good distinct lunacy wards. 
I will now take the private patients separately and exclusively, and state their dis- 
tribution so far as regards their residence in the public asylums, the proprietary asylums, 
and the private dwellings. (Tablev, 1st column.) Of a hundred such patients con- 
siderably more than half, viz., 55, reside in the public asylums, about 39 per cent, in 
proprietary asylums, while the remainder, 5 per cent., are single patients in private 
dwellings. 
In one of my tables the location of private patients is given in more detail (Table 
Vi ); but I will not weary you with the particulars at the present moment. 
If next we take the pauper class, also separately, we find that nearly three-fourths 
are in the public asylums, a little more than one per cent, in private asylums, 16 per 
cent, in our workhouses, and 8 per cent, in private dwellings, but supported out of the 
rates, and under official inspection. (Table V, 2d column.) 
I pass on to give you a summary of the distribution of lunatics and idiots in Scot- 
land, from which you will see that it differs in a striking manner from the correspond- 
ing figures in England and Wales. (Tables VII and vill.) The last returns for Scotland 
give about 11,000 as the number of insane and idiots under official recognition in 
that country. Now, of these, nearly 60 per cent, are confined in public asylums, while 
the trifling proportion of a little over one per cent, are placed in proprietary asylums. 
Twenty per cent, are in workhouses, some of which, however, are of a superior kind, 
and would by some be considered on a par with county asylums.* (Table VIII.) 
Lastly, there is nearly the same proportion (19.47 per cent.) placed in private dwell- 
ings, mostly boarded out and under official inspection. You will therefore see that the 
Scotch have proceeded much further than we have in England in making use of houses 
other than asylums for the insane and idiotic classes, while they make scant use of pro- 
prietary institutions. When we take the location of private patients separately, in 
Scotland, and compare this with the corresponding distribution in England and Wales, 
we see, again, a great contrast. (Table ix.) Thus, in Scotland, of private patients, 85 
per cent, are in public asylums, barely 8 per cent, in proprietary asylums, while the 
remainder, about 7 per cent., are single patients in private dwellings, under official 
inspection. ( 
I now turn to the statistics of the insane and idiotic in the United States. (Tables 
XI-XIV.) The attempt to compare these with the corresponding classes in our own 
country is beset with difficulty, and it requires the greatest possible care to avoid erro- 
neous and misleading comparisons. To some of these I must for a moment refer. In 
the first place, our lunacy returns include idiots; yours distinguish between them and 
the insane. I have thrown together these separate returns of yours in order to allow 
* Dr. Lockhart Robertson adopted this view in some instructive statistics he prepared in 
1881; hence some discrepancy between his figures and mine. (See Journal of Mental Science, 
January 1882.) 240 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of parallel facts being brought together. Again, our returns take no notice whatever 
of patients living in their own families and not under the supervision of the commis- 
sioners in lunacy. It is, therefore, necessary, when instituting a comparison between 
the methods of provision for the insane and idiotic classes in the two countries, to 
exclude the patients at home from our statistics. Otherwise, it is clear that the rela- 
tive percentages would be totally misleading. Once more: It is extremely difficult to 
ensure similarity in the grouping of institutions in America and England when we 
attempt to draw a parallel between them. I must ask your indulgence, therefore, 
if my comparative grouping differs from what you would consider just, remembering 
that I tread upon ground hitherto untrodden by any inquirer into the relative methods 
pursued in your country and ours in regard to the provision for these unhappy and 
dependent members of society who (we shall agree) are emphatically the "wards of 
the State, " as, I believe, your Horace Mann so well said long ago. 
There were in 1880, in the United States (see Table xil), 60,571 insane and idiots, 
exclusive of patients residing in their own homes (and here let me say, in passing, 
that I must content myself, at the present moment, with the statistics of your last 
census). Now, of this number nearly half (47.8 per cent.) were placed in what you 
call State and Territorial asylums, but which correspond (in some respects at least) to 
our county and borough asylums. (Table XIII.) I hesitate to add to this group what 
you call county and city asylums, because I regard these as scarcely comparable, for the 
most part, with the asylums in our own country which bear the same designation. 
Taking them, therefore, separately, I find that in your county and city asylums there 
were about 14 per cent. (14.5). In almshouses there was the large proportion of 25 per 
cent. Some of the larger ones are, I ought to say, not included (in accordance with 
your own census grouping) under this category, but are returned under public institu- 
tions. 
Then we come to the corporate or endowed hospitals for the insane, including your 
Catholic institutions for this class. Here were located five per cent. I am at a loss to 
know whether I ought to add your training schools for idiots to this division, and have 
therefore kept them distinct. They are represented by a proportion of four per cent. 
In your Government Asylum in Washington there is one per cent. (1.44) of your insane 
are idiots. And here it may be well to warn any one who may study our Lunacy Blue 
Books that what he will find described there as " State Asylums," corresponds to your 
term " Government," or " owned by the United States." We next come to proprietary 
asylums, a term which, I must repeat, I adopt in this place in preference to "private " 
(as we are accustomed to say), in order to avoid confusion arising out of your custom 
of including under this designation your corporate hospitals for the insane. Now these 
proprietary institutions in your country are only represented by a fraction (.56) per 
cent. This is a very striking fact. Strange to say, there are more in your jails, 
although the percentage is also only a fraction (.73) per cent. 
From what I heard when I was in America, I gathered that there was likely to be 
an increase of private asylums. It is a remarkable fact, that while in Britain the cur- 
rent of feeling flows in the direction of the larger appropriation of the public asylums to 
the wealthy classes, there is this reaction in the United States in favor of private enter- 
prise. Notwithstanding this, however, there is, I suppose, no likelihood of your depart- 
ing, to any very considerable extent, from the system now in vogue. So long as private 
asylums are provided, the friends of patients are left at liberty to choose between the 
two classes of asylums. This is, I think, as it should be, provided always that adequate 
supervision is enforced, as well as checks placed on the admission of sane persons from 
interested motives. 
I proceed to compare with these percentages the corresponding ratios in England 
and Wales at the same date (1880,) (see Tables HI and iv), premising that, as SECTION XVII PSYCHOLOGICAL MEDICINE. 
241 
regards our own country, the proportions between the several classes, then and now, 
have not materially changed. Taking, then, our county asylums, which correspond in 
their appointment, although not socially, to your State institutions, our returns show a 
percentage of 62 (62.61) as against yours, which is somewhat under 50 per cent. 
We had a smaller proportion in almshouses (or, as we term them, workhouses) than 
you,viz., 16 as against your 25 per cent. In our corporate asylums,which we call regis- 
tered hospitals for the insane, there were about four per cent, as against your five. In 
regard to Government institutions the percentage was almost identical with yours, being a 
little over one per cent, in both countries. Then, as regards proprietary asylums, we find 
a marked difference, for as against your petty fraction, we have fully six per cent. In 
this you resemble the Scotch rather than the English. There remain outside these 
relative statistics, the insane and idiots in your country who are in the training schools 
for idiots (four per cent.) and in your city and county asylums (14 per cent.). As I have 
said before, I hardly know to what in our own country to compare your county and city 
asylums, but I should be disposed to class them with our workhouses. There is one par- 
ticular-and a most important one-in which your provision for the insane and idiots 
differs from our own. I have said that your State asylums resemble our county asylums 
in their appointment or constitution-they differ socially to a great degree, inasmuch as 
you provide in these institutions for the rich as well as the indigent, while our asylums 
are provided by act of Parliament for the indigent only. Now, were I to take your 
county asylums as corresponding to ours in consequence of their being also restricted to 
the poor, the disproportion would be extraordinarily great; the ratio would be as 14 in 
America to 62 in England and Wales. To the former should injustice be added the 
number of indigent patients in all your State asylums, but I am not aware that this 
information is provided in any of your official returns. Nor am I able to compare the 
distribution of your private patients separately with ours in Britain. It is to be hoped 
that some of your statistical alienists will endeavor to work this out. Indeed, my paper 
will have achieved one of its objects if this, as well as other points, are carefully 
elucidated by your own men. 
I ought to state that having had to omit from my comparative statistics the insane 
and idiots who are reported in your census of 1880 to be residing in their own families, 
I have necessarily passed over one important feature which the census reveals, viz., the 
very large number so resident. Thus, as is shown in one of my tables, of the total 
number (168,854) no less than 108,283, or 64 per cent., were at home or in private 
dwellings. 
I have decided to retain in the English table for 1880 the number of patients in 
private dwellings, as they are under official inspection, and I understand that yours are 
not. How many there were in private dwellings in the States, in 1880,1 am unable to 
discover. I mean patients not residing at home. 
Dr. Dana and Dr. Sylvester have done some good work in utilizing the census 
returns, but these returns could not help them to thresh out the point in question. 
One would, of course, like to compare these numbers with those in our own country, 
but I am afraid that, however correct your returns may be, our own would not j ustify 
our making the comparison. The only way by which to arrive at anything like an 
approximation, would be to deduct the lunacy returns from those of the census. This 
would leave some 10,000 insane and idiots as residing at home without any official 
recognition, or about twelve per cent. It is highly improbable that such an enor- 
mous disparity exists between the number of patients retained by their friends at home, 
in the two countries. It is probably true that the number of this class is greater with 
you than with us, and greatly in excess of what it ought to be. 
I would now go back for a moment to the fact of my having based the foregoing 
statistics on the official returns made so long ago as the year 1880. No other course 
Vol. V-16 242 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
could be safely pursued, and I have given, for purposes of international comparison, 
our own returns for that year. It is no doubt quite certain that since that period the 
number of the insane and idiots in American asylums has greatly increased. What 
that increase has been, there are no means of knowing with accuracy. Some 
statistics have, however, been published in "The International Record" for April, 
1887, prepared by Mr. F. H. Wines with his usual care, and from these it appears that 
there are at the present time in hospitals of which he has been able to ascertain the 
population, forty per cent, more insane patients than were reported in 1880. Mr. 
Wines, in a letter which I have received from him, states that possibly the creation of 
the new institutions not contained in the census list would bring the entire increase in 
the number of patients up to over fifty per cent, more than were enumerated in 1880. 
He thinks it probable that the total population of the insane hospitals in the United 
States to-day amounts to very nearly 60,000. Whether the increase in the number of the 
insane residing in their homes is equally great, there are no means of judging with 
qertainty, but Mr. Wines thinks not. Again, there are, unfortunately, no figures (except 
in certain States) to show whether the number of the insane in jails and almshouses 
is increasing or not. In short, we do not know for certain whether the proportion 
which obtained between the several modes of distribution in 1880 is materially altered 
in 1887. 
In the same table in " The International Record " the capacity of 88 institutions 
for the insane is given. Now the number of institutions recorded in the census of 1880 
was 139; and, as is well known, many institutions have been established since that 
year. The number of insane and idiots in asylums in 1880 was, we have seen, 42,083. 
In the 87 institutions reported in Mr. Wines' table, the number amounted in that year 
to 32,982, or fully three-fourths of the whole. In 1886 the number in the said institu- 
tions was 46,438, showing an increase of about 40 per cent, during the seven years. 
Mr. Wines points out that at this rate the institutions which contained 42,000 in 
1880 will contain 67,000 in the year 1890. If to this number be added the inmates of 
the many institutions which have been erected since the census, the whole number of 
patients in institutions for the insane may amount, when the next census is taken, to 
80,000. Mr. Wines states that the average capacity of 79 hospitals was, in 1880, 417 
beds, while the present average capacity of the same institutions is 587 beds. We in 
England have therefore no difficulty in perceiving that you areadvancing with but too 
certain strides to the huge institutions of the mother country, though you are still 
far behind us in the race. 
In asking permission to say a few words on the question which has so greatly 
agitated your minds of late years-the best means of effectually caring for the accumu- 
lation of chronic cases of insanity-I would say that, perhaps, there is a temptation to 
take sides, as it were, and to lay down some hard and fast lineswhichshall.be observed 
by ail persons engaged in the work, and in all places in which the insane have to be 
provided for, whereas I hold that we must have the greatest variety possible in the 
modes of providing for patients of different classes, whether socially or mentally. Allow- 
ing, then, for special circumstances, including locality, the provision already made, 
and the social position of the patients, I would venture to express my satisfaction with 
the progress made of late in your country in the direction of segregation of the insane. 
I believe that while this plan may, like every other, be abused, and when so abused, 
may involve difficulties of an opposite kind from those from which it is intended to 
escape, the work has already been productive of the greatest service, and is sufficiently 
successful to justify its adoption, modified as experience may dictate, in other States. 
I can have no doubt that the Willard Asylum constituted a vast advance on what had 
been previously done and regarded as orthodox in the United States. This experiment SECTION XVII-PSYCHOLOGICAL MEDICINE. 
243 
reflected great credit upon Dr. Chapin's admirable powers of organization and con- 
structive ability. If Kankakee must still be regarded as, to some extent, upon its trial 
as to the extent of the multiplication of the separate houses, I do not think that there 
is any reason to regret, but quite the contrary, that this great undertaking has been 
attempted. If I am correct in this view, the friends of the insane have cause to be grate- 
ful to Mr. F. H. Wines for the freshness which his energy and freedom from bias have 
infused into this cause, and to Dr. Dewey, for the loyal, conscientious, and persevering 
manner in which he has devoted soul and body to the accomplishment of the difficult 
and often discouraging task to which he was appointed. I understand that the ideas 
embodied in the Kankakee Asylum have been more or less fully carried out in three other 
institutions, since erected. I refer to the one at Toledo, Ohio, that at Richmond, Indiana, 
and that in Dakota. Then, again, you have the new asylum for the pauper insane 
about to be erected by the city of New York on Long Island, which, in many particu- 
lars, resembles Kankakee, though I am informed by Mr. Wines that it owes its inspira- 
tion not so much to that asylum as to Alt-Scherbitz, in Germany. If this statement be 
correct, in regard to the extension of the system of a cheaper style of architectural con- 
struction, and of detached wards in connection with existing institutions, as the best 
method of providing for the increase of the number of patients, it would appear that 
Committees of Management and Superintendents are directing their steps in this 
direction, and that something like a revolution in this great field of work has been 
effected during the last few years, and promises to extend further and further. 
I would here revert to our Metropolitan District asylums, which I mentioned in the 
enumeration of our institutions, because they form an important experiment in the pro- 
vision for the chronic pauper class, an experiment which, in some respects, has been 
attended with success, however repugnant to one's wishes is the herding together of 
such large numbers of insane. 
In a Paper on the ' ' Provision for the Insane, ' ' which appeared in the ' ' Proceedings 
of the Twelfth Conference of Charities and Corrections," Dr. Chapin, I am glad to see, 
recognized hopefully the present tendency to adapt your plans to the various classes and 
conditions of the insane, and refers to the serious accumulation of bed-ridden patients, 
epileptics, and feeble dements. He points out that in the usual arrangements of an 
ordinary hospital for the insane, they scarcely have a proper location. Their habits are 
distressing to patients of another class, and they have been too often thrust into the 
highest part of the building, and, in consequence, rarely go out of doors. This has 
been but too true of asylums both in England and the United States. In our own 
country, distinct wards for the classes referred to have been prepared in many asylums, 
as at Hanwell; or separate institutions, like the Metropolitan District asylums, have 
made special provision for this class, with large day rooms and huge dormitories, con- 
stantly supervised at night. Dr. Chapin prefers a separate building to allotting more 
wards in the original asylum. His recommendation is in accordance with the course 
pursued in the asylums referred to in England. He prefers that they should be one 
story in height, including an associated dormitory, with a few single rooms and a large 
dayroom. 
It is interesting to find that Dr. Chapin's experience at the Willard Asylum showed 
that ten per cent, of the whole number of patients might be placed in such a building as 
he recommends. I quite agree with him when he says, ' ' that it seems that some special 
arrangement for this class is very desirable where the number is sufficient to warrant 
it." For noisy dements it is essential to have single bedrooms, for the sake of the other 
patients, and therefore this class must not be retained in asylums not provided with 
some single rooms. 
It may be of interest to state briefly what the cost of these asylums has been, for the 244 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
economical provision for the insane is a question which is pressed upon us in both 
countries. Doubtless in England we have traveled along the same road that you have, 
in exceeding in some instances the bounds of moderation, and have indulged in too 
lavish an expenditure upon the buildings provided for the indigent insane, while 
one has always a fear lest the economist should interfere with the efficient provision 
for the insane. Still, I think that in recent years the experiment of the Metro- 
politan District asylums has proved that it is possible to build institutions for quiet 
dements, idiots, and imbeciles, at a very much smaller cost than that expended upon 
our magnificent county asylums. I am able to give you the cost of three of these 
institutions in the neighborhood of London, viz., Caterham, Leavesden and Darenth. 
In this outlay I include the land, the building, plant, roads, furniture, etc., and in 
short, all the expenses connected with the construction. Caterham was built for the 
accommodation of 2050, and cost £97 per head ($485). Leavesden, built for 2000 
patients, cost £90 per head ($450). Darenth Asylum and Idiot Schools, containing 
900 adults and 500 children, cost £185 per head ($925)-the higher cost being due to 
the character of the building for the Idiot Training School. But for this, the cost of 
the Darenth Asylum would probably have been about the same as Caterham and 
Leavesden. 
The most recently built county asylum for insane paupers, for acute and chronic 
cases, and provided with every convenience, cost in land, buildings and all expenses, 
£240 per head ($1200), the number of patients accommodated being 1124, but the 
Recreation Hall and Chapel will, if necessary, seat 2000. The excess of this cost over 
that just given is very great. That it may be required for asylums receiving acute and 
curable cases is not denied, but I think that a large class of the indigent insane may 
be comfortably provided for in much cheaper institutions, say from $450 to $600 per 
head ; institutions, it is needless to say, infinitely better than the average almshouse or 
workhouse. 
I should like to say a word on a subject in which I found, on visiting your country, 
there had been very considerable and gratifying reform in some localities, but on which 
I could not fail to perceive that much, very much, remained to be done and undone. 
I allude to the number of patients still in almshouses. I could not avoid the impression 
that there was a large amount of neglect and of ignorant treatment of the insane in 
these receptacles, some of them totally unfit for the use thus made of them ; and I fear, 
from the statements which I have seen in papers forwarded to me from America, that a 
strong necessity exists for putting a stop to the treatment of poor insane patients, who 
require medical attention or restraint, in ordinary almshouses instead of asylums 
specially constructed for the insane, officered by medical men, and under State control. 
I am glad to see in the Ninth Biennial Report of the Board of State Commissioners 
of Public Charities of Illinois (1887) a strong expression of opinion in regard to the 
improper use of almshouses in the place of State institutions. Says the Report : ' ' The 
uniform testimony of persons competent to form an opinion as to the condition and 
treatment of the insane in almshouses is, that these are not suitable and proper places 
for their care. There are many towns and counties in the United States in which the 
care of paupers is committed by the authorities to the lowest and best bidder ; a practice 
which virtually makes merchandise of their misfortunes, and results, as a rule, in the 
selection of persons least fitted to care for them arightThe condition of the 
insane in almshouses is often deplorable, not so much owing to the brutality of their 
keepers as to their ignorance." Much more is said to the same effect, but I am glad 
that the writer can honestly add, " As a counterpart to this dark picture, it must never- 
theless be said, that in some almshouses the insane are well treated in all respects ; 
they enjoy a large degree of personal freedom, and are usefully employed according to SECTION XVII-PSYCHOLOGICAL MEDICINE. 
245 
their capacity to work ; association with sane paupers is an advantage to many of them, 
and they are more accessible to their friends." 
The result of my visit to the almshouses in Wisconsin was to form a favorable opin- 
ion of the provision made there for the insane. I do not say it was the very best 
that could be made, but that which seemed to me fairly good. One must have 
regard to the enormous expense which the ordinary State asylum involves, and the 
continual tendency, in consequence, to thrust the indigent insane into the miserable 
houses to which the foregoing Report refers. I say that better far than the latter, and 
as satisfactory a compromise as can be expected, are the almshouses and small 
county asylums of Wisconsin, for suitable cases, under their present system of inspec- 
tion, combined with State control. These are absolutely essential conditions. 
I am interested in observing that a definite experiment has been made, with the 
sanction of the law, in Massachusetts, to provide for a certain class of patients in 
families. Mr. Sanborn, the able Inspector of Asylums in that State, in a paper read 
before the National Conference of Charities and Corrections, July, 1886, states that the 
anticipations of a lady member of the Massachusetts State Board (Mrs. Leonard) have 
been more than justified by the result, although the number has not been so large as 
expected. I see that Mr. Sanborn estimates that no less than 500 out of the hospital 
population of nearly 6000 in that State could be provided for in this way, without dan- 
ger, at a cost of $3.25 (or 13s.) a week. This system must, however, be most carefully 
carried out, not so much in consideration of the patients as the families in which they 
are boarded. In Scotland the proportion of patients boarded out is 19 per cent, as 
against 8.25 per cent, in Massachusetts; but applications, it appears, have been made 
by suitable families sufficient to provide for twice as many patients as have been fur- 
nished. The danger is that a house which has no more rooms than are really necessary 
for the health and comfort of the family, will have them seriously lessened, even if 
there is not absolute overcrowding. I strongly hold that all available means of pro- 
viding for the insane should be entertained, and the caution which evidently controls 
this praiseworthy attempt in Massachusetts may prevent abuse ; but nothing to my 
mind can be more certain than that, of all forms of location, this is the one which, while 
it may be a blessed change to the patient, requires the greatest possible consideration 
to save the families in which patients are domiciled from unwarrantable discomfort 
and even lamentable consequences. I regret that, in the discussion of this question, 
these dangers are so frequently ignored. 
Before passing from the distribution of the insane and idiots in the United States 
and Great Britain, and the best mode of providing accommodation for them, I will 
very briefly summarize what I have said. 
1. In England, the great majority of patients are placed in our county asylums. 
While regretting the size to which many of them have attained, I believe them to be 
the best means of providing for the great mass of the insane poor, if proper provision 
be made for curable cases. Some, if not most, of these are needlessly expensive for the 
quiet demented class and imbeciles, and for such the cheaper constructions of the 
Metropolitan District asylums are, on the whole, a successful experiment. 
2. In Scotland, the boarding-out system is the most striking feature. It offers suffi- 
cient encouragement for carrying it out in the United States to make it worthy of imi- 
tation in suitable localities, but extreme care is requisite to avoid doing moral mischief 
to the families with which the patients are boarded. 
3. The provision for the paying class of patients and for those high in the social 
scale, but unable to pay, is made in England and Scotland by charitable institutions, 
and as regards the former class by private enterprise. The tendency of popular senti- 
ment and of attempted legislation, with us, is to encourage the system of charitable 246 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
institutions, to add to county asylums some accommodation for the .higher classes, and 
to limit, if not eventually abolish, all proprietary asylums. 
4. In America, the provision of asylums by the States for mixed classes of patients 
is a salient feature. The question arises whether the paying classes have not been 
thus provided for out of proportion to those of the pauper class, the latter being rele- 
gated to inferior county asylums and almshouses. Must not the answer be in the 
affirmative ? 
5. The location of the insane and idiots in almshouses in the United States is much 
in excess of what obtains in England, and it is a subject for congratulation that at no 
time was there a greater endeavor made to lessen the evil arising out of this undue 
resort to such buildings than at the present time. Although the Wisconsin experiment 
of county management of almshouses under State control has ensured a vast improve- 
ment in the system, and will continue to do so as long as an active and intelligent 
board is in office, the highest standard of excellence must not be for a moment lost 
sight of. 
6. The movement in favor of variety in the construction, arrangement and position 
of the buildings of an asylum so allowing of judicious segregation, is worthy of imita- 
tion, provided, always, that the violent, dirty, and sick patients are not so isolated as 
to be deprived of efficient medical supervision. 
Allow me now to proceed to the second division of my Paper. 
In reference to the use of mechanical restraints, the circumstance which strikes me 
as very marked, and one which I regard as of good omen, is the approximation in general 
sentiment between American and British alienists in regard to the best mode of dealing with 
the refractory insane, this having taken the place of what I think at one time was 
too obvious a divergence to admit of dispute-a divergence of opinion and practice- 
which led to some degree of antagonism between us in psychological matters. 
I have observed that several of your medical superintendents have in their reports 
spoken in strong terms of praise of the total discontinuance of mechanical restraint, and 
I am assured on high American authority, that if a correct census were now taken of 
the restraints employed in your asylums, they would be distinctly less than when the 
census was taken in 1880, the only available record in my reach when I prepared my 
report of the American asylums in 1884.* Moreover, there is no question at all that 
the returns of 1880 would have shown a great change of practice, and therefore of opin- 
ion, had there been any similar return ten years previously with which to compare it. 
The sum of all this is that the experience of superintendents of asylums in the 
United States increasingly favors the treatment of the insane without resort to the old- 
fashioned methods of coercion. 
I cannot better substantiate the statement than by citing the Medical Superintendent 
of the Pennsylvania Hospital of the Insane, Dr. Chapin, who, although he would not 
adopt " Conollyism " in the extreme form in which that excellent man, Dr. Conolly, 
would have formulated it, thus expresses himself : ' 'As a matter of fact, a great diminu- 
tion of the use of mechanical restraint has actually taken place. In many of the asylums 
it is abolished or dispensed with, except in special cases where its use would not be 
questioned. The concurrent experience and testimony are that with its abolition there 
have followed an improved service in all parts of the asylum, diminished excitement 
and violence, and an entire change in the wards set apart for refractory patients. " 
("On Provision for the Insane," p. 9.) The answer Dr. Chapin gives to the question 
how this great result has been brought about is undoubtedly correct. " The substitu- 
* See "The Insane in the United States and Canada." 1884. SECTION XVII PSYCHOLOGICAL MEDICINE. 
247 
tion of an improved personal attendance has not been, and cannot be, effected success- 
fully by an impulse or the issue of an order. There must precede the patient training 
and preparation of a corps of attendants to appreciate that non-restraint in the manage- 
ment of the insane is a substitution of an improved and higher quality of personal 
attendance for mechanical and architectural contrivances, and that abolition of mechan- 
ical restraint is not the whole of the system." Truer words were never spoken on this 
subject. Again, " The existence and amount of restraint may be said to be a gauge and 
measure of the quality of service rendered by attendants in any asylum." (loc. cit.) 
I now turn to our own country, and I have no hesitation in saying that, while the 
old mode of restraint is dead and buried past resuscitation, there is far less disposition 
to sit in judgment upon those, whether in Britain or America, who honestly believe that, 
as a last resort, use may be made of some form of mechanical restraint. Some use strong 
dresses with side arms, and a few resort to the straight waistcoat. The total amount 
of restraint is very small, but it serves to show that what is called " Conollyism " is not 
the Shibboleth that it once was, and that men refuse jurare in verba magistri in this 
matter. Rightly or wrongly, the result is what I have intimated-a drawing on the 
part of the alienists of the two countries to one another, for obviously, so long as Conol- 
lyism was the flag under which the battle was fought, there could be no compromise. 
It was Cæsaraut nullus. To-day it is much easier for the two countries to understand 
their apparent differences, and to take "sweet counsel together," as in truth it is but 
fitting that the mother and her illustrious child should, and as I trust will do, at this 
Congress. 
America may say to us, "You can understand why we were cautious not to become 
too doctrinaire on this question, and why we thought you sometimes worshiped a name 
a little too much. At the same time, we Americans fully admit we have been too tardy 
in reducing the amount of our mechanical restraints, and hope to advance further in the 
same direction. You in Britain have found restraints more necessary in some cases 
than Conolly held them to be, and so, while we come a vast deal nearer to you, you 
approach a little nearer to us. We need not employ a surveyor to measure the exact 
point in the road where we meet ! Enough that we do meet, and do not boast of being 
separated by some impassable barrier." 
I cannot illustrate what I mean more aptly and forcibly than by pointing to a paper 
read recently at a meeting of the Medico-Psychological Association by Dr. Savage, 
entitled, ' ' Whether there is ever sufficient reason for the use of strong clothing and side- 
arm dresses ?' ' * and the discussion which took place thereon. In favor of ' ' Conollyism, ' ' 
in its original and severely logical form, not a single word was said. The abstract 
principle which he and Gardiner Hill contended for did not find a solitary supporter. 
Yet Dr. Savage said what every one in England feels the truth of, and doubtless to a 
wider extent than you in America yet do, that there is a terrible danger of abuse 
directly you make an exception to the general rule. Facile, indeed, is the descent to 
the Avernus of the old system of the barbaric mal-treatment of lunatics. 
Sed revocare gradum, superasque evadere ad auras 
Hie labor, hoc opus est. 
Were man a well-balanced animal, reasonable and free from extremes, and capable 
of cutting his loaf with a sharp knife without ever cutting his fingers, it would be quite 
a different thing. But seeing that he is an ill-balanced animal, is most unreasonable, 
and is constantly running into the most stupid extremes, there is need of great care 
how we place in his hands those means of doing evil to others which can be so readily 
abused. I for one earnestly hope that the tendency so manifest in your asylums to 
See Journal of Mental Science, April, 1887. 248 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
reduce the amount of mechanical restraint, may extend further and further, and that 
this may be the outcome of experience rather than the adoption of an abstract principle 
which falls to the ground the moment a single instance of necessary restraint occurs. 
It is like a pledged teetotaller breaking his pledge. Nothing less. Let the principle 
of treatment be infinitely higher and broader than any mere pledge or system, the 
principle, namely, of humanity or the substitution of kindness for cruelty. Applied to 
the insane, this involves, among many other things, the avoidance of all means of 
restraint not absolutely required for the patient's treatment and safety. 
Here my already too lengthy Paper must close, and I conclude with the expression of 
the hearty wish and the belief that your great country and ours may proceed hand in 
hand in protecting the helpless classes to which this Section is devoting its attention, 
from ignorant and interested care-takers, and in providing for them such accommoda- 
tion and humane treatment as shall most effectually ensure their recovery, and when 
this is hopeless, their constant supervision and comfort. 
TABLES SHOWING THE SEVERAL MODES IN WHICH THE INSANE AND IDIOTS 
ARE PROVIDED FOR IN GREAT BRITAIN AND IN THE UNITED STATES. 
Table I.-In England and Wales, January 1st, 1886, 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
County, Borough and Government® ) 
Asylums, and Registered (or J- 52,204 | 
4,641 
52,895 
57,536 
Endowed) Hospitals J 
Metropolitan District Asylums 5,332 J 
Proprietary Asylums 
3,249 
1,190 
4,439 
Workhouses 
11,868 
11,868 
Private Dwellings (under official supervision) 
447f 
5,866 
6,313 
Totals 
8,337 
71,819 
80,156 
Ratio per 10,000 of the population 
2.98 
25.78 
28.76 
Table II.-Percentages of the Foregoing Table. 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
County and Borough Asylums 
Government Asylums 
.60.05'1 
. 1.05 1 
5.79 
65.99 
71.78 
Registered (or Endowed) Hospitals.. 
Metropolitan District Asylums 
. 4.02 f 
. 6.66 J 
Proprietary Asylums 
4.05 
1.49 
5.54 
Workhouses 
.... 
14.80 
14.80 
Private Dwellings (under official supervision) 
.56 
7.32 
7.88 
Total percentages 
10.40 
89.60 
100.00 
* These are, called " State" Asylums in England, but to avoid their being confused with the "State" 
Asylums in America I have adopted the term Government. 
+ Exclusive of 248 Chancery Lunatics, in accordance with the custom of the Lunacy Commissioners. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
249 
Table III.-Lunatics and Idiots in England and Wales, January 1st, 1880. 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
County and Borough Asylums.... 1 
Government Asylums > 43,730 
Registered (or Endowed) Hospitals J 
Metropolitan District Asylums 4,473 
Proprietary Asylums 
Workhouses ...... 
3,744 
3,408 
' 468» 
44,459 
1,141 
11,991 
5,980 
48,203 
4,549 
11,991 
6,448 
Private Dwellings (under official supervision) 
Totals 
7,620 
63,571 
71,191 
Table IV.-Percentages of the Foregoing Table. 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
County and Borough Asylums 56.32'1 
Government Asylums 1.13 1 
Registered (or Endowed) Hospitals... 3.98 [ 
Metropolitan District Asylums 6.29 J 
Proprietary Asylums 
Workhouses 
5.25 
4.78 
' '.67 
62.47 
1.60 
16.84 
8.39 
67.72 
6.38 
16.84 
9.06 
Private Dwellings (under official supervision) 
Total percentages 
10.70 
89.30 
100.00 
Table V.-Location of Private and Pauper Patients (Insane and Idiots), in Percent- 
ages OF THEIR OWN CLASS, IN ENGLAND AND WALES, JANUARY 1ST, 1886. 
LOCATION. 
PRIVATE. 
PAUPER. 
County and Borough Asylums "I 
Government Asylums j 
55.67 
73.66 
Registered (or Endowed) Hospitals 1 
Metropolitan District Asylums J 
Proprietary Asylums 
38.97 
1.66 
Workhouses 
16.52 
Private Dwellings (under official supervision).... 
5.36 
8.16 
Totals 
100.00 
100.00 
Table VI.-Location of Private Patients (Lunatics and Idiots) in England and 
Wales, January 1st, 1886 (in More Detail). 
LOCATION. 
NUMBER. 
PERCENTAGE. 
Z 
Proprietary Asylums 
3,249 
3,054 
38.96 
Registered (or Endowed) Hospitals 
36.63 
Government Asylums 
846 
10.14 
County Asylums 
741 
8.91 
Private Dwellings (under official supervision).... 
447 
5.36 
Totals 
8,337 
100.00 
* Exclusive of 208 Chancery Lunatics. If included, the percentage would be .95. 250 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Table VII.-Location of Lunatics and Idiots in Scotland, January 1st, 1886. 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
Public Asylums, including Perth Prison 1 
1,524 
5,065 
6,589 
and Training Schools J 
Workhouses .... 
' 139 
2,281 
2,281 
Proprietary Asylums 
139 
Private Dwellings (under official supervision) 
120 
2,058 
2,178 
Totals 
1,783 
9,404 
11,187 
LOCATION. 
PRIVATE. 
PAUPER. 
TOTAL. 
Public Asylums, including Perth Prison | 
and Training Schools J 
13.62 
45.28 
58.90 
Workhouses;ii 
20.39 
20.39 
Proprietary Asylums 
1.24 
1.24 
Private Dwellings (under official supervision) 
1.07 
18.40 
19.47 
Total percentages 
15.93 
84.07 
100.00 
Table VIII.-Percentages of the Foregoing Table. 
Table IX.-Location of Private and Pauper Patients in Scotland, in Percentages of 
their Own Class, January 1st, 1886. 
LOCATION. 
PRIVATE. 
PAUPER. 
Public Asylums, including Perth Prison and 1 
Training Schools J 
85.48 
53.86 
Workhouses 
24.26 
Proprietary Asylums 
7.79 
.... 
Private Dwellings (under official supervision).... 
6.73 
21.88 
Totals 
100.00 
100.00 
Table X.-Location of Private Patients in Scotland, January 1st, 1886 (in More 
Detail). 
LOCATION. 
NUMBER. 
PERCENTAGE. 
Registered Hospitals 1 
1,191 
66.80 
Royal or Chartered Asylums...' J 
County ("District") Asylums 
139 
7.80 
Proprietary Asylums 
139 
7.80 
Training Schools 
132 
7.40 
Private Dwellings (under official supervision).... 
120 
6.73 
State Prison at Perth 
62 
3.47 
Totals 
1,783 
100.00 
* Including some "Parochial" Asylums. SECTION XVII-PYSCHOLOGICAL MEDICINE. 
251 
Table XI.-Location of the Total Number of the Insane and Idiots in the United 
States (with Percentages), January 1st, 1880. 
LOCATION. 
NUMBER. 
PERCENTAGE. 
At Home and in Private Dwellings (not under ) 
official supervision) J 
Public Asylums or Hospitals for the Insane and 1 
Private Asylums j 
Almshouses 
108,283 
42,083* 
15,139 
2,429 
476 
444 
64.15 
24.92 
8.96 
1.43 
.28 
.26 
Training Schools for Idiots 
Other Institutions 
Jails 
Totals 
168,854 
100.00 
Table XII.-Location of the Insane and Idiots in the United States, January 1st, 
1880 (Exclusive of those at Home and in Private Dwellings). 
LOCATION. 
NUMBER. 
PERCENTAGE. 
In Public Asylums and Proprietary Asylums 
42,083 
69.46 
Almshouses 
15,139 
25.00 
Training Schools 
2'429 
4.01 
Other Institutions . 
476 
.80 
Jails 
444 
.73 
Totals 
60,571 
100.00 
Table XIII.-Location of the Insane and Idiots in the United States, January 1st, 
1880, Exclusive of those at Home and in Private Dwellings (in More Detail). 
LOCATION. 
NUMBER. 
PERCENTAGE. 
Government Hospital for the Insane 
873 
1.44 
State and Territorial Asylums 
28,947 
47.80 
City and County Asylums, including three large 1 
8 822 
14-56 
Almshouses J 
Corporate Hospitals 
3,098 
5.10 
Training Schools for Idiots 
2,429 
4.01 
Proprietary Asylums 
'343 
.56 
In other Institutions. •. • 
476 
.80 
Almshouses 
15,139 
25.00 
Jails 
444 
.73 
Totals 
60,571 
100.00 
* This includes some of the largest almshouses. 252 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Table XIV.-Location of the Insane only in the United States, January 1st, 1880, 
Inclusive of those at Home. 
LOCATION. 
NUMBER. 
PERCENTAGE. 
At Home and in Private Dwellings, without | 
official supervision J 
Public Asylums, Hospitals for the Insane and 1 
Proprietary Asylums j 
Almshouses 
41,083 
40,942 
9,302 
397 
235 
44.78 
44.42 
10.12 
.43 
.25 
Jails 
Other Institutions 
Totals 
91,959 
100.00 
DISCUSSION. 
Dr. Savage said-I have always felt most strongly that the question of restraint 
or non-restraint depended solely, or should depend solely, upon the physician. If a 
man be properly trained to supervise patients and attendants, it is for him to judge 
and act according to his deliberate judgment-not in the hasty way that within a 
month I have heard a doctor say he would act ; that rather than restrain a man who 
threatened to tear out his eyes he would prefer that the man should succeed in his 
purpose. The sooner such an ideal as that is destroyed the better. In direct relation- 
ship with civilization in a country is the humanity with which insane patients are 
treated. My friend and traveling companion to America, Dr. Sandwith, who has 
recently been in charge of the reforms in some of the hospitals in Egypt, tells me 
details that you would scarcely believe ; of chains, of manacles, of every conceivable 
form of mechanical restraint, that he within the last three or four years has destroyed 
in Egypt. Just before I left London a patient was brought from an island in the 
south of Europe. He had been an excited patient, and while there had been thrust 
into a kennel into which daily a modicum of food had been served to him. The 
civilization of the people was far below the civilization of Europe and America, 
hence the humanity was defective. Just before coming to America, I attended a 
meeting at which this question was treated. One young doctor-we considered that 
he had the enthusiasm of youth with its faults-considered that Conollyism was the 
only principle that was to be preached. He would have open doors, no restraint, 
nothing but freedom. Now, it is all a question of degree. If you are to have no 
restraint on any condition, if you are to have open doors everywhere, why send 
patients to asylums at all? It is but for the preservation of society, for the patient's 
good and for society's good that he must be secluded, and it is for the physician to 
decide how he is to be restrained. It is always well to have high principles, but I 
suppose none of us quite lives up to his principles. But it is better to aim high, 
and, therefore, the old principle of non-restraint should be preached, though not 
always necessarily practiced. My opinion is this : When you have to deal with 
attendants-and they are, of course, our right hands in the treatment of the insane 
to a great extent-it is not well to let it get into their heads that you restrain 
patients, for this will do an immensity of harm, and you will find that behind your 
backs your patients are restrained. If you have your flag of non-restraint out, as a 
kind of banner of "Excelsior," I believe it will lead to good, but I hope that no 
one who is narrow-minded enough to say that it is impossible that restraint should 
ever be necessary will be listened to. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
253 
Dr. Andrew's.-I would like to say one word upon this subject. It seems to 
me that the bond of union between the English and American alienists has been 
stated very clearly in the paper of Dr. Tuke and also by Dr. Savage. When our 
English brethren preached Conollyism, the American alienists could not accept that 
doctrine. Perhaps we were too literal in our interpretation ; as we believed when 
they said with Conolly, that restraint was never to be used, that they adopted that 
principle entirely. Since then, by studying the returns of the English Commission, 
we find that they do not adopt the principle of Conolly-that no restraint is to be 
used on any occasion-as restraint is reported in all of the blue books of the English 
Commission and for purposes which meet a hearty response in the minds of every 
American superintendent, unless, perhaps, in those of a few who have recently 
given themselves over to the non-use of restraint and have proclaimed themselves 
ardent advocates of that system. The union of the two countries in this respect is 
now, I think, quite complete ; and the use of restraint is substantially the same. 
It is certainly used very little in this country, and only when a medical superintendent 
believes it an absolute necessity as a mode of treatment, and I think our English 
brethren accept it and employ it in the same way. 
THE RELIGIOUS DELUSIONS OF THE INSANE. 
LES ILLUSIONS RELIGIEUSES DES ALIÉNÉS. 
ÜBER DIE RELIGIÖSEN DELUSIONEN DER WAHNSINNIGEN. 
BY HENRY M. HURD, A.M., M.D., 
Pontiac, Mich. 
Religion has to do with the relation between man and his Maker. To every indi- 
vidual it has an inward, hidden development and an outward manifestation. It is a 
combination of precepts and actions, formulated beliefs and corresponding duties. 
It excites the highest hopes and stirs the deepest fears known to man. In its highest 
sense it is spiritual and exalting, the noblest aspiration of the human soul, the com- 
munion of mortal man with his immortal Creator, the homage of the weak and finite 
to the all-powerful and infinite. In its lowest sense it becomes dogma and ritual-an 
external manifestation without an indwelling spirit. Religious sentiments are innate, 
but their development depends upon age, natural characteristics, education, mental 
peculiarities, habits of thought and modes of expression. In childhood they are largely 
the result of education, and have an emotional rather than intellectual origin. Later 
in life, if the intellectual training of the individual is limited and his mind is not dis- 
ciplined to thought or reflection, a similar emotional phase of religious feeling gives rise 
to ecstacies, raptures, fears, hallucinations of vision or hearing, and irrational conduct. 
In persons possessing mental training, religious sentiments have an intellectual origin, 
and the emotional nature being affected through the intellect is subsidiary to it and held 
in wholesome restraint. In proportion to the degree of mental discipline, religious sen- 
timents become matters of the intellect as well as of the emotions. When symmetri- 
cally developed they have to do with the emotions, the intellect and the daily life alike. 
The predominant characteristics of religious sentiments being hope and fear-a hope 254 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of eternal reward and a fear of lasting punishment-it is evident that when these sen- 
timents are deranged there must be morbid hope and morbid fear. The insane man 
may, on the one hand, believe himself to be an exalted personage, under the patronage, 
protection and blessing of the deity-possibly deity itself-or, on the other hand, under 
the wrath of God, an outcast, a sinner, a blasphemer, and unfit to receive the slightest 
mercy. Between these extremes every phase of religious sentiment may exist. (The 
asylums contain "Gods," "Saints," "Virgin Marys," "Mediators," " Kings of kings 
and Lords of lords," and "Lord's Vicegerents" without number, and an equally 
numerous throng of " Fiends, " "Devils," "Lucifers," " Fallen Angels, " "Dragons," 
and the like.) 
I will now proceed to consider more at length the delusions which are developed in 
different forms of mental disease. 
1. The Religious Delusions which accompany the mental development of over-stimulated 
and injudiciously educated children. 
These delusions are apt to take the form of morbid fear. The child being morbidly 
conscientious and impressible, and his reasoning powers imperfectly developed, his 
emotional nature is stirred unduly by vivid descriptions of the joys of heaven and the 
pains of future punishment. Realizing but little of the ethical side of religion, he con- 
founds the emotional state which accompanies religious observances with religion itself. 
The moment he fails to derive pleasure and an emotional glow from prayer or praise he 
fancies that some duty has been neglected or improperly performed. Hence he becomes 
harassed by fears, tormented by doubts and overwhelmed by remorse for fancied mis- 
deeds or sins of omission. The following case illustrates this type of disease :- 
E. C., aged nine years, weight 51 pounds, was decidedly below the average in 
height and possessed a neurotic temperament. He had been healthy and vigorous until 
six years of age, when he had a tedious illness accompanied by a discharge from the 
right ear, and was afterward delicate. Owing to ill-health he had not been allowed to 
go to school until eight years old, but his subsequent development had been precocious. 
He had applied himself diligently, and had succeeded much better in his studies than 
other scholars of the same age. He had also attended Sunday School with painstaking 
fidelity, and had taxed his memory much to commit verses from the Bible He had 
from infancy been morbidly conscientious and anxious to do right. Six months prior 
to his coming under observation it was noticed that when he attempted to say his prayers 
at night he was not sure he had spoken them correctly and wished to repeat them again 
and again until they were ' ' perfect. ' ' On some occasions he spent half the night on his 
knees, or until sleep overpowered him, in this attitude of devotion. This condition, 
under injudicious stimulation in study, increased progressively during the following six 
months, until he became forgetful, absent-minded and the victim of imperative concep- 
tions. The predominant religious delusions in nervous children at this age are, as 
might be expected, when their half-starved and over-stimulated brains are considered, 
essentially those of fear and apprehension. The delusions of this class have much in 
common with the following, which will now be considered :- 
2. The Religious Delusions characteristic of the Insanity of Pubescence. 
The characteristics of the insanity of pubescence are periods of stupidity, mental 
hebetude, listlessuess, indifference and lack of power of application, alternating with 
periods of elation, restless excitement, uncontrollable impulses and moral perversions. 
During the period of mental hebetude there are great physical and mental depression, 
which in the religiously educated give rise to a fear of death and consequent eternal 
punishment, and engender a strong desire to do some religious act as a penance, or more 
probably to purchase peace of mind and inward satisfaction. The boy or girl desires 
to join the church, or to go upon a mission, or to sacrifice some cherished luxury, and 
is seemingly absorbed in religious observances. The religious zeal, however, is short SECTION XVII PSYCHOLOGICAL MEDICINE. 
255 
lived, and never lasts through the succeeding period of elation. Such persons, as a 
patient once said to me in relating her own experience, "are converted every winter 
but backslide during the summer." When depressed, they are scrupulous of religious 
forms and ceremonial observances ; when elated, all restraint is thrown to the winds. 
In the former state they derive much comfort from religious exercises ; in the latter 
they are irreverent and often blasphemous. Unlike genuine cases of melancholia, their 
religious assiduity seems to bring relief and a degree of satisfaction.. The condition 
under consideration is not so much one of actual delusion as of morbid feeling and vague 
apprehension. Such patients become observant of little matters and attach great weight 
to the consequences of the neglect of a single religious duty. One school girl, for exam- 
ple, neglected to pray, as had been her wont, prior to opening a -letter from home, and 
when she tore it open found, as she believed in consequence of her neglect, an announce- 
ment of the death of her mother. The feeling is not developed on account of general 
sinfulness and wholesale wrong doing, as in melancholia, but is rather excited by omis- 
sions to do minor acts of religious worship or whatever may have been prescribed by 
the minister or priest as the full measure of religious duty. There is little true intro- 
spection. 
3. The Religious Delusions of the Insanity of Masturbation. 
The delusions of the victims of self-abuse vary in character at different stages of the 
insanity of masturbation. At the outset, as might naturally be anticipated when the 
neurotic organization and age of the victims of this habit are taken into consideration, 
the phenomena of morbid fear predominate. To these are added a study of the Bible 
and a habit of introspection. The patient fears that he has committed the unpardon- 
able sin, and suffers from remorse, gloom and mental distress. He redoubles his efforts 
to make amends for fancied wrong doing, and is scrupulous in all religious observances. 
As not unfrequently happens in similar morbid mental phenomena, sooner or later a 
transformation of the delusion occurs, and the person who has committed the unpar- 
donable sin finds himself singularly forgiven, blest and holy. Delusions of religious 
superiority develop, and, with other evidences of mental deterioration, a silly vanity in 
religious matters. The patient has visions, trances, hallucinations of hearing, raptures 
and ecstasies. The connection between self-abuse and religious delusions is probably 
to be ascribed to a combination of causes. At first, religious delusions originate in a 
fear of deserved punishment for the violation of nature's laws. To relieve this burden, 
consolation is sought in reading the Scriptures and in religious exercises, and the morbid 
fervor thus engendered soon leads the patient to the opposite extreme. Eventually he 
believes himself, in consequence, highly moral and superior to his associates and sur- 
roundings. A second factor in producing it is a general nervous erethism or emotional 
susceptibility, which may be considered the direct result of the vicious indulgence, and 
is developed at the expense of the higher faculties. The final factor is an actual weak- 
ening of the intellectual centres, from exhaustion and premature mental decay. A 
process of transformation thus goes on from year to year until the intellectual centres 
are in practical abeyance, and the emotional nature assumes complete control. In the 
analysis of religious delusions it should not be forgotten that for their development a 
substratum of religious education must generally exist. Where there has been no 
religious training in childhood, and no religious bent given to a man's nature, the effect 
of self-abuse is not to develop it. (This, however, is not invariably true.) In the latter 
case the effect is shown in hypochondriacal fancies, a silly vanity, a sickening egotism, 
etc. Many illustrative cases might be given of this form of religious delusions, but the 
annexed case must suffice. 
The following case illustrates the effect of masturbation to produce religious delu- 
sions in an organization predisposed to mental disease. It is fortunately in an individ- 
ual who possessed considerable ability to analyze and describe morbid mental states. 256 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
G. B. H., aged forty-one, was a single man without hereditary tendency to mental 
disease, a teacher, not a church member, but a believer in spiritualism, of a studious 
and retiring disposition, not addicted to alcoholics, tobacco or opium, a masturbator for 
many years, and one who had never been successful in business. He had been aspiring, 
ambitious, but had lacked sufficient ability to bring himself into notice. In pursuit of 
his calling as a teacher of elocution he had wandered about the country. At the age of 
twenty-one he heard a voice saying to him, " Come up higher," which seemed to have 
been a distinct aural hallucination. This heavenly admonition subsequently gave him 
a strong desire to elevate the human race. Poverty humiliated his pride by making it 
necessary to dress shabbily and stint himself in his daily allowance of food to such a 
degree that his health'suffered. Five years ago, while in the West, he was induced to 
investigate spiritualism, and afterward believed himself a medium chosen by God to a 
special work in the elevation of the human race. Four months previous to his admis- 
sion to the Eastern Michigan Asylum, in consequence of hardships, privations and 
probably excesses in masturbation, he had an attack of excitement and was treated at 
the asylum, at Taunton, Massachusetts, for about two weeks, when he became quiet 
and was able to be removed to his home in Michigan, where he maintained composure 
for several weeks, although obviously unnatural in manner. He suddenly, however, 
became "the Medium of God," and was much excited for hours. He thought God 
directed all of his thoughts and acts, and would make him a great orator, so that he 
might be the medium of spreading truth throughout the world. When admitted to 
the Eastern Michigan Asylum in October, 1885, he was free from special excitement, 
but vain and self-important in manner. He was proud of his voice, and was disposed 
to practice singing in a discordant fashion, 'and had much to say of his divine mission. 
He was disposed to withdraw himself from the society of his associates, to commune 
with his own thoughts. He also had tendencies to denude himself, but was ashamed 
when discovered nude, and always had a plausible excuse for his conduct. After a 
month he wrote to a relative in reference to hallucinations of hearing and a fancy that 
he could converse with persons at a distance, and seemed to be making an honest 
effort to correct certain morbid impressions. In this direction his efforts were seconded 
by a brother who, in a long interview, told him frankly of his delusions. For eight 
months thereafter he was quiet, self-controlled, able to participate in literary exercises 
and to give recitations and readings. He seemed free from delusions and was thought 
to be well enough to go away from the asylum. He complained, however, of head- 
ache after slight exertion and an inability to concentrate his thoughts. He subse- 
quently confessed that his mind had not been free from religious delusions during any 
portion of this time, and that he had continued the habit of masturbation. During 
this period of quiet he wrote the following letter :- 
Pontiac, Aug. 19th, 1886. 
My Dear Brother :-I am hopeful of success afterward, as my trust is in God. Through 
all the years of my adverse life previous to the last, I have trusted him in a dim, blind way, for 
doing one's duty as he sees it is putting faith in Deity. During the last year-a tithe of whose 
bitter experiences you know not-my trust was implicitly in God. One night at Onset, while lying 
awake, sleepless as usual and suffering, a voice that filled me with its vast impressiveness said, 
"My child, tell your mother that out of pain shall come blessing ; out of pain shall come blessing; 
out of pain shall come blessing." That I will find it so I have no doubt. Through all the fiery 
trials of the past fifteen months, which subjected me to so much reproach, I trusted that great 
voice. At any time I could have stopped and turned back had I not been constrained by a sense 
of duty to go on. In every fiery trial and in hours of darkest doubt has come that same voice, 
saying, "Trust in God," "Your triumph cometh," and lesser voices would say, "Be brave, be 
strong, be true." Oh, that calm, steady "Trust in God," how it has rung silently through the 
consciousness of centuries ! May we all follow it up the long path of years, till it widens forever 
into the fields of joyous and sublime endeavor ! 
I remain, yours affectionately, G. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
257 
Soon after he showed increased mental disturbance, and on one occasion tried to take 
liberties with female employés, under the direction of the "Eternal Voice," and thought 
he had frequent communications from the spirit world. During the following two or 
three months he had periods of severe mental disturbance, coming on at midnight, 
during which he called loudly upon the "Infinite One." On several of these occasions 
he attempted to mutilate himself by tearing out his genitals, in order that he might 
suffer pain for "Jesus' sake." During the daytime he was free from excitement, and 
talked of his midnight experiences as the workings of a diseased mind. He confessed 
to an excessive indulgence in masturbation, under the impression that he was bringing 
himself thus into closer relations with the spirit world. He also had impulses to pray 
with his associates and to read his Bible diligently. In a letter he said that he had 
" sought truth and love and happiness through spiritualism instead of Christianity," 
and had been deceived, and announced his conversion to a "love of the Lord Jesus." 
He added: "The Lord Jesus actually speaks to me often, very often, and counsels me 
what to do, so great is my weakness and ignorance of the Bible and of the Christianity 
I have despised. ' ' 
Soon after, impelled by an idea of self-sacrifice, he assaulted his attendant, with 
the intention of bringing injury upon himself. After a period of great mental disturb- 
ance, of several weeks' duration, he suddenly cleared up, and spoke intelligently and 
sorrowfully of his condition. He desired to be rid of the voices which he considered 
the causes of his attacks. These, he explained, were not audible voices, but thoughts 
which came into his mind in the shape of well-formed sentences, which recurred again 
and again, without any effort of his own, and, in fact, contrary to his volition. They 
warned against the errors of spiritualism, and urged him to deeds of self-denial for the 
cause of Christ. They even gave him explicit commands to do acts which were dis- 
tasteful to him. At first he struggled against and overcame them temporarily by an 
effort of will to devote his attention to other matters. Soon, however, he lost his ability 
to withstand them, and eventually became enslaved. 
A short time after this conversation he again became wholly dominated by suicidal 
impulses. He refused food, endeavored to mutilate himself, and recklessly exposed his 
life and health. For three nights, in the depth of winter, he denuded himself of clothing 
and w7as sleepless, from bitter mental and physical agony. At the end of three months 
he came to himself, and thus described his sad condition. He said the "influence," as 
he termed it, stole upon him imperceptibly. It came as a " gentle, benign, fatherly 
voice," and spoke persuasively and not commandingly. It came in the attitude of "a 
loving, all-wise father to an erring child." Slowly he was forced to listen. As the 
influence deepened he felt called upon to make some form of self-sacrifice. At first a 
sacrifice was exacted in a quarter where he experienced the strongest desire. If, by 
previous fasting, he had become ravenously hungry, he was commanded to abstain 
from some article of food. The voice said, "My child, are you willing to reject this 
portion ? ' ' and he found himself unable to turn a deaf ear to the seductive tone. At 
first he was told that his bare willingness to abstain from food was sufficient, but soon 
actual abstinence was required, sometimes of some article of food, but more frequently 
of the entire meal. Afterward, his past life was unfolded to him, with all of its errors, 
and he was asked if he were willing to make amends. He was informed also how he 
might avert certain anomalous sensations which he believed to be threatening epilepsy. 
Old faces came back to him with great distinctness. At one time the face of a former 
mistress, who had given birth to a child a few months after her marriage to another 
man, appeared to him. Her child might possibly have been his, and this possibility 
became a reality in his disordered mental state. The voice told him that this child 
had inherited epilepsy from him, and died finally from this disease. He was com- 
Vol. V-17 258 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
manded to expiate this sin by passing nights without sleep, denuded of clothing and 
in bodily torture from extreme cold. 
It is a curious circumstance that in his natural state of mind he had no actual faith 
in the existence of God, but was an agnostic. His delusions gradually disappeared, 
and at the end of four months he left the asylum on trial. 
4. The Religious Delusions of Paranoia. 
In Paranoia we have a mental organization which is congenitally abnormal and pre- 
disposed to perverted action. In the great majority of cases there exists, as early as 
puberty, in both sexes a precocious sexual excitability, which gives rise to an unnatural 
religious susceptibility and induces boys to plan to enter the ministry or to become 
priests, and girls to lead a life of devotion. Later in life the same persons become 
introspective and inclined to revery and day-dreams. As a rule they are inactive in 
their habits, disposed to read the Bible, to seclude themselves from society and to 
scrupulously observe religious ceremonies and services. They have a strong religious bias 
and are apt to embrace peculiar views, or to be attracted by the latest novelty in re- 
ligion. The immediate cause of the development of religious delusions is generally some 
physical ailment, an illness or a severe mental or physical shock. In rare instances 
they are the outcome of the delirium of fever ; more generally, the result of physical or 
nervous exhaustion, and most frequently the sequence of excesses in masturbation, or 
sexual exhaustion. The development of the fully formed disease is usually marked by 
sleeplessness, hallucinations of vision or hearing, strange bodily sensations or acute 
mental distress. One patient after praying for several nights in a corn field, in great 
agony of mind, felt the burden of sin fall from his aching shoulders and saw it glide 
away in the darkness, dark, sinister, and, to use his own expression, ' ' like a small 
wood chuck." Another recovering from typhoid feter, had a vivid dream of heaven, in 
which he saw himself seated upon the throne a recipient of divine homage. Ever after, 
when fatigued or exhausted, this graceful vision recurred to him until he finally had a 
fixed delusion that he was Christ. Another, after a period of prayer, fasting and vague 
distress, at the age of 19 years, heard an audible voice conferring upon him the gift of 
prophecy. Such conditions of nervous tension, generally due to a physical cause, have 
been aptly termed by Krafft-Ebing " receptive stages " of paranoia, during which ideas 
and fancies are rapidly elaborated but imperfectly assimilated by the mind of the indi- 
vidual. The mental concepts in this stage may be likened to paintings in a picture 
gallery. They are mental images which do not seem to have any intimate connection 
with his own personality. He views them as a spectator simply, and feels interested 
in them in a general way. Like all other states of mental exaltation, this condition is 
not permanent, but is sooner or later followed by ideas of persecution and great mental 
distress. The unfortunate patient who had enjoyed a little time before a vision of 
heavenly realities and "saw what it is not lawful for man to utter," suddenly finds 
himself at the mercy of a wicked world, ruined in property and reputation, and the 
laughing stock of his unfeeling associates who fail to appreciate his religious enthusiasm 
and care nothing for his aspirations. The stage of persecution thus inaugurated becomes 
a period of mental conflict, during which he is torn with doubt, overwhelmed with the 
taunts and threats of his friends, and an object of persecution and derision. After a 
time the ideas and fancies which accompanied the receptive stage above described recur 
to his mind unbidden and offer a grateful contrast to the annoyances and persecutions 
of his daily life. Hallucinations of vision and hearing also help to confirm these pleas- 
ing impressions. He delights to dwell upon and derives pleasure from them when 
alone, but the cup of happiness is repeatedly dashed from his lips by the taunts and 
sneers of his vigilant persecutors. After days, months and sometimes years of alternate 
agony and bliss, despair and blessedness, the apparent truth finally dawns upon him SECTION XVII-PSYCHOLOGICAL MEDICINE. 
259 
that he is persecuted because of some peculiar divine power, heavenly gift or special 
religious calling. All is now revealed to him. His life of mental anguish and distress 
has been a preparation for his sacred ministry. He consults his Bible and finds refer- 
ences to himself in nearly every passage. He is the "Saviour," "Shiloh," "the 
Prince of Peace," etc., and is destined to receive honors and blessings far superior to 
any earthly king. Generally, even in women, a strong sexual irritation is connected 
with these extravagant religious delusions. He desires to marry, to perpetuate a holy 
race, or to become the father of a Pope or the founder of a Holy Priesthood, or if a 
woman, she fancies herself destined to give birth to a Saviour. The following illus- 
trative case will serve as a type of many others :- 
A. H., whose mother was insane and father eccentric and ill-balanced, at the age of 
thirteen years displayed a precocious sexual sentiment and began to talk of matrimony. 
During the following ten years he offered himself in marriage to seven different per- 
sons, but for some reason was rejected by each one. At the age of twenty-four years 
he became unsettled in mind and devoted himself to erratic inventions and the study 
of the Bible. Believing that God had commissioned him to preach, he dressed him- 
self in a fantastic suit of scarlet velvet and armed himself with a two-edged sword. 
Thus attired he preached and distributed tracts of his own composition, which were 
largely composed of Scripture texts and his own incoherent comments upon them. He 
announced himself a prophet and ' ' the man on a white horse, ' ' spoken of in the 
Revelation, whose special mission was to convert and restore fallen women. With 
these extravagant delusions were mingled delusions of persecution. He believed him- 
self defrauded of property and "persecuted for righteousness' sake." He was finally 
arrested and lodged in jail because of frequent threats to kill a relative, and was brought 
from the jail to the asylum. He said that he had done no violence to any person and 
had been guilty of no unjustifiable threats. He acknowledged that he was eccentric, 
that he had worn a fantastic suit and carried a two-edged sword in order to attract 
attention, but that the latter paraphernalia were " a powerful agency " and calculated 
to attract attention and ' ' do good. ' ' He explained that he threatened his sister and 
her husband because they ill-treated his mother, and that he destroyed property and 
threw articles from the house because he desired to get possession of his own. He 
claimed to have broken no law, and said that " the joke had gone far enough." He 
displayed many extravagant fancies. He knew more about the Bible than any other 
person, and through careful study was better qualified to teach the Scriptures than any 
divine. He spoke of the rottenness and hypocrisy of the church, and declared that 
several immoral women were church members at home. He declared that he had 
received much immoral solicitation and had witnessed lewd conduct on the part of 
several church members. When asked if his conduct was not calculated to cast doubts 
upon his sanity, he replied that martyrs in all ages had been persecuted for righteous- 
ness' sake. He turned to the forty-ninth chapter of Genesis and read as follows : 
"Judah, thou art he whom thy brethren shalt praise ; thy hand shalt be in the neck 
of thine enemies ; thy father's children shall bow down before thee. Judah is a lion's 
whelp ; from the prey my son thou art gone up : he stooped down, he couched as a 
lion, and as an old lion ; who shall rouse him up ? The sceptre shall not depart from 
Judah, nor a lawgiver from between his feet, until Shiloh come ; and unto him shall 
the gathering of the people be. He claimed to be "Shiloh," and to prove it, quoted 
from the nineteenth chapter of the Revelation : "And I saw heaven opened, and behold 
a white horse, and he that sat upon him was called Faithful and True, and in righteous- 
ness he doth judge and make war. His eyes were as a flame of fire, and on his head 
were many crowns, and he had a name written that no man knew but he himself, and 
he was clothed in a vesture dipped in blood, and his name is called the Word of God. 
And the armies which were in Heaven followed him upon white horses, clothed in fine 260 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
linen, white and clean. And out of his mouth goeth a sharp sword, and with it he 
shall smite the nations, and he shall rule them with a rod of iron, and he treadeth the 
wine-press of the fierceness and wrath of Almighty God. And he hath on his vesture 
and on his thigh a name written, King of kings and Lord of lords." He further said 
that his coming here was prophesied, and read from the twentieth verse of the second 
chapter of the Revelation to the close of the chapter. The adulterous woman referred 
to above he was shown in a vision by an angel of the Lord one year ago. He had offered 
himself in marriage to seven lewd women in succession without knowing their charac- 
ter, and had been rejected by each of them on account of his religious belief, but after- 
ward received a vision from the Lord which showed to him their true character. He 
also read numerous quotations from the Old Testament Prophets, which announced his 
coming and imputed to him supernatural powers and a divine mission. 
During his stay in the asylum he was at first much distressed by the lack of oppor- 
tunity to carry out his divine mission, and made many complaints. With the lapse 
of time he became interested in useful employment, and also displayed a talent for 
drafting and mechanical work. He developed a fatal facility for falling in love, and 
wrote many tender epistles to many different persons, of which the following will 
serve as a sample :- 
Jer. xxxi, 22. A woman shall compass a man. 
Darling Mary:-I cannot take "no" for an answer. I know you love me and that is 
enough. Says God, "Woe to them that take away the right from the poor of my people." Isaiah 
x, 1. My grandfather was an English Lord in Ireland and left a great estate of which I am 
the only heir, of the Rothschild lineage. But I have something better still, talent and 
genius, which never fail to secure for its possessor a position. There is a crown hanging over 
your pretty head and you may wear it soon if you can venture to strive for it a little. " Are not 
my princes altogether kings," Isaiah x, 8. Oh, my lovely angel Mary, please promise me now 
and do not delay any longer, for I cannot rest day nor night for the excess of my passion of love. 
(Your pretty hand.) Why not enter into that greatest of all pleasures, matrimony? I have 
long wished to be a man among men and have a family of my own, but there was always some- 
thing stood in my way, as you see does now. There is a cause for this. My children are to be a 
sign of God's blessing to Israel (Isaiah viii, 18), and this is the depths of Satan to destroy the 
sign, that is, to destroy the tree and its fruit (Jer. xi, 19-23). A great many clubs in a tree is a 
pretty good sign it bears good fruit. Hence my persecution." 
5. The Religious Delusions of Epilepsy, Dementia and General Paresis. 
Contrary to the general opinion which has obtained, the delusions which accom- 
pany epilepsy are not generally of a religious character. It is true that confirmed 
epileptics are much inclined to religious observances, attendance upon church services 
and Bible reading, but these acts are generally the result of a previous religious edu- 
cation, and are continued from force of habit after the development of mental disease. 
There is never, or rarely any sense of religious fear or unworthiness, but rather a sense 
of satisfaction in the performance of religious duties. The epileptic frequently in con- 
versation praises his own devotion to religion, or commends himself for having read 
the Bible most diligently, but there is beyond this no deep-seated religious feeling. 
His religious talk is automatic and the result of previous training. The same is true 
of the religious characteristics of confirmed dementia. Sometimes there is a semblance 
of religious extravagance on the part of a demented man, but generally it may be traced 
to a previous religious education. Occasionally, also in the dementia which follows 
religious melancholia there is an abiding habitual sense of religious unworthiness and 
spiritual deadness. In general paresis, on the other hand, there may be extravagant 
delusions of religious importance which closely resemble those which are developed in 
acute or chronic mania, and are due to the rapid flow of ideas through the brain, and SECTION XVII-PSYCHOLOGICAL MEDICINE. 
261 
are a part of the general cerebral excitement. They are usually evanescent and rarely 
become systematized or controlling after the excitement passes away. None of these 
forms seem to require any illustrative cases. 
6. The Religious Delusions of Melancholia and Climacteric Insanity. 
In considering the religious delusions of those who suffer from melancholia it 
should not be forgotten that the entire mental training of many persons is in a religious 
direction. Their minds are disciplined to reflect upon religious doctrines and their 
acquired knowledge is largely about their relations to God and His dealings with them. 
Outside of these abstruse topics they have little abstract thought, study or even read- 
ing. Their mode of thinking and bent of mind become eminently religious, and they 
are largely occupied with doctrinal discussions and theoretical speculations as to sin, 
repentance, future punishment and future reward. Oftentimes their views of God's 
relations to them are crude and faulty, too often derived from a literal interpretation 
of Old Testament passages or the study of the lives of Biblical worthies or the legends 
of middle century saints. These erroneous views frequently originate painful delu- 
sions and suggest intellectual difficulties which would not have been developed had 
their original conceptions of religious duty been less faulty. Depressing religious 
delusions, such as characterize melancholia, develop more frequently among Protestants 
than Roman Catholics. Among the former, too, delusions of distrust and unworthi- 
ness are more apt to be elaborated by processes of thought, and hence give rise to 
greater and more persistent mental distress than among the latter. The delusions of 
Protestants usually relate to their exposure to divine wrath in consequence of a failure 
to perform some ethical duty. The delusions of Catholics generally relate to the non- 
performance of a devotional act or penance or ceremony prescribed by the Church. 
Among Protestants religious delusions are generally based upon conceptions of God as 
a stern, unyielding ruler who commands instant obedience in thought, word and act. 
Hence, motives are inquired into and conscience is put upon the rack to discover short- 
comings in intention, failures in refraining from thoughts of evil, and other equally 
hidden misdeeds. The mind of such a Protestant is, in consequence, constantly under 
a severe strain, and conscience holds it remorselessly up to an ideal standard of ethical 
duty, with little assistance from outside sources. Among Catholics, on the other hand, 
absolution, confession and penance give support to the mind by showing that wrong- 
doing is not unpardonable and sin may be expiated. The melancholic religious delu- 
sions of Protestants, therefore, are those of despair, and are frequently accompanied by 
intense mental distress and strong suicidal proclivities. Among Catholics melancholic 
delusions are more apt to take the form of fastings, penance, the adoration of relics, 
etc., and are less hopeless. Among the religiously educated or piously inclined, delu- 
sions of distrust and fear generally develop in consequence of causes of exhaustion, 
such as ill-health, defects of digestion, overwork, over-worry, grief, want, pregnancy, 
lactation and the climacteric. The last-named period of female life seems especially 
liable to awaken religious melancholic delusions. This period marks a period of life 
when certain organic forces and activities cease. There is a lowering of the vital tone 
and an interference with the spontaneity of vital processes. The mal-uutrition of the 
brain finds its expression in religious doubts, fears, mental distress and suicidal propen- 
sities. At this age depressing delusions are persistent and give rise to intense and last- 
ing mental distress. The sufferings of the religious melancholic far exceed in intensity 
those of any other form of insanity. The paranoiac suffers, it is true, but he is com- 
forted by the thought that he is wrongfully accused and has a consciousness that he 
deserves benediction rather than reproach. The victim of melancholia, on the other 
hand, is doubly distressed by the feeling that he deserves it all and much more. The 
religious fear extends to motives, duties, privileges, present happiness, future misery : 
" every thought and intent of the heart" seem to unite to destroy the mental peace of 262 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the individual. The restlessness and religious despair which accompany atheromatous 
degeneration among the aged are similar in character and mode of development. 
Examples of religious melancholia are unfortunately so common as not to require any 
special illustrative cases. 
7. The Religious Delusions of C hronie Mania, Alcoholic or other Toxic Insanity. 
The religious delusions of chronic mania, alcoholic or toxic insanity are generally 
of an extravagant character, and relate to the possession of great power, personal 
importance, and attributes which, if not divine, are certainly superhuman. In the 
majority of cases the delusions seem but the crystallization of the feeling of extrava- 
gance which accompanied the period of maniacal excitement of alcoholic or opium 
intoxication. There is, however, this striking peculiarity in these delusions: they are 
not invariably developed in persons of a religious training or a devotional habit of 
mind. In many instances these persons have been the reverse of religious and have no 
conception of a devout attitude of mind. The melancholic, like the publican of old, 
"standing afar off," turns his attention to religious matters and humbly acknowledges 
his ill-desert. The chronic maniac or the alcoholic case perceives no impropriety in 
arrogating to himself religious pretensions. In certain rare instances when hallucina- 
tions of hearing are present the delusion becomes a depressive one. Numerous illus- 
trative examples may be given. A male patient thought he was Jesus Christ, and it 
was his duty to hold up his right hand. If it fell he feared the whole world wrould be 
destroyed. He afterward fell into a trance and thought he was the " Crucified Christ." 
He also called himself the " Lion of the tribe of Judah," " Heaven's New-born King," 
" God with us," etc. Another thought he must expiate his sins and put himself in 
the attitude of "Christ on the Cross." Another heard the voice of God distinctly 
command him to leave the asylum, to cross the ocean to India to seek a mountain of 
gold which no one else had been able to discover. He had been commissioned by God 
to make its location known to the world. Later, he stood constantly in an attitude of 
prayer because God had commanded him to give himself up for the sins of the world 
" to stop its wickedness." He asked to be shot through the right temple, and declared 
it is a sin against God to allow him to live. He had a tubercular disease of the testicle. 
Connection between Vicious Indulgences and Religious Delusions. 
The connection between sexual impulses and the development of religious delusions 
is not from any necessary association of ideas, but rather from the close association and 
inherent unity of emotional states. Whenever the emotions are stirred by any event, 
joy and sorrow, love and hate, hope and fear, pleasure and pain are found closely 
related. In the sphere of the emotions, one emotion may be quickly followed by an 
associated or contrasted emotion without any adequate cause or logical reason. This 
part of man's mind is like Pandora's box. If one emotion is set free all the others 
escape. In certain states of nervous instability the human mind becomes the theatre 
of shifting, constantly changing and conflicting emotions, which dominate the reason 
and coerce the conduct. They are excited by sights, sounds, odors even, and muscular 
movements, events, abstract ideas, reminiscences, and, in short, by everything which 
is external to man, and in turn they also give rise to trains of thought, mental concep- 
tions, other emotions and voluntary or automatic acts. Emotional states predominate 
in the sexual and religious life of every individual. Religious and sexual emotions 
have this in common. They are individual and personal, arising from organic causes 
which are mysterious and never to be fully understood, and leading to actions which 
are equally incomprehensible. Under the control of sexual impulses and religious 
emotions a man is revealed as he is in his inmost soul, without disguises or false appear- 
ances. Sexual impulses and religious sentiments have their origin and highest devel- 
opment alike in emotional states, even in a healthy mind. In states of disease arising 
from sexual abuse or sexual excess, a morbid religious feeling develops among the SECTION XVII-PSYCHOLOGICAL MEDICINE. 
263 
religiously educated as a part of a general nervous erethism. In these cases the reli- 
gious delusions are the expression of a general state of emotional instability which had 
its origin in sexual emotions. No better evidence can be given of the truth of this 
statement than the combined sexual and religious sentiments of monks and nuns in the 
middle ages. Exhausted by penance and fasting, emotionally excited by constant 
dwelling upon religious topics and a life of asceticism and active devotion, it is little 
wonder that their adoration for the Virgin Mary or the Saviour was expressed in the 
language of earthly love. The same is also true of the earlier stages of insanity from 
alcoholic, opium or other narcotic indulgence. The quickening of the cerebral circula- 
tion and the hyper-nutrition of brain tissue give rise to delusions of religious extrava- 
gance. Later, however, when the nutrition of the body has become impaired by 
vicious indulgences, and nerve and brain cells suffer from mal-nutrition, delusions of 
religious fear replace them. 
The Course and Termination of Religious Delusions. 
The religious delusions of over-stimulated children are generally relieved by rest, 
freedom from study and a judicious correction of the educational errors which produced 
them. In many instances, however, the tendency to a degree of dementia is. not fully 
arrested, and the child grows up to manhood or womanhood with a prematurely weak- 
ened brain and a liability to subsequent attacks of insanity. The same is true, in a 
great measure, of the religious delusions which accompany the insanity of pubescence. 
They are not systematized and soon pass away. The insanity of pubescence, however, 
is liable to become a periodic or recurrent mania with a vicious circle of depression 
and excitement, and it is interesting to note that the religious delusions are generally 
lost sight of when mental disease becomes fully and unmistakably established. The 
religious delusions which accompany the insanity of masturbation are not necessarily 
incurable. They are, however, liable to become persistent and are not readily amen- 
able to treatment. They may be considered incurable whenever the patient has 
reached the stage of religious extravagance, which is surely indicative of mental dete- 
rioration. The religious delusions of paranoia are essentially incurable, being the 
legitimate development of a mental ' ' twist ' ' and the outgrowth of an abnormal per- 
sonality. They eventually become thoroughly assimilated by the mind and an inte- 
gral part of its constitution. During the stage of persecution they may at times pass 
from the mind, but after the stage of transformation they cannot. The religious delu- 
sions of epilepsy, general paresis, chronic mania, alcoholic and toxic insanity require 
little special mention. They are the débris of decay and the broken fragments of a 
hopeless mental wreck. The religious delusions of melancholia are more curable. 
They mark deep seated disease, but the prognosis is not hopeless. 264 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SECOND DAY. 
MILIARY ANEURISMAL DISEASE, ETC. 
MALADIE ANÉVRISMALE MILIAIRE. 
ÜBER MILIARANEURYSMATISCIIE ERKRANKUNG. 
BY EDWARD C. SPITZKA, M.D., 
Of New York. 
Pauline F., aged 24 ; first consulted Dr. Koehler August 15th, 1886. She manifested 
a peculiar, anxious, and timid demeanor, and complained of a continual feeling of dry- 
ness in the mouth. In the course of the further examination she became taciturn, a 
fact attributed by her aunt to tiring caused by the exertion of speaking. For some 
weeks there had been insomnia and considerable anorexia. On the two preceding 
afternoons she had what was described as distinct febrile movements, lasting about 
seven minutes and followed by sweating. For this Dr. Koehler prescribed anti-periodic 
remedies, with satisfactory results as regards the fever. A more thorough examination 
on the occasion of his second visit, August 19th, revealed distinct scanning of speech, 
which the patient made evident attempts to conceal by speaking slowly and avoiding 
certain words. She complained of great motor weakness, and it was very unwillingly 
that she walked across the room to demonstrate her gait. This was of a partly paretic 
and partly spastic character. At this time the kneejerks were found exaggerated, the 
cutaneous reflexes and the movements of the pupil normal. Subsequently it became 
impossible for the girl to leave her home and report at Dr. Koehler's office. 
Inquiry revealed the following regarding the earlier history : Since the summer of 
1879, she experienced almost every night a peculiar mental disturbance, beginning 
about eleven o'clock, after she had fallen asleep, and continuing four hours. She would 
then wake up rambling in her conversation, which chiefly related to dogs, cats, and 
thieves, and at times leave her bed as if in terror of these objects. She entered service 
in January, 1882, and remained, doing light housework, till near the time of her first 
reporting to the physician named. During this time it had been frequently noted that 
she dropped objects immediately after having seized them. This was particularly 
liable to happen if she had seized them quickly. On four occasions she was noted, after 
preliminary tottering and swaying, to fall down suddenly, as if fainting. She recovered 
and rose of her own accord in a few moments. Her general health remained excellent 
down to March, 1886, and in her waking moments her mental state was, on the whole, 
fair, if anything, inclined to be sanguine and gay. 
From this time on her nutrition imperceptibly deteriorated. Her menses ceased in 
July and remained absent until her death. During the years 1884, and 1885, the noc- 
turnal mental disturbance had nearly disappeared. In March, 1886, it reappeared and 
was controlled by bromides. August 24th she was again seen and found mentally 
clear, but indisposed to speak. Her cardiac action was very feeble, the pulse 64, weak SECTION XVII-PSYCHOLOGICAL MEDICINE. 
265 
and compressible. She showed a marked intention tremor and there was a decided 
increase in the paretic-spastic gait already noticed. She could only walk from room to 
room. Her gait was spastic and paretic, and she caught hold of a chair to prevent her- 
self from falling. A marked intention tremor-almost ataxic in character-was devel- 
oped on inducing her to attempt approximation of both index fingers. 
The patient after repeated temporary improvement in her nervous symptoms, aside 
from the speech and general nutrition, which both deteriorated progressively, sank into 
coma and died. The diagnosis of some organic spinal affection related to disseminated 
sclerosis was made. 
Dr. Koehler while treating this patient was reminded of the fact that he had also 
treated her brother, who had died of nervous symptoms at about the same age as his 
sister. There were multiple cerebral and spinal symptoms, some of which (mild 
opisthotonos and facial distortion) pointed to a meningitis. No autopsy was allowed. 
The father of these two patients had died in his fortieth year, of symptoms said to 
have closely resembled those of his daughter. 
The autopsy was made by my assistants, Drs. Brill and Mollenhauer, at Dr. Koeh- 
ler's invitation. Only the brain and spinal cord were permitted to be removed. 
The membranes were found entirely normal ; the arachnoid was clear and trans- 
parent everywhere. The brain did not fill the skull to quite the normal degree, but 
there was no evident gaping of the sulci. The ventricular surfaces, fluids, and propor- 
tionate size of their cavities were entirely normal. 
To sum up, there was no anomaly in the color or consistency of the cerebral tissues, 
nor were there any evidences of vascular disease externally, except in a tortuosity of 
both classes of vessels on the frontal and mesal faces of the hemispheres. Those of the 
cord seemed altogether normal, the arteries, if anything, thin walled. On making 
cross sections of the cord we were surprised by finding a large number of large blood 
islands, chiefly in the gray, but occasionally, and less marked, in the white substance. 
Minute examination showed that they were closed sacs, constituting round, oval, but 
chiefly spindle-shaped ectases of the normal arteries of the parts. In many places the 
white substance near these bodies had a grayish lustre, and in a few did not sink under 
the section level as readily as the remainder of the section surface. In the dorsal cord 
these ectases were comparatively few, in the lumbar they were numerous. 
Everywhere cortex and white substance showed a similar condition of the vascular 
apparatus. On the whole, it might be said that the aneurismal dilatations were more 
frequent in the brain, but of larger size in the cord, in one instance occupying the 
locality usually occupied by a group of ganglion cells, which, crowded to one side, 
showed no intrinsic change. In the tegmentum of the pons they were so numerous as 
to appear to equal the intervascular tissue in square area. 
The interest attaching to this case is twofold. First, it illustrates how a multiple 
affection not involving coarse tissue change may ape the clinical picture of disseminated 
sclerosis to a certain extent. Second, it shows how an apparent family type of nervous 
disease may be in reality but a manifestation of a tendency to degeneration of that 
system, which is as profoundly under the control of hereditary influences as any other 
-I mean the vascular. 
Dr. Spitzka next exhibited the cerebellum, pons and oblongata of a child, whose 
case as a whole had been studied by Dr. Boldt, of New York, and reported in part by 
Dr. A. Jacobi, of the same city, under the heading "Congenital Lipomatosis." The 
special point to which he wished to direct attention was the cerebellar deformity. It 
conclusively showed that the asymmetry was due to causes inherent to the laws of 
brain growth, uncomplicated by any pressure on the part of the skull, or premature 
synostosis. The one hemisphere was greatly atrophic, but its white substance was 
exposed on the ventro-lateral aspect. On the other hand, the left hemisphere was not 266 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
only overgrown, but the folia of the caudo-lateral part were ectropic, thus demonstrating 
an inherent tendency to redundancy. In passing, he would mention that the cerebral 
hemispheres were atypical. 
DISCUSSION. 
Dr. Savage said-Mr. President and Gentlemen : I have had a somewhat 
similar case to the one presented by Dr. Spitzka, and with a satisfactory pathological 
examination. The history was something similar to the case quoted by Dr. Spitzka 
except that there was not such a direct inheritance. It was the case of a lad who 
developed all the symptoms of disseminated sclerosis: in fact, he was for several years 
the stock case in London hospitals, just as regularly as the lecturing season commenced. 
He was regarded as a typical case; had the intentional tremor, the astigmatism, and 
everything. This case finally became very excited and maniacal, and had to be sent 
to an asylum, and after being sent to other hospitals it was thought advisable to 
send him back to Bethlem, thinking it possible we might trace its pathological 
nature. After six or eight months he lost control over many of the muscles, was 
often found wet and dirty. Here his symptoms were also regarded as typical. He 
was finally sent to a county asylum, where he died, and when the tissues or part of the 
tissues were sent to me for examination, I regret to say that no insular sclerosis 
could be found. There were not even any allied changes-absolutely nothing to be 
found that would answer to insular sclerosis. The points raised by Dr. Spitzka are, 
it seems to me, extremely interesting, and I think we are all now willing to admit 
that it is rather the order of the disease than the quality of the disease; that a largely 
and widely spread disease affecting the motor or general tract-especially the motor 
tract-will give incoordination; will give rise to symptoms that in former years 
would have been attributed to the cerebellum. I think the Section has reason to be 
very grateful to Dr. Spitzka for putting this case on record. 
ONE SOLUTION OF THE PHASES OF CIRCULAR INSANITY. 
UNE EXPLICATION DES PHASES DE L'ALIENATION CIRCULAIRE. 
EINE LÖSUNG DER PHASEN DES PERIODISCHEN WAHNSINNS. 
DANIEL CLARK, M.D., 
Toronto, Canada. 
Among the multiform phases of periodicity in nature, none have to me a greater 
interest than the remissions and intermissions of insanity in the same individual. For 
aught we know to the contrary there is uniformity in pathological conditions during 
the varied phases, yet the physical and psychical signs and symptoms vary, as do the 
incoming and outgoing tides. The cause is apparently undergoing no change, except it 
be in unvaried progression, yet the startling and pronounced manifestations as indicated 
in the words and conduct of the individual, point to the influence of some subtle agency 
which excites and incites to pronounced overt acts, in obedience to its behest. 
It is true these times of periodicity are seen everywhere in nature. The throb of 
revolving planets; the intermissions of heart beats; the oblivion of sleep; the quiet of SECTION XVII-PSYCHOLOGICAL MEDICINE. 
267 
a muscular fibre; the alternate rest and labor in glandular industry; the remissions of 
thermal conditions in fevers; the physiological impulses of emotion, affection, desire, 
and volition in well organized humanity, and the imperative demands made for rest 
in every cell and fibre of our nature-are all examples of this great and universal law. 
Health and disease revel in antitheses. The paroxysmal crises of our system in appa- 
rent unvaried conditions and causation, seen in all neural diseases, in malarial invasion, 
in cancerous cachexias, and in all glandular diseases, are phenomena which excite our 
interest and prompt investigation. The mere fact of these constant intermissions is 
wonderful, and when the additional phase is observed, that the invasion, or its intensity, 
is often uniform as to time, our desire to fathom the mystery is intensified. For exam- 
ple, why is there such regularity in the rise and fall of heat, morning and evening, in 
typhoid fever, or in acute inflammations ? Why are the invasions and departures so 
regular in ague, and why do successive attacks come so punctually, at definite periods 
much earlier, at each unwelcome visit? Why does neuralgia assume this paroxysmal 
character, even when it is not malarial, but organic, and when it follows anatomical 
lines in its painful course ? In short, why is it that in the mechanical, chemical, and 
physiological operations of our bodies we find these periodic laws in operation? It is 
evident one general agent is at work, irrespective of health or disease, and whose potent 
energy is only known in these varied phenomena. In fact, were we to find unchanging 
sameness in natural phenomena, as is said to exist in the workings of health and disease, 
we would see exceptions to the universal experience of every day's observations. In 
a philosophic sense there is no absolute inertia in the wide expanse of matter. So in 
a wide sense there are perpetual motion and uniform intermissions in physiological con- 
ditions of organized existence. The building up and the tearing down, the construction 
and the destruction, the impairing and repairing, are going on night and day, at one 
time the one having the mastery and at another time the other, until at last vitality 
gives place to disintegration. The forces which have kept up the gallant fight capitu- 
late and leave the fortress, which they have defended for-it may be eighty years-dis- 
mantled and going to ruin. During all these years those life-giving forces obey the law 
of their being by seeking renewed strength in the rest of remittances of operation. 
There is another law in operation which is not to be forgotten. Existing causes may 
continue in force for a short time, but when kept in tension above the normal they 
must be followed by feeble action to a corresponding degree on the minus side of the 
equation. Only in this way can time be given to accumulate fresh power. This alterna- 
ting condition explains the sudden invasion and departure of pathological causes accom- 
panied by spasms, fits, or convulsions; also in health the rhythmic movements of 
automatic life. We cannot grip continuously. We suffer when we keep our bodies in one 
position for a length of time. The periodical eruptions of the lungs, the heart, the 
bowels, the uterus, and it may be also of such busy laboratories as the liver, the kid- 
neys, and the stomach, show the necessity for periods of rest. We cannot think con- 
tinuously without intervals of rest, because the act is also physiological. I endeavored 
fully to elaborate this physiological fact in a monograph read in this city, to a medical 
convention similar to this, held in 1878. I endeavored to show this on a physical basis, 
and that the molecular building up of muscular fibre, nerve elements, and cell forma- 
tion, took place under this general law. I showed that the certainty of all such 
structures, including the wonderful polarization of nerve cells, were dependent on this 
law of work and rest. 
We know it to be a fact that the more we descend in this vital series toward the 
lowest forms of mere organic life the less is organized matter endowed with nerve power, 
and the more it has to depend on inherent energy and adhesion to maintain its specific 
existence and formation. Nerve power has circumscribed pathways, and has not the 
diffuseness of animal magnetism, which is bounded by no particular property of physical 268 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
structure. In other words, in the generations nearest the inanimate, the psychic, and 
the specializing nerve forces are absent, and only the first steps of chemical and vital 
energy are made manifest. 
It matters not what theory is adopted as to the operation of any such influence on 
organized tissue, this statement is correct. The ordinary opinion is that building up 
or contractibility is brought about by direct nerve influence, or that construction or 
contraction is not dependent on such power or stimulation, but that on the contrary 
the agency is inherent in all tissue, independent of all nerve influence. In both views 
animal magnetism must be taken into account as the active agent of all life building 
and maintenance. Not only so, but its potency is not confined to normal and healthy 
structure. It is a remarkable fact, which we so often see post-mortem and know in the 
history of the insane, that we find a large portion of the brain-or it may be a section 
of the spinal cord-of the consistency of cream. The nerve substance has become 
homogeneous by gradual disintegration ; yet there may be no local or distant effect 
commensurate with the breaking down of nerve tissue and the evident destruction of 
nerve cells, nor is there always mental disturbance consequent thereon. Brown-Séquard 
says (vide Lancet, September 16th, 1876) "that considerable alteration and even com- 
plete destruction of parts can exist without the appearance, or at least any marked 
degree, of paralysis, whether the lesion exists in motor parts, or in other parts, or in 
both simultaneously." * 
It is almost a primer lesson in physiology for me to say that animal magnetism will 
produce similar phenomena to frictional or atmospheric electricity. It affects the needle 
of the galvanometer, decomposes iodide of potassium, produces light and heat, and a 
pile made of organized living tissue will give shocks such as are felt in the electric dis- 
charges of the torpedo fish or eel. The law of the correlation of forces is thus made 
manifest by this agent. Light is eliminated from the black hair of a nervous person 
by friction with a vulcanized rubber comb, or by friction from the fur of a cat, and heat 
is generated at the same time. It is present in muscle and nerve only during life and 
as long as the natural warmth remains, but is completely absent in rigor mortis ; yet, 
if warm blood be injected into an animal after rigor has been established for a few 
hours, relaxation will return and with it animal magnetism ; even contraction will be 
induced. 
This power is continuously acting upon matter, from its lowest to its highest forms. 
It is the cunning workman that builds up in varied forms the ultimate elements of 
organic matter, and whose presence in the human body is evident by phenomena the 
most complicated and marvelous in the animal kingdom. In the simple form it is 
cohesion and electricity. In the second series of operations it is vitalism and in the 
highest it is psychism. These three substances are possibly the same in essence and the 
higher including the lower, just as the brain of man is built up by this force in a more 
elaborate way than is done in the simple ganglia of the lower forms of animal life. 
These three forces are necessary to mental life, and the trinity is always '1 a committee 
of the whole" in the brain of man. The vital force is denied to chemical bodies, yet 
the same laws of chemical and electrical aflinity and selection are brought into play in 
building up a muscle or nerve cell, as are exercised in forming a grain of wheat or a 
crystal. We do not see the worker, but on all sides is indubitable evidence of his 
handiwork. At one time it is being stored for future use as " potential energy, " and 
at another time it is manifested as active energy. 
Insanity is no exception to this general law, and no doubt a similar influence in 
health and disease is in operation wherever animated nature may exist. It is called 
chemical and electrical in dead matter, chemical and vital in the vegetable and animal 
worlds, chemical, vital and psychical in the higher forms of animal life. This com- 
plete series of forces is necessary to maintain the integrity of psychical existence. Not SECTION XVII-PSYCHOLOGICAL MEDICINE. 
269 
a cell or fibre ; not a bone or corpuscle ; not a nerve or fluid ; not an automatic move- 
ment or an act of volition ; not a state of consciousness or an emotion could have exist- 
ence or being without the occult handicraft of these master builders, or rather, dare I 
say, of the multifarious manifestations and complex work of one force in different 
stages of correlation to one another. It shows marvelous unanimity and uniformity 
in the atomic selection and building up of a crystal ; in the adaptive affinities of vege- 
tation ; in the building-up processes of our physical system, and in the corpuscle phe- 
nomena of mental life. Now, this force, in all its forms, is either remittent or inter- 
mittent in its operations, in obedience to general law. In physiology it is seen resting 
from its labor regularly in all the organs of our bodies. In pathology, which is also 
governed by unfailing and invariable law, we have periods of highest activity and 
seasons of cessation or relaxation. 
It is not, then, to be wondered at that the insane are no exception to the general 
rule, considering their susceptible and morbid conditions. We even see those remis- 
sions in the semi-torpid body and sluggish mind of the dement. From day to day, and 
by comparison of one long period of time with another, the defective classes show inter- 
mittency in bodily conditions and mental activity. The same is true of those afflicted 
with morbid melancholy. They have fluctuating periods of mental anguish. The 
periods may be irregular, but they are patent to any alienistic student. There are not 
only regular changes daily, but also remissions during definite and prolonged lengths 
of time. These are more pronounced in some persons than in others, in proportion to 
the physical condition of the afflicted individual and to the profundity of the disease. 
That this ebb and flow of the mental tide exists in either acute or chronic mania none 
will deny. Not only so, but the system will accumulate vital and psychic force by 
rest, as will an electric battery which has been exhausted by an excessive outflow. We 
know, by the exhaustion in all forms of mental alienation-especially the exhaustion 
of mania-that animal magnetism is being depleted by abnormal muscular and mental 
activity, in much the same way as occurs in chemical action. In melancholy, and in 
the apparent abnormal conditions seen in circular insanity, between the extremes of 
mania and melancholia, we find the influence of this subtle fluid below normal. This 
means that not only has the usual supply of this ever-active and indispensable agent 
been exhausted, but the reserves have also been consumed, and nature is only able to 
utilize what is being generated. This is capable of proof, and here is a solution of the 
existence of the pronounced phases of circular insanity. Let me put the statement in 
another form. There can be no vital and psychic energy without its presence and 
cooperation. It is an indispensable condition of existence. When the rigor mortis of 
death sets in, it takes its flight; hence the evidence of its intimacy with and necessity 
to vitality. It has, in normal physiological operations, seasons of remissions and inter- 
missions, and it determines their intensity and duration in organic life. In chronic 
pathological conditions the same law exists, but it necessarily, by virtue of low vitality 
attended with excessive energy, makes the intervals more extended and the symptoms 
more pronounced in the ever-recurring periodicity and alternations. 
If this simple key to open the door to this enigma of morbid life be accepted, then 
is there no necessity to propound the many theories based on the derangement of eccen- 
tric organs or on the abnormality of brain-cell formation in reproduction and decay, 
or on the irregularity of blood supply, or on any of the cachexise, or on hereditary 
defect. We need only to go behind all these and trace a universal law operating analo- 
gously everywhere, to explain this outgoing and incoming psychical wave, which is 
only obeying nature's behest, in unison with all the other laws of being. 
My experience as to order of invasion is consonant with this theory. Mania, and 
consequent exhaustion, is the first form in which this round of phenomena appears, 
and it reappears as soon as the bodily rest enables nature to refill the reservoir with 270 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
renewed energizing power. The vital battery has accumulated reserve force as well as 
running power, and as a result we have a repetition of the former manifestations. The 
cycles thus continuously repeat their weary rounds until the final capitulation in the 
battle of life has taken place. 
We glibly speak and write of the tonicity of muscle fibre-of the lack of power in 
nerve tissue-of the inherent healthiness of cell life, and of the reproductive capacity 
of glandular organs. These terms only refer to constructive manifestations. The 
motive power which lies behind these is not studied with that intelligence and perse- 
verance which might have been expected, seeing that these material but subtle forces 
are the ultima thule of human knowledge in the world of mind and matter. 
DISCUSSION. 
Dr. Blandford, in discussing Dr. Clark's paper, said : Mr. President and 
Gentlemen : We are all of us familiar with the periodicity-the periodical phenomena 
in life and in disease-and there is a great deal in Dr. Clark's paper with which we 
must cordially agree, but it seems to me there are certain things in the paper which 
the Doctor should further explain. We are all of us familiar with remissions and 
intermissions in insanity, and we have often seen that one man has many remissions 
of the same kind throughout life, perhaps. I knew the case of an old man who 
became insane first in his seventeenth year, and who had attacks of insanity until he 
was eighty-five. He was admitted to the same asylum five and thirty times, and 
had each time precisely the same kind of attack, with the same symptoms, precisely, 
as I heard. He died at his own house at last, at the age of eighty-five. These were 
attacks of mania, very similar in character during the whole of his life. 
We are all familiar with many patients who go round the circular ground from mania 
to melancholia, from melancholia back to mania, and, as I need not tell you, these 
do not follow one upon the other-so that it may be said that the attack of mania, 
on account of the exhaustion produced by it, culminates in an attack of melancholia, 
-but we often find a considerable period of convalescence between the two. A 
patient recovers from an attack of mania and remains for a time perfectly well, but 
the next time he falls ill with melancholia; he recovers from that in the same way, 
and then again there is a period of convalescence; but then there does not come 
another attack of melancholia, but an attack of mania, afid so he goes round in the 
way so familiar to all of you, and that constitutes the folie circulaire. Now it would be 
very interesting if we could bring Dr. Clark's theory to bear upon that, and if he 
will tell us how to account for these different manifestations of mental symptoms. 
Dr. Clark.-I may say that my experience in insanity is somewhat different 
from Dr. Blandford's. I never yet saw an intermission in foïie circulaire when the 
patient had normal mental health. There are fluctuations in the man's mental con- 
dition, sometimes higher, sometimes lower. In these intermissions of so-called com- 
parative health they seem to have stored up a sufficient supply of psychic energy to 
appear well, but in my experience they are never the same. 
Dr. Savage.-I perhaps may not have had sufficient physiological instruction, 
but when I hear of animal magnetism it means to me that force related to hypnotism, 
about which we know very little-which is not at present defined. The force re- 
ferred to here by Dr. Clark is not a satisfactory thing to me. There is another thing 
to which he has referred. He stated that the brain and cord may be in a creamy 
condition, and yet there may be no serious lesion. All I can say is that my experi- 
ence, which has been somewhat extended as far as post-mortems are concerned, is SECTION XVII-PSYCHOLOGICAL MEDICINE. 
271 
that, if my post-mortem is made sufficiently early, or if the patient has been dying 
very slowly, if I found a creamy condition of the nervous centres I should be 
very much in doubt as to whether it was a post-mortem result-taking post-mortem 
in the largest acceptation of the term. I do not fully understand what is meant by 
this animal magnetism. This question of correlation of forces was written upon by our 
English Justice Grove, and of course it is a very important thing. We are taught 
nowadays that there is only one force, and therefore if there are manifestations of 
all kinds there must be correlations of the one force. Of course one believes that 
there are interchanges, that chemistry and electricity are modifications of some kind 
of force, and we are. all prepared to accept that what we call vitality is a combination 
of all these forces. I cannot accept as a statement of fact that the insanity I see 
answers in any way to the alterations that have been described by Dr. Clark. First 
of all we have the alternations Dr. Blandford has described. I see men who once in 
five or six years, from similar causes, go through the same set of performances. One 
man I know of will be ready at the end of a fortnight now to tell me a very inter- 
esting history. I have three of them-almost word for word the same histories. I 
can prophesy now that in another week he will smoke leaves and tell me they are 
better than tobacco, and so the whole thing moves on. It does not go up and down ; 
it moves on in anything but a vibratory way, and I cannot at present understand 
any relationship between that process, which is to my mind an automatic action 
that has been established during some period of his past life, rather than the result 
of any force he has stored up. I say, first of all, that I do not recognize animal 
magnetism ; second, I do not recognize the class of cases as described ; and third, 
there are certain cases in which complete remissions take place as Dr. Blandford has 
said. I emphatically say complete-that there are cases in which the manifesta- 
tions are circular, if you will, in which there are as complete remissions as it is pos- 
sible to have. Then again there are remissions of most complete description in cases 
where there is organic disease which is progressing to a fatal end ; cases of general 
paralysis of the insane that are going down hill as steadily as they can. One such 
case I remember very well, and I shall be very glad to contribute the material to Dr. 
Clark if he so desires. This was the case of a man who, ten years ago, had all the 
marked symptoms of general paralysis of the insane. He was looked upon as dying, 
and his wife was with him. He had developed an enormous carbuncle between his 
shoulders. Now, instead of dying, he had such a complete remission that he was 
granted leave of absence, and afterward demanded a restitution of his civil and 
other rights, and appealed to the Lord Chancellor in the matter. For seven or eight 
years he lived in good health, and only died two years ago, of some nervous com- 
plaint, while under the care of Dr. Ferrier. That there should be such complete 
remissions in not only acute cases, but in those with progressive degeneration, I can- 
not see is explained by this force spoken of by Dr. Clark. If this force is the 
result of a battery, and if this battery itself is wearing out, I do not see how it is 
possible that, the battery having more than half worn out, the force of animal mag- 
netism is still acting as well as it did before. But there is an old saying that a fool 
may often ask a question and a wise man find it difficult to answer. 
Dr. Ferguson.-Dr. Clark has in connection with the remissions and intermis- 
sions of insanity brought forward the idea of cyclical or recurrent movements as a 
means, as it were, of explaining these intermissions or remissions, and then in con- 
nection with that has advanced some thoughts as to the cause of cyclical or 
rhythmical movements. There are certain things in the physical world as well as in 
the mental world in which a wall is raised and it may be said-thus far and no 272 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
further. Occasionally if we break over this it is only to find another wall. We 
may speak of a certain irritation as causing a muscular movement or movements, 
but I believe, in its essential nature, the movement itself is one of the unexplained 
phenomena. The Doctor comes forward with the idea of electricity, somewhat in 
the form of a trinity, and although some portions of his notions of it may be 
tangible to us, other portions are more or less metaphysical. Dr. Clark, however, 
forms a unity, from his trinity of force, comparable to some notions of a unity of 
matter. I believe the natural result of such a conception of unity is the idea of 
absolute rest. 
Dr. Hughes.-Mr. Chairman and Gentlemen: We have to bear in mind in 
considering the organisms in our mind the fact that there is a vasomotor organism 
whose physiology, although now dimly seen, is yet probably destined to furnish 
explanations far beyond our present ken in neuro-pathology and neuro-psycho- 
pathology. In nature there is no vasomotor organism. Here it seems to me is a 
stumbling-block in the way of accepting the conclusion of this paper. I shall speak 
to the question of the recurrence of mental aberration, and to add my humble testi- 
mony to the undoubted fact-so far as the best of my judgment has been able to 
determine-of the restoration from insanity in cases of folie circulaire. I have 
been accustomed in my own mind to invoke in explanation the existence of a vaso- 
motor mechanism, and to assume that the explanation existed in the fact that 
the insanity in cases of folie circulaire was mainly one of a vasomotor mechanism, 
and that the control of the vasomotor mechanism over the arterioles touched differ- 
ent psychical centres in the recurrent forms of folie circulaire. This, in the present 
state of our neuro-pathology and neuro-physiology, is but a conjecture, but still, 
how much more of our knowledge is conjecture? 
In regard to general paresis, within the past year one of my patients, a case of 
general paresis resulting from syphilitic destruction, made a valid will-it possessed 
all the attributes of validity according to legal tests-and made a distribution of his 
property as he had intended to distribute it before he suffered from mental disease. 
The great obstacle in the way of discussing Dr. Clark's paper is the barrier which 
physiology has placed in the way of allying physical organism with chemical organ- 
ism, and which consists in the vasomotor mechanism and the part which it plays in 
neuro-pathology and neuro-physiology. 
Dr. Clark.-I am glad that my paper has elicited so much discussion. The 
gentlemen who have discussed the paper will notice that while I have made a key to 
try to open the lock, they have applied no key at all. The question is-what is the 
explanation of this subject? I have tried to say what it is. I may say that I do not 
hinge upon galvanism in my arguments. I only take that as the last of a descend- 
ing series, chemical force, vital force, and animal magnetism. Simply to nail these 
arguments against the last of these is not exactly fair. I can only say, if you can 
present anything to account for this peculiar form of insanity, let us have it. 
I may say here that I do not believe that any man ever recovers exactly from 
insanity. I do not believe that any man who has had physical disease in his brain- 
footprints of which are found there after death as they are in any part of his 
body-has ever the same functional activity as before the onset of this disease. 
He may do his business well, he may seem well to his friends, and to keenest 
observers the same, but I have inquired of dozens upon dozens of these men who 
have apparently recovered, and have heard something like this : I am not the same 
man that I was before I was insane. Recovery is only a relative term, which means SECTION XVII PSYCHOLOGICAL MEDICINE. 
273 
that he has come back to continuity of thought, ability to hold on to a mental group 
as he did before. But patients tell me that they never come back to the same 
mental power they had before the insanity came on. That is the experience of 
many alienists with whom I am acquainted, as well as my own. 
OCCUPATION IN TREATMENT OF INSANITY. 
OCCUPATION DANS LE TRAITEMENT D'INSANITE. 
ÜBER BESCHÄFTIGUNG IN DER BEHANDLUNG DES WAHNSINNS. 
HORACE WARDNER, A.M., M.D., 
A life spent in aimless idleness is a life of morbid discontent, even in the midst of 
luxurious surroundings. This is true, as we all know, of people in the sane world, 
and it is likewise true concerning the insane. 
It is a well-recognized physiological fact that the systematic exercise of the muscles 
is essential to a proper growth and development of the physical powers ; and the same 
is true in regard to the development and strength of the mental faculties. The best 
results are obtainable only when both the physical powers and the mental faculties are 
properly and systematically exercised within the limits of the powers of endurance, 
but without excessive fatigue or exhaustion. All will agree that this is true of persons 
who are in their normal state of health. 
It is also a well-known fact that the proper exercise of a part that is recovering from 
an inj ury caused by violence or disease is an essential element of the treatment after a 
suitable period of quiescence, during which there is a readjustment of tissues. 
The individual parts under the readjustment may not bear the same relation to 
each other that they did before the injury or disease affected them. The movements of 
such injured part may .not be the same as they were before. It may be crippled in the 
performance of its functions, and its usefulness may be greatly impaired. Judicious 
exercise of such an affected part is, however, essential to the restoration of its func- 
tions. Without such exercise, a limb, for example, that has been fractured would, in 
time, suffer atrophy, and its usefulness would be entirely destroyed. 
In recovering the functions, there will, in a large proportion of cases, be a deviation 
from the normal action, depending upon the alteration of the tissues from loss of sub- 
stance, the presence of adventitious matter or change of relation and adjustment. 
These facts are as true concerning the brain and nervous system as of any other 
part of the body. 
Insanity is the result of injury from violence, or from disease, either functional or 
structural, by which the operations of the mental faculties are disarranged, perverted 
or paralyzed. 
The treatment of acute mania is analogous to that of an injured limb, both requir- 
ing restraint, rest and suitable medication during the period of exaltation, as indicated 
by the inflammatory action in one case, and by the abnormal and excited mental action 
in the other. 
The analogy may be traced through subsequent stages; but it is the stage of conva- 
lescence with which we are at present most concerned. It is during this period that 
Vol. V-18 
Of Anna, Ill, 274 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
we attach the greatest importance to such occupation as will interest the patient and 
divert his thoughts from himself and his imaginary troubles. 
With the commencement of the stage of convalescence, when the patient begins to 
recognize his surroundings and realize the fact that he is under the care of other per- 
sons and is deprived of his liberty, he becomes discontented, and grows weary of the 
restraint of hospital life, and longs for his freedom and his home. He cannot under- 
stand why he is kept under surveillance, and is likely to attribute sinister motives to 
his friends and the attendants. Somebody is doing him injustice for selfish ends. 
Being relieved of all personal responsibility, and his life being regulated for him, he is 
left to the contemplation of himself and his imaginary troubles. If left in idleness he 
dwells upon the wrongs that he thinks have been inflicted upon him, and continues a 
prey to his delusions until they may become fixed; or he may dwell upon the subject 
of his home and family, who are, as he believes, unjustly deprived of his society and 
help. 
If his returning energies during convalescence are repressed and not permitted to 
gain strength by proper exercise, the ennui becomes depressive, and he may sink into 
a condition of listless inactivity or dementia. 
It is at this stage of his case that diversion and occupation should be made avail- 
able for his benefit. He should be encouraged in every way to think upon subjects 
outside of himself, and muscular exercise in the form of some light work in which he 
can become interested and to which his thoughts will be diverted, is the most suitable 
aS a hygienic and therapeutic measure. 
With no effort of this kind at this stage of his disease the patient will in no great 
period of time show the effects of such neglect. The scope of his mental life will 
shrink, and the brain and muscular system will become weaker, until he reaches a con- 
dition of permanent debility from which he may not be reclaimed. 
Here the analogy holds good as between the treatment of insanity and the treatment 
of other forms of somatic injury. 
But all patients do not recover. In fact, the majority become chronic and incur- 
able. With all the efforts that can be made in their behalf, some must pass into the 
state of dementia, in which they are incapable of any intelligent action, while others 
will retain a certain degree of mental capacity that suffices for some kind of useful 
occupation. They will, however, be found to have suffered loss of certain faculties and 
a weakening of others, and mental action will remain crippled during the rest of their 
lives. They undergo, as it were, a reorganization upon a lower plane of mental life. 
Occupation or labor not of a severe character is essential to the welfare and happi- 
ness of this class of patients. 
I select a few cases from among the many to illustrate more fully this idea:- 
CASE I.-P., age thirty-nine, was a man born with an insane temperament, who 
had received a fair degree of mental training. He was educated to a profession and 
had been successful in its practice. 
Under the influence of a growing hallucination that it was his duty to preach, he saw 
the Holy Ghost, one night, who commanded him to give up his profession and assume 
the duties of an evangelist. He obeyed the mandate of the spirit, and demanded ordi- 
nation and consecration, which he obtained. But the devil laid snares for him and his 
mental troubles increased. His eccentricities led him into various errors and excesses. 
He formed a strong and controlling delusion concerning his wife, against whom he 
manifested the bitterest of feelings. He broke up his family, and after a short but 
checkered and stormy career lost all self-control and was placed in a hospital for the 
insane, where he remained for many years suffering under the weight and torture of 
his delusions, which assumed different forms and degrees. However, after five or six SECTION XVII-PSYCHOLOGICAL MEDICINE. 
275 
years the mental excitement had sufficiently subsided so that he took kindly to the 
suggestion of light occupation in one of the departments of the hospital, an occupation 
with which he had had some familiarity in his boyhood. 
He worked in this way more or less of the time for several years, and became quite 
proficient and skillful, and was trusted with the management of the department. 
Although his delusions had become fixed, they were gradually more or less buried, 
and ceased to control his daily thought and action, and he began to think more of the 
world at large and his relations thereto. The idea of freedom and independence gradu- 
ally grew upon him. He began to realize that his services were of value, and he 
became clamorous for compensation. This was an expression of natural feeling, and 
was considered as indicative of returning reason. 
He became confident that he was capable of taking care of himself, and, without 
waiting for official sanction, acted upon the idea that his time had come to leave the 
institution, and, taking advantage of a favorable occasion, left the place, and rested not 
until he had put himself outside of the jurisdiction of those who had power to arrest 
and detain him. 
After various struggles for about one year to gain a livelihood, he finally settled 
down to the work he had followed at the hospital, opened a small shop and eventually 
established himself in a fair business, which he has conducted regularly and with fair 
success for several years. He has lost all interest in his former profession, has sunk it 
in the ocean of forgetfulness, as he has also the idea that it is his duty to preach. 
His life has, in fact, been rearranged on the plane and basis of his early experiences, 
and he is as happy and contented as the average of humanity, except, perhaps, an 
occasional disturbance when something occurs to bring to the surface a memory of his 
buried delusions and troubles. 
I have no doubt that had this man been kept in idleness in the wards, he would 
now be a hopeless dement, or have fallen a victim to fatal disease. 
Case II.-W., a school teacher, aged fifty-three, became insane through pressure 
of domestic affliction, and was committed to an asylum. For more than three years he 
was in dense mental darkness and governed entirely by his delusions. He was greatly 
excited and was considered a bad case. In time, the abnormal excitement gradually 
subsided and he was capable of some small degree of self-control. There came sufficient 
rays of returning mental light to enable him to realize that something was wrong with 
himself, but everything appeared to him as dark and hopeless, and he constantly 
lamented the great misfortune that had overtaken him. At this point he was encour- 
aged to think of other things and to do something that would be useful to himself and 
others. 
By a few hours' light work each day, he became in a few months time so much 
improved that it was deemed safe to trust him with the liberty of the grounds on 
parole. 
His inclinations taking a turn for thrift, he was encouraged, by promise of a reward 
for his labors, to prosecute the destruction of rats and other pests of the institution. 
He became much interested in the pursuit of this work, and was a great benefit to 
the institution, and the diversion was a much greater benefit to himself. He gradually 
regained the control of his thoughts and emotions, and came finally to regard himself 
as having been insane. By his efforts he showed clearly that he had the ability to take 
care of himself. He reasoned well, and was correct and clear in his business transac- 
tions. 
About this time he was sent away from the hospital on furlough, and placed upon 
his own responsibility. He continued to improve, overcame his delusions and preju- 
dices, and was regarded as recovered, and was so discharged. 276 
Without the encouragement to the exercise of his mental faculties in connection 
with physical exercise, there is no doubt in my mind that he would still be an inmate 
of the hospital and still be under the influence of his delusions and enveloped in mental 
darkness. 
Differing in result from the foregoing, the following cases are typical of a class that 
may become useful under proper care and guidance :- 
Case hi.-K., aged thirty-seven, was a night watchman who had become insane, 
as was supposed, from want of sleep and religious excitement. His insanity was of the 
maniacal form. He made several attempts at homicide before he was committed to the 
hospital. 
After some years, when the maniacal excitement had somewhat subsided, he was 
encouraged to assist about the farm ; but it was a long time before there was sufficient 
self-control to enable him to do anything in a proper manner. As his homicidal 
impulses ceased, he was permitted to go about the premises, and was induced to help 
take care of the young stock. 
This proved to be the occupation that fitted his case. He began to take an interest 
in it, and eventually became a very useful man. The young cattle are his daily com- 
panions, and no one could be more faithful in the care of them. 
He has forgotten wife and children, and apparently all the past. Conjugal love, 
paternal affection and all the ambitions of his former life are dead. He is only a rem- 
nant of his former self, but his remaining faculties have been readjusted to fit the 
environment of a new life-a life reorganized ou a lower basis and very limited in its 
range of thought. 
Case iv.-Mary D., spinster, aged thirty-three. Prodromic symptoms were noticed 
for a period of three months before acute mania developed, which lasted more than 
three years. 
From the exhaustion resulting from long-continued excitement, she was to all 
appearances passing into a stage of drooling dementia, when the attending physician 
made an effort to kindle into activity what little spark of intellect there might be left. 
He attempted to engage her in the common game of checkers. She had no concep- 
tion of the game. It was necessary to take hold of her hand and aid her to move the 
pieces. Little by little she began to understand, and eventually became a rery fair 
player. She was also, as she improved, given some light, easy work to do, under the 
care and direction of an attendant. 
At the end of three years of this kind of care and exercise she was capable, under 
supervision, of doing ordinary work in a very fair manner, could talk with some degree 
of intelligence, regained her self-control to such an extent that she could act in harmony 
with the environment of hospital life ; but on being taken to her home on a trial visit, 
it soon became evident, when this restraint was removed, that the mental machinery had 
lost its governor, and that the régime of an asylum is necessary to keep her impulses 
and actions under proper control. 
These cases represent classes of cases found in every asylum. The first presents an 
example of those cases in which the delusions are buried, at least for the time, but may 
retain a slumbering vitality that may be awakened into activity by certain exciting 
causes. 
This man does not acknowledge that he has been insane. His delusions are fixed, 
and while he has learned to conceal them, in deference to the opinion of others, his belief 
in them as realities is as firm as ever. This may be easily awakened by a well-directed 
question or by conversation directed to awaken his suspicions. 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
277 
The safety of this man's future will depend upon the absence of such exciting causes, 
and an environment calculated to keep the mind in channels of thought that will lead 
away from the contemplation of his delusions. Occupation in which the patient will 
be interested is the only resource in his case. 
In the second case we observe a recovery after a long period of convalescence. 
This man recognizes the fact that he has been insane. He has corrected or con- 
quered his delusions by rational processes. In his case employment was the best of 
therapeutic agents, and was the means of accomplishing what drugs could not do. 
In case number three we observe the loss of mental powers that in many cases follows 
an attack of insanity. But this loss does not extend to the condition of dementia. It 
is, to a great extent, a loss of adjustment. The rearrangement of the mental forces on 
a lower plane and with narrower scope is such as to render him a very useful man under 
proper oversight. 
The fourth case represents a large class of the chronic insane who become amenable 
to the régime of hospital life, under which they may render some useful service, but 
are without rational and self-guiding powers when removed from this controlling 
environment. 
In all these cases employment is an important factor in effecting a cure or modifying 
the course of disease. 
Comments on the subject of occupation for the insane have appeared of late in many 
of the reports of the superintendents of the American asylums. The following extracts, 
taken from these reports, show the tendency of American thought at the present time:- 
Dr. C. W. King, of the Dayton Asylum, says: "Insanity, being largely a functional 
disturbance, frequently independent of organic lesions, the rational remedy in such 
cases would be to furnish healthful exercise to the organ whose functions are disturbed, 
and to prescribe such employment as will best meet the requirements of each case and 
most thoroughly divert the patient's mind from thoughts of himself and his condition. 
"Functions of the brain, as well as those of the muscles, are impaired by inactivity, 
and no patient who has not degenerated into chronic dementia should be permitted to 
remain in a ward from day to day and week to week unemployed ; no doubt many 
cases have been lost where, if proper employment had been supplied in the beginning, 
they might have been saved." * 
Dr. C. M. Finch, of the Columbus Asylum, says: "The prime object should be to 
throw around the insane an environment of agencies which has for its objects the 
attainment of mind diversion, mental employment and bodily exercise of a proper 
kind and quality sufficient to secure and maintain physical health." f 
Dr. W. W. Godding, of the Government Hospital for the Insane, says: "Whatever 
may be exceptionally true of the need of rest and the avoidance of all mental applica- 
tion in some acute, and, rarely, some recurrent cases, the fact remains that with our 
inmates the best road to quiet content, if not to cure, lies in the regular occupation of 
body and mind, with some work not too hard of comprehension nor too taxing to the 
strength in its performance. 
Dr. James Olmstead, Inspector of Asylums and Public Charities, Province of Onta- 
rio, says: "When acute symptoms are succeeded by convalescence, and when the 
disease has passed into the chronic and incurable state, the foremost question is: "What 
can be done to divert their attention from hallucinations, to stop them from nursing 
their delusions, and to aid them to retain at least a remnant of intelligent activity ? 
* Dr. C. W. King. " Thirty-first Annual Report Dayton Asylum for the Insane, Ohio." 
f Dr. C. M. Finch. " Forty-seventh Annual Report Columbus Asylum for the Insane, Ohio." 
J Dr. W. W. Godding. "Thirty-first Annual Report of the Government Hospital for the 
Insane, Washington, D. C." 278 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Occupation here becomes an element of treatment which receives increased attention 
from year to year, as the old shackles of mechanical restraint drop off."* 
Dr. A. H. Knapp, of the Osawatomie Asylum, observes that "the good effects of 
regular work are forcibly illustrated by the contrast presented, not only in the physical 
but mental condition, when accustomed exercises are suspended during the winter 
months. When our outside working force goes into winter quarters, and have nothing 
to do for three or four months, it becomes interesting, and in a few cases painfully so, 
to note the individual changes which take place. All grades of mental worry and 
discontent, a gradual return of vicious propensities, depression and excitement, a capri- 
cious 'appetite, loss of sleep, loss of flesh and strength, are noticeable changes which 
occur in a greater or less degree with many of this class of patients. On the contrary, 
those who are furnished regular employment the year round are exempt from the reac- 
tionary mental and physical changes mentioned as affecting those who are, by force of 
circumstances, deprived of work for several months in the year. As a rule, those who 
go out to work regard it as a privilege which carries with it at least an implied obliga- 
tion to place themselves upon their good behavior. This aids and strengthens their 
power of self-control, and helps to lift their deranged minds from the ruts and grooves 
into which real or imaginary troubles invite them, enlarges their sphere of thought 
and observation, and, with all who are susceptible of recovery, operates as a powerful 
factor in restoration. "f 
Dr. G. B. Chapin, of the Pennsylvania Hospital, says: " Even work of a continuous, 
monotonous character leads to the formation anew of habits of industry which become 
fixed and reestablished. " J 
These utterances are all of recent date. They are taken more or less at random 
from a number of reports, in which the subject of occupation is discussed. 
One or two experienced superintendents maintain conservative views on this subject, 
but the current of thought is .against them. 
The conclusions to which we arrive are:- 
First. That occupation is one of the best of therapeutic agents in the treatment of 
insanity, especially during convalescence. 
Second. That it is of the greatest value in diverting the chronic insane from their 
fixed delusions and turning their thoughts into healthier channels. 
Third. That it is the treatment most favorable to a readjustment and equilibrium 
of mental forces from the wreck of acute mania, in which the mind is only partially 
destroyed. 
Fourth. That while it is applicable to the treatment of nearly all cases of insanity, 
its use requires good judgment, more especially in the acute forms of mania. 
Fifth. That it should be considered as an essential element in the organization and 
administration of hospitals for the insane. 
* Dr. James Olmstead, Inspector of Asylums and Public Charities, Province of Ontario, 
f Dr. A. H. Knapp. " Fifth Biennial Report of the Osawatomie Asylum, Kansas." 
J Dr. Gr. B. Chapin. "Annual Report Pennsylvania Hospital, 1886." SECTION XVII PSYCHOLOGICAL MEDICINE. 
279 
TREATMENT BY OCCUPATION IN AN ENGLISH PRIVATE ASYLUM. 
TRAITEMENT PAR L'OCCUPATION DANS UN ASILE PRIVÉ D'ALIÉNÉS EN 
ANGLETERRE. 
ANWENDUNG DER BESCHÄFTIGUNG IN EINER ENGLISCHEN PRIVATIRRENANSTALT. 
BY DAVID BOWER, M.D., 
Of Bedford, England. 
Mb. President and Gentlemen :-I bring before you this subject very shortly, 
and with the hope of eliciting discussion and hearing suggestions from the members of 
this Section of the Congress. 
It is a matter of common observation among alienists who have traveled, that 
insanity presents much the same features in all lands, and we may take it that in a 
greater or less degree the types of insanity are the same among the rich as among the 
poor. How then comes it that in a very essential part of the treatment a difference is 
made between the classes and the masses, greatly to the disadvantage of the former. 
So much, however, is this the case that Bucknill and Tuke, in their work on ' ' In- 
sanity," speak of the pauper asylums of England as "hives of industry," and stig- 
matize the asylums for private patients as " castles of indolence." This is a reproach 
which some of us in England are trying to wipe out. 
Some seven or eight years ago I became very much discontented with the usual 
private asylum routine, with its idleness and want of life, as compared with the busy 
routine of the pauper asylums. In the pauper asylum the patient has regular duties 
and work to attend to, much in the same way as he would have at home, and as a 
natural result, he gains in bodily health and in greater mental rest and quietness. In 
private asylums, on the contrary, the patient is usually left without regular employ- 
ment, and with merely a continual round of forenoon and afternoon walks, with bil- 
liards, cards, dancing and such like amusements in the evenings. Now, 1 am far from 
underrating the benefits of a good sharp walk, or of a well-filled programme of amuse- 
ments, but I thought something more was wanted, and determined to try whether 
patients of the professional and middle classes could not be induced to do some regular 
work in addition to their walking exercise and amusements. 
I had a little difficulty at first, but in the course of two years I had got the plan of 
occupation in full working order, and found work for all able-bodied patients. So far, 
I have been able to keep this up, and it now gives me practically no trouble, unless in 
the case of patients admitted from other asylums. New patients, when they come in, 
see all the other residents going out to their daily duties, and at once fall in with the 
habits of the place. The advantages of keeping the patients employed are obvious and 
have been ably pointed out by Dr. Wardner. The patients of the better classes them- 
selves like it, and many of them recognize that it is of great service in promoting their 
recovery. I have only lost two patients whose relatives thought honest work deroga- 
tory. 
The kind of occupation I have found of most benefit has been work in the open air, 
in the gardens and grounds, and in tending the cows, rabbits and pigs. In wet weather 
we are able to find indoor-work for many of the patients. Some do fret-sawing, some 
painting, some carpentry, and some chaff cutting, pumping, and other work not of a 
menial character. 
So far, I have found the most suitable occupation for the patients indoors, to be 
copying lawyers' writings-I -can usually get as much copying to do as the patients 
have time for-and I get for the work, when done, the usual law stationers' charges of 280 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sixpence a sheet, which is handed over to the patient to spend in any luxury he may 
fancy. 
For the ladies, indoor work is easily found; they do sewing, knitting, fancy work, 
china painting, etc., and those who can be trusted, go into the housekeeper's room and 
help to prepare fruits, preserves and puddings. One lady patient, indeed, serves out all 
the wine for her fellow patients. 
Many other forms of employment are in use, but I will not occupy your time in 
enumerating them. I trust, however, to hear from some of the members present sug- 
gestions as to suitable and novel forms of employment. 
In more than one asylum on this continent I have seen patients spinning and 
making brushes, and I hope to introduce these industries on my return to England. 
As to statistics, I am usually able to keep 75 to 85 per cent, of the male patients at 
work for two and a half or three hours daily, and they have still time for a daily walk 
or drive and for tennis, billiards, cards and other amusements. 
I hear that in several private asylums, in England, attempts are being made to 
employ the patients, also in some of the lunatic hospitals taking patients of the private 
class, notably at St. Andrews, Northampton, where a large farm has been acquired, 
and where Dr. Bayley has been able to employ as many as one-third of his male 
patients. 
I should much like to hear the experience of those superintendents on this side the 
Atlantic who have been able to employ patients of the better classes. 
DISCUSSION. 
Dr. Andrews.-I would like to say one word upon this subject. It is now some 
ten years, I should say, since a great deal was said about the great amount of occu- 
pation that was made use of in English asylums, and we in America were read very 
strong lectures about our remissness in not making use of occupation to a greater 
degree. I think that at that time there was some justice in the comments that were 
made. Occupation did not then hold the place it does now, nor that it did in English 
institutions. My own judgment is that in neglecting it we deprived ourselves of a 
great means of treatment and certainly of enjoyment to our patients. At the present 
time I think this is entirely changed. I think that the importance of occupation is 
now as fully recognized with us as it ever was abroad. Years ago, when I used to 
note the large percentage of patients employed in some of the English asylums, I 
questioned in my own mind whether those statistics were really honest and correct. 
But after years in making use of occupation, and in having an opportunity to control 
the matter, I fully believe that those statistics were correct. At present we are able 
to employ from 75 to 77 or 78 per cent, of all the patients in the Buffalo asylum, and 
I do not know that it is anything specially different from other institutions. I do not 
think we can over-estimate the importance of occupation. The directions in which it 
benefits the patients are, of course, obvious to every one. I believe that every one is 
happier for work, whether he be a rich man and able to pay large sums for his care, or 
whether he be a pauper, and I believe that the more fully occupation can be given 
him, within moderate and proper limits of physical and mental condition, the better 
and happier the patient will be. 
Dr. Ellis.-Doctor, can you tell us how you encourage your patients to 
work? 
Dr. Andrew's.-It is done entirely by moral measures. I endeavor to make 
every one understand that he is expected to work, and that it is the proper thing to SECTION XVII-PSYCHOLOGICAL MEDICINE. 
281 
do. We have never yet given any payment for services performed, and when that 
has been broached I have always said to the patient : You get the best end of 
the bargain altogether ; you are improved by the occupation, and you ought to be 
thankful for the opportunity that we are able to provide something in which you 
are enabled to expend your energies; your health and your happiness are promoted 
in every way, and it is you who receives the benefit. Throughout the asylum there 
is an influence, a spirit of that kind, which simply by its own weight brings about the 
result. 
MONOMANIA AND ITS MODERN EQUIVALENTS. 
MONOMANIE ET SES ÉQUIVALENTS MODERNES. 
ÜBER MONOMANIE UND IHRE MODERNEN ÄQUIVALENTE. 
BY THEO. W. FISHER, M.D., 
Boston, Mass. 
The term, monomaniac, as applied to certain forms of partial insanity, has been in 
use about fifty years. Esquirol first employed it in 1838 ("Maladies Mentales ") as 
descriptive of that form of insanity in which the mind is generally sound, and no great 
emotional disturbance exists, while the patient is controlled by some expansive delusion 
or ambitious project. It is well known, however, that this form of insanity has existed 
and been observed almost throughout the historic period. 
No class of lunatics have in all ages so caught the popular attention as monomaniacs. 
This they have done by reason of their methodical madness, so to speak; their systema- 
tized delusions being acted on with a certain amount of design and deliberation. Their 
general soundness of mind in contrast with their extravagant ideas upon some particular 
subject, and their often picturesque, although absurd conduct, has always greatly 
interested the idle fancy of the public. For different reasons no form of insanity has 
more attractive features for the student of mental disease than monomania. It shows 
delusion so gradually evolved from the normal processes of mind as to be easily observed ; 
in short, it often shows insanity in the making, as a gradual perversion of the physio- 
logical functions of the brain. 
Historical examples have been numerous, from the time of Joan of Arc to that of 
Guiteau, showing the power of a monomaniac to change the current of events and to 
make a new bit of history. In early Christian and mediaeval periods demonomania was 
extremely common, and as Ribot states (" L'Hérédité, "p. 177), was often hereditary in 
kind from generation to generation. Wandering Jews were also numerous, being pos- 
sessed of the delusion that, having taken part in the persecution of Christ, death was to 
them impossible. To the present day false Christs, or better, imaginary Christs, Virgin 
Marys, prophets and apostles are abundant in all Christian lands. The power of these 
monomaniacs to affect the history of their times is rapidly passing away in all civilized 
countries. Their influence, usually for harm, is still felt to a surprising degree among 
the ignorant and superstitious in remote or semi-civilized lands. 
Lady Hester Stanhope, in the present century, so impressed her insane claims, in 
relation to the second coming of Christ, on the natives of Syria as to acquire the title of 282 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
'1 Queen of Lebanon. ' ' Lamartine gives an excellent account of this famous mono- 
maniac, in his ' ' Voyage en Orient. ' ' 
Italy has, within ten years, seen the advent of a Messiah who, for several years, 
persuaded the peasants of a mountainous district of the truth of his claims. The 
national army was at last required to overcome his deluded followers, who had risen in 
revolt against the State. 
History constantly repeats itself, and instances like the above are numerous. Take 
the rebellion of Riel, the French-Canadian half-breed, as the very latest. Little doubt 
is entertained now, among good authorities, of Riel's insanity. Since his execution 
several papers have been written expressing this opinion. One by Dr. H. Gilson (L' 
Encéphale, January, 1886), entitled "A Study of the Mental Condition of Louis Riel," 
and one by Dr. Daniel Clark, of Toronto, read before the Superintendents' Association 
at Detroit, on the same subject. Riel is shown to have conducted his military operations 
under the direction of angels whose voices he constantly heard. He claimed to hare 
been ordained by spirits to celebrate mass, and publicly rebuked priests at their own 
altar. 
The career of El Mahdi is still fresh in the public mind. He was no doubt inspired 
by an insane belief in his own pretensions. Even General Gordon, who was sent against 
him, had something of the religious monomaniac in his composition. The insanity of 
Guiteau was, and perhaps still is, an open question. Its thorough discussion at this 
time and place might lead to inharmonious debate. The writer, however, with many 
other better authorities, never doubted for a moment that he was insane. The form of 
his insanity was the only point in doubt. I am now of opinion that his case was one 
of monomania, or primäre Verrücktheit. 
I should hesitate to dwell on this popular aspect of my subject if it were not essen- 
tial to a complete picture of the disease in question. A learned and eloquent clergy- 
man once asked me if " exaltation of the ego " was not the essence of all insanity. It 
certainly was the essential feature of his own case when he afterward became insane, 
and it often is so in cases of monomania. So thoroughly does the monomaniac believe 
in his delusions of self-importance, that he bends all the remaining powers of his mind 
to demonstrate and enforce them. Often men of great intellectual attainments, of 
original mental vigor, of a high degree of genius, even like Swedenborg, are the sub- 
jects of this malady. Their influence for evil is correspondingly great. 
The definition of monomania has been constantly changing, from the time of 
Esquirol to the present. He defined it as " that form of insanity in which the dis- 
order of the faculties is limited to one or a small number of objects, with excitement 
and predominance of a gay and expansive passion." 
Baillarger and other French writers showed that the emotional disturbance in 
monomania was sometimes melancholic under the depressing effect of painful or perse- 
cutory ideas, and the definition was enlarged accordingly. 
Pritchard said that intellectual monomania usually grew out of a single morbid 
perception. Delusion based on a single false conception the French writers called a 
"fixed idea." The latter authorities, Baillarger says, "were agreed in using mono- 
mania to designate all cases of partial delirium, with a dominant series of ideas, what- 
ever may be the accessory phenomena. ' ' 
It was soon seen by Esquirol himself, as well as by other followers of the psycho- 
logical method of classification, that there was a partial emotional insanity, and a par- 
tial derangement of the instinctive faculties. Hence came the terms affective and 
instinctive monomania. Pinel's reasoning madness or mania sine delirio, and Pritch- 
ard's " normal insanity," might have been classed under these heads. 
In spite of these changes the term monomania has been retained. There has 
always existed, however, among alienists as well as others, much confusion of mind as SECTION XVII-PSYCHOLOGICAL MEDICINE. 
283 
to its exact definition. Some mean by it a fixed idea; some partial exaltation, or sim- 
ple mania; some a single morbid impulse. The mistake has been made of regarding a 
single one of the faculties of mind as disordered, in monomania. This idea Bay very 
properly refutes ("Juris, of Insanity," 1871, p. 200). Maudsley also says, in defending 
the unity of mind, " that the mind is not unsound on one point, but an unsound 
mind expresses itself in a particular morbid action " ( ' 'Reynolds' System of Med., ' ' 1872, 
p. 30, Vol. ii). 
Another common error has been the confounding of monomania with depression 
consequent on persecutory delusions, and melancholia with delusions of persecution. 
This error is natural unless the case is studied with reference to its origin. In mono- 
mania the delusion is primary and the emotional disturbance is expansive or depress- 
ive in accordance with it. In melancholia the delusions grow out of a permanently 
depressed state of mind. 
Monomania finally came to include all partial insanities characterized by any pre- 
dominating delusion, emotion or propensity. There seemed to be a monomania for 
subdivision and minute classification, on the part of some German writers, so that every 
morbid impulse or insane act had its own designation. The list is well known, from 
dipsomania to "Frauenschuhstehlmonomanie." Spitzka very properly remarks, while 
condemning this absurdity, that ' ' these terms have a definite meaning and 
position in science secondarily " ("Insanity," p. 287). Weuse the terms homicidal and 
suicidal mania, dipsomania, etc., with a tolerably definite idea of their meaning and 
limitations. 
Among the first to rebel against this artificial classification was Moreau. He says, 
"We are mad or we are not mad." Falret, père, prefers the term partial expansive 
insanity to monomania. Sankey ("Lectures on Men. Dis.," 1866, p. 85) says the popular 
opinion about monomania is erroneous. He thinks it best to drop the term and use 
chronic insanity instead. Griesinger ("Mental Dis.," 1867, p. 74) says " the establish- 
ment of a class monomania in distinction to mania, relating less to the existence of a 
single fixed idea than to the one-sided dominion of a particular impulse, is not to be 
approved of." Ray and others confined the use of this term to those rare cases of single 
delusions, growing out of perverted organic sensations, or to melancholia with a single 
delusion. 
From this state of unmerited neglect and misunderstanding the disease in question 
has sprung into importance again. Spitzka, in his recent work, devotes two chapters 
to it. Clouston is equally appreciative, and devotes an entire lecture to ' ' States of fixed 
and limited delusion," which he groups under the head of monomania or monopsy- 
chosis ("Lectures on Men. Dis.," 1884). Spitzka assigns to Morel the credit of having 
first called attention to the intrinsic nature of the delusion in monomania, viz., its 
systematized character. He says we owe to Snell and later German authorities ' ' a 
clear demarcation of the systematized insanities as a whole, under the designation 
primäre Verrücktheit.'' The main fact which they determined was that these system- 
atized insanities are of primary origin and not secondary to other psychoses, as Grie- 
singer and the followers of that eminent alienist believed. He further says that 
Griesinger, shortly before his death, recognized his error and formally accepted the 
doctrines of Snell. In 1883 the Association of German alienists passed a resolution 
recognizing "a primary form of chronic insanity known by them as primäre Verrückt- 
heit and equivalent to the monomanie of the French. " He further asserts that Snell 
accepted monomania as a good English equivalent for these terms. 
Folsom ("Am. Syst. Med.," Vol. V, p. 167) avoids the use of the term monomania, 
and substitutes for its various forms the terms primary insanity and primary delusional 
insanity. Primary insanity he regards as a disease of defect and degeneration equiva- 
lent to primäre Verrücktheit. Primary delusional insanity he places among the 284 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
psychoneuroses equivalent to Verrücktheit and folie systématisée. This avoidance of a 
term so long in use seems unnecessary. New meanings and limitations can easily be 
applied to it. At any rate it may be retained until a general agreement is arrived at 
as to what term shall supplant it. The questions, " What are the essential character- 
istics of monomania ? Is it a disease of defect or a psychoneurosis ? Is it primary 
always or sometimes secondary ? ' ' must be answered before a satisfactory name can be 
given it. Folsom does not admit any secondary form of monomania. 
In this he differs from Clouston and many other authorities. Although Snell and 
his contemporaries claimed that all monomanias were primary, the Association of Ger- 
man Alienists merely resolved that there was a form of primary insanity, viz., primäre 
Verrücktheit. Spitzka admits that while in the vast majority of cases monomania is 
based on an inherited taint of insanity or transmitted neurotic vice, it may also develop 
after typhus fever, head injuries, acute alcoholism, etc., in persons entirely free from 
all evidence of inherited or acquired neurotic taint or defect. Great emotional strain, 
the functional perversion occurring in dreams, harping of the mind on one subject, are 
given by Spitzka as causes of the development of monomania. If these causes may 
produce it, why may it not occur secondarily to an acute attack of mania or melan- 
cholia ? 
Clouston says monomania may arise in four ways : (1) It is a gradual evolution out 
of a natural disposition, a proud man becoming insanely proud, or a suspicious man 
passing the border line of insanity with his suspicions. (2) It remains as a permanent 
brain result and damage after mania and melancholia. (3) It follows alcoholic and 
syphilitic poisoning, injuries of the brain, sunstroke, etc. (4) From perverted organic 
sensations and local diseases misinterpreted by a weakened brain. 
Krafft Ebing and Schule, the two most recent German authorities, agree in dividing 
insanity into two classes -first, mental diseases of the normal brain ; second, conditions 
of mental degeneration. They also agree in placing primary monomania among the 
degenerative forms of insanity. Among the psychoneuroses, or diseases of the normal 
brain, each has a form of secondary delusional insanity. This form Spitzka calls 
secondary confusional insanity, and says it has been unfortunately classed with the 
monomanias. He says the mind in this form of insanity loses, as it grows weaker, the 
power to correct the delusions of the primary stage of mania or melancholia, and fixed 
delusions remain as a result of cerebral habit. They are not elaborate nor defended 
with skill and a show of judgment, as in monomania-in short, they are not truly sys- 
tematized. 
Spitzka and Folsom, while following essentially the latest German authorities on 
this subject, differ in regard to the use of the term monomania. The former would 
retain it as an equivalent of primäre Verrücktheit. Verrücktheit corresponds very well 
with our English word "cracked." It means literally "shifted out of place." I 
should say it corresponded equally well with the word " crank," so familiar all over 
the country since the Guiteau trial. Spitzka objects to the term primary delusional 
insanity, as delusion is not characteristic of that form of monomania with which imper- 
ative conceptions and delusions are found in other forms of acute and chronic insanity. 
He also objects to the term partial intellectual insanity, as based on a purely meta- 
physical distinction, and because in monomania there are also perceptional anomalies, 
disorders of will, imperative conceptions, delusive interpretations, systematized pro- 
jects and morbid speculation. He says that episodical scenes of violence in asylum 
wards in the course of monomania are common. The Germans call them primordia 
délirien and the French delire hesanique. 
Monomania presents three principal varieties, viz., (1) monomania with delusions 
of unseen agency, suspicion or persecution ; (2) with delusions of personal exaltation ; 
(3) with delusions of perverted sensations. Although it may sometimes be secondary SECTION XVII-PSYCHOLOGICAL MEDICINE. 
285 
and sometimes arises in a perfectly normal brain, it is usually primary and associated 
with somatic signs of cerebral degeneration, as Morel first taught. It may even be 
congenital, as Sander taught, mental peculiarities existing in infancy and increasing 
with the development of the mind. There is also an abortive form of monomania, as 
Spitzka claims-a reasoning monomania, or monomania sine delirio. In some cases 
only a single morbid impulse or delusive suspicion may exist; an imperative conception 
he regards as a rudimentary delusion. 
Among the most recent writers on the subject are Dr. Ralph L. Parsons and Dr. 
Richard Gundry in America and Dr. J. Séglas in France. Dr. Parsons, in a recent 
paper, advocates the term oligomania {Jour. Nervous and Mental Diseases, Vol. XIV, 
No. 24). Dr. Gundry read a paper on paranoia, which the writer did not hear, before 
the Association of Superintendents, at Detroit, in June. Dr. Séglas, assistant physi- 
cian at Bicêtre, has a very complete paper on "La Paranoia" in the Archives de> 
Neurologie, 1886-7 (Vols, xii-xiv). He describes an acute form of primary halluci- 
natory paranoia, with grand and persecutory ideas, mingling or alternating with 
excitement, followed by calmness and delusions of poisoning, etc. This form may be 
recovered from, or become chronic. 
The chronic form is characterized, above all, by hallucinations. It may follow 
acute diseases, the puerperal state, hysteria or epilepsy, inebriety or the morphia habit, 
according to Dr. Séglas. He says Mendel (1883) admits the occurrence of secondary 
paranoia, and reported three cases following melancholia. He says Amadei and 
Tonsiène ( 1883) describe a degenerative form and a psychoneurotic form. In the lat- 
ter there is an entire absence of constitutional symptoms. The following classification 
is that adopted by these Italian writers. 
FORMS OF PARANOIA. 
I. Paranoia degenerative. 
(A) Original or congenital. 
(a) Simple, with persecutory, ambitious, religious or erotic delusions. 
(&) Hallucinatory, with the above delusions and hypochondria. 
(B) lardy, or developed later in life. 
(a) Simple, etc. 
(&) Hallucinatory, etc. 
II. Paranoia psychoneurotic. 
(A) Primary. 
(1) Acute and curable. * 
(a) Simple, etc. 
(&) Hallucinatory, etc. 
(2) Incurable. 
(a) Simple, etc. 
(ö) Hallucinatory, etc. 
(B) Secondary. 
{a} Post-maniacal. 
(&) Post-melancholic. 
Before considering the subject further I will briefly describe three cases of primary 
monomania, out of a large number which have come under my observation. Such cases 
abound in all our hospitals, and if they are not properly classified and reported, it is not 
because they do not exist. Spitzka thinks one-fourth of all chronic cases are of this 
class. I find 20 per cent, at present in the Boston Lunatic Hospital. Clouston found 87 
out of 822 cases in his hospital. Very few British or American hospital reports, in 
which a table of forms of insanity is found, report any cases of monomania. They are 286 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
probably reckoned as cases of mania. When mentioned the number of cases is usually 
absurdly small. Neither the blue book of the British Lunacy Commission nor that of 
the Massachusetts Board of L. & C. mention it. 
CASE I.-PRIMARY MONOMANIA-NO WELL-MARKED HEREDITY-HALLUCINATIONS 
OF HEARING-DELUSIONS OF PERSECUTION - CONTINUED ABILITY TO TEACH 
SCHOOL SUCCESSFULLY. 
Miss A. B., thirty-three years old, is the daughter of a physician, who denies any 
insane or neurotic heredity. Patient is small and delicate constitutionally. Gradu- 
ated from the Girls' High and Normal School in Boston, and began teaching a primary 
school in that city, at the age of twenty. Has taught the same school to the present 
time, with great success, her class being taken as a model for others. Is very scrupu- 
lous in the performance of all school duties, and gets very much worn out at the close 
of the school year. 
Early formed the habit of reading or preparing her school work late at night. Was 
ambitious to excel and to earn more money, so she took up the study of French, Ger- 
man and short-hand, and for years seldom got to sleep until after midnight. Was very 
obstinate in this course, and disobeyed her father in the matter. She has had only 
about six hours' sleep, rising hastily at eight o'clock and hurrying off to school, often 
without breakfast. She remains at school during the noon recess, eating little and 
practicing short-hand. Eats a hearty supper but gets little exercise. She has a large 
class also in Sunday-school. Her vacations have for several years been spent at the 
West, in company with a religious enthusiast, or fraud possibly, who pretends to starve 
herself to give to the poor, who also teaches short-hand writing and absorbs all the 
patient's earnings by way of tuition. 
The patient admits that all these occupations begin to wear on her. Has pressure 
on the top of her head. Her eyes have given out several times, and at the close of her 
last vacation she found her ability to write short-hand suddenly leave her. For a fort- 
night was unable to fix her attention on it. She gave the writer a long account of cer- 
tain mysterious occurrences at night, which have troubled her for several years. One 
night, three years ago, she looked from her window, which is on a frequented corner 
where five streets come together, and saw a man standing in the street. He remained 
for two hours in one spot. The next night she saw the same man and also a dozen or 
more boys, one of whom hid in a doorway. The next night more men appeared and 
two hid in a doorway. These and other strange actions continued all winter, and she 
spent much time in watching them. Various wfiistles were given as signals; carriages 
driven away; lights appeared here and there; a man leaped the fence of her own rear 
yard. She misinterpreted these common street sights and sounds, and felt that some 
wicked worked was being carried on. 
One night she though t she was observed, and then the movements began to indicate 
hostility to her. Another night she became convinced, by whisperings, soft steps and a 
light which moved up and down, that one of the gang was in the house. Her father 
often came up stairs softly, in the night, and listened at her door, to see if she was 
asleep. She finally summoned courage enough to open her door and listen in the upper 
entry. She thought she heard a pistol click below. She struck a knife against her 
pitcher, to make the intruder think she had a pistol. Then, just as a dark lantern was 
flashed on her, she dashed the pitcher down stairs and ran into her room. 
On her return from the west, in 1884, she found a new servant in the house, and at 
once assumed that she was an emissary of the gang, sent to murder her. She now 
began to hear voices in the street referring to her. A street vendor cried, " Bananas ! 
Fanny ! bananas !" and a teamster said, "Get up! get up!" not to his horses, but to her. 
One of the gang, in the guise of a house painter, looked through her keyhole, and she SECTION XVII PSYCHOLOGICAL MEDICINE. 
287 
prayed to know what to do, getting an answer mentally, " Protect yourself, if you are 
going to !" 
While at the west she consulted a lawyer and a detective, telling her story so that 
it might he on record in case she should disappear mysteriously. She has since corre- 
sponded with the detective, paying him money. On her last journey west she heard a 
voice outside the car say, " Fanny's aboard ! we've kept track of her ! I have passed 
her along from one porter to another !" She is now suspicious of all around her. The 
janitor of the school, trades-people, car drivers and others insult her. Once a shot was 
fired at her while in a horse car. She feels that something must be done, and wants 
my honest opinion as to whether she is insane or not. I tell her the nature of her case, 
advise her as to her conduct. She still adheres to her delusions and neglects the 
advice. Her health and her ability to teach hold out wonderfully. She has of late 
been dabbling in Christian science and the faith cure. 
CASE II. -PRIMARY MONOMANIA ; ECCENTRIC HEREDITY ; MINGLED EXPANSIVE AND 
PERSECUTORY DELUSIONS ; NO HALLUCINATIONS ; EPISODICAL DELIRIUM AND 
HOMICIDAL ACTS. 
Mr. C. V., age forty-six, married; father eccentric; a brother and sister peculiar. 
Neither think the patient insane, and the brother tries to explain the case from a 
metaphysico-scientific standpoint. It will be remembered that Guiteau's brother held 
similar theories, and preferred that his brother should be hung rather than that testi- 
mony of his father's insanity should be put into the case. 
As a child the patient was delicate but manifested much intelligence, learned read- 
ily, especially music and drawing. He was temperate and affectionate as a youth, but 
very sensitive to criticism, and had a fanciful sense of honor which led to frequent 
explosions of temper. He was not given to sexual excesses, and had a horror of any- 
thing vulgar or indelicate. He lived mostly at home till the age of twenty, being 
taught by his father in his two accomplishments of music and architectural drawing. 
From the time when he began to support himself his mental peculiarities became 
more prominent. He began to display an intolerance of discipline which brought him 
into frequent collision with his employers. Failure to obtain as much pay as he 
thought he deserved made him think all employers unjust. For the past ten years he 
has had frequent quarrels with the leaders of the different orchestras in which he has 
played. He has also failed as a book agent and as a bill collector. He had no definite 
delusion until 1877, when he was arrested on a groundless charge, as he says, of felo- 
nious assault, and locked up for the night in a station house. From that time he 
regarded the police as a set of hirelings paid by the rich to oppress the poor. 
On a later occasion he drew a pistol on the leader of an orchestra, who had him 
ejected from a theatre. He wrote to the chief of police for redress, and getting no 
reply, began to send to that official and to the editors of a Boston paper, postal cards, 
denouncing them as " God-damned, hypocritical, lying fiends of hell !" At this time 
and on one or two subsequent occasions the writer was called to examine him. I cer- 
tified each time to his insanity, but each time his brother begged the Judge of Probate 
to try him once more, promising to be responsible for his good conduct. On one of 
these occasions he knocked his brother down in. my presence. He was finally sent to 
the Taunton Lunatic Hospital, in June, 1882, having shot at the officer sent to arrest 
him. He was released from Taunton in three months, on his promise of good behavior. 
He soon began sending his abusive postal cards again, and was sent to Danvers 
Lunatic Hospital, in August, 1883. I am indebted to an interesting paper by Dr. 
Gorton, on this case (Jfed. & Swrg. August 7th, 1884), for some of the facts nar- 
rated here. Dr. Gorton says he has "a well-developed symmetrical head and clear-cut 
intelligent features." Nothing abnormal was found, except a hernia and an exagger- 288 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ated patellar reflex. He used, in reference to society, some such expressions as are com- 
mon among fanatical social agitators. A week after admission he had a paroxysm of 
excitement. On being refused his discharge he became furious, gesticulated wildly, 
assumed an intensely dramatic expression, and shouted: "You have no right to say I 
am insane; you know I am not insane; in the name of God I say I am not insane ! 
in the name of God I say my liberty has been unjustly taken from me; in the name of 
God I say you are a liar," etc. Half an hour later he was quiet and rational. He 
refused to read or work, or take exercise, or play in the hospital orchestra, or to talk 
about his case. He says he is shut up as a lunatic by his enemies, and must be careful 
what he does and says. He writes two or three letters daily to his wife and sister, all 
worded nearly alike. They present a characteristic appearance, nearly every word 
being underscored and the phrase " in the name of God " often repeated. 
CASE III.-PRIMARY MONOMANIA; SINE DELIRIO OR UNDEVELOPED MONOMANIA, 
WITH GREAT SELF-CONCEIT, EXPANSIVE IDEAS, BELIEF IN HIS FATHER'S HOS- 
TILITY TO HIM; IMPERATIVE CONCEPTIONS AND ACTS OF VIOLENCE. 
Mr. C. D., age thirty-nine, recently entered the Boston Lunatic Hospital as a volun- 
tary patient. He had been arrested for a violent assault on his father, and consented 
to come, pending an examination into his mental condition by Drs. Jelly and Folsom. 
The patient inherited a decidedly neurotic constitution from insane and eccentric 
though talented ancestors. He was small of stature, but his head was of good capacity 
and symmetrical, only lacking in the bitemporal diameter. The measurements com- 
pared favorably with those of Krafft-Ebing's averages, with this exception. 
He was precocious in many ways, and learned to draw well before he could write. 
He studied music and painting before the age of ten. As a boy he was impulsive and 
emotional, and gave himself entirely to one pursuit until he tired of it. Read abstruse 
books at an early age, and showed great conceit and assumed airs of self-importance. 
At sixteen he became intensely religious and joined the church. He read books on 
asceticism and tried to practice it. Aimed to be as " high church ' ' as possible, and 
read many books on speculative philosophy. 
At college he proved a brilliant student at first, but did not fulfill this early promise. 
He became seriously addicted to self-abuse, it is said, and ran down greatly in health. 
He was sent west for his health, where he became so reduced that life was despaired of. 
He rallied, however, in a few weeks, and after extensive travels and mountaineering 
in the northwest, returned in good health but poor in pocket. He then started a pri- 
vate school, which he taught a year. He then entered the Divinity School at Harvard 
and graduated creditably, showing great taste for philosophical studies. He became 
ambitious to be made professor of speculative philosophy, and actually wrote an exten- 
sive work on this subject, for which, however, he could find no publisher. 
About this time his father failed in business and was unable to supply all his wants, 
although willing to give him a home. From having been an affectionate son and 
brother he became alienated from his family. He felt himself to be on a plane superior 
to them in every way. Money getting he regarded as a low and mean occupation, and 
to fail at that, as his father had done, he considered especially degrading. He seemed 
to forget his own frequent failures. About this time he tried to get a position as editor 
on a daily paper, and from slight encouragement claimed that the place was offered him. 
He failed as a teacher of Greek and Latin and as a private tutor. He failed to get a 
place in the custom-house, in the public library, and as professor in Johns Hopkins 
University. 
His ill-success he finally attributed to the secret opposition of a certain clergyman 
and to his father's failure to assist him actively. These delusive ideas he expressed 
freely in his father's family and to his acquaintances. He wrote a most impassioned SECTION XVII-PSYCHOLOGICAL MEDICINE. 
289 
appeal to the public, about four years ago, setting forth the high attainments of a certain 
young man, whose family opposed him, and sent it to a daily paper for publication ; 
meanwhile he avoided his family as much as possible, supporting himself by writing 
book notices. He claims that he has not slept more than two hours a night for two 
years, and has been on the verge of starvation several times. It was his custom to walk 
the streets with bowed head, or stand in doorways, gazing at vacancy, by the hour. 
Eight months before his admission he went home to live, having had no food for 
four days. Although sitting at the family table at first, he felt life at home to be "hell 
upon earth." He at times berated the family, calling them "damned fools." He 
refused to be helped by his father at table, and often took his pla'e away to eat by him- 
self. On a recent occasion of this kind his father followed him and told him he could 
no longer remain in the family and behave as he did. He thereupon seized a chair and 
knocked his father down stair's. 
He had on several other occasions given way to violence. He once struck an express- 
man who hit him accidentally. Five years ago he shook up his grandmother because 
she objected to having his wet clothing on her bed. Later he assaulted his sister vio- 
lently, and was about to throw her from a balcony for some trifling cause. He showed 
no regret for these acts, and described the assault on his father as "having had a nasty 
little time of it." 
In this case, although the delusive idea is general and less irrational than in some 
others, it is evidently the controlling motive of his conduct. Out of an overweening- 
conceit in his own mental capacity, grew astonishment at his want of success, which he 
could only explain on the ground of secret opposition by his family. At the hospital 
he was always calm and plausible, guarded in his speech, and either concealed or denied 
his delusions. He was kept a few months and discharged at his own request, as the 
law requires, when all danger of arrest for the assault had passed over. He resumed his 
genteel vagabondism, and two years after applied for admission as a voluntary patient 
in order to get something to eat. In a week, not being allowed all the liberty he desired, 
to go out on parole, he demanded and received his discharge. 
There are some points of resemblance between this case and that of Guiteau. There 
was less positive delusion and less moral and intellectual degeneration in the former, 
but the same basis of egotism, the same attempts at a career above his capacity, the 
same inability to accept failure as the natural result of this incapacity. There was the 
same absorption for a season, at the age of puberty, in religion; the same incapacity 
for study, through excessive self-abuse. There was an inherited neurotic constitution, 
in less degree than with Guiteau. There were the same futile literary efforts, the same 
restlessness and Quixotic schemes for personal advancement, the same hatred of his 
family, with violent outbreaks on trifling provocation. Fortunately there has been no 
premeditated homicide. Premeditated violence is seen occasionally in monomania, 
although impulsive acts are more common. Still, when the delusions of hostility and 
persecution constantly relate to the same person, there is likely to be a succession of 
threats, in successive outbreaks of excitement, and perhaps, a constant state of prepara- 
tion on the part of the patient to defend himself or to commit violence. Such patients 
often go around for months before committing any assault. To sum up the likeness of 
this patient to Guiteau, it is safe to say he had what Krafft-Ebing calls ' ' an hypertrophy 
of character in an abnormal direction. ' ' 
It would be easy to report a score of cases in full detail, and of great variety and 
interest, of primary monomania. It is not so easy to present a single case, undoubtedly 
secondary to mania or melancholia. Cases secondary to inebriety are, however, common 
in the writer's experience. Instead of reporting further cases in detail, I will analyze 
and classify briefly the large number of cases of svstematized delusion, at present in the 
Vol. V-19 290 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Boston Lunatic Hospital. Out of a total of 250 patients, 47, or about 20 per cent, are of 
this class. 
CASES OF SYSTEMATIZED DELUSION'S IX THE BOSTON LUNATIC HOSPITAL. 
00 
*s 
s 
Females. 
Total. 
Heredity 
6 
13 
19 
No heredity 
12 
7 
19 
Heredity unknown 
4 
5 
9 47 
Primary 
10 
16 
26 
Secondary to inebriety 
10 
0 
10 
Doubtful 
2 
9 
11 47 
Delusions of grandeur 
1 
0 
1 
Delusions of persecution 
4 
4 
8 
Alternate or mingled delusions of grandeur and 
persecution 
17 
20 
37 
Hypochondriacal monomania 
0 
1 
1 47 
Hallucination of hearing 
19 
16 
35 
Hallucination of sight 
4 
5 
9 
Episodical excitement 
13 
19 
32 
Homicidal 
6 
3 
9 
Suicidal 
2 
2 
4 
It will be seen by the table that in 50 per cent, of the cases no insane or nervous 
heredity was discoverable. It will further be seen that the majority of cases were of 
primary origin, while a large number were secondary to inebriety. Habitual inebriety, 
without inducing either mania or melancholia, leads to hallucination of hearing and 
consequent delusions, usually of a persecutory type at first, but as dementia advances 
delusions of self-importance occur. This is a very common form of insanity. 
The eleven doubtful cases are either of such long standing that the precise method of 
their origin is obscure, or they were first committed to some other hospital where the 
acute stage of insanity was passed. In a few cases which at first sight appeared to have 
been secondary to mania or melancholia, it was found that the delusions were present 
from the first, and sometimes long antedated the excitement. Here the excitement 
was evidently episodical and not causative. There is a form of acute paranoia reported, 
but none of the cases here are of that type. 
There is a remarkable case of hypochondriacal monomania in the hospital, the 
patient having for years believed that the roof of her mouth was eaten away, and her 
whole system poisoned, by the rubber plate of a set of false teeth. Mingled delusions 
of grandeur and persecution were present in 37 out of 47 cases. Hallucinations of 
hearing were present in 35 cases. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
291 
NOTE ON THE CLASSIFICATION OF INSANITY. 
REMARQUE SUR LA CLASSIFICATION D'INSANITÉ. 
BEMERKUNG ÜBER DIE KLASSIFICATION DES WAHNSINNS. 
BY H. M. BANNISTER, M.D., 
Of Kankakee, Ill. 
lu January of the present year I published, in Dr. Jewell's Neurological Review, 
an article on ' ' The Classification of Insanity in Asylums or Hospitals for the Insane, ' ' 
in which I reviewed some of the plans that have been proposed, and offered one which 
seemed, according to my own experience, to best meet the requirements. Subsequent 
consideration of the subject has made me wish to restate some of the principal points of 
that paper, with such modifications as have suggested themselves to me since their pub- 
lication. 
It is generally admitted that all the classifications of insanity are necessarily more 
or less defective, and that a perfectly scientific and satisfactory one is an impossibility 
in the present state of our knowledge. We know so little of the higher functions of the 
brain and the mechanism of disordered mental states, that a pathological classification 
of insanities is impracticable, at least in its finer details. Any such that is attempted 
must be theoretical in the extreme, full of errors, and subject to modification with each 
advance in our knowledge of the subject. Nevertheless, a pathological system would 
be the only really scientific one, and so far as it can be utilized with our present know- 
ledge (possibly in the larger and more general divisions), pathology should, I think, 
form the basis of any system of classification. How far it can be utilized is, perhaps, a 
question that is not easily settled. 
A purely psychological system, one which classifies the insanities according to the 
mental faculties presumably affected, carries üs still more into the region of theory and 
off from practical ground. It is only in so far as it is also a clinical system that such a 
classification possesses any advantage. 
A so-called clinical plan of classification is the ætiological one, which is shown in 
its extreme development in the system of Skae and his followers. I stated in my for- 
mer paper that a great objection to this plan is that it tends to obscure clinical features: 
that even high authorities, in using it, grouped together under the same head the most 
diverse clinical forms; how Clouston, for example, includes maniacal, melancholic, and 
demented cases under his clinical species "senile insanity," and makes other ætiologi- 
cal species similarly comprehensive. When other less eminent authorities use ætiologi- 
cal species, as I can testify from experience, the tendency to a slovenly diagnosis is very 
great, and I have not much doubt, as I have stated in the paper referred to, that in 
asylum statistics very many cases of climacteric, senile, puerperal, etc., insanity are so 
referred, solely on the ground of their antecedents. There are other valid objections to 
ætiological species, but this one is apparently sufficient to properly exclude them from 
any classification designed for asylum statistics. 
The best plan for a classification of insanity for asylum purposes is, in my opinion, 
the clinical, or perhaps more correctly the symptomatic, one. It alone affords us an 
opportunity of judging each case by itself apart from all statements as to history or 
antecedents, which are often imperfect and misleading, and not infrequently lacking 
altogether. It is also apparently the most natural one, whether we consider insanity 
as a symptomatic condition merely, or as a series of diseases or syndromes the underly- 
ing pathological conditions of which are yet very imperfectly known. All other diseases 
were first recognized and classed in this way. Next it should be reasonably simple and 292 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
yet have a capacity for subdivisions that can, without allowing any extreme looseness of 
definition, include all the principal clinical varieties of insanity. This can be attained 
by having under the more general heads a certain number of varieties or sub-species 
that may be used or not as the purposes of the classification may require. This plan is, 
I think, every way better than encumbering the system with a multitude of species of 
apparently equal value, covering all the distinctions that are recognized. The more 
complicated and elaborate a classification the more difficult it is to practically apply it 
to a large insane population. 
Lastly, an asylum classification should be reasonably consistent with itself; it should 
not have part of the species based on one set of distinctions and another part on another ; 
it should not make one on the symptoms presented, another on the accompanying bodily 
ailment, another on the cause, etc. If the forms of insanity recognized are to be based 
on symptoms, as I believe is the best plan for a practical classification, they should be 
so arranged consistently and throughout. 
The division of the insanities here offered is the one which I have myself found most 
easily applicable to the population of a large asylum, and is substantially the same as 
that proposed in my former article. It is as follows :- 
I. PRIMARY INSANITIES. 
Original forms of the disease and not the sequelae or terminal conditions of prior 
mental derangement. 
I. Teratological Forms.-Dependent on original structural defects or malformations. 
Species 1.-Idiocy. 
Species 2.-Imbecility. 
Species 3.-Pseudo-paranoia monomania (in part) of Spitzka and others. 
Originäre Verrücktheit of Sander. 
II. Pathological Forms.-Dependent on alterations due to disease occurring in an 
average normally constituted individual. 
Species 4.-Mania. Including sub-species. 
(a) Hypomania (simple, mild maniacal excitement). 
(b) Maniacal frenzy (ordinary "acute mania"). 
(c) Mania gravis (acute maniacal delirium, delirium grave, typhomania). 
Species 5.-Melancholia. Including sub-species. 
(a) Simple melancholia. 
(ö) Melancholia frenzy. 
Species 6.-Dementia. Including sub-species. 
(а) Simple dementia (primary, general mental deterioration). 
(б) Primary confusional insanity. 
(c) Stuporous insanity. 
Species 7.-Paretic dementia. 
Species 8.-Transitory frenzy. 
III. Mixed Forms.-Generally pathological, but in part probably due to original 
structural defects. 
Species 9.-Cyclical insanity. Including sub-species. 
(a) Recurrent mania. 
(ft) Recurrent melancholia. 
(c) Circular insanity. 
(d) Katatonia.* 
(e) Periodical morbid impulse (dipsomania, etc.). 
* The above differs slightly from my former arrangement, in that I have placed katatonia in 
the mixed forms and given it only the rank of a sub-species of cyclical insanity. SECTION XVII PSYCHOLOGICAL MEDICINE. 
293 
Species 10.-Paranoia (delusional insanity, monomania of authors). 
Species 11.-Epileptic insanity. 
Species 12.-Hysterical insanity. 
Species 13.-Moral insanity. 
IV. Secondary Insanities.-Secondary or terminal conditions of mental derangement 
succeeding to the primary disorder. 
Species 14.-Secondary paranoia. 
Species 15.-Terminal dementia. Including sub-species. 
(a) With excitement, chronic mania. 
(ö) With depression, chronic melancholia. 
(c) Secondary confusional insanity. 
(d) Simple terminal dementia (terminal general mental deterioration). 
The first grand division of this classification into primary and secondary insanities is 
a practically convenient one, and is not, I think, altogether unscientific. It is not merely 
lapse of time, but actual change of character, easily recognizable by the practiced phy- 
sician, that relegates a cause from the primary to the secondary forms. Many cases of 
cyclical insanity, of paranoia, melancholia, and even of mania, may last for years before 
passing into the mentally deteriorated state of the secondary insanities, and this divi- 
sion, in a general way, is also that between the curable and incurable forms. 
The division of the primary insanities into the teratological and the pathological 
forms, is also, I think, a natural one, though some may possibly question the reference 
to the former of that phase of insanity which I have distinguished under the name of 
pseudo-paranoia. It seemed necessary, however, to recognize the difference between 
these cases of physical and mental deformity and those of delusional insanity proper. 
In the one case we have original brain defect and consequent irregular development, 
with a mental condition closely related to imbecility, in the other a condition without 
essential demonstrable lesions, and not incompatible with a very high degree of general 
intellectual development. In making a division of primary insanities into teratological 
and pathological forms the pseudo-paranoias would necessarily fall into the first of 
these divisions, while the genuine paranoias would almost as clearly be read of it. The 
name pseudo-paranoia here proposed indicates the prominent characteristic of these 
cases ; they resemble paranoia, but are different from it, and the difference in the men- 
tal symptoms is not hard to detect with proper observation. 
I have placed paranoia proper, or delusional insanity, in the third group of mixed 
forms, which is a concession to the doubt as to certain species being strictly pathological, 
though the original structural defect is not detectable. 
In placing mania gravis as a sub-species of mania, I have been led by the clinical 
resemblances, though they are probably only different in that the pathological changes 
are more advanced and extensive in one than in the other. In one we have morbid 
excitement through a much milder form of vasomotor disturbance than in the other, 
where there are actual inflammatory conditions, and the clinical symptoms vary accord- 
ingly, to a certain extent. But really and practically, I believe they are only different 
degrees of the same general condition. 
The other species, I think, need no extended explanation. Epileptic and hysterical 
insanities are not ætiological species, and do not, as here understood, include all cases 
accompanied by or caused by epilepsy or hysteria, but are readily recognizable clinical 
syndromes. I admit moral insanity and transitory frenzy as rare but possible forms of 
mental disorder that may be occasionally met with in asylums for the insane. 
In presenting this classification, it is not claimed that it has any special merit other 
than that of being easily applied to asylum statistics. 294 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE TRUE NATURE AND DEFINITION OF INSANITY. 
LA VRAIE NATURE ET LA DÉFINITION DE LTNSANITE. 
ÜBER DAS WAHRE WESEN UND DIE DEFINITION DES WAHNSINNS. 
BY C. H. HUGHES, M.D., 
Of St. Louis, Mo. 
A morbid process which engenders defect and deranges or suspends the perform- 
ance of normal function in an organ, is none the less a real disease, and is none the 
less entitled to be called such, because it happens to begin, or even to end, in foetal life, 
than if it takes place solely or partly out of the womb. A disease destined to se damage 
the brain as to destroy the otherwise predestined normal harmony of the mental opera- 
tions or suppress them altogether, so that they can never be displayed, may be sown in 
the germinal seed and develop with the growth of the brain, evolution and dissolution 
going on together, the latter modifying the former, so that a mental monstrosity is the 
result. 
This is disease, destroying the power of normal mental display; and whether the 
destruction be complete or but partial, or whether it takes place within the womb partly 
or solely, or altogether out of it, it has the essential nature of, and truly is, insanity. 
For conventional considerations, but without good reason, a certain degree of this 
morbid implication-because beginning in pre-natal or in early post-natal life, has been 
called idiocy, another degree imbecility. But idiocy is an insane condition of the organ 
of mind, none the less entitled to be so considered than dementia simply because it 
displays itself at or nearer the beginning of organic existence and the incipiency of the 
display of mental power, while the latter, quite similar in its psychical symptomatic 
expression, is universally acknowledged by alienists to be a terminal phase of cerebro- 
mental disease. 
Both dementia and its closely-allied morbid kindred-imbecility and idiocy-are 
alike diseases implicating the cerebro-mental mechanism in destruction at the conclu- 
sion of a preexisting morbid process, the last two being the degenerative outcome of 
subtle neuropathic influences affecting the nutrition and normal development of the 
psychical area of the cerebrum during intra-uterine or infantile life, the former being 
the same or a similar thing (psychically considered), displayed later in the individual's 
life history. The dissolution simply begins a little nearer the germinal life in the one 
case than in the other ; but in both, through what we call hereditary entailment-the 
real cause of the organic dissolution, though the determining factor may be different- 
may antedate, through what we call heredity, the life of the germ, and often does in 
both cases, as we have learned from critical observation, and as we are likely to learn 
more and more, as our inquiries become more diligent and far-reaching, if what we 
have thus far discovered of the ancestral influences tending to the development of 
damaged cerebro-mental conditions be a just warranty for what we now assert, on the 
authority of the universally-confirmed testimony of psychiatric science, regarding the 
essential causative potency of hereditary conditions. 
Indeed, it is no longer gainsaid, as the most eminent of our confrères in psychiatrv 
have proclaimed, that all cerebro-mental disease, whether it be shown in intellectual or 
moral aberrations or incapacity for the display of the psychic powers (unless due to 
direct mechanical or toxic violence) antedates, in some, at least, of its causative influ- 
ence, the individual in whom the psychic failure appears to our view. Hence the 
dictum of the great Ray, and the confirmatory testimony of his colleagues, that insanity 
is usually the product of two or more generations. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
295 
To draw a distinction in states of cerebro-mental disease between powers arrested in 
process of evolution, powers destroyed and powers undergoing destruction, is well 
enough for purpose of designation of different states of cerebro-mental disease, but 
misleading and pernicious to a correct understanding of the real nature of insanity, if 
we mean thereby to obliterate the idea of a preexisting morbid process in the one case 
and retain it in the others; for all cerebro-mental disease is cerebro-psychical cell evolu- 
tion modified (delayed, arrested, retrograded) through the morbid process. The dis- 
tinction is, in fact, without an essential pathological difference, except in time and 
degree, and if it is made to signify more, it leads to confusion of our conceptions of the 
real nature of mental disorder, which is but a compromising of the mental powers 
through disease, implicating the centres of psychical display, whether that implication 
be one of limited derangement or general destruction of mental power, so far as the 
normal functioning of the mind is concerned ; the damage is as real, and the disease of 
the brain as significant and seriously to be considered, whether the powers be simply 
diverted and deranged from their natural channel, through the perverting influence of 
disease and to the detriment of the individual, or whether they be totally obliterated, 
from the same cause. The difference is in degree, not in kind, and is a difference rather 
of prognosis than of morbid nature. It is also one of diagnosis, but only in a limited 
sense, the determination of which may lead to difference in treatment, just as the dif- 
ferential diagnosis of an exanthem ipay modify our remedial efforts, though we may 
know in the beginning of the different forms of eruptive fever that whatever may be 
the appearance of the cutaneous exanthem after the incubation period has passed, it is 
the blood which is primarily affected, and when the precise nature of the trouble 
unfolds itself we know we have a blood disease to deal with. 
Just so in regard to every condition in which the mind's manifestations are embar- 
rassed by disease affecting the brain. In the case of the ordinarily recognized forms of 
mental disease which we may see in the incubation stages, we may note that the brain 
is affected long before we determine the precise character of the disease. The incipient 
symptoms of acute delirious mania are not always essentially different from those of 
ordinary acute mania, and a melancholia may be the precursor of a violent maniacal 
outbreak or of a terminal dementia paralytica. A phase of epileptic insanity and of 
folie circulaire may be precisely similar, and an appearance of dementia may usher in a 
form of mental malady in which high maniacal excitement is the sequel, though real 
dementia is rarely primary. A condition of imbecility may confront us in the early 
stage of insanity not materially different from congenital imbecility, and may abide 
with the patient to the end of his life; and so in regard to that undoubted form of 
constitutional insanity called paranoia by some, imbecility, moral monstrosity, moral 
insanity or primäre Verrücktheit by others. 
In all these cases, and the many more, associated, for instance, with the paralytic 
and puerperal states, we simply withhold our conclusions as to the form, but not in 
regard to the nature, of the malady. Why should we, therefore, seek to give to cases 
of cerebro-mental damage, in which the mind is a little more compromised in the 
beginning rather than toward the ending of life, a different meaning and a different 
nature ? Obviously, we make in these cases a nominal distinction to signify too much 
difference, unless we make it with proper qualification ; and the proper qualification in 
regard to idiocy and imbecility would be one of insanity, in which the mental powers 
are prematurely destroyed or greatly impaired in the one instance and remotely or after 
maturity in the other. They are both states of insanity. 
They are kinds and degrees of insanity, as much so as the mental derangement of a 
congenital epilepsia, which, though a little tardier in effecting its damaging influence 
than the pre-natal influences engendering idiocy sometimes are, finally destroys, after 
perverting, the mind, and secures a place in our nomenclature as epileptic insanity» 296 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
though the last state of epileptic idiocy is no better, mentally or prognostically con- 
sidered, than the early dementia of extreme congenital imbecility. 
To the terms idiocy and imbecility, as degrees and forms of insanity, there can be 
no serious objection. To consider them as separate morbid entities is without, thus 
far, any real pathological warrant which would cause our conception of insanity in 
general to be changed. To say that one mind is deranged and the other mind destroyed 
would vitiate our understanding of many well-recognized forms and features of mental 
disease. Where, for instance, with such distinction without essential difference in 
psychical symptomatic expression, would we place the final stage of general paresis, the 
last stages of apoplectic mental derangement, chronic epileptic insanity, paranoia and 
acute dementia ? If we seek to differentiate and define these conditions upon a purely 
pathological basis, then these varieties of insanity are different diseases, and as much 
entitled to be set apart from other forms of insanity, which have a less defined and more 
indistinct pathology, as idiocy and congenital or early acquired imbecility. 
The differentiations of epilepsia, apoplexia, and paresis, accompanied with psychical 
derangement, are appropriate enough as varieties of the cerebro-psychoses, but improper 
if we dissever them in our minds from mental disease in general. 
The millennium in cerebral pathology has not come and is not likely soon to dawn 
upon us. The new light we have only brings into view more and more unexplored 
territory. When it does come, we may then differently define all these varieties as 
special entities, including with them idiocy and imbecility, and may then narrow the 
legitimate definition of insanity to more restrictive boundaries than we now, from any 
neuro-pathological light before us, can reasonably anticipate. 
In the light of all present knowledge on the subject, the attempt to make distinct 
and separate pathological entities of idiocy, cretinism, imbecility, and allied states, and 
exclude them from our definition of mental disease, embarrasses all effort at compre- 
hensive definition, and cripples and misleads our understanding of the true nature and 
essential characteristics of disease involving the entirety of the mental display. Tera- 
tological defect (so-called), though itself the result of cerebro-pathic and neuropathic 
processes which modify the display of mind, is ruled out, as unworthy of a place in our 
definition of insanity, simply because we must have a nominal distinction for purposes 
of scientific designation between certain marked states of cerebro-psychic functional 
display. This vicious and perverting precedent, which has led to the misconstruction 
of the nature of mental disease, must be swept aside in the interest of insanity defined 
on its true basis, as affecting, in whole or scientific exactness, and in part, the display 
of the normal mental functions and all states of perverted, damaged, suppressed or 
destroyed mental function due to injury of brain, classified and defined within their 
legitimate morbid realm, which is disease of brain affecting the mind so as to modify 
or prevent its normal manifestations. Then the place which exceptional cerebro-mental 
states find in our treatises on insanity, because they can properly be treated of nowhere 
else, will be recognized as the legitimate and proper place for their discussion, and the 
anomaly of describing them in these treatises as dissevered entities will cease. They 
will take their place in the family of diseases, not as relatives in law, but as true neuro- 
pathic kindred, having a common paternity and progeny, as they do ; for, do not the 
genealogical tables of our asylums for the insane and the homes for our idiotic and 
feeble-minded indubitably establish (if permitted so to speak) the neural consanguinity 
-the real neural kinship ? 
I know that this view is open to objection, but the objections are mainly those of 
precedent and custom ; and after we shall have become accustomed to the new usage, 
especially if thereby we remove the real stumbling block which long habit of thought 
and expression have established to a correct comprehension and broader definition of 
insanity, we shall feel ourselves well rewarded for having accepted the change and thus SECTION XVII-PSYCHOLOGICAL MEDICINE. 
297 
thrown out an erroneous differentiation from our nomenclature of morbid cerebro-mental 
states. 
Definitions of insanity, in the present state of our knowledge, as in the past, must 
of necessity have mainly a symptomatic basis, just as most other diseases are mainly 
defined ; when pathology advances to the period of its greatest perfection, a period at 
present far remote, the definition of mental diseases, as of diseases generally, may be 
different. 
***** * ***** 
We know that the brain is pathologically implicated in insanity, either in its circu- 
lation (vasomotor mechanism), in its vascular apparatus as well as circulatory condi- 
tions, in its cells and ganglia, its neuroglia, or its meninges, in short, in some quality 
of its structure or in the mechanism that sustains its structure and functions or growth 
of structure. The brain is somewhere wrongly touched, either by direct or reflected 
impression, if the responsive mental operations are inadequate or unnatural, and we 
need no longer discuss the question whether it is the organ of mind deranged since it 
is known to be the organ of mind normally displayed. 
The undisputed pathological basis of insanity is therefore a morbid material impress, 
originating within the system and proceeding from the brain in abnormal manifesta- 
tion. It may be as much insanity if the natural and normal psychical response to a 
healthy impression from without cannot be elicited by reason of the central disease, as 
the exaggerated or non-response to patellar tendon percussion is indicative of sclerosis 
located in the antero-lateral or posterior columns of the spinal cord, or of obstructed 
afferent or descending inhibitory neural transmission from other causes. Whether 
disease of the spinal cord be located in the motor or sensory centres, the meninges or 
medullary portion, it is spinal disease, and no affection, whether of this part of the 
cerebro-spinal axis, though it be congenitally entailed, as in spina-bifida, and displayed in 
arrested development, or as shown in early Pott's disease, is designated otherwise than as 
a spinal disease; so likewise are all affections of the brain deranging mental function enti- 
tled to be classified as forms of insanity. These affections of the vertebral canal, when 
they disorder the cord's function, might even be termed insanities of the cord, and those 
widely differing forms of brain disease disordering mental function and commonly 
called insanity may justly be regarded as mental diseases ; the few other forms which 
are excluded from the common appellation might with as much reason be included in 
it. Imbecility, therefore, as well as dementia, are upon the same morbid footing. The 
trivial circumstance that the one appears earlier than the other should count for noth- 
ing against our estimate of its nature as a cerebro-mental affection. All cerebro-mental 
affections are of the nature of insanity, and the term insanity should include them all. 
It may be inconvenient at times, in view of the artificial distinctions which psy- 
chiatry has created between imbecile and idiotic states, to include what have been thus 
differentially designated as teratological defects. The tenant of the neurological home 
may be a disagreeable and unwelcome one to recognize, but if it belongs naturally on 
the premises we cannot justly divest it of its birthright. We may assign it a separate, 
though not a dissevered place in the family and domain of mental disease, and this is 
what in practice we do. We can never treat of the subject of insanity as technically 
differentiated from these other cerebro-mental states without likewise discussing them 
and recognizing their undoubted kinship to mental aberration. We recognize and dis- 
cuss the higher gradations of imbecility into paranoia and the aberrations of the 
affective mental life, and, drawing an arbitrary line which nature has not demarked, 
we have called the mental derangement of the one pathological condition unsoundness, 
and the other insanity, of mind; as if the mind were sound in insanity and only 
unsound in these congenital or nearly congenital states; as if such arrest of healthy 
cerebral development as compromises and destroys mental integrity before it has 298 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
matured, could be justly called health, while only that which destroys matured cere- 
bro-mental integrity should be termed disease. We violate this precept every day, in 
the recognition of insanity in childhood and youth. We recognize insanity equally, as 
hereditarily predestined to mental obliteration, and showing itself in idiotic and imbe- 
cile conditions, oftentimes no further removed from birth than we see it displayed in 
what we call the teratological defects in contradistinction. 
We cannot erect a scientific distinction between insanity and unsoundness on the 
hypothesis of arrest in the one case and destruction in the other of evolution, because, 
in fact, the underlying cause of both results is a morbid one, whether an ideational 
centre, for example, break down after it has matured, or break down in process of 
maturation when, if it had been in a normal and healthy state, it ought to have gone 
on to maturity. A process which dwarfs a cell or centre of power in the organism 
below its natural physiological standard is morbid. The process of dissolution has 
begun somewhere antecedent when this is the result, as much so as if dissolution and 
destruction have only become apparent after full maturity. Maturity of an organ can- 
not be made an essential to the recognition of disease in it, for close upon maturity 
follows physiological decadence. Involution begins with completed evolution, especially 
in the microscopically discernible life of the organism. Premature dissolution and 
consequently premature failure of evolution applied to the cell life, are the proper 
criteria of disease, and we find these exist in insanity and all kindred states of brain 
and mind, insanity, as now recognized by all, being a more or less teratological or 
defective entailment, though usually manifest more remotely from the period of infan- 
tile life and early childhood than those states under discussion which have been differ- 
entiated from it. 
Mind is either a force of the brain or a force so intimately allied to this organ as to 
be practically inseparable from the brain in the display of its powers, so that mental 
function and brain power in the latter's psychical area at least are practically co- 
ordinate, and may, for our present purpose, be considered as convertible terms. 
The definition of insanity must, therefore, be psycho-somatic, psychical because of 
perceptible change in mental function, somatic because of the invariable departure 
from the normal standard found in the brain} or indirectly through disease in the 
organism, disturbing the brain in its circulation, membranes, cells, neuroglia or gene- 
ral conformation, associated with the psychical alteration. 
We know that wherever the ante-mortem and post-mortem search has been sufficiently 
thorough, somatic as well as psychical aberrations have been found. 
Aberration from the normal individual standard of organic functional life is disease; 
and if psychical derangement be dependent on such physical aberration it is in the 
nature of diseased function, whether the mind itself may be diseased or not, and 
whether that disease be hereditarily entailed or subsequently acquired. 
If insanity be defined on the basis of disease, it must have the same symptomatic 
characteristics as disease in general, and this symptomatic characteristic is a compro- 
mise of function-a notable departure from the normal function of the organ (if the 
disease be acquired after the maturity of the organ) as compared with the established 
and natural character of function-an incapacity of full functional power, if the disease 
expend itself during the developmental period, as in intra-uterine life, in infancy, 
childhood, or youth, before the natural character is evolved. 
The true essence of insanity, so far as we can comprehend it, is an embarrassed or 
compromised function of mind dependent on disease. The basis is disease, and the 
evidence is disordered mind in relation to brain diseased. 
If the brain and mind have matured and the mental character, which is a function 
of the brain and allied neural organism, be consequently established before the disease 
has attacked it, then we may take the individual character for comparison, and say SECTION XVII-PSYCHOLOGICAL MEDICINE. 
299 
with Combe, that ' ' insanity is a departure, without adequate external cause, from the 
natural and healthy character, temper, and habits when in health, that is the true fea- 
ture of disorder of mind in all cases," but we need not, and indeed cannot, qualify our 
definition with the words prolonged departure, as Combe did his. Combe's qualifica- 
tion, without adequate external cause, compels us to look within the brain for the cause, 
where it always resides in all cases of true insanity, though the morbid cause may only 
be indirectly there and remotely in the liver or kidneys or heart, modifying the quality, 
or quantity, or regularity of the cerebral blood supply. The causes may be external to 
the brain but somewhere in the body. 
But if the insanity attack an individual before the mental character is matured or 
fairly established, our standard of comparison must be other than the individual char- 
acter. We have then to take our standard of comparison from the family type or the 
ordinary mental character, with regard to the proprieties of life prevailing at the par- 
ticular age and in the life station of the individual coming under our notice for. our 
opinion. If mental disease begin to show itself in a child, or even much earlier, and 
prevent that mind from developing into its proper mental character, it is none the less 
disease because a character has not been formed with which to compare it. The stand- 
ard of self-comparison, therefore, while exceedingly valuable and practicable for most 
of the forms of insanity which are displayed at or about maturity, is not practical in 
some other forms of earlier manifest cerebro-mental disease. The well-known and 
now universally recognized forms of hereditary mental defect, disease, seen in child- 
hood and youth, and even sometimes apparent, to the discerning alienist, in infancy, 
and abiding, often without a break in the mental manifestations, to riper years, demand 
a broader measurement than that allowed in the change of character rule. 
The change of character rule is a most excellent criterion, and needs no modifica- 
tion if we apply it only to cases in which previous sanity can be undoubtedly shown; 
but all teratological defect and consequent cerebro-mental disorder would be, and has 
been, too often ruled out by its too rigid application, especially before courts, to the 
great wrong, in many instances, of the undoubtedly insane, accused of crime and 
entitled to the benefit of the extenuating fact of disease, none the less entitling them 
to exemption from responsibility before the law because their ancestors endowed them 
with the morbid heritage, but rather more entitling them to lenient judgment and 
exemption from penalty than if their mental derangement had been vice-induced or 
otherwise voluntarily acquired disease, as insanity often is, later in their lives. 
We are objecting now only to the too narrow and unwarranted change of character- 
rule as we see it sometimes wrongly applied by medical witnesses in court. The 
change of character criterion, as first laid down by Andrew Combe,* if we accept it 
and apply it as its author promulgated it, will embrace every case of insanity coming 
under our observation, excepting only the feature chronicity, which Combe unwisely 
insisted upon in his famous definition. '1 It is the departure from the natural and 
healthy character, temper and habit ' ' that Combe insisted upon as constituting symp- 
tomatic insanity; a departure from the state of feeling and modes of thinking usual to 
the individual when in health, that is the true feature of disorder in mind, he says. If the 
man may never had a healthy mind, then the self-standard only fails as applied to the 
particular individual, because the disease began further back; and to apply it truly we 
must simply go to the beginning of the morbid mental heritage. It is sophistical and 
illogical to say no insanity exists, because the morbid mental change had its inception 
in the cradle, or antecedent to it, rather than after maturity. Insanity cannot be 
crowded out of existence nor the disease limited by such restrictive application of a 
* "Observations of Mental Derangement." Edinburgh, 1830. 300 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
definition which is legitimately entitled to the qualification, and consequently more 
extended application, upon which we here insist. 
If it were only true in point of fact, as Prichard says: "that insanity always 
involves that particular circumstance which is supposed to be characteristic of it," but 
"unfortunately the reality is otherwise," we might make a very simple category of 
mental diseases, and designate a great many forms of insanity as something else, to 
accommodate disease to our definition, as psychiatry has often tried to do, but the 
disease comes up like Banquo's ghost, and will not down at our bidding. 
We may, in restrictive phrase, define and re-define the status of mental aberration, 
and it will overleap our narrow boundaries, until we shall have become content to follow 
nature only, and describe it in a manner so comprehensive as to take into the family 
of insanity all true cerebro-mental diseases. 
The criticism of James Cowles Prichard, to which we have just reverted, was made 
under peculiar circumstances. A new and undoubted cerebro-mental condition, worthy 
to be classed as insanity, was ruled out by the narrow view which made delusion in its 
narrowly accepted sense the essential criterion of mental derangement, and as previous 
definitions shut out the moral insanity of Prichard and the manie sans délire of Pinel, so 
present definitions may be used to exclude from recognition not only the later discovered 
forms of mental disease, but others undoubtedly yet to come before us for study and 
psychiatric classification. 
To obtain a just conception of mental aberration we must therefore consider the 
whole organism and the whole individual, for though approximatively, with Cabanis, 
who asserted that the brain secretes thought as the liver secretes bile, we may say the 
brain is as specially concerned in the display of thought as the liver is in the secretion 
of bile, or the stomach of gastric juice, it, like both of these lower organs, has the blood 
and the whole physiological machinery of the organization behind it and inter-related 
with it in function. The more we study the inter-dependence of mind upon organism 
and organism upon mind, in relation to mental disease (whatever mind may be, whether 
a psychical ' ' self-subsistent entity, ' ' as Sir William Hamilton calls it, or subtle physical 
force evolved by the molecular movement of neural matter), the more forcibly the 
maxim of Aristotle that the (soul and life principle) resides in the whole, and 
the whole in every part of the nervous system, impresses itself upon us, a view of the 
relationship of the psychical to the physical and the physical to the psychical which 
has both physiological confirmation and clinical proof. Not, of course, in the literal 
Aristotelian sense, which made the mind as well as the principle of organic life one and 
omnipresent in the organism, as much and as immediately at home in the great toe as 
in the encephalon, a doctrine sought to be revived by Prof. S. S. Law,f and partly 
revived by Hammond, but disapproved by the one fact that sensation is not immediate, 
but for all practical purposes sufficiently approaching the truth, because of the intimate 
and multiform avenues of neural communication of the psychical area of the brain with 
* Arist. Ilepi i v, 31. 
* * * èv eKarepai rwv ftopitov 
iiravr èvvnàpxei rà juopia rrçç k, t. À. 
"In the Greek Philosophers, the term (soul) comprehends, besides the sensitive and 
rational principle in man, the principle of organic life, both in the animal and vegetable king- 
doms." 
Vide Sir Wm. Hamilton's Leets, on Metaphysics, pp. 271-273, and Dr. S. S. Law's Essay, 
infra. 
j- "Thesis on the Dual Constitution of Man, or Neuro-Psychology," Archives of Electrology 
and Neurology, November, 1885. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
301 
the remainder of the organism, and the close and inseparable connection of mind and 
man in the inseparably blended functions of psychical and physical life in the human 
being. So that while the brain is the especial organ of mind, through which it impresses 
and acts upon environment, psychical function is in a manner associated with and 
dependent upon the entire body. The whole human organism is or ought to be a har- 
monious psychical as well as physical being. As the Neapolitan neurologist, E. Mor- 
selli, has recently very cleverly stated the fact- 
"Every mental act, even the most simple, is the result of a very complex elabora- 
tion and association of precedent psychical states produced by an inextricable train of 
psychological elements, the gross result of an infinite number of elementary biological 
phenomena. The study of human and animal psychogeny parallel with that of neuro- 
embryogeny must lead us to admit that the smallest particle of the organism participates 
in the most complex psychical phenomena, namely, the conscious mental act. From 
the point of view of psychogeny and ontogeny, the spirit is not only a function of the 
gray substance of the convolutions, but of all the encephalon, of all the central axis, of 
all the nervous system, of all the organism." 
From this view of mind in relation to organism must we study insanity. In this 
disease it is the individual that is affected, the ego that is morbidly touched through 
his organism, the self-feeling and consciousness that are altered by disease; and this con- 
sciousness and self-feeling are the expression of diverse psychical states which are the 
products of a multitude of impressions proceeding from all parts of the organism. So 
that while insanity always involves the brain in morbid expression it does not always 
begin there. The brain is neither always alone nor primarily at fault in mental aberra- 
tion, but the mentality of the individual and all the conditions, physical and psychical, 
that enter into mental impression and expression, are often concerned in the phenomena 
of insanity. The restricting of insanity to the brain exclusively instead of to the brain 
and all the organic influences that operate upon it through its allied nervous system so 
as to influence the mind, has led medical, legal, and lay students of psychological 
science into too restrictive views of this disorder. The " knowledge of right and wrong " 
tests of the Law, the delusion criterion of Medicine, that is, delusion restricted to 
morbid concept originating in disordered reasoning or in derangement of the seat of the 
special senses in the brain, has often misled justice and misjudged the victims of 
insanity when not thus markedly affected. 
To delusion in its broadest sense and newly defined as we now propose to define it, 
not restricted to any special and formulated or formulable concept or special sense 
perception, there can be no objection. On the contrary, delusion, in this true and 
broader sense, is the real criterion of mental disorder. All insane appear to be thus 
deluded, and they give evidence of delusive influence which, swaying them, if not in 
insane speech, in morbid action, which speaks with equal force, if not more forcibly, 
of character transformed, of self-feeling and judgment changed. Their actions often 
speak louder to the psychiatric clinician than words; for the latter may conceal rather 
than express the real feeling of the insane no less than of the sane. 
If therefore we should group together all the phases of mental aberration with 
which psychiatry is familiar, and include all forms in one broad and comprehensive 
classification, how should we formulate an expressive definition that should prove broad 
enough and not too broad, and narrow enough and not too restrictive ? 
Insanity being a condition of the organism that expresses itself in change of mental 
character from what is natural to the individual, or what ought to be his natural char- 
acter, the real basis, cause, and essence of that alteration of the psychical nature is the 
true disease. In every insane person there must be and always is apparent, if we study 
our patients aright and scan their symptoms with the skillful discernment that comes 
from large clinical experience in the observance and comparison of psychiatric symp- 302 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tomatology, a subjective morbid change in the organism (due either to ante-natal or post- 
natal conditions, but usually to both), in the nature of deranged organic or special 
sensation. 
Insane impulses are consequences or concomitants of morbid feeling, if they co-exist 
with consciousness ; and if they do not, suspended consciousness is itself a disorder of 
sensation, and disorder of sensation is generally delusional to the insane mind. Organic 
feelings deceive the reason and may prove as delusive as special-sense subjective perversions, 
misleading the intellect so that it acts in a manner neither natural to the individual nor to the 
normal type of that individual. The standard of comparison in insanity cannot always 
be self, but the normal self-type before the morbid ancestral departure. 
The hitherto recognized delusional insanities, because they reveal morbid mental 
action associated with subjective mistaken concepts or perceptions, or pure intellectual 
delusions founded on illusion or hallucination of the special senses, are not the only 
forms of delusional insanity which should be recognized in psychiatry. Other subjec- 
tive sensations which are at the foundation of the morbid egoism and perverted impulses 
of insanity are equally delusive, such as the exaggerated muscular sense or feeling of 
strength, or vice versa, hyperæsthesia or anæsthesia and other perceptional morbid 
states and motor subjective illusory conditions, and those undefined perversions of 
feeling displayed in melancholia and megalomania and suicidal and homicidal impulses, 
as well as the kleptomaniacal, pyromaniacal, nymphomaniacal, and the yet unnamed 
morbidly erratic feelings, delusions of duality, of unilateral personality, accompanying 
personalities, etc., etc., which mislead the judgment and conduct of the insane. The 
organic feelings are as delusive as the perverted special-sense perceptions, and as justly entitled 
to recognition, when perverted and delusive in their nature and influence on the mind. 
The organic conditions of the emotional forms of insanity, as of religious exaltation 
and insane enthusiasm, and the condition of the nervous system, in fact, in all psycho- 
sensory forms of mental derangement is in a sense delusional to the individual, and 
so modifies mental conduct, though not delusional in the hitherto recognized sense. 
The basis of insanity, therefore, is a delusive feeling and associated morbia impulse or 
conception, an underlying perverted feeling, special or general, dependent upon morbid organic 
conditions, and impressing itself on the conduct or mental character of the person affected by 
it. Delusion, in this broad sense and wide interpretation, is the true nature, and con- 
stitutes the basis of a correct conception and definition, of insanity. 
It finds expression in harmony with the deranged mental state which it induces and 
with which it co-exists, in imperative conceptions* and overpowering impulses to 
unnatural and singular speech and conduct, often well defined in classical, intellectual 
delusion, often vaguely but no less certainly expressed to the experienced psychiatric 
clinician, in conduct inharmonious, unnatural, and inconsistent with the natural 
character. 
Definitions of insanity describing a departure from natural habits of thought, feel- 
ing, or conduct are correct descriptions of the non-hereditary and most common forms 
of insanity; but the essential condition is the unusual, unnatural, and misleading sub- 
jective impressions of the insane person, coupled with the resultant change of conduct or of 
reasoning, or both. This is delusion and its consequence on character, and this is 
insanity. 
Delusion, therefore, notwithstanding the antiquity of the criterion, is the real test of 
insanity, if we no longer unwarrantably restrict its meaning to perverted special intel- 
lectual concepts and the old-time special-sense delusions restricted to the five senses, 
* So far as I know, Spitzka was the first to make record of imperative conception as delu- 
sional, a view which the writer has long held, and which, in this essay, he plainly considers fully 
tenable. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
303 
but extend its meaning to any subjective morbid condition of the nervous system which 
misleads the mind or conduct. This latter phrase defines our conception of a delusion; 
and such delusive subjective morbid states of the organism are at the foundation of all 
insanity. It is the abnormal condition of the organism which deranges the normal 
display of psychical function, gives rise to imperative conceptions when the delusion 
cannot be classically defined, and causes the departure from what we recognize in the 
individual, or in the healthy members of his family, or in mankind in general, as 
naturally healthy mentality. The victim of insanity is misled and perverted in the 
exercise of his psychic powers by conditions of the system induced by disease, either 
primarily affecting the intellectual faculties and disturbing the normal self-conscious 
relation to surroundings-usually first affecting the organic feelings, and, secondarily, 
influencing the reasoning powers-so that but for this degree of disease the latter 
might act correctly, and the reason becomes,. under the dominion of the dominant 
morbid feeling, either a perverted or an aberrant servitor. Sometimes, however, the 
reason seems first affected, and delusive concepts appear to precede the morbid change 
of feeling or action; but this is usually more apparent than real. 
Alienism has many symptomatic data, because of the many varieties of insanity 
and the many-sided observations of the disease, but all the data of mental alienation 
may be formulated in one proposition, viz., morbid delusive perception and conception of 
subjective origin, causing change of mental character as compared with former self or normal 
ancestral type, through organic conditions originating in disease within the system, and 
primarily or secondarily involving the brain. External motives play but a secondary 
part when they influence at all the mental conduct. Change of character in the mature 
healthy mind is the ultimate symptomatic expression of insanity; change of mental con- 
duct the immediate. And repetitions of conduct make character. 
Delusion, as we understand it, and of the kind for which we are contending, may 
originate in the muscular sense, in any tactile sense, in the thermal or general sensory 
centres of the brain, as well as at the seat of the special senses (so called), or in the 
more purely intellectual area of the psychical concepts; or it may be only definable in 
a vague abnormal unconsciousness of the proprieties due to environment, or undefin- 
able and only expressed in conduct, speech or action, a negative delusive state, in 
which consciousness of the impropriety of act or word and normal psychical inhibi- 
tion are momentarily abeyant and obliterated by the act, though they may be present 
before and after.* 
Change of function is the symptomatic expression of all disease, to which mental 
disease offers no exception; and, obeying the laws of hereditary transmission, it may 
in its hereditary forms exhibit only an abnormal aptitude, requiring an additional 
excitant factor to develop it into active morbid expression ; or the inborn defect may be 
so great as to require only the natural organic evolution of growth to reveal it, or still 
greater, it may require not even this to unfold it, but may display itself in states of 
organic retrogression and nerve instability so extreme as to be perceptible at the earliest 
period when the display of mind is perceivable at all-idiocy, congenital imbecility and 
infantile insanity. 
These latter states are the extreme products of preexisting insanity, the death stages 
of a previous mental derangement in which psychical function has been disordered by 
disease. Here, however, function is not perverted, but often ceases because of the 
cessation of the psychical cell-life-the cerebral substratum of mentality. Mental 
® The mind is a sensori-psychic centre, acting on impressions exciting it either from within or 
without the area of the encephalon. Its intellective, like its motor centres, are sensori-motor. 
Bastian's views, I think, are more tenable than those of Ferrier on this subject. Sensation and 
thought, though not necessarily conscious sensation, are co-equal. 304 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
disease has preexisted and may be said to still exist, but only in the sense that necrosis 
following an inflammatory process may be called disease. 
This is our conception fortified into an unalterable conviction by long and intimate 
observation. The real nature and essence of insanity is this delusion, organic delusion 
dominating the mental character and perverting speech or conduct, or both. Under 
this definition all hitherto described or yet to be discovered forms of cerebro-mental 
disease may, in our judgment, be included. 
In the display of every form of insanity known to us we see a marked perversion or 
alteration of natural perception, conception, volition or impulse, one or all combined. 
The underlying psycho-physical substratum of all this change of psychical character is 
a more or less perceptibly delusive state of physio-psychical organism, which causes a 
morbid departure in mental character from the normal self-type of the individual, 
immediate or ancestral, by which the individuality is in unnatural or unhealthy con- 
trast with his own or his family's natural and healthy type of mental character. The 
individual, under the dominion of morbid delusive impression, is either not his natural 
self in thought, speech, or conduct, or not the personality he ought naturally to have 
been had not disease, affecting his cerebro-psychical organism, effected an abnormal 
and unnatural change in him. Insanity is a departure from the natural cerebro-psychical 
self-type, as it is or ought to be, when not changed by disease affecting the cerebro- 
psychical organism, as we have here explained our conception of it, or an immediate or 
remote disease-induced change in what is or ought to be the natural mental character. 
The underlying nature of that change is a delusive feeling (perception or conception), 
and consequent disharmony of conduct and thought in relation to environment. 
The sum of this cursory view of an almost boundless subject, as we view it, is 
this:- 
Mind is the representative and expressive sum of aggregate organism in vital action. 
This expression of the organism, as a whole, represents character. All insanity is 
insanity of character. The chief characteristic of insanity is delusion, as expressed in 
perversion of the character, whether that perversion of character be shown in morbid 
impulses or emotions, or in the classical perceptional or ideational delusions, or in the 
many varieties of abnormal states of consciousness by which the individual is placed, 
and acts, out of normal harmony with what is or ought naturally to be his normal 
environment. Mind and consciousness are closely allied. A disorder of consciousness, 
either by suspension or perversion in any degree, is delusive in its nature. The per 
verted mental states of epilepsia are all in the nature of delusion. In convulsion and 
morbid impulse, normal inhibition is abeyant and mind is more or less suspended in its 
activities and deluded in its ordinary relation to environment. 
To accept this view we have simply to widen our conception and enlarge our defini- 
tion of insane delusion, so that it may harmonize with all the psycho-pathological facts 
in the recognized and recognizable phenomena of mind deranged. Though insanity 
has been defined a change of character without adequate external cause, the change of 
character is only its symptomatic expression, and the external cause is often an all 
sufficient one. 
The transformed ego, or self-feeling and nature transformed, which we consider to 
have been transformed by disease that distorts external appearances into illusions or 
hallucinations, and perverts the normal impressions which environment makes upon the 
healthy and natural mind into delusion or delusive feeling, and morbid impression and 
deranged psychical or psycho-motor impulse, with volition consequently perverted and 
normal inhibition abeyant, constitutes the disease. 
In insanity, as in all other diseases, there is an unequal balance between waste and 
repair ; a retrograde change in the nutritional and force-producing processes has taken 
place, and the corresponding expression of power is unnatural and irregular. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
305 
The stored-up psychical force is spent in outbursts of passion which transcend the 
bounds that are natural to the individual ; grief and mental pain that did once have 
endings in repose in the person seem to go continually on so long as any reserve psychical 
force remains, and when this is all expended, it is not again so fully restored as it would 
be in the healthy brain ; mental impulses transform themselves at once into action more 
readily than they did in health, and without the usual even momentary consideration 
or restraint of the will, like the rapid reflex knee-kick that responds to infra-patellar 
percussion in antero-lateral sclerosis ; or, on the other hand, an abnormal delay is shown 
in the mental responses to external impressions, as in typical forms of locomotor ataxia. 
The machinery of the mind is about run down, as in dementia, or partly run down, 
as in the slow and sleepy and spasmodic responses it makes to external impression in 
the somnic, cataleptic, comatose, or semi-comatose forms of mental aberration, and in 
the conditions of imbecile derangement following a succession of exhaustive epileptic 
seizures, or in the psychical equivalent of an epilepsia, the perverted somnavolism* and 
cerebral automatism, which appear during the status epilepticus or supplement epilepsia 
in its larvated forms. 
The free will of every insane man is restrained and influenced by his disease. The 
free play of his volition is interfered with either by his disease direct or the manner in 
which environments impress the relationship between his knowledge and his will. 
What he was accustomed to refrain from doing in his sane estate, because his reason 
told him it was wrong, he no longer avoids doing, even though in a manner he sees, as 
formerly, that the thing is wrong. A something which he does not understand impels 
him to do wrong acts which the mental habit of his former life would neither suggest 
nor approve ; and just as muscle is moved by previous sensory impression, conscious or 
unconscious, so the insane man's mind is moved to action by conscious or unconscious 
delusive impressions, and the normal volition is perverted or suspended thereby. 
Enough of his normal mental character may still remain with him to condemn and 
regret an act which a disease-enfeebled will power or a morbid impulse have made 
resistless. He has not the grace of an ordinarily untrammeled organism, and his will 
cannot have free course to do only those things which his reason, his interest, or his 
welfare alone, or together, would suggest and prompt him to do or refrain from doing. 
His actions may even have the semblance of entirely voluntary ones ; judged inde- 
pendently of the deranged state of his mental organism, they may even have the abstract 
qualities of voluntary deeds, or semblances of deliberation, postponement, and something 
of the appearance of motive, and yet be those of a will shackled or driven by disease. 
Since insanity is not necessarily total destruction of mind, but only mind morbidly 
modified in its movements by underlying disease, neither premeditation, nor delibera- 
tion, nor previously-planned purpose, nor ultimate motive, necessarily destroy the pos- 
sibility of insanity, though the display of these semblances of healthy mental action 
should add extreme caution to our conclusion of mental disease. Nevertheless, we do 
find overwhelming cerebro-mental disease to excite an over-mastering power in certain 
directions, plainly discernible to the eye of the skillful and expert alienist, when the 
general conduct of the individual presents all the outward semblances, to the casual 
observer, of mental soundness. 
What is it, then, that we find in these obscure and interesting forms of mind 
deranged ? 
It is the underlying change in the organic feeling by which causeless suspicions 
arise, supplanting the previous healthy confidence, and the character and conduct 
changes in harmony with the morbid feeling, the conduct natural enough if the changed 
* If this term be allowable for hypnotic and. somnambulistic states. 
Vol. V-20 306 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
feeling were only a justifiable one, brought on by proper and natural external influences, 
instead of proceeding from within. 
Under this disease-caused change of feeling, morbid and groundless aversion takes 
the place of natural attachment, hate and violence the place in the heart of love and 
kindness, suspicion and distrust the place of confidence, fear the place of former courage, 
and morbid impulsions that of normal conduct. 
Melancholia supplants the natural hope, and an innumerable train of self-recrimi- 
nations and morbidly unreal forebodings supplement the individual's natural charac- 
teristics. Lasciviousness takes the place, may be, of the natural chastity ; impurity 
and wickedness dwell in the once pure and clean heart ; arson, theft, murder, rapine 
come into minds which in their sane, undeluded estate would not entertain a thought 
of crime. But the change is in the organic feelings and susceptibility to the impres- 
sions of environment ; and whether it be expressed in act of grossest impropriety and 
crime, or in nothing so marked as to attract general attention, the insanity is the same. 
The experienced engineer may know something is wrong with his boilers long before 
the passengers discover it in a destructive explosion. A flaw in the machinery, unseen 
by others, may give him just alarm ; and a rudderless ship, or one equally badly off 
with a drunken helmsman, may appear to be going well enough and yet be going fast 
toward destruction. The "inhibition " at the helm that guides aright when wind and 
wave are adverse may fail at a critical moment and all may be wrong, though appear- 
ing well to those not in position to know properly. It is so with many a mental bark 
launched or become unseaworthy on life's stormy sea, good enough for sunshine and 
calm, and appearing well to those who only see it in a calm-so well that they would 
willingly and rather cheerfully and eagerly go into court and swear the vessel was 
sound. But as the testimony of the average passenger as to the sea-fitness of an ocean 
vessel is of but little value, so equally valueless is the opinion of a non-expert medical 
or other person not familiar, by adequate and appropriate study and observation, with 
the nature of the human mind in health and under the storm and stress of disease. 
There are blots upon the brain, as there are blemishes in the construction and equip- 
ment of a sea-going vessel, which only those of certain experience and qualified to see 
and judge, can discern. In regard to the human mind in disease, the thing which the 
true alienest expert searches for most intently is neither the ordinarily looked-for vio- 
lence and delusion or generally bizarre conduct and unseemly speech, but the underlying 
transformation in the self-feeling, post- or ante-natally acquired, which makes a change 
that only disease could have wrought; a something in the mental texture and cerebral 
foundation, which impresses itself upon the psychical character in varying degrees and 
shades of departure from natural mental conduct, often markedly perceptible, as often 
scarcely appreciable to ordinary observation. It is this that constitutes the true insan- 
ity; the altered character is its more outward sign. 
The true nature of insanity is not therefore in this or that aggregation of symptoms 
constituting a more or less prolonged departure from the ordinary, natural character of 
the individual, but in the transformed mentality, wrought by immediate or remote 
ancestral disease, often and most frequently of both, which makes certain mental feeling 
and conduct at variance with the natural mental character possible; a change which 
makes not only a symptom grouping made up of morbid egoism, morbid aversion, 
morbid fear, distrust, hate, suspicion, dread of violence, special-sense delusion, and 
insomnia, or the reverse of these, its characteristic, but many blendings of these, or a 
single one intensified, its distinguishing symptomatic feature. 
Insanity may be so plain in its manifestations that a fool may see it, or so obscure 
that only the wisest expert most familiar with its hidden mysteries may, after the most 
searching investigation, discover its obscure presence and subtle influence on the char- 
acter of an individual. It is not in its plainest symptomatic aspect that expert judg- SECTION XVII-PSYCHOLOGICAL MEDICINE. 
307 
ment is required to detect it, any more than skilled observation is necessary to discover 
bad breaks in ordinary machinery. Any one may discover when a cylinder head blows 
out or a piston breaks and the machinery stops short in consequence, but only the 
engineer familiar, by long experience, with his engine, can tell whether its movements 
are in every respect natural, and his quick eye and ear will detect deviations of motion 
the bystander does not observe. And when he discovers something wrong, he knows 
that the essential fault is not in the wrong movement, but in the disturbance in the 
mechanical adjustment. The fault may be found to have been in the original construc- 
tion, in a loose bolt or valve, or overworn journal, or far away in the boilers or in their 
water supply, or under them in their fuel supply. If movement is wrong, something is 
always found wrong in the organism ; so the psychologist knows something is wrong 
in the organism of the brain whose function departs from normal. 
We need not understand perfectly the intimate construction of every form of me- 
chanical adjustment in order to comprehend the law that derangement of a mechanical 
device disorders function. So we need not insist on knowing the still obscure things 
concerning the brain and its function, mind, before we dare to attempt to define healthy 
mental function and its opposite, insanity. 
The nature of mind, like the nature of its Creator, is beyond our knowledge, but 
like the manifold evidences of the Creator's existence and wisdom, its functions and 
creations are plain enough, and we may modestly study them as we study the laws of 
nature, and comprehend them without fully understanding God. 
Before studying nature no one deems it necessary to enter first into a disquisition 
upon the character of nature's God; so, to define insanity, we need not try to define 
the nature of mind, except so much as we may see as the function of the brain, nor 
need we construct any certain metaphysical conception of mind. 
The attempt to make of mind a certain definite entity, and to frame definitions of 
insanity upon a metaphysical misconception, or, rather, inadequate, incomplete, or par- 
tial conception of mind, and to describe something different from that as insanity, 
underlies many of the failures at defining insanity. This, and a searching after a 
definite symptomatology, has been at the bottom of all failures in this direction, and a 
definition once reached upon a symptom-grouping basis, it, became necessary, from time 
to time, as new and undoubted forms of cerebro-mental disease came fairly into view, 
to make for them new morbid categories. Thus have imbecility and cretinism, idiocy, 
epilepsy, and inebriety, in active, continuous form, delirium tremens, febrile delirium, 
etc., been excluded. 
Yet the insanity stage of epilepsy, delirium, and inebriety, and the constantly- 
abiding conditions of feeble-mindedness, congenital foolishness, hystero-catalepsy, etc., 
are conditions of insanity that should be embraced in every comprehensive definition 
of a disease in which the individual's relation and response to normal and natural 
environments is abnormal and unnatural. A cerebro-mental organism that responds 
abnormally to the impressions of its environment is j ust as much an insane one, whether 
its defect may have resulted after birth, in the process of eatfra-uterine development, or 
in utero, from the kick of a brutal father, the imprudent tight lacing of a silly mother, 
or the intemperance or other vice-disease of either parent, or from blood-depraving and 
nerve-undermining causes not due to voluntary or accidental parental vice or crime. 
Arbitrary distinctions, without real difference, except in some accidental or incidental 
causative circumstances, are not justifiable,, and a definition of insanity that must 
exclude pre-natal causative influences, and make exceptions of intra-uterine accidents 
and congenital damage, is too artificial, narrow and unnatural to endure. 
It would be as reasonable to endeavor to define disease with exceptions based on 
post-mortem changes-for instance, in those exceptional cases where petrifaction sup- 
plants the ordinary putrefaction. 308 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The many definitions of insanity which have had their day, because they were 
incomplete and partial descriptions, representing each writer's more or less comprehen- 
sive conceptions of mind and its symptomatological expression in disease or in its dis- 
ordered state, have all had this fault of being too narrow or too broad. More definitions 
have, accordingly, sought to define what, in the minds of different authors, insanity 
ought to be than what it really is, and when new forms and phases of mental derangement 
have appeared, they have, if not squaring with these preconceived formulae, been con- 
tested and denied a place, for a time, in psychiatry. 
It would be far better to have no such definite conceptions of mental aberration than 
to entertain views of its nature so circumscribed as to exclude from recognition new 
forms that must inevitably appear in the advance of civilization, insanity's chief great 
causative factor, and in the progress of psychiatry, which must take account of, and 
find an appropriate place for, the most erratic and varied forms of mental disease which 
are yet to be revealed through the increasing and still to be increased intricacies of the 
cerebro-mental activities. Because, as culture advances and the arts of civilization 
multiply, the strain upon the brain increases, and the activity and number of its psychic 
centres grow and multiply. We may learn more of mind through physio-cerebral 
pathology than through its physiology alone, and reach more accurate conclusions than 
the metaphysicians did who ignored all pathological data. Psychiatry is still suffering 
in her definitions from the unnatural and abnormal influence of the metaphysics of 
the past. 
[A paper by Dr. Walter Channing, on "The International Classification of 
Mental Diseases" was read, but has since been withdrawn from publication in the 
Transactions by the author.-E. D. F., Sec'y.] 
DISCUSSION. 
Dr. Yellowlees, in discussing Dr. Channing's paper, said, I have always felt, 
Mr. President, that the classifications of insanity we have been using are a standing 
reproach to us. It is a great step toward our further progress that we should 
acknowledge this to ourselves. We all of us know quite well in our inner consciousness 
that such words as mania, melancholia, and dementia are simply labels for symptoms; 
that we know very little about the pathological condition which underlies them, and 
that we are driven to adopt these labels simply because we do not know better, and, 
as I say, this frank confession is a great step toward progress. As to this classifica- 
tion (Dr. Channing's), I do not believe we shall ever universally adopt it until 
we get a far more secure basis for classification than we now have. If you look at 
this classification you find under different names quite similar conditions, and I think 
if a patient were brought into this room, gentlemen here present would be liable to 
attach different heads in this classification to describe his condition. Circular mania 
is not found in his table. Chronic mania continually mixes itself up with dementia. 
The classification which we generally adopt is valueless except for the fact that we 
generally and roughly know what we mean by it. I know that it is a strong speech, 
but we each of us know how liable we are to great fallacies just because of the 
indefiniteness of nomenclature. Take primary delusional insanity ; many people 
will say that it is not primary ; it develops from melancholia or some incidental 
condition, as we have all seen it do. Another says I can't discriminate between 
primary dementia and the acute stupor of melancholia. And so this classification, SECTION XVII-PSYCHOLOGICAL MEDICINE. 
309 
founded upon simply labeling symptoms, is a very unscientific one, and we are driven 
to it because we cannot help it. Speaking again of Dr. Channing's classification, 
the thing which seems most definite about it is general paralysis. Yet even general 
paralysis in its early stage is oftentimes quite undistinguishable from acute mania ; 
you can't tell in its early stage whether it is acute mania or whether it will eventuate 
in general paralysis. That is our universal experience. 
As to Dr. Hughes' paper all I have to say is, that if all morbid psychical condi- 
tions are to be included under the term insanity, we must alter very strongly its ordi- 
nary acceptance, because there are very many morbid psychical conditions which are 
not so regarded now. Although the term may be philosophically right, if we tell 
the public that every queer manifestation amounted to insanity, I am afraid they 
would rebel very much. 
Dr. Channing.-In regard to Dr. Yellowlees' criticisms I would say that this 
matter is nothing personal to me, but is something that was adopted last summer at 
Saratoga. My paper was simply the entering wedge, offered to see if it was possible 
to get anything that would be universally practicable. That was the point, and this 
seemed to me the best we could do. Circular mania would not find a pigeon-hole in 
this classification, but when that point came up in the discussion at Saratoga, the 
gentlemen present thought that these cases of insanity could be brought into the 
classification under one of these forms of recurrent mania or melancholia. Of course, 
pathologically or clinically, the classification is not correct. But we have to do some- 
thing with this class of cases. Every asylum superintendent has them and must 
make statistics. Can we get up a table that will be useful for our purposes and have 
it used as an international classification ? 
Dr. Düquet.-I have but a very few words to say. I do not see why we should 
put puerperal mania in this classification. If we do, why should we not have a gouty 
insanity, a gouty mania. It would be better, I think, if we defined acute, subacute, 
and chronic mania, and left the puerperal, which might be put in as a subdivision. 
I would do the same thing with melancholia. If a patient comes to an asylum in an 
acute stage of the disease, either mania or melancholia, and if the physician knows 
nothing about the former attacks, how is he to distinguish if it is a recurrent acute 
mania or the first time that the patient is attacked ? As far as primary delusional 
insanity is concerned, I find it pretty hard to translate, even in French, and to give 
it a clear definition. I think the term paranoia given by Krafft-Ebing would be 
better than this, because it gives a certain class that every one knows. I think this 
division of dementia is too large. I should include in it, however, general paralysis, 
which is nothing but dementia. It is true that in the beginning it may resemble 
mania or melancholia, but I should consider it the same as the other dementia. 
Dr. Hughes.-Mr. Chairman : I think the more we attempt to divide the more 
we confound confusion. Everybody who has studied insanity for any length of time 
has sought to make a classification. Some have made a classification on the patho- 
logical condition, others from the causes represented, and others on the symptomatic 
expression. It occurs to me that any classification which embraces all these is a 
hybrid one. Now when you enter into puerperal insanity as a positive form of 
insanity, why not go through the whole range, as has just been stated ; then you get 
a classification that is absolutely endless ; a classification which would be longer than 
the moral law, and would embrace the full extent of each individual perception of 
the real or probable causes of insanity. Now what more potent cause of insanity is 
there than gout, and rheumatism, and venereal poisoning-and you can't stop ; the 310 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
classification must be defective if it draws a line on puerperal, and epileptic insanity, 
and alcoholic insanity. You can't possibly make a classification of that kind. Then 
in the present state of our knowledge of diseases of the brain we cannot form a 
classification based at all upon pathology ; we must give that up. 
Now I always feel a kind of sympathy for any man who attempts to formulate a 
classification of insanity. I have tried that myself, and I have got disgusted with 
myself. It may help the man who gets it up, but it helps no one else. Almost 
every man has different ideas in regard to different forms of mental disease, and he 
will classify and define insanity according to his deductions. But in a court the 
simpler the classification the better. I generally satisfy myself with mania, melan- 
cholia, and a few other forms that jurymen can comprehend. If a man uses the 
term moral insanity in a court-room he is sure to get into trouble. 
In the paper I have read I do not mean to exclude idiocy, imbecility, and cretin- 
ism, but to include them in our definitions of insanity, and it occurs to me that the 
real barrier in the way of all people who object to a comprehensive definition of 
insanity is the question of responsibility. I think we will have to confess the ques- 
tion. Now we have permitted the courts to step in and say to science : "You must 
give us such a definition as will suit the law ; which will suit us as a test of responsi- 
bility. ' ' Even as eminent a gentleman as Dr. Bucknill has fallen into that error. 
He has stepped beyond the confines of science to obey the dictum of law. We have 
nothing to do with the question of responsibility as persons engaged in the pursuit 
of a scientific study of the mind in its morbid manifestations : we have simply to 
reach such a conclusion as seems to harmonize with nature, that seems to be expres- 
sive of the facts of nature as we discern them, and to express that conclusion, and 
let the results be what they may. We can tell, of course, although they interdict 
us from doing so. We may say that any state of disease affecting the brain so as to 
disorder the mind in its normal manifestations is insanity, and we know it to be so. 
Any state of the brain, any disease which causes the mind to manifest itself in an 
abnormal and unnatural manner is insanity, whether the individual be responsible or 
not, and we must take that as our definition. 
As to congenital defects, they are called teratological, and they do not come under 
the definition given by one of the most distinguished alienists, a man who has con- 
tributed more to this subject than any one else, Combe. Insanity, according to him, is 
a prolonged departure from the natural habits of thought and feeling of the individual, 
without adequate external cause. This may be and is usually useful before the courts. 
But it does not include anything beyond the ordinary forms of mental aberration. 
Has any one here seen the few recent cases of what we call paranoia, or what is 
called primary delusional insanity, in that classification ? Combe gave a definition 
that has done more to enlighten alienism than any other man that ever wrote upon 
that subject. I believe that is without question. I think I have heard the most 
eminent men in alienism make use of that classification over and over again. Our 
own Ray used it in his fine work upon insanity and adopted that as the basis of his 
knowledge. It has been of more service in the explanation of morbid manifestations 
to the average man than any other definition that was ever given, and yet that defini- 
tion excludes idiocy, imbecility, and cretinism, and we have to make that explanation 
always wThen we use it. I often use it in court. Now we should adopt a classifica- 
tion so comprehensive as to include these ; they are as true forms of mental disease 
as any other. Let us adopt such a classification, be the consequences what they will. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
311 
THIRD DAY. 
ÜBER DEN URSPRUNG DES OBEREN (AUGEN-)F AGI ALIS. 
ON THE ORIGIN OF THE UPPER (OCULAR) DIVISION OF THE FACIAL NERVE. 
SUR L'ORIGINE DE LA DIVISION SUPRA-OCULAIRE DU NERF FACIAL. 
VON PROF. DR. MENDEL, 
Berlin, Deutschland. 
Es ist eine bekannte Thatsache, dass bei den verschiedensten Erkrankungen des 
Grosshirnes eine Parese oder Paralyse derjenigen Muskeln des Gesichtes eintritt, welche 
von der unteren Abtheilung des Nervus facialis (Mundfacialis) versorgt werden : der 
Mund steht schief, der Mundwinkel der afficirten Seite hängt herunter, die Nase kann 
nicht ordentlich gerümpft werden, die Backe bläht sich bei der Exspiration mit 
geschlossenem Munde stärker auf als auf der gesunden Seite, u. s. w. Kurz und gut, 
es entsteht im Gebiete des Mundfacialis dasselbe Bild, das wir bei den peripherischen 
Facialislähmungen zu sehen gewöhnt sind. Nicht ebenso verhält es sich im Gebiete 
des oberen (Augen-)Facialis. In der Regel besteht kein Lagophthalmus, wie bei der 
peripherischen Facialislähmung ; das Auge wird gut geschlossen, auch das Runzeln 
der Stirn zeigt keine besondere Abweichung. 
Allerdings kann man in einer Anzahl von Fällen eine gewisse Schwäche des Orbi- 
cularis palpebrarum nachweisen, aber nur in einem Theile der Fälle, und auch in 
diesen nur in unerheblicher und in der Regel vorübergehender Weise. Das geschilderte 
Bild der Facialislähmung, Ergriffensein des unteren, Verschontbleiben des oberen 
Facialis, ist ja das ganz gewöhnliche, wie es uns z. B. alltäglich im Gefolge der Apoplexia 
cerebri sanguinea entgegentritt. Diese Thatsache nöthigt zu der Annahme, dass im 
Hirnmark die zu den Muskeln der Augenlider und den Umgebungen des Auges gehen- 
den Fasern des Facialis an einer anderen Stelle verlaufen, als diejenigen, welche die 
Muskeln der Lippen und ihrer Umgebung versorgen. Dazu kommt, dass die patholo- 
gischen Erfahrungen in Bezug auf die Localisation der sogenannten motorischen Centren 
in der Hirnrinde zeigen, dass das Centrum für den Augenfacialis im Gyrus angularis 
liegt - in der Nähe des Centrums für die Augenmuskeln -während das Centrum für 
den Mundfacialis gesondert von jenem am unteren Drittel der vorderen Central Windung 
sich befindet. 
Die anatomische Trennung in Bezug auf den centralen Verlauf dieser beiden im 
Stamme des peripherischen Nervus facialis zusammen verlaufenden Theile der Nerven 
wird aber noch mehr zu einem Postulat, als die Erfahrungen bei der Bulbärparalyse 
ergeben, dass der Kern des Facialis zerstört, resp. atrophisch bei der Untersuchung 
post mortem gefunden wird, ohne dass während des Lebens irgend welche Störungen 
im Gebiete des Augenfacialis nachzuweisen waren. Es hätte danach den Anschein, als 
ob der obere Facialis überhaupt nicht seinen Ursprung in demj enigen Kern nähme, den 
wir als Facialiskern bezeichnen. 312 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Ich habe nun versucht, auf dem Wege des physiologischen Experimentes zur Lösung 
des Zwiespaltes zwischen den Ergebnissen der pathologischen Erfahrung und den 
anscheinend sicher gestellten anatomischen Thatsachen zu gelangen. 
Meine Methode bei diesen Versuchen war eine Modification der Gudden'schen. 
Dieser riss bekanntlich beim neugeborenen oder ganz jungen Thiere den peripherischen 
Nerven aus und hemmte dadurch die Entwickelung, resp. brachte zur Atrophie die 
centralen Theile, von denen der betreffende Nerv seinen Ursprung nahm. Ich beschränke 
mich in meinen Versuchen darauf, gewisse Muskeln, resp. gewisse Muskelgruppen 
beim neugeborenen oder ganz jungen Thiere zu zerstören, und erwarte, dass die Kerne, 
resp. die Theile der Kerne, aus denen die jene Muskeln versorgenden Nervenfasern 
ihren Ursprung nehmen, atrophiren, resp. nicht zur Entwickelung kommen. Es gelang 
mir auf diese Weise, durch Zerstörung einzelner Muskeln im Gebiete des unteren 
Facialis den Facialiskern nur zu beschränkter Entwickelung kommen zu lassen. Ich 
will jedoch von den dabei gewonnenen Resultaten heute nicht sprechen, sondern nur 
von denjenigen, die den oberen Facialis betreffen, und dieselben an einem Experimente 
erläutern, von dem ich die gewonnenen anatomischen Präparate Ihnen hier vorlege. 
Einem zehn Tage alten Kaninchen wurde am 4. Januar 1887 der linke Orbicularis 
palpebrarum und der linke Mscl. frontalis vollständig zerstört ; dabei war es auch 
selbstverständlich nicht möglich, den Levator palpebræ superioris vollständig intact zu 
lassen, jedoch versucht, möglichst viel von demselben zu erhalten. Der Bulbus wurde 
gegen äussere Schädlichkeiten geschützt, und dass dies vollständig gelang, zeigte die 
Obduction, welche den Bulbus unversehrt erwies. Die Beobachtung des Kaninchens 
ergab Lagophthalmus, die Function des Levator palpabræ superioris erschien nur in 
nicht erheblichem Grade gestört. 
Das Kaninchen erlag einer im Stalle ausgebrochenen Epidemie am 5. Juni 1887, 
also ca. fünfeinhalb Monate alt. 
Die Untersuchung der Stärke des Facialis ergab keine derartige Differenz zwischen 
den beiden Seiten, dass man eine pathologische Veränderung hätte constatiren können; 
ebensowenig ergab die microscopische Untersuchung entscheidende Anhaltspunkte. 
Das Gehirn wurde in gewöhnlicher Weise gehärtet und dann eine vollständige fron- 
tale Schnittreihe hergestellt. Die Untersuchung ergab in Bezug auf die Facialiskerne 
absolut keinen Unterschied zwischen beiden Seiten oder irgend welche pathologische 
Veränderung. 
Dagegen ergiebt diejenige Schnittserie, welche den Oculomotoriuskern enthält, in 
gewissen Bezirken Unterschiede zwischen beiden Seiten, welche ohne Schwierigkeit 
macroscopisch zu erkennen sind. Die f ünfunddreissig vordersten (proximalen) Schnitte 
zeigen die Oculomotoriuskerne auf beiden Seiten gleich. Ich mache darauf besonders 
aufmerksam, weil dadurch von vorneherein der mögliche Einwand entkräftet wird, 
dass die weiter nach hinten auftretenden Differenzen zwischen beiden Seiten Product 
einer schiefen Schnittrichtung seien, bei der auf der einen Seite etwa der Kern noch 
in seiner grössten Ausdehnung in den Schnitt fiel, während er auf der anderen Seite 
nur noch Reste desselben oder auch ausserhalb desselben das Hirn getroffen hätte. 
Die jenen fünfunddreissig vorderen Schnitten folgenden dreiundzwanzig, in denen 
der Oculomotoriuskern wenigstens noch auf einer Seite zu erkennen ist, zeigen nun in 
verschiedener Höhe sehr verschiedene, aber immer deutlich ausgeprägte Differenzen. 
Schnitt 204 zeigt rechts 25, links 3 Zellen im Oculomotoriuskern ; 215 : rechts 42, links 
16 ; 220 : rechts 35 grosse Zellen, links einige wenige kleine ; 225 : rechts 22, links 4 
Zellen. Am weitesten nach hinten sind überhaupt gegen das hintere Ende des Kernes 
hin nur rechts noch einige Zellen zu erkennen, links keine. Regelmässig ist der Defect 
im Oculomotoriuskern, soweit er überhaupt nachweisbar, auf der linken Seite, ent- 
sprechend der Seite der Operation bei dem jungen Thiere. 
Es liegt nun in erster Reihe nahe, anzuuehmen, dass diese mangelnde Entwickelung SECTION XVII-PSYCHOLOGICAL MEDICINE. 
313 
des Oculomotoriuskernes auf der linken Seite der theilweisen Entfernung des linken 
Levator palpebræ superioris entspricht, und würde dann der vorliegende Befund eine 
Bestätigung der Annahme sein, dass der Levator palpebræ superioris seinen Ursprung 
in der hinteren Abtheilung des Oculomotoriuskernes hat. Mit Rücksicht aber darauf, 
dass diese Veränderungen nach anderweitigen Controlversuchen viel zu erheblich sind, 
als dass sie dem Ausfall eines einzigen Muskels entsprächen, abgesehen davon, dass 
dieser Muskel hier nicht einmal in seiner ganzen Ausdehnung entfernt war und in 
gewisser beschränkten Weise auch intra vitam functionirte ; ferner mit Rücksicht 
darauf, dass für die zerstörten Mscl. orbicularis und frontalis kein anderweitiger cen- 
traler Befund zu entdecken war, speciell der Kern des Facialis normal war, nehme ich 
keinen Anstand, zu sagen, dass die Aeste des Facialis, welche Orbicularis palpebrarum 
und Frontalis versorgen-wenigstens beim Kaninchen-ihren Kernursprung in der hintersten 
Abtheilung des Oculomotoriuskernes haben. 
Es würden dann die physiologisch zusammengehörigen Muskeln, welche den Bulbus 
bewegen und schützen, auch in entsprechender Weise anatomisch zusammen gelagert 
sein, und der getrennte, corticale Ursprung der beiden Theile des Facialis würde 
auch in der Vertheilung auf zwei verschiedene Kerne zur Geltung kommen. 
Es entsteht nun die weitere Frage, wie gelangen die aus jenen Zellen des Oculomo- 
toriuskernes entspringenden Fasern in den peripherischen Stamm des Nervus facialis, 
in dem sie ja unzweifelhaft verlaufen. Meine Untersuchungen nach dieser Richtung 
hin sind noch nicht abgeschlossen, doch halte ich nach Dem, was ich gesehen, es für 
höchst wahrscheinlich, dass die Fortsätze aus jenen Zellen in das hintere Längsbündel 
treten, in demselben nach hinten verlaufen, um dann in das Knie des Facialis überzu- 
gehen und hier dem übrigen Theile des Facialis sich beizugesellen. 
Verläuft der Facialis central in der geschilderten Weise, dann hat es nichts Auffal- 
lendes mehr, wie bei den meisten Herderkrankungen des Hirnes der obere und der untere 
Facialis in so verschiedener Weise betheil igt sind, und dass eine Affection des Facialis- 
kernes bestehen kann, ohne dass krankhafte Erscheinungen im Gebiete des oberen 
Facialis eintreten. Die anatomischen Thatsachen würden dann nicht mehr, wie bisher, 
mit den klinischen Erscheinungen im Widerstreit stehen. 
DISCUSSION. 
Dr. Spitzka.-The discovery of Prof. Mendel clears up some of my own doubts. 
I have never been able to satisfy myself that the entire facial nerve arose from the 
ventral facial nucleus, and finding that an accession of fibres occurred in the region 
of the genu, thought that these comprised the palpebral fibres and came from the 
abducens nucleus, in opposition to the statements of von Gudden and the well-known 
observations of Gowers. But this discovery of Prof. Mendel explains the whole 
thing. It is in complete harmony with the view which anatomists were gradually 
approaching, that nerve nuclei are arranged rather with reference to physiological 
harmony than peripheral distribution or segmental symmetry. 314 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
LES ALTÉRATIONS HISTOLOGIQUES, SURVENANT À LA SUITE 
D'AMPUTATIONS, DANS LES NERFS PÉRIPHÉRIQUES, LES 
GANGLIONS SPINAUX ET LA MOELLE. 
THE HISTOLOGICAL CHANGES IN THE PERIPHERAL NERVES, THE SPINAL 
GANGLIA AND CORD, IN CONSEQUENCE OF AMPUTATIONS. 
DIE HISTOLOGISCHEN VERÄNDERUNGEN IN DEN PERIPHEREN NERVEN, DEN SPINAL- 
GANGLIEN UND DEM RÜCKENMARKE, IN FOLGE VON AMPUTATION. 
LE PROF. E. A. HOMÉN, 
De Helsingfors, Finlande. 
Les altérations histologiques des systèmes nerveux à la suite d'amputations sont 
d'une grande importance théorique ; elles le sont spécialement quant à la moelle, parce 
qu'elles permettent à un certain degré d'y suivre les différents trajets de conductibilité. 
Pourtant les opinions des auteurs sur ce point ont été jusqu'ici assez différentes et sou- 
vent contraires. Cela doit en partie dépendre de ce qu'on a trop souvent basé ses con- 
clusions sur une ou deux observations seulement, et qu'alors on n'a pas fait assez atten- 
tion aux différences physiologiques qui peuvent exister entre les deux côtés de la moelle; 
quelques cas aussi ont été publiés où. d'autres causes, comme la tuberculose, ont pu 
contribuer à provoquer des altérations histologiques, au moins dans les nerfs périphé- 
riques. Pour éviter ces causes d'erreur et pour pouvoir examiner à fond la nature et 
l'évolution des altérations dans les nerfs, les ganglions spinaux et la moelle j'ai fait, à 
l'institut pathologique de Helsingfors, une étude expérimentale de la question stir un 
assez grand nombre, une trentaine de chiens. Pour voir l'influence de l'âge de l'ani- 
mal sur l'évolution de ces altérations je me suis servi d'animaux de différentes âges, 
depuis de petits chiens d'une semaine jusqu'à des individus adultes. J'ai en général 
fait des exarticulations et pour voir s'il y avait une différence dans le degré des altéra- 
tions de la moelle selon que la section était pratiquée dans des parties plus ou moins 
éloignées du centre, je les ai faites tantôt dans la cuisse, tantôt au genou, de la jambe 
postérieure, quelquefois aussi j'ai opéré une des extrémités antérieures. J'ai conservé 
les animaux en vie un, deux jours, etc. jusqu'à trois ans et demi, en effet, les premiers 
de ces animaux ont été opérés en Janvier, 1884. Les pièces ont été durcies dans le 
liquide de Müller, puis transportées dans l'alcool, pour les nerfs périphériques je me 
suis servi aussi d'acide osmique. 
Pour pouvoir comparer immédiatement les altérations déterminées par des amputa- 
tions avec la dégénération secondaire proprement dite, j'ai provoqué chez quelques ani- 
maux, en leur coupant deux racines postérieures des nerfs lombaires du côté sain, une 
dégénération ascendante dans le cordon postérieur correspondant. 
Je vais maintenant donner un petit résumé de mes recherches, lesquelles du reste 
ne sont pas encore complètement achevées. Je commencerai par la description des cas 
où les altérations sont arrivées presque à leur complet développement, c'est-à-dire des 
petits chiens qui ont vécu au moins cinq à six mois après l'opération, car à partir de ce 
moment la marche ultérieure du processus paraît insignifiante. Pour ce qui regarde 
d'abord la moelle elle-même, on y constate une atrophie assez considérable de certaines 
parties du côté opérée. Après une exarticulation de la cuisse, l'atrophie est le plus 
prononcée dans le renflement lombaire, spécialement dans la partie moyenne de celui-ci. 
Cette atrophie affecte principalement le cordon postérieur et la corne postérieure, 
mais légèrement aussi la corne antérieure et en général toute la substance grise du côté 
opéré ; dans les cordons antéro-latéraux, je n'ai pu constater aucune atrophie. Dans SECTION XVII-PSYCHOLOGICAL MEDICINE. 
315 
les cordons et même dans les cornes postérieures, cette atrophie peut être telle que les 
parties ne sont quelquefois guère plus que la moitié des parties correspondantes des 
côtés sains. Quant au cordon postérieur, où l'atrophie est un peu plus prononcé que 
dans la corne, je dois constater, contrairement à l'opinion de quelques auteurs, que cette 
atrophie, probablement provoquée par l'atrophie et la disposition des fibres des zones 
radiculaires est presque également reparties sur tout le cordon et non principalement 
sur la partie antérieure. A un examen soigneux au microscope on ne peut constater 
aucune différence de structure histologique des cordons et des cornes postérieurs des 
deux côtés, si ce n'est peut-être que les fibres des cordons des côtés opérés ; sont eu 
partie un peu plus fines. Pourtant il faut relever que le nombre des noyaux est sur la 
même surface à peu près le double du cordon postérieur du côté opéré, ce qui correspond 
environ à l'atrophie ; aussi les racines postérieures sont notablement diminuées, surtout 
les fibres internes qui passent à travers la partie externe des cordons postérieurs avant 
de pénétrer dans les cornes. 
J'ai spécialement porté mon attention sur des cellules nerveuses des cornes antéri- 
eures, en les énumérant et les comparant avec celles du côté sain dans un grand nom- 
bre de préparations. J'ai constaté une petite atrophie et même la disparition d'une 
partie d'entre elles dans le renflement lombaire ; cette altération, si non si exclusive et 
si prononcée que Friedländer et Krause l'ont constaté chez l'homme,* est au moins 
principalement bornée au groupe latero-postérieur. Le nombre des cellules de ces 
groupes monte pourtant, aussi dans les cas bien prononcés à environ f du nombre de 
celles du groupe correspondant du côté opposé. 
Les altérations décrites ici diminuent rapidement dans la direction ascendante, ainsi 
dans la partie supérieure du renflement lombaire et dans la partie inférieure de la moelle 
dorsale il n'y a à constater qu'une petite atrophie dans les cordons et les cornes posté- 
rieûrs, laquelle on peut suivre à peine jusque vers le milieu de la moelle dorsale. Mais 
dans ces parties on constate une autre altération assez intéressante, c'est-à-dire dans les 
colonnes de Clarke, altération sur laquelle Friedländer a récemment attiré l'attention. 
Elle consiste dans une diminution, pourtant peu considérable, des cellules dans ces 
colonnes ; je n'ai pas pu suivre cette diminution plus haut que dans la partie inférieure 
de la moelle dorsale ; déjà au niveau du neuvième ou du huitième nerf dorsal, elle est 
à peine constatable. Il n'y a aucune diminution appréciable des fibres à myéline, 
comme c'est le cas chez les tabétiques. 
Chez les petits chiens exarticulés au genou de la patte postérieure, on trouve les 
mêmes altérations bien qu'à un degré un peu moins prononcé, contrairement à ce que 
Friedländer et Krause ont trouvé chez l'homme. 
Quant aux chiens adultes, il y a aussi les mêmes altérations, mais elles sont encore 
moins prononcées, même après une exarticulation de la cuisse ; ainsi l'atrophie du cor- 
don et de la corne postérieurs chez les animaux qui ont vécu un à deux ans après l'opé- 
ration n'est pas si grande que ces parties ne fassent encore les trois-cinquièmes ou les 
trois-quatrièmes des parties correspondantes du côté sain ; et l'atrophie de la corne 
antérieure du côté opéré est à peine appréciable ; aussi l'altérations des cellules des 
cornes antérieures et des colonnes de Clarke est très peut prononcée. 
Chez les animaux dont la patte antérieure a été exarticulé à l'épaule, il y a une 
atrophie de la corne et du cordon postérieurs du renflement cervical au moins aussi 
grande que celle qu'on trouve dans le renflement lombaire des animaux exarticulés 
dans la cuisse. Il y a aussi une atrophie insignifiante de la corne antérieure du côté 
opéré, ainsi qu'une légère atrophie et même disparition d'une partie des cellules ner- 
veuses, tout spécialement de celles du groupe latéro-postérieur. L'atrophie du cordon 
postérieur est bien prononcée encore dans la partie supérieure de la moelle cervicale. 
* Voir " Fortschritte der Medicin," Bd. 4, No. 23. 316 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Quant aux nerfs périphériques les altérations y correspondent, quant au degré, à 
celles de la moelle. L'altération consiste en ce qu'un grand nombre de fibres sont assez 
fines et plus éloignées l'une de l'autre qu'à l'état normal, quelques-unes mêmes, sans 
doute, complètement disparues, car dans les coupes transversales on peut trouver par 
places une grande partie occupée par des fibres grêles de tissu connectif et des restes de 
fibres atrophiées, avec, de loin en loin, quelques fibres d'appareuce saine.-En général, 
les différents faisceaux sont diminués de volume.-Pourtant l'altération n'est pas à 
beaucoup près si prononcée que le décrit Dickinson,* à peine autant que Friedländer 
et Krause l'ont constaté chez l'homme. Une augmentation des noyaux est évidente. 
L'altération est le plus patente dans les préparations par l'hématoxyline d'après Wei- 
gert ; là, même si le liquide de décoloration a été extrêmement dilué et que la décolo- 
ration se soit par conséquent faite très lentement, ait duré des heures, il peut arriver 
qu'à peine plus que la moitié des fibres, en comparaison du côté sain, sont bien colo- 
rées, et encore un grand nombre d'entre elles sont-elles assez fines, tandis que le reste 
de la coupe se compose de fibres plus ou moins atrophiées, dont la gaine de myéline ne 
s'est pas colorée en noir comme à l'état normal; de fibres et lames connectives épaissies, 
et de restes de nerfs atrophiés. Dans les fibres abnormalement colorées on peut pour- 
tant le plus souvent bien distinguer le cylindre-axe et la gaine de myéline qui est à peu 
près de la même couleur jaunâtre que lui et que le tissu connectif environnant. 
Dans les préparations par le bleu d'aniline et le picrocarmin on voit, outres les fibres 
d'apparence normale, un grand nombre de petits points plus ou moins bleus ou rougeâ- 
tres (les cylindres-axes atrophiés), entourés d'un anneau incolore ou un peu bleuâtre 
(dans les préparations par le bleu d'aniline), mais très-mince, quelquefois à peine 
appréciable. Ces points, ainsi que aussi les fibres bien conservées, sont en général un 
peu éloignés l'un de l'autre, séparés par un tissu bleuâtre ou rosé. Dans les prépara- 
tions incolores les parties atrophiées sont plus claires et plus transparentes, et les fibres 
y n'ont pas le brillant normal. 
Mais ce qui est ici d'une grande importance et donne à ces recherches un intérêt 
tout spécial, (un fait sur lequel Friedländer et Krause ont aussi attiré l'attention) c'est 
que seulement les fibres sensitives, pourtant pas toutes, sont altérées. Ce fait ressort 
d'une manière évidente dans les coupes transversales faites immédiatement au dessous 
des ganglions spinaux, où les parties motrices et sensitives du nerf sont encore bien 
séparées. Alors on constate dans la partie sensitive les altérations décrites ci-dessus 
bien prononcées, tandis que dans la partie motrice on ne peut constater aucune altéra- 
tion, au moins aucune altération évidente. 
Naturellement aussi les racines motrices sont, du moins en apparence, intacte. 
Quant aux racines postérieures, il m'a semblé par comparaison avec les racines du côté 
sain, comme s'il y avait une petite altération, semblable à celle des nerfs, mais il est 
bien difficile de se prononcer absolument sur des différences insignifiantes. Je continue 
du reste encore mes recherches sur ce point. 
Aux ganglions spinaux, qui dans les cas publiés jusqu'ici n'ont pas été observés, 
j'Ai consacré une attention spéciale. J'ai fait des coupes longitudinales et transversales 
et toujours comparé avec des coupes semblables du ganglion correspondant du côté 
sain. Ici aussi on se trouve en présence de la difficulté de j uger de petites différences 
quantitatives; je crois pourtant avoir trouvé, surtout dans les coupes transversales, qu'il 
y a dans les ganglions du côté opéré une légère atrophie et diminution des fibres, peut- 
être aussi un peut d'atrophie des cellules, quoique je ne sois pas encore à même de me 
prononcer avec certitude sur ce point. 
Pour étudier le début, l'évolution et même la nature du processus, j'ai commencé 
par un examen au microscope des pièces des animaux qui ont vécu un, deux jours etc. 
* Journal of Anatomy and Physiology, in, 1869. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
317 
après l'opération. Je me suis servi pour cette étude des méthodes de Weigert, de la 
coloration double de Sahli par le bleu de méthylène et par la fuchsine-acide, de la colo- 
ration double de Merkel par l'indigo et le carmin, du bleu d'aniline, du picrocarmin, 
etc. J'ai aussi mis des tronçons de nerfs aussi frais que possible, dans une solution 
d'acide osmique (1 :100), et après un séjour de 10 à 20 heures je les ai légèrement dis- 
socies ; puis je les ai examinés immédiatement ou après un séjour d'au moins 24 heures 
dans le pikrocarmin, ou le carmin au borax. 
Je n'ai réussi, par aucune de ces méthodes, constater une différence qualitative 
entre le côté opéré et le côté sain, ni dans les nerfs (excepté l'extrémité tout-à-fait ter- 
minale du nerf dans le voisinage immédiat de la section, où il y a une altération gra- 
nulo-graisseuse), ni dans la moelle, aucune dégénération ou destruction comme dans la 
dégénération Wallerienne, dans le bout périphérique d'un nerf sectionné ou réaction 
caractéristique, comme pour la dégénération secondaire par la fuchsine-acide, comme je 
l'ai montré dans un travail précédent. Mais au bout de huit jours, chez les petits ani- 
maux, opérés à l'âge d'une semaine, on commence à constater dans les nerfs périphé- 
riques de petites différences quantitatives, en ce qu'on rencontre un nombre relative- 
ment grand de fibres assez fines, et des fibres dont la myéline ne se colore pas assez 
fortement par l'hématoxyline d'après Weigert. Cette altération s'étend sur le nerf 
dans toute son étendue. Au bout de deux ou trois semaines l'altération est évidente, 
ainsi qu'une atrophie dans le cordon et la corne postérieurs de la moelle du côté opéré. 
Peu à peu, à mesure que ces altérations progressent, on constate aussi les autres altéra- 
tions mentionnées ci-dessus ; et après cinq ou six mois le processus fait très peu de pro- 
grès. 
Chez les chiens adultes ce n'est qu'au bout d'un à deux mois qu'on peut constater 
les premières altérations évidentes, du reste de la même nature, mais qui n'atteignent 
amais le même degré. 
Il ressort de ce qui précède qu'il s'agit ici d'une atrophie simple sans changement 
de la structure histologique, et absolument différente de la dégénération granulo-grais- 
seuse du bout périphérique d'un nerf sectionné et de la dégénération secondaire de la 
moelle, contrairement à ce que croit Forel.* Cette différence ressort d'une manière évi- 
dente des cas où j'ai, du côté sain, coupé deux racines postérieurs des nerfs lombaires et 
provoqué ainsi une dégénération secondaire ascendante du cordon postérieur correspond- 
ant, lequelle est appréciable déjà cinq à six jours après cette opération et débute par 
d'altérations caractéristiques, c'est-à-dire par une tuméfaction et une décomposition en 
granules des cylindres-axes, ainsi que par l'impuissance à se colorer par les substances 
ordinaires, tandis qu'ils le sont très-fortement par la fuchsine-acide. Comme je l'ai 
montré dans des travaux précédents.! Il n'y a, du réste, pas lieu d'y revenir ici, pas 
plus que sur les détails topographiques de la dégénération secondaire ainsi provoquée. 
Enfin, pour ce qui concerne l'explication du fait que, après les amputations, une 
partie seulement des nerfs s'atrophient, je n'oserais pas encore émettre une hypothèse. 
En tout cas, l'hypothèse de Friedländer que seuls les nerfs s'altèrent, qui se terminent 
par des appareils spécifiques, me semble peu probable, déjà par la raison que j'ai con- 
staté une différence dans le degré des altérations, selon que j'ai fait la section plus haut 
ou plus bas. D'un autre côté il doit être permis de conclure que les parties notable- 
ment altérées de la moelle, par conséquent aussi les cellules du groupe postéro-latéral 
des cornes antérieures, sont en rapport avec la sensibilité. • 
Mes recherches expérimentales finies, il me restera encore à faire la comparaison 
* Archiv f. Psychiatrie. Bd. XVin, H. 1. 
f Voir Homén : "Contribution expérimentale à la pathologie et à l'anatomie pathologique de 
la moelle épinière," 1885, et Fortschritte der Medicin, Bd. ni, H. 9. 318 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
avec des pièces de quelques cas d'hommes amputés, que j'aurai à ma disposition, com- 
paraison dont j'espère pouvoir donner les résultats dans quelque antre occasion. 
(La communication était accompagnée par demonstration de preparations et des photogra- 
phies de preparations.) 
DISCUSSION. 
Dr. Spitzka asked Dr. Homen to state more definitely the location of the degen- 
erated area. He referred to the fact that in some cases a part, in others the whole, 
of the hind leg, in still others the whole of the fore leg, had been amputated ; the 
area of secondary ascending degeneration must have been different in each case. It 
seemed to him that in the last-mentioned case the degeneration should be in the 
comma-shaped field, in the former two in special parts of the column of Goll. 
Dr. Homen.-Je veux encore relevé, contre Spitzka, qu'il ne faut pas confondre 
l'atrophie de certaines parties de la moelle, survenue à la suite d'amputations, et la 
degeneration secondaire proprement dite ; ce sont deux choses complètement diffé- 
rentes, comme je l'ai montré dans ma communication. Quant à la dégénération 
secondaire, elle est toujours bien limitée, surtout après la section des racines posté- 
rieures, et débute par d'altérations caractéristiques des cylindres-axes, comme je l'ai 
montré dans des travaux précédents. (Voir Virchow's Archiv, Bd. 88, H. 1, et 
mon travail : " Contribution expérimentale à la pathologie et à l'anatomie patholo- 
gique de la moelle épinière," Helsingfors, 1885.) 
Dr. Savage said the demonstrations of Dr. Homen were most interesting from 
a physiological as well as from the pathological side ; they were valuable because 
they had been most carefully conducted, the experiments having extended over some 
years. It was a fruitful field, not only associated with general paralysis of the insane, 
but also with cases of locomotor ataxy. He was heterodox enough to believe that 
there may be ataxic symptoms due to progressive degeneration from the periphery, 
and that they were common with degeneration with some as yet undescribed cortical 
area. He regretted that he had not the opportunities for pursuing these investigations 
and experiments possessed by the French. 
Demonstrations of microscopic preparations, the staining of ganglion cells by 
magenta, comparisons of methods, and the superiority of magenta over conium 
and hæmatoxylon were then given by Dr. Ernest Otto, of Munich, Bavaria, SECTION XVII-PSYCHOLOGICAL MEDICINE. 
319 
ON THE ASSOCIATION OF A PROW-SHAPED CRANIUM WITH 
NEUROTIC AILMENTS. 
SUR LE RAPPORT D'UN CRÂNE EN FORME DE PROUE AVEC LES AFFECTIONS 
NÉVRITIQUES. 
ÜBER DEN ZUSAMMENHANG DES SKAPHOKEPHALEN SCHÄDELS MIT NEUROTISCHEN 
AFFECTIONEN. 
BY J. LANGDON-DOWN, M. D., 
Of London, England. 
For some years past I have been accustomed to differentiate cases of feeble mind 
among the young into three categories :- 
1. Those which are of accidental origin, meaning thereby those which have received 
injury in their early days from falls, from injury at parturition, from meningitis arising 
from disease of the internal ear sequential to scarlet fever or other affections. 
2. Those which are of congenital origin from causes interfering with development 
at the early periods of embryonic existence, or from causes which have their origin in 
the antecedent history of the sperm or germ cell. 
3. A by no means unimportant class which manifest themselves only at develop- 
mental epochs after birth, and which I have proposed to call " developmental cases." 
These have their origin during the later months of embryonic existence. They have a 
nervous organization fitted for the ordinary growth of the individual, but are prone to 
break down at one or other of the great developmental epochs of first and second den- 
tition and puberty. In a large number of cases they are characterized by a prow-shaped 
cranium arising from deferred synostosis of the medio-frontal suture. 
The kind of cranium which thus results I regard as a neurotic cranium, because of 
its frequent association with one or other of the neuroses. A large number of cases 
of epilepsy and of chorea occur at the periods of second dentition and of puberty, where 
there has been nothing in the early years of the children to occasion anxiety, but who 
have in a more or less marked degree the evidence of a neurotic cranium. 
The medio-frontal suture is a foetal condition and should disappear by synostosis at 
or before birth. If the synostosis be deferred, it is often associated with a prominent 
ridge marking the union of the two organic frontal bones, so that instead of the centre 
of the coalesced or synostosed frontal bone being plane or concave, preserving the rela- 
tive prominence of the centres of ossification of the frontal eminences, there is a promi- 
nent ridge corresponding to what was the medio-frontal suture, and imparting a charac- 
ter to the cranium which has induced me to call it prow-shaped. 
During the last twelve months I have had under my observation three boys, who, 
at between the ages of eight and nine years, had lost speech. There was no indication 
of any hemiplegic lesion, nor had there been anything in the conduct of either of the 
children to give rise to any apprehension. They had gone through the period of growth 
without any difficulty. I saw the school reports of two of them, and while both were 
creditable, one was certainly that of a precocious child, and he had given evidence of 
remarkable promise. They were all the subjects of prow-shaped crania. I have 
recently seen a child of seven years of age ; he has been taught since the age of five in 
a kindergarten school, and is said to have given no anxiety or trouble. There is a 
history of great emotional distress on the part of the mother at or about the seventh 
month of pregnancy, in consequence of the sudden illness and death of the father. For 
the last six months the child has given great trouble, gets into sudden fits of petulance, 
destroys his clothes, strikes his brothers and sisters, and is altogether an enfant terrible 
in the house. An examination of his cranium revealed a remarkable prow-shaped 
condition. He does not appear to lack intelligence. His memory is good and he has 320 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
not been pushed unduly. My view is that the emotional condition of the mother 
arrested the synostosis of the medio frontal suture, determining a prominence along the 
line of suture when the post-uterine ossification took place, and that the same emo- 
tional cause interfered with the development of the cerebrum, leading to an unstable 
condition of the brain, of which the prow-shaped cranium is an outward and visible sign. 
A short time since a young lady came under my treatment for epilepsy, who had 
had perfect freedom from epilepsy or other nervous affection till the age of fifteen, 
when she had attacks of petit mal. In about six weeks from the incidence of these 
attacks she had two serious epileptic fits, and rapidly became the subject of frequent 
attacks of a like nature. Her cranium was remarkably prow-shaped, and there was a 
very well-authenticated history of severe illness on the part of her mother during the 
later months of gestation. 
With somewhat similar history and with the same description of crania I have 
notes of five cases of stammering, three taking place at second dentition and two at 
puberty ; six cases of enuresis, three coming on at second dentition and three at pu- 
berty ; ten cases of convulsions at second dentition ; three cases of night terrors attended 
by screaming at second dentition ; one case of destruction of clothing, with paroxysmal 
outbursts of temper originating at the same period. As a practical outcome of these 
observations, it should be noted that intellectual pressure at the developmental periods 
is baneful to children who have well-marked prow-shaped crania. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
321 
FOURTH DAY. 
PATHOLOGY OF HAY FEVER. 
PATHOLOGIE DE L'ASTHME DE FOIN. 
ÜBER DIE PATHOLOGIE DES HEÜ-ASTHMAS. 
Of Chicago. 
Synonyms.-Nervous catarrh, nervous coryza, hay asthma, rose cold, June cold, July 
cold, peach cold, summer catarrh, autumnal catarrh, pollen poisoning. 
Latin Equivalents.-Catarrhus æstivus, coryza vaso-motoria periodica. 
French Equivalents.-Catarrhe d'été, catarrhe de foin. 
German Equivalents.-Fruhsommer catarrh, heu-asthma. 
Italian Equivalent.-Asma dei mietitori. 
Goethe has tersely said : " If a man write a book, let him set down only what he 
knows." In medical literature there is much writing of the negative sort. But if a 
man take an invoice of his mental stock, he is forced to admit that a large percentage 
of it consists of negations. The object of philosophy is the knowledge of phenomena in 
all their relations, and it cannot be attained independently of theories and hypotheses. 
Not less indispensable are the same methods of investigation and reasoning, and not 
less latitude must be enjoyed, in discussing a subject of the peculiar nature of the one 
which forms the title of this paper. One must divest the mind of previously-conceived 
opinions before it is free to apprehend causes and conditions in their true proportions 
and relations. Much has been written concerning biology, electricity, phrenology, 
magnetism ; yet who has mastered the principle we call life ? What Æolus restrains 
the electric currents of the world ? Who measures the molecular activity of the brain 
when his own thought is evolved-labels this atom love, or that causality ? Who can 
define odylic force and the law of its operation ? But though our path is beset with 
discouragements, and our work of investigation hemmed in by the natural restrictions 
of human thought and the limitations of our knowledge of pathological processes, the 
laboratory, lens and logic may yet triumph. 
The name hay fever is a misnomer. It is employed to designate a condition to 
which numerous other terms have been applied by various observers, with equal fitness. 
To the array of names already in use, ill-chosen because they are misleading, I have 
had the temerity to add another. In a published lecture, delivered in the Chicago 
Medical College in 1885, I proposed the term nervous catarrh. Since then, several 
authors have adopted this expression. One writer, however, calls it nervous coryza ; 
but coryza is from the Greek /copvfa, signifying only a running at the nose ; while the 
word catarrh, from admits of a much broader application, and with properly 
modifying adjectives may be applied to affections of various mucous membranes. 
Coryza is a specific term ; catarrh is generic, and obviously the more correct one to 
SETH S. BISHOP, M. D., 
Vol. V-21 322 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
characterize a disease which is not confined to the nasal cavities. Nervous catarrh is 
so comprehensive a term, and is so tersely suggestive of the pathology and symptoma- 
tology of certain neurotic derangements, as to be susceptible of a much larger usefulness 
than has been accorded it. To illustrate : There is a truly nervous intestinal catarrh 
which attacks and leaves a certain class of individuals of the nervous temperament as 
suddenly as an attack of hay fever does. I have known a musician to suffer severe 
attacks of diarrhoea just previous to his appearance before an audience which he was 
announced to entertain. Immediately after his performance all symptoms of intestinal 
disturbance would vanish, only to return again at his next appearance in public. I 
might cite a case of an orator of the evening who was similarly afflicted. The nervous- 
ness induced by the contemplation of addressing the audience would so react on the 
nerve supply of the intestinal tract as to cause sudden and copious diarrhoea. No 
sooner would the oration be finished than all unpleasant symptoms ceased. We have 
nervous dyspepsia occasioned by mental emotions. A certain combination of objective 
and subjective causes operating on one individual produces morbid phenomena refer- 
able to the mucous membrane of the turbinated bodies, resulting in an attack of hay 
fever-nasal nervous catarrh. In another, the seat of the resulting manifestations will 
be in the bronchial mucous membrane, eventuating in an attack of asthma-bronchial 
nervous catarrh. In yet another, the intestinal mucous coats are the scene of this 
breaking of a nerve storm, and copious watery discharges result-intestinal nervous 
catarrh. All these are undoubtedly coordinate morbid conditions of the nervous sys- 
tem, finding expression in exaggerated and perverted functional activity. 
The pathology of this disease has been evolved from a chaotic state, in which it 
remained from the time of its first description by Dr. Bostock, of London, in 1819, 
until the last decade. Instead of looking upon hay fever as a simple congestion or 
inflammation of the Schneiderian membrane, as eminent English authors have in the 
past and yet do, prominent American authorities favor the neurotic theory. In this 
connection it is interesting to note that a recent writer in the Lancet treats of common 
nasal catarrh as a reflex neurosis, and in support of his position adduces numerous 
instances in which purely nerve remedies succeeded in arresting attacks of acute 
coryza. 
Although I maintain that this malady is essentially due to an abnormal suscepti- 
bility of nervous tissue, I do not claim that there exists any organic lesion of the nerve 
centres to which the disease is attributable. It being a functional disturbance, it never 
destroys life, and no opportunity is afforded the neuro-pathologist to make post-mortem 
observations. But if the affection be a reflex neurosis, can we hope for microscopy to 
determine with precision the condition of nervous structure which primarily constitutes 
the disease ? 
If we examine the arrangement of the nervous supply of the respiratory passages, 
we find that it is favorable to the existence of reflex phenomena. One sympathetic 
nervous centre, the spheno-palatine ganglion, supplies branches to the lining membrane 
of the nose, pharynx and Eustachian tubes. It has a motor, a sensory and a sympa- 
thetic root. It communicates with the facial and pneumogastric nerves, thus uniting 
in the closest sympathetic connection the nose, pharynx, middle ear, larynx and 
bronchi. Furthermore, the Schneiderian mucous membrane is continuous with that 
lining the nasal ducts and eyelids, the pharynx, the Eustachian tubes and tympani, 
the larynx, trachea and bronchial tubes. Ablation of the spheno-palatine ganglion 
sets up a severe catarrhal state of the Schneiderian membrane. Congestion once started 
in this structure may extend with unobstructed facility to the contiguous membranes, 
very like the spreading of an erysipelatous inflammation from one area of the skin to 
another. But the continuousness of the mucous membranes throughout these various 
organs does not satisfactorily account for all the symptoms produced in one part by SECTION XVII-PSYCHOLOGICAL MEDICINE. 
323 
impressions upon another. Certainly, an inflammation in the throat may extend along 
the Eustachian tube to the tympanum, but there is no such reason to account for the 
sudden, transitory tinnitus aurium which occurs in some persons immediately upon 
the ingestion of a draught of cold water, or the inhalation of tobacco smoke-or for the 
cough which is occasioned by the contact of instruments with the external auditory 
meatus, with the inferior turbinated body or septum nasi-or for the paroxysms of 
sneezing produced by irritating the scalp. These symptoms are all examples of reflex 
nervous impulses, and these intimate sympathetic relations between various portions of 
the animal economy exhibit themselves with exceptional force in patients of a nervous 
temperament. The theory that lesions situated in the nasal cavities may be respon- 
sible for the existence of common asthma has lately acquired a considerable following 
in this country. But this is directly in the line of our reasoning, for it argues the 
reflex neurotic character of a disease which possesses close kinship to hay fever, not 
only in its aetiology, symptomatology and therapeutics-but in the morphology of its 
secretions. The manner in which exciting causes bring about attacks in hay fever is 
much the same as in the case of asthma. In a hay fever subject, let brilliant rays of 
light fall upon the retina, or pollen impinge upon a sensitive area of nasal mucous 
membrane, and what follows ? The end organs of the sensory nerves supplying the 
parts affected being over-sensitive to thp presence of that particular kind of stimula- 
tion, are instantly thrown into a state of intense excitation or irritation. Immedi- 
ately the impression is flashed along the sensory nerves to a nervous centre-brain or 
ganglion-thence, changed to motor impulse, it is switched back, on the one hand, 
along the vasomotor nerves to the blood vessels of the seat of irritation, causing dilata- 
tion, engorgement, swelling and flux; and, on the other hand, along the pneumogastric 
and sympathetic nerves to the organs concerned in the act of sneezing; and through 
extensive sympathetic nervous relations, all the respiratory tract and its connections 
may participate in the disturbance and become involved in a fully-developed attack of 
hay asthma-sneezing, coughing, wheezing, nasal flux, expectoration and lachryma- 
tion. 
Thus, it appears, from the manner in which paroxysms of hay fever are started and 
developed, that there are three conditions upon which the existence of the disease 
depends: 1st, abnormally susceptible nerve centres; 2d, hyperæsthesia of the peripheral 
termini of the sensory nerves; and 3d, the presence of one of a large variety of irri- 
tating agents. Exclude one of these conditions and the paroxysms are prevented. 
Allay the susceptibility of the nervous centres by certain cerebral sedatives and an 
attack is averted or arrested. Anaesthetize the nervous supply of the over-sensitive 
areas and the result is the same. Remove the patient beyond the reach of exciting 
causes and he is as comfortable as any mortal. 
Another fact in support of the theory that this is a functional disease of the nervous 
system is its hereditary character. I might quote many cases in support of this state- 
ment were there time, but three representative instances will suffice:- 
In Dr. Morrill Wyman's family there were six sufferers from this disease besides 
himself. In the family of the Rev. Henry Ward Beecher there were two besides him- 
self afflicted with hay fever. In the family of Chief-Justice Shaw there were six 
members who had different forms of this malady. 
To be sure, heredity alone does not establish a neurotic character, but taken in 
connection with all other facts in the case, it is a weighty argument in support of the 
assertion that this is a constitutional disorder of a neurotic type. 
Again, the nervous temperament is the predominating one among this class of 
patients-an argument which needs no elucidation. The same may be remarked con- 
cerning asthma, and the admitted kinship of the two diseases only serves to strengthen 
my position in this discussion. The periodicity of the disease points to nothing if not to 324 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
its nervous nature; for one cannot conceive how the pollen theorists, from their point 
of view, can reconcile this feature of the complaint with their own doctrine. Is it rea- 
sonable to assume that the pollen of various plants which give rise to attacks in different 
individuals will be set free, to float away on their fructifying pilgrimages, on exactly the 
same day, and at nearly the same hour, each recurring year, and that they will reach the 
nostrils of sufferers in their varying localities and situations and avocations simultane- 
ously, year after year ? The variations which occur in the yearly advance of the seasons 
preclude this hypothesis. And again, the identity of the different forms of the malady 
strengthens the nerve theory, while it weakens the pollen argument; for it shows that 
the disease exists under conditions which are least favorable to the operation of pollen, 
in fact, when the pollen theory is inadmissible-in the winter and spring. I do not 
wish to convey the impression that I undervalue the importance of pollen as an exciting 
cause, but I do wish to be understood as maintaining that it constitutes but one of three 
factors which render the existence of the disease possible. Other arguments which 
may be briefly mentioned are the suddenness of the onset and disappearance of attacks, 
the fact that the most potent palliatives are nerve sedatives, tonics and stimulants, and 
that mental emotions and physical exertion may prevent or arrest paroxysms. 
The principal argument urged against the nerve theory is, that many hay fever suf- 
ferers have diseased turbinated bodies. But we may say the same of that much larger 
proportion of our population who do not have hay fever. That we should find nasal 
hypertrophies, etc., concurrent with hay fever, is not surprising in this catarrh-producing 
climate. Indeed, the diseased turbinated tissue may be a coincidence or sequence, 
rather than the cause, of this malady ; for it is natural to suppose that years of con- 
stantly-recurring attacks of even a functional disturbance of the vasomotor supply of 
these parts would result in a passive hyperæmia which would eventuate in proliferation 
of cells in the mucous and submucous tissue, and the growth of hypertrophies which 
might serve as a nidus for the reception and retention of irritating agents. But to 
argue that this condition is responsible for hay fever in infants, youths, and even adults, 
in whom there is no evidence of inflammatory changes before or between attacks, is not 
reasonable. The paroxysms do not so much resemble the symptoms of an inflammation 
as they do an irregular and explosive discharge of a superfluity of nervous force-a 
nerve storm, if the expression may be permitted. It has been claimed that destructive 
treatment of the sensitive areas in the nasal cavities would permanently cure hay fever, 
and many cases have been so treated by American physicians during the last three 
years. However, the most sanguine practitioners of this method have recently con- 
fessed disappointment at the results. Cases that were supposed to have been cured 
still suffer, others are only slightly benefited, while a few are worse for the operations. 
So far as I have been able to obtain definite data, they demonstrate that not one-half 
the number treated are claimed to be cured. This points to the fact that it is not a 
simple local inflammatory disease. If it were, the treatment would be attended with 
success. For reasons which I have set forth, we cannot expect this method to cure all ; 
but granting that it may cure many, the nerve theory would not suffer in the least by 
the admission ; for it assumes a pathological condition of the receptive end organs of 
the nerves as well as of the perceptive nervous centres. Eliminate the susceptibility 
of either the central or peripheral nervous system, and you remove an essential element 
in the disease-destroy its entity. But what are we to say of that other large propor- 
tion of patients in whom paroxysms are produced by irritation of the retina, the scalp, 
etc., or chilling of the skin ? Are we to be logical, and, reasoning from analogy, must 
we destroy the sensitive area-the retina, enucleate our patient's eyes, scalp or skin 
him? Yet if you follow the reasoning of this school of theorists to its logical conclu- 
sion it will lead you to this reductio ad absurdum. 
The neurotic theory is supported by the nature of the following causes: electric SECTION XVII-PSYCHOLOGICAL MEDICINE. 
325 
(and gas) light, over-exertion, anxiety, indigestion, dampness, chills, camphor, gases, 
feathers, perfumes, odors from animals, dry, hot, and impure air, various kinds of 
fruit, etc. It will he observed that pollen and dust do not enter into the causative 
nature of these excitants. 
This theory also receives support from the fact of the excessive irritability and 
nervousness which patients experience just preceding and during attacks : the coor- 
dinate action of muscles is affected and they complain of feeling "jerky" and ill- 
tempered for a time. 
I-n studying this disease it should not be forgotten that the statement of sufferers 
relative to the history and phenomena of their malady should be given greater credence 
than is usually accorded the assertions of some other classes of patients, inasmuch as 
they enjoy the distinction of being superior to the average in intelligence and culture. 
This is far from being an idle assertion, for it voices the experience of authorities on 
the subject, and is borne out by a reference to the list of membership of the United 
States Hay Fever Association. 
I cannot consider the treatment of this subject as approaching completeness without 
referring briefly to two other important points. Microscopists have been recently 
examining the nasal and bronchial secretions from hay fever and asthmatic subjects, 
with the result, it is claimed, of establishing the kinship of the two diseases, by demon- 
strating the presence in each of products which have been called gravel. It is sup- 
posed that this so-called gravel accumulates in the secretions of the respiratory passages 
and acts as a local irritant in much the same manner as any foreign body would. 
Thus far I have made use of analogy only as it applied to the relationship of hay 
fever and asthma, but students of this malady will appreciate the force and analogy of 
the following facts relating to affections of the skin : Intense itching over the surface of 
the whole body may be produced by morbid alterations in the ovaries or uterus, anoma- 
lies of menstruation, diseases of the kidneys, liver, etc. Again, Neuman says: " There 
is no doubt but that a large proportion of cutaneous diseases depend upon disorders of 
the vasomotor nerves which cause certain derangements of the circulation in the arte- 
ries, veins and cutaneous glands. Anæmia and hyperæmia of the skin happen from 
vasomotor irregularities, some from the brain, some from the spinal cord, or from the 
action of cold or the electric current," etc. Now, since it is admitted that there are 
both immediate and reflex functional nervous disorders of the skin, with what show of 
reason can it be denied that there are similar neurotic disturbances of that other skin 
which covers the interior surfaces of the body ? The latter membrane is more vascular, 
more delicate, more sensitive, more highly organized than the skin. It possesses 
susceptibility to all agents which affect the skin and to many others besides. For 
example, noxious gases to which the skin is insensible will irritate the mucous covering 
of the respiratory organs. The same laws which govern the action of the vasomotor 
nerves of the skin also regulate the vasomotor supply of the mucous membranes. If 
itching and burning of the skin are produced by morbid alteration in the ovaries, so is 
pruritus urethrae produced by disease of the bladder; pruritus nasi is generally accepted 
as a sign of worms in children; urticaria results from irritation of the gastric or intes- 
tinal mucous membrane; so may asthma arise in the same manner, or from an irritant 
applied to the post-nasal mucous surface; ear-cough is occasioned by bringing instru- 
ments in contact with the skin of the external auditory meatus ; and hay-fever paroxysms 
result from irritation of the retina, the upper lip or the scalp, or from chilling of the 
skin. 
Finally, from a study of all the facts in our possession, we are forced to the conclu- 
sion that the weight of testimony is in favor of the doctrine that hay fever is a reflex, 
functional, nervous disease. 326 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. Ferguson expressed himself as thoroughly in accord with Dr. Bishop's 
convictions relative to the pathology of hay fever. 
Dr. Channing regarded Dr. Bishop's paper as a remarkably clear presentation 
of the subject. It was easy to accept his statements, but the difficulty lay in deter- 
mining whether or not it should be dignified by the name of a neurosis. We could 
understand that the disease was caused in the way he explained, but we had other 
similar irritations of mucous membranes which we should not be ready to classify in 
that way. We had, for instance, the irritable throat from which people in Boston 
and near the coast suffered. Such patients had to leave Boston in the spring on 
that account. We should not classify those throat troubles as neuroses in the strict 
sense of that term. Such cases certainly occurred more at one season than at any 
other, namely, early summer and spring. It seemed to him that there must be 
something favorable to their development, a strong outside cause, the essential ele- 
ment in aetiology being a weakness of that special mucous membrane. The cases 
with which he was most familiar were those occasioned probably by the pollen of 
flowers or similar irritants ; coming on at that time in the spring when those influ- 
ences were most prevalent-the only cure or palliation was a removal to new sur- 
roundings. People had to go to the White Mountains, the Isle of Shoals or some 
other place, Nova Scotia, for instance. He knew of no remedy which was suitable 
for any form of nervous trouble that would actually cure those sufferers or produce 
a sufficient amount of palliation to make it possible for them to stay at home, and 
he must say in reference to a point in Dr. Bishop's paper, that in the cases he had 
seen the nervous temperament was not in all of them prominent, though in a certain 
percentage it was so. He would like to ask Dr. Bishop if in the cases of Henry 
Ward Beecher and others he had mentioned, there was an inherited neurotic 
temperament. 
Dr. Brush suggested that like the temperance lecturer he might offer himself as 
a horrible example. Dr. Channing had referred to the question of pollen. He 
never had hay fever until five years ago, when he awoke in the middle of the night 
to find himself suffering acutely from it. Since that time he had had attacks 
ranging all the way from July until the fall. The first attack was in July, and this 
summer he was free from it until he reached Washington. Last night he was kept 
awake by a terrific attack of hay asthma. The neurotic temperament had been 
referred to, but he did not know that he was of an especially nervous temperament. 
Dr. Hurd believed in the neurotic origin of hay fever very strongly until this 
summer. The present season had been an unusually severe one upon nervous 
invalids. The intense heat of the months of June and July, continuing for many 
weeks, had depressed the vitality of almost every person suffering from nervous 
diseases, or predisposed to them. Now, as a matter of fact, hay-fever sufferers had 
suffered far less than usual this summer. In many localities they had escaped 
entirely ; in other places the attacks had been transitory, and removal from home 
had not been necessary. In the section of Michigan in which he lived, they had 
ragweed (ambrosia trifida). While he did not suppose that ragweed was the only 
cause of hay fever, he was sure it was an extremely potent one. The climatic influ- 
ences of the season had been such that ragweed had not flourished ; it had grown 
very slowly, had flowered imperfectly, and he supposed in consequence its pollen had 
been very imperfectly distributed. The effect, in his opinion, was to secure an 
almost complete immunity from hay fever in most of the localities. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
327 
Another point which was difficult of explanation hy the theory of the nervous 
origin of hay fever was the marked annual periodicity with which the attacks occur. 
He had a brother whose attacks began on the 18th of August at two o'clock in the 
morning, year after year. One could hardly think that a periodicity due to a state 
of the nervous system would display such extreme regularity. It had always seemed 
to him that the majority of persons suffered from these attacks at a time when the 
pollen of plants was generally and thoroughly distributed in the air, and that 
mechanical irritation had much to do with their origin. 
Dr. Andrews commended Dr. Bishop's paper. It must be admitted that he had 
thus enumerated all possible causes of the development of the disease in ascribing 
them to a central, a peripheral and an irritant origin. 
The reason that some could not recognize hay fever as a disease depending in all 
cases upon a neurotic diathesis was perhaps because the cases we were familiar with 
were due to one or the other of the two other causes mentioned, and not cases of 
central origin. 
It did not seem necessary that we should have in al! cases a neurotic diathesis in 
the individual. He regretted that Dr. Bishop had not gone into the matter of treat- 
ment and enlightened us upon that special point. He would like to know what he 
had found to be the best therapeutic measures, especially in cases of central origin. 
Dr. Bishop.-I should have been only too happy to have entered into the treat- 
ment of the disease, but I found the time too limited. In answer first, to a gentleman 
who spoke here and who asked if Henry Ward Beecher and those patients who 
suffered from the disease were of a nervous temperament, I would say that we must 
make a distinction between a diseased condition of the nervous system, or a nervous- 
ness which may result from a condition of nervous disease, and a nervous temperament. 
One may be a nervous individual, have a nervo-sanguine temperament, and still have 
no disease of the nervous system. Take these patients suffering most severely; at 
other portions of the year they are in perfect health, so far as any one can ascertain. 
There are some who suffer only in the hot portions of the year, while during the fall, 
winter and spring, they are as healthy as anybody. Henry Ward Beecher was com- 
pelled to go to the White Mountains during the summer, leaving his lecture and 
other engagements and spending a number of weeks there, to escape the severe 
attacks of hay fever to which he was subject. He was a fleshy and a brawny man 
physically, but he certainly had a nervous temperament. How many men are there 
in the world who have done as much as Henry Ward Beecher has done who have not 
nervous temperaments ? Now a man may have nothing but the hay fever, and it is 
a strong argument, in my opinion, in favor of the neurotic theory, that they are not 
conscious of having any nervous trouble during the year, but let them be exposed to 
any form of suffering to which they are susceptible and they suffer most excrucia- 
tingly. So these people are susceptible to many things; they cannot eat certain forms 
of food, shell fish, lobsters. I have had one or two patients who have frequently 
declared to me that eating strawberries would throw them into convulsions. I have 
now come to believe almost anything in regard to the abnormalities of the nervous 
system. 
It is a fact that hay fever is experienced only during the most depressing weather 
that we have during the year. Its attacks come when the nervous system is subjected 
to the most depressing effect of heat. Still there are others who, if they at any time 
enter a poorly ventilated hall, are certain to have attacks of hay fever, not so severe as 328 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in midsummer, but they differ in people. They are attacks of hay fever, only less 
severe than those suffered from in midsummer. 
Dr. Andrews asked if Dr. Bishop had any remarks to make in answer to Dr. 
Hurd's reference to the definite periodicity of the disease and its relation to its being 
a neurotic condition. 
Dr. Bishop.-There is one case in my mind, that of Judge Grant Goodrich, who 
tells me that on the 20th of August, every year, if he remains in Chicago he is 
certain to have an attack of hay fever. If he leaves Chicago he escapes. If he 
remains away during the whole season of his attack, which lasts until the first of 
September, he is entirely free, but just so certain as he remains in Chicago, just so 
certain on the 20th of August he has an attack of hay fever. He is as nervous and 
wiry a man as can be. Both he and Beecher possessed especially nervous tempera- 
ments. During the rest of the year the Judge has perfect health. Now can we 
reconcile the theory of the pollenists with this exact periodicity of the disease ? We 
cannot suppose that the pollen from certain plants, whether the season be advanced 
or retarded, can reach these patients on exactly the same day and at exactly the 
same hour in each recurring year without any exception. It is not reasonable to 
suppose that. There can be no such thing as the pollen of certain plants, for instance 
the ragweed, setting out each year and reaching the patient at exactly the same day 
and hour without exception. This is the experience of hundreds of patients in the 
United States. 
Dr. Bower.-The Doctor has omitted to answer one of the most important 
questions, that is, in reference to the treatment he found most beneficial. 
Dr. Bishop.-If I maybe allowed, Mr. President, to digress from the subject 
of the paper, I shall be glad to discuss the treatment of this disease. 
The treatment so far has proved to be simply palliative and not curative in the 
majority of cases. There is one gentleman whose statistics I have in relation to 
treatment, who has treated quite a large number of cases, who claims that about 45 
per cent, of those which he has treated by the galvano-cautery applied to the septum 
nasi has resulted in their complete or partial relief. I talked yesterday with another 
gentleman who has treated a number of cases in a similar manner who claims 75 per 
cent, of cases were greatly benefited by treating the nasal cavities in that manner. 
I have found the use of a combination of sulphate of morphia, and atropia, in the 
proportion of one-fiftieth of a grain of atropia to one-half grain of sulphate of mor- 
phia, to have the most beneficial effect. Do not imagine that I give half a grain of 
morphia at once to patients ; it is very rarely that I have done that, but I have 
tablets in which morphia and atropia are combined in that proportion and I divide 
these tablets into four parts ; they are small, compressed to about the size of the 
top of a lead pencil. That gives me one-eighth of a grain of morphia at a dose. 
Now if a patient will take one or two of these tablets when he feels the first 
premonition of the attack coming on it will usually abort it. If he feels it very 
severely, let him double the dose and that will stop the attack. My plan is to give 
the largest dose that is safe, in order to prevent the attack, at first, rather than to 
give it in minute doses at frequent intervals, because if you give a sufficiently large 
dose at first to produce a profound impression upon the nervous system, you are far 
more likely to prevent an attack than by giving small and repeated doses. It is not 
well to have a larger proportion combined with the atropia than this. In the pills 
for sale at the druggists it is combined with morphia in much larger proportion, and SECTION XVI-PSYCHOLOGICAL MEDICINE. 
329 
I have had amaurosis produced by these pills. I would like to speak of a few other 
remedies, providing I do not take up too much time. Sometimes a cup of hot 
strong coffee will arrest an attack, or prevent an attack, of hay fever. Have the 
asthmatic patient, when he first feels the symptoms coming on, take a cup of strong 
coffee, and this will frequently prevent the attack altogether. In the heat of summer 
weather, it is well to have the patient take cooling drinks before retiring at night- 
these attacks often occur at night, as we all know-lemonade, cold water, or ice 
cream ; something of that kind, if taken, will make him less liable to an attack. 
In the daytime, if he keeps himself cool he is far less likely to have an attack. 
Another thing is to have the patient run up a long flight of stairs as quickly as he 
can when the attack is coming on. I have used quinine in small doses during the 
days of great suffering from hay fever, and that will alleviate the suffering very 
materially. I do not want to say that it will prevent attacks entirely, but it seems to 
have an effect in deadening the sensibility, so that the discharge may go on undi- 
minished and yet far less discomfort be experienced. But beware of too much qui- 
nine. It will produce a congestion of the ear ; it will produce an irritation of the 
auditory nerve. I have been led firmly to believe that deafness was produced by 
overdoses, and the long-continued use of quinine. I think there are many cases 
to-day whose hearing might be fairly good if they had never touched quinine. 
In closing the discussion of this paper, Dr. S. S. Bishop said : In reply to the 
request of our President that I give an outline of my treatment of hay fever, I will say 
that preventive measures are attended with much more successful results than pallia- 
tive or curative treatment. If one passes the usual season of attack either at the 
White Mountains or at some other resort which is free from the exciting causes in 
any given case, or if a sea voyage is taken at this time, he is pretty sure to escape 
suffering. Hay-fever sufferers, like asthmatics, may experience a marked mitigation 
of their symptoms by changing from a country residence to one in the midst of a 
great city, where there is little or no vegetation to fill the air with pollen, and where 
the dust is laid by the constant use of street sprinklers. 
The body should be clothed in woolen or silk, preferably the former, rather than 
cotton or linen. Animal fibre prevents, while vegetable fibre favors, chilling of the 
skin. 
The air of sleeping and living rooms should be kept pure and moist and not 
above 70° F. in the winter. Plenty of rest and sleep must be had, and the bodily 
temperature should be modified in hot weather by means of cooling drinks and ices. 
The generous use of these before retiring will reduce the temperature and avert 
attacks. In cold weather the body may be heated and bathed in perspiration by 
means of a cup or two of hot, strong coffee. I have repeatedly observed this 
simple remedy avert attacks of hay fever, as well as of asthma. A glass of wine sub- 
serves the same purpose. Coca wine has an additional exhilarating effect. By the 
use of nerve stimulants, tonics and sedatives, we may conserve and increase the 
powers of resistance, combat exhaustion and soothe irritability of the nervous 
centres. 
Remedies to prevent enervation should be taken before and during the periods of 
suffering. The most reliable in this class are quinine, iron, strychnine, arsenic, 
phosphorus, caffeine and electricity. Grindelia robusta has proven so unsatisfactory 
in my hands that I cannot indorse it. In that form of hay fever where there is 
active or passive congestion of the brain, ergot is indispensable. Bromide of soda, 
for the same purpose and for its tranquilizing effect on the irritable nerve tissue, 330 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is preferable to potassium bromide, in that it contains a larger percentage of bromine, 
is less vitiating to the blood and is less disagreeable than the potash. 
Quinine in tonic doses may not only prevent attacks, but will greatly mitigate 
them if taken in doses of two or three grains every two to four hours during the 
day. But quinine in large and continuous doses produces congestion of the middle 
ear, and probably of the auditory nerve. I have had numerous cases in which there 
was no room for doubt that it caused permanently impaired hearing and tinnitus 
aurium. Chloral hydrate alone, or combined with the bromides, is more certain 
still. 
Better than all other drugs, in my experience, has been a happy combination of 
morphia and atropia sulphate in easily divisible compressed tablets. Not more 
gratifying results could be expected from palliative medication than I have obtained 
from this. For several years past I have rarely employed morphine in my practice 
without administering atropia with it, believing that the antidote should accompany 
the poison. The relative proportions which have proved most satisfactory are 
grain of atropia to one-eighth of a grain of morphia, grain of atropia to one- 
fourth of a grain of morphia, grain of atropia to half a grain of morphia, if 
this dose were required. A larger dose of atropia, in repeated doses, is likely to 
cause a temporary dimness of vision. If carefully adapted to any given case, I do 
not believe one need fail to prevent an attack or modify one already begun. 
When I have been able to administer the remedy myself in the early stage of hay 
fever or of acute nasal catarrh, I have never failed to prevent the development of 
an attack, or at least materially abridge it. If the impending attack is a light one, 
one-eighth of a grain of morphia should be given at the first premonition. If the 
symptoms disappear, that suffices. If they return after a few hours the dose 
should be repeated, and in this way the paroxysms should be entirely prevented. 
If the threatening attack promises to be a severe one, I give one-eighth or one- 
fourth of a grain of morphia (with atropia always), and I have found it necessary 
in a profound seizure to give half a grain before the trouble could be subdued. 
Minimum doses may be better, as a rule, but in this malady the reverse is often 
true. When a small dose may not prevent suffering, a little larger one, to produce 
a decided impression on the nerves, may be entirely successful. 
The inhalation of amyl nitrite in five-drop doses will often relieve attacks, espe- 
cially if they are accompanied by asthma. Chloroform, camphor, eucalyptol and 
the fumes of nitre-paper are often useful. Cocaine, when properly applied, gives 
instantaneous relief in many cases. The patient should never omit clearing the 
membrane of mucus before applying any remedy, else the medicine is diluted and 
prevented from acting on the seat of irritation. A powder of cocaine (six or ten 
per cent.) and sugar of milk is especially efficacious, applied with a powder blower 
which I have constructed for hay-fever patients. The latter is small enough to carry 
in the vest pocket and to be used unnoticed the instant an attack threatens. The 
vulcanite tip of the soft rubber tube should be applied to the lips, when a gentle 
puff of the breath will blow a cloud of the anæsthetic powder into the nasal cavity, 
when the hard rubber tube is properly directed. This instrument is constructed after 
my large office insufflator, which is operated by a rubber bulb containing soft rubber 
valves. 
The effects of cocaine may last several hours, but repeated applications may be 
necessary to keep up continuous insensibility of the membrane during prolonged 
attacks. However, some patients possess an idiosyncrasy which forbids the use of SECTION XVII-PSYCHOLOGICAL MEDICINE. 
331 
cocaine. The primary action may produce anaesthesia and anaemia of the membrane 
regularly, but the blood vessels may become dilated and remain so, instead of return- 
ing to their normal calibre, as they do in most cases. This condition of secondary 
hyperaemia is attended with intense hyperaesthesia and all the symptoms of severe 
hay fever. Fortunately, there seems to be few who are so distressed by this remedy. 
I have employed it in many cases of various diseases without observing any dis- 
agreeable symptoms. 
Bishop's Pocket Insufflator 
Bishop's Office Insufflator. 
Concerning the operative treatment by the galvano-cautery, chromic acid, the 
saw, snare and knife, I care to say but little at present. This treatment is in the 
experimental stage and has proved disappointing to its most sanguine advocates. 
There are surgeons who claim as high as forty-five per cent, of beneficial results, but 
the cases operated upon two and three years ago, and which were supposed to have 
been cured, are lapsing into their old seasons of suffering. 
THE TREATMENT OF NEURALGIA IN GENERAL PRACTICE. 
TRAITEMENT DE LA NEVRALGIE DANS LA PRATIQUE GÉNÉRALE. 
ÜBER DIE BEHANDLUNG DER NEURALGIE IN DER ALLGEMEINPRAXIS. 
BY GUSTAVUS ELIOT, A. M., M. D., 
Of New Haven, Connecticut. 
No disease of the nervous system comes under the care of the general practitioner 
more frequently than neuralgia. Concerning the treatment of no common disease, with 
the possible exception of dyspepsia, are the directions contained in the popular text- 
books more inharmonious and indefinite. A writer often speaks in terms of the highest 
praise of some drug which other authors scarcely mention ; while other drugs, to the 
value of which many have testified, are simply named, without any remarks in regard 
to the special indications for their use, the proper doses, the necessary frequency of 
administration, and the length of time for which they should be continued. 
Most of the recent contributions to the therapeutics of neuralgia-and they have 
not been few-have been descriptive of drugs or remedial measures which are not appli- 332 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cable to ordinary cases, but have proved useful in cases presenting unusual character- 
istics, or in cases which might have been cured with equal, and perhaps greater, prompt- 
ness by the use of better known and well-established remedies. It is not of the former, 
the unusual cases, nor of peculiarly obstinate cases, that this paper is intended to treat, 
but of the ordinary acute attacks which lead the sufferers to consult a physician at the 
outset of the disease, when a prompt, complete and inexpensive cure is demanded. 
Active and efficient remedies are requisite for such patients. Often they see the phy- 
sician but once, and expect that a single prescription will effect a cure. What plan of 
treatment shall be adopted at the first consultation ? What remedies are the most 
reliable ? How far can they be depended upon ? Such problems as these again and 
again confront the general practitioner. 
Before entering the strict confines of the subject, it is desirable, in order that the 
grounds upon which some of the conclusions are based may be understood, that some 
general observations should be made concerning the nature and relations of neuralgia. 
As commonly seen in practice, it is, so far as has been demonstrated, a purely functional 
disturbance of the affected nerves. The painful phenomena due to pressure and neu- 
ritis are of a different nature and deserve separate consideration. Almost any of the 
sensory nerves may be affected. Those which suffer the most frequently are the dif- 
ferent branches of the trigeminal, cervical, brachial, intercostal, lumbar and sciatic 
nerves. Certain recurrent, painful, paroxysmal affections of the visceral nerves are 
also truly neuralgic. Not every case of colic or spasmodic affection of the hollow 
organs and passages of the abdominal and pelvic cavities should, however, be included 
under this head. On the other hand, that painful, unilateral, paroxysmal affection of 
the head known as migraine may fairly be classed as neuralgia. 
In order to select a rational plan of treatment, it is necessary to have some definite 
ideas in regard to the relation which the disorder in question bears to certain other 
diseases and abnormal states. One of the most important conditions which favor the 
development of neuralgia is an alteration of the blood, and particularly a deterioration 
of its quality. Romberg said : " Pain is the prayer of a nerve for healthy blood," and 
in a large proportion of the cases of neuralgia the influence of anæmia is very striking. 
Especially in chronic and obstinate forms of the disease is a recognition of its influence 
an important prerequisite for successful treatment. 
The presence of certain abnormal substances in the blood may directly, or in con- 
nection with other predisposing conditions, cause neuralgic manifestations. The con- 
tamination of the blood by the products of certain abnormalities of digestion and 
assimilation, as well as by certain excrementitious substances which have escaped 
elimination, deserves particular mention as an ætiological factor. Certain morbific 
agents, which ordinarily cause other manifestations, may also occasionally give rise to 
an attack of neuralgia. 
In certain sections of this country-among which is Connecticut, the residence of 
the writer-it has become customary to describe as malarial nearly every disease which 
shows an intermittent or remittent character, and to consider this diagnosis of the 
aetiology of the affection as completely demonstrated if benefit follows the administra- 
tion of the cinchona alkaloids. Many seem to be ignorant of, or to forget, the fact (to 
which Dr. Daniel Clark, of Toronto, called the attention of this Section on Tuesday 
morning) that neuralgia is a paroxysmal disease, and is characterized by remissions and 
intermissions. When it is remembered that quinine is one of the most active tonics 
and stimulants of the nervous system, it will readily be seen that the influence of that 
drug upon the neuralgic symptoms must be regarded as of little value in proving 
or disproving their malarial origin. Unquestionably some cases are due to malarial 
poisoning, but the ratio which these bear to the total number is much smaller than it 
is generally believed to be. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
333 
Another less prevalent, but equally erroneous, view attributes a rheumatic origin to 
many cases of neuralgia. The truth of the matter is that such a relationship can be 
definitely established only with extreme infrequency. 
Syphilis-the pains following syphilitic periostitis and the osseous pains being 
excluded-occasionally, though not very commonly, can be recognized as causing true 
neuralgia. 
A lithæmic condition somewhat predisposes to painful affections, including neu- 
ralgia, generally of a subacute or chronic character. 
Equally important with these anaemic and toxæmic influences, and frequently asso- 
ciated with them, stands the influence of an excessive expenditure of nervous energy. 
Fatigue and exhaustion, either physical or mental, strongly predispose to attacks of 
neuralgia. In much the same way cold and dampness call for an extra amount of 
nervous energy in order to maintain the usual functional power of the nerves, and 
when this is not forthcoming neuralgia often follows. 
The dependence of neuralgia upon reflex causes is a subject of considerable com- 
plexity and uncertainty. The most common and obvious illustration of this relation- 
ship is the dependence of trigeminal neuralgia upon caries of the teeth. This is often 
proven conclusively by the relief which follows the extraction of the diseased tooth. 
Of all the drugs which have been recommended and tried in the treatment of neu- 
ralgia, three are invaluable. They are morphine, quinine and iron. In acute attacks 
of marked severity morphine is almost indispensable. It is preferably administered, if 
the patient is seen while severe pain continues, by hypodermatic injection. Given by 
this method, in doses of one-quarter or one-half grain, at the onset or during the per- 
sistence of a paroxysm, the relief which follows is prompt, grateful and often com- 
plete. Thus used, it is always palliative, and sometimes curative-a second attack never 
occurring. 
It is, however, rather unusual to see the course of neuralgia immediately arrested 
by this treatment, if it is commenced after more than one paroxysm has occurred. In 
these cases it is desirable to prescribe, if possible, some remedy which is more directly 
curative. The drug which acts more positively in this direction than any other, which 
more justly than any other might be called a specific, is quinine. It should be given 
in large doses, and is of value in all cases, but especially in those which are markedly 
paroxysmal, and, most of all, in those which are dependent upon malarial poisoning. 
The relation of neuralgia to this cause, and the necessity of giving large doses of qui- 
nine in order to effect a cure, are illustrated by the history of one of the first cases which 
came under my observation six years ago, during my service as Resident Physician at 
the New York Workhouse. 
Case of Malarial Supra-orbilal Neuralgia.-J. C., male, thirty-two years old; while 
under treatment for an ulcer of the leg, suffered an attack of intermittent fever, which 
was promptly cured. A few days later he had an attack of neuralgia affecting the right 
supra-orbital nerve, which recurred every morning. Fifteen-grain doses of sulphate of 
cinchonidia, given early each morning, had no effect upon the recurrence or severity of 
the paroxysms. The dose being doubled, and thirty grains given at once, no further 
paroxysm occurred. He remained in the hospital two months, during which he enjoyed 
complete immunity from the disease. 
Similar observations as to the efficacy of large doses of quinine have been recorded 
by different authors, with regard to cases in which a malarial origin could not be 
detected. 
In a considerable proportion of cases anaemia is not a prominent feature. The 
patients are well-nourished and full-blooded subjects. In them neuralgia is the éxpres- 
sion of an exhaustion of nervous force-perhaps due to cold, or to over-exertion, or of 
a toxaemia-perhaps malarial, or of some reflex irritation. In the latter cases the 334 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
removal of the source of irritation is, of course, indicated. In the other cases, in con- 
nection with proper hygiene, including, as of highest importance, rest and good food, 
a combination of quinine and morphine is of the greatest value. In such cases, seeing 
the patient in the interval between the paroxysms-when, of course, the hypodermatic 
use of morphine is not indicated-it is often convenient to give the two drugs together. 
One drachm of sulphate of quinine and one grain of sulphate of morphine, having been 
thoroughly mixed, may be divided into twelve powders. Of these one may be given 
two or three hours after each meal, and two (or more, if necessary) at once one or two 
hours before the paroxysm is expected. 
In another large class of cases anæmia is the predominant characteristic. These cases 
are often exceedingly obstinate and likely to recur. For them no drug is more valuable 
than iron. When given continuously, as the quality of the blood improves, the neu- 
ralgic tendency grows weak. 
As remedies of secondary value may be classed gelsemium and aconite. These drugs 
have both been highly commended for the cure of neuralgia. They certainly deserve 
to be ranked as valuable adjuncts to the remedies previously named. The danger of 
producing unpleasant toxic effects with either drug is, however, so great as to render it 
inexpedient to rely upon either as a single remedy in ordinary cases. The uncertainty 
in regard to the strength of the various preparations, as manufactured by different 
pharmacists, is also so great as to constitute a serious hindrance to the general use of 
either drug. Furthermore, the varying susceptibility of different patients introduces 
another element of uncertainty. I desire, however, to bear personal testimony to the 
utility of five-drop doses of the fluid extract of gelsemium, repeated every four hours, 
and given in connection with quinine and morphine. These three together will often 
give most favorable results. 
As remedies of the third class may be mentioned arsenic, nux vomica, belladonna, 
phosphorus and iodide of potassium. These have long been highly commended. I 
name them rather in deference to popular opinion than because I consider them of great 
value. I have used them all, but have failed to obtain with them results which warrant 
me in commending them. Arsenic, in particular, has been recommended by many 
authors. I have never seen very marked improvement follow its use. On the con- 
trary, I have seen symptoms of considerable severity develop in spite of its administra- 
tion in full doses, advised with the hope of preventing the attack. As an adjuvant of 
iron in cases of anæmia, it is unquestionably of value in curing the anæmia. Thus 
indirectly it may contribute to the cure of neuralgia. Similarly, nux vomica and its 
alkaloid, strychnine, are of use as stomachic tonics when the general nutrition is 
impaired by indigestion. 
External applications are of considerable utility as adjuvants to internal medication. 
Counter-irritants have been largely used. In obstinate cases, particularly of sciatica, 
blisters and cauterization sometimes do great good. In cases of moderate severity, as 
in intercostal neuralgia, sinapisms, applied either over the seat of pain or over the 
origin of the affected nerve, often afford some relief. Various sedative applications 
have some value as palliatives. I have frequently used a mixture containing one part 
of oil of gaultheria and two parts of olive oil ; or a combination of equal parts of oil of 
origanum, tincture of opium, spirit of ammonia and olive oil-known as Fahnestock's 
liniment-warmed, and thoroughly rubbed along the course of the affected nerve and 
its branches, hot flannel being superposed, and have found that either will produce a 
palliative effect in many instances. 
Electricity is of unquestionable value in the treatment of neuralgia. The majority 
of cases, however, get well without it. In order that it may be used satisfactorily, it 
is necessary that the practitioner should own expensive and cumbersome apparatus, and 
that he should have sufficient special knowledge to enable him to keep it in order, and SECTION XVII-PSYCHOLOGICAL MEDICINE. 
335 
to use it. As the majority of neuralgic cases cannot be induced to make frequent and 
regular visits to the physician's office, and as many of them are seen only at their homes, 
often at long distances and at not very brief intervals, it is apparent that electricity can 
hardly be classed among those remedies of which the general practitioner would be 
likely to make early trial. 
In the treatment of subacute and chronic cases occurring in overworked, underfed 
and half-rested subjects, in whom indigestion is a frequent accompaniment of the neu- 
ralgia, remedies applicable to the digestive disturbance are to be used with general 
tonics, in addition to the drugs which act more directly upon the nervous system. 
Useful combinations of this kind include aloes, strychnine, arsenic, quinine, iron and 
phosphide of zinc, or gelsemium with cardamom, nux vomica and cascara sagrada. 
In conclusion, I wish to emphasize the impracticability of relying upon any single 
drug or therapeutic measure in the treatment of neuralgia. The most useful drugs 
produce the best results only when given in such large doses that there is danger of the 
production of unpleasant symptoms. It is, therefore, far more wise to combine different 
remedies in such a way as to effect a cure without causing the patient discomfort. 
Morphine, quinine and either gelsemium or iron, with warm sedative external appli- 
cations, will prove useful in the majority of acute cases. In subacute and chronic cases 
the morphine should be omitted and stomachic and intestinal tonics substituted therefor. 
DISCUSSION. 
Dr. Crego thought it was our duty to see our patients frequently and not to 
wait to treat them after their paroxysms had begun. If we used morphine we did 
not cure our patient; we established the morphine habit. He was very sorry to 
notice the emphasis Dr. Eliot had placed upon this method of treatment. We did 
infinitely more harm than good by the use of morphia in any way. It was our duty to 
use arsenic and iron and that class of remedies only. Most cases could be controlled 
by electricity. Morphia and quinine were of very doubtful utility. 
Dr. Duquet referred to the hypodermic injection of chloroform in sciatica. He 
had had a good many cases, and had always found that in the beginning of the disease 
deep injections of twenty drops into the muscles had relieved the paroxysms imme- 
diately. He did not think, with Dr. Crego, that simply because there was danger of 
the morphia habit being formed in some cases the drug should be set aside in the 
treatment of neuralgia. He considered it a very useful remedy. 
Dr. Heber Ellis referred to the hydrochlorate of ammonia as a remedy that 
had been used in Germany as well as in his own practice with great success. He was 
inclined to believe that morphia should not be used in the first instance. Other 
drugs should have a preference. As to quinine, he could only say that if it were used 
in such heroic doses as thirty grains, he should think chronic deafness would follow, 
as a former speaker had suggested. 
Dr. Russell added his voice to those who opposed the use of morphia in the 
treatment of neuralgia. 
Dr. Brower entered a protest against the wholesale use of morphia and quinine 
in the treatment of these sensory disturbances. No little share of his work was for 
the relief of people who by reason of these sensory disturbances had found themselves 
habitues of morphia. He believed that all ordinary cases of neuralgia, certainly so far 
as his experience went, could be relieved without resort to morphia at all. He knew 
that there was a brilliant result, a great deal of éclat, gained by the physician by instantly 
relieving the sufferings of his patient; every one was impressed with his power and 336 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the pain was instantly relieved, but it meant subsequent danger to the patient. Now 
the use of heat, sometimes the use of cold, the use of electricity-which one speaker 
objected to on account of its cumbrousness-the use of galvanic electricity by batteries, 
now so easily managed, so portable, that they should be part of the physician's outfit, 
it seems to me will relieve ninety-nine cases out of one hundred. I know of no better 
way of treating sciatica than by massage. I believe there are few cases of it that 
cannot be relieved by this treatment. Heat, massage and galvanic electricity will 
certainly relieve ninety-nine cases out of one hundred without resort to morphia or 
such enormous doses of quinine. I can certainly endorse, too, the remarks of the 
gentleman from England as to the value of the chloride of ammonium, a remedy of 
great value, and certainly a remedy that patients will never get into the habit of 
using. 
Dr. Clark thought we must be guided in the treatment of neuralgia by its 
causes. If we found that our patient lived in a malarial district and that his 
neuralgia was periodic in its nature, we would find that quinine and arsenic would be 
the remedies to be employed, and he believed all other remedies would fail, to a large 
extent. If it were caused by some derangement of assimilation, then appropriate 
remedies should be prescribed. Should the disease be local, a reflex, as we find in 
neuralgias from decayed teeth, then we had the remedy before us in extraction. It 
was utterly impossible to lay down rules for the application of remedies for all cases; 
the causes of the disease were multifarious and their manifestations must be observed 
and treated accordingly. 
In regard to the morphia, he thought the drug has its place-a very important 
one-in therapeutics. His plan was never to let the patient know what he was get- 
ting. If he gave it internally by the mouth it was with some nauseating drug of such 
bitterness that he had no fear the patient would ask for it unnecessarily. If he gave 
it hypodermically, he never told what it was. This should be the rule to be followed 
by every physician. 
Dr. Andrews spoke most highly of cod-liver oil. In his hands it was one of the 
most important agents in the treatment of chronic neuralgia, and he found nothing 
to compare with it. It was usually employed in emulsion, which could be fortified 
by adding hypophosphites, iron, arsenic or other remedies. In all cases of anaemia, 
debility or lack of nutrition, there was no remedy to be compared with it. The use 
of this and heat, by hot-water bags, constituted very important means in the treat- 
ment of neuralgia. 
Dr. Gertstrom, ofHermosands, Sweden, remarked that massage must be regarded 
as a remedy of great value in the treatment of some forms of neuralgia, and that this 
resource, which he believed to be well known in America, had been used for a long 
time by the Swedish physicians with markedly beneficial effect. 
The best results by that treatment were observed in those cases of neuralgia 
dependent on rheumatic disease, in the widest sense of the term, and where there 
is compression, as at the emergence of the nerves from the cranium and spinal 
column; also in myositis and perineuritis. Over-exertion can be the cause in these 
cases as well as cold and dampness, and it is generally found in anaemic and debili- 
tated subjects. 
A proper nourishment-iron in the first instance and arsenic in the second-could 
be recommended as adjuvants to the massage, but morphine is always to be avoided, 
for fear of chronic intoxication, while it has but a palliative effect in the cases of 
which I speak. SECTION XVII-PSYCHOLOGICAL/MEDICINE. 
337 
THE BORDERLAND, EARLY SYMPTOMS AND EARLY TREATMENT 
OF INSANITY. 
LES FRONTIÈRES, LES PREMIERS SYMPTÔMES ET LE TRAITEMENT DU COM- 
MENCEMENT DE LA FOLIE. 
DER GRENZBEZIRK, FRÜHE SYMPTOME UND FRÜHE BEHANDLUNG DES WAHNSINNS. 
BY IRA RUSSELL, M.D., 
Winchendon Mass. 
Insanity is a physical disease due to some abnormal condition of the brain. What 
that condition may be is, with few exceptions, unknown. It is impossible to give a 
definition of insanity that will embrace all its phenomena without including or exclud- 
ing too much. A sound mind is like a sound body. One in perfect health is scarcely 
aware that he has a body-a head, a heart, a stomach. So with a healthy mind-the 
thoughts are projected outward, and we hardly know we have a mind. When any part 
of the body is diseased and we suffer pain, then we are fully impressed with the fact of 
our bodily existence. Thus it is with the mind-when the thoughts are turned inward 
and give mental pain, then we have mental disease. 
Here is a Borderland, where it is impossible to draw the line between sanity and 
insanity, as it is between health and disease, so gradually do they shade into each 
other. In diagnosing a case of insanity we have to trace the line which separates wild, 
ungovernable, impetuous passion from the excitements of mania, and the delusions of 
lunacy from fanaticism and the false reasoning and absurd conclusions of many sane 
persons. 
There is an insane diathesis, a predisposition to insanity peculiar to some persons, 
just as in others there is a tendency to consumption, cancer, etc., without which these 
diseases would not be developed. Traumatism, alcoholic stimulants, syphilis, and 
toxic drugs, like morphine and cocaine, may develop insanity without any predisposi- 
tion thereto ; but without the ever increasing energy of heredity cases of insanity 
would be more rare. The insane diathesis may exist without developing its malign 
influence, or be so far inhibited as scarcely ever to pass the line of sanity, while in 
other cases less favorable environments develop the tendency to an actual outbreak of 
insanity. The usually assigned causes, such as domestic infelicities, grief, disappoint- 
ments in love, reverses in business, etc. would alone lead to insanity. The predisposi- 
tion to insanity is not always an indication of nervous and physical degeneration. Some 
of the most distinguished and illustrious men, some of the most profound thinkers, 
have possessed this diathesis. Cæsar was epileptic ; Peter the Great had cataleptic 
attacks; Napoleon was subject to long fainting attacks; Charles the First-grandson of 
Isabella of Spain,-was a man of great political sagacity and an epileptic; Martin 
Luther, Pascal and Swedenborg had hallucinations ; Dante was a hypochondriac ; 
Cowper wrote some of his most beautiful hymns while a victim of melancholia. 
One of New England's most distinguished clergymen had periods of great religious 
exaltation, followed by days of depression and gloom. The great American preacher 
of world-wide fame-recently deceased-gives, in a letter to his medical adviser, an 
interesting account of his hallucinations of hearing. He belonged to a family of great 
and varied intellectual power, his father before him having had times of mental depres- 
sion. A brother, also a clergyman and an officer of distinction in our late war, after 
its close resumed his work as pastor of a church, performing his duties in a very accept- 
able manner ; suddenly he left his charge, went into the woods, and there in a cabin 
built by his own hands lived the life of a hermit, without books, that he might enjoy 
communion with God and nature. At first he bad most ecstatic enjoyment, which was 
Vol. V-22 338 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
followed by loss of hope, mental depression, suspicions and loss of will power, the case 
ending in suicide. 
The cases just referred to belong to the Borderland from which our asylums are 
recruited. 
It is just this class of cases that is neglected. 
The popular idea of what constitutes insanity is very erroneous. Friends attribute 
symptoms that are to the trained eye unmistakable, to anything but the true cause. 
As a result the patients are allowed to drift on month after month, sometimes on one 
side of the line and sometimes on the other. The friends, and alas ! too often the family 
doctor, take no note of the insomnia, willfulness, irritable temper, likes and dislikes, 
hatred and groundless suspicions. The treatment of such cases by the general medical 
adviser is often wrong. Those who need quiet are sent to the mountains, to the sea- 
shore or on long sea voyages. ' The overworked business man who needs separation 
from home and business cares is allowed to continue his business, on the plea that no 
one understands his affairs but himself. How often in such cases we hear it said that 
such a one cannot be insane, because, though on isolated matters he may have strange 
notions, yet on most things he is just as clear as the normal person. Often the first 
deviation from mental soundness is very slight. A man of hitherto strictest moral 
integrity commits some immoral act entirely foreign to the whole tenor of his life. 
A bank cashier whose accounts for years have been a model of correctness, suddenly 
turns up in Canada, and soon after develops unmistakable symptoms of general paresis. 
Not all our Canadian emigrants have general paresis, however. While all wrong-doing, 
all selfishness, all ill-temper are not indications of insanity, still on the Borderland we 
find examples of all these things. So long as a man holds his emotions, temper, appe- 
tites and will in subjection, so long he is sane. But when a man's will fails to govern 
him, and his emotions and appetites are not in control, be is most certainly in the 
Borderland or has already crossed the line of sanity. All criminals are not insane, but 
many insane are criminals. Depravity is not insanity, but many insane are depraved. 
Take for instance a dipsomaniac. At the first he is a model man, a good husband, 
devoted to his wife and children. After years moderate drinking is succeeded by un- 
controllable thirst for drink, and a debauch follows, to the great chagrin of himself and 
family ; with periods of rest come other attacks, until finally pronounced insanity fol- 
lows. All alcoholic inebriates are not dipsomaniacs. The law of heredity gets an 
especial expression here. 
Mere eccentricities and peculiarities are not, necessarily, indications of insanity, 
but they are very often found on the Borderland. A lady, now hopelessly insane, had, 
in her girlhood, a great repugnance to receiving anything from another's left hand. 
Married to a clergyman, she was noted for her brilliancy and high mental attainments; 
but her old habit clung to her, and other oddities were added, until she became a 
mental wreck. 
Now, all this great class of cases are hardly proper subjects for an insane asylum, 
where legal commitments are required, and sometimes jury trials. What greater 
absurdity can there be than to take a nervous, delicate lady before a jury, and have her 
case made the sport of lawyers who know no more of insanity than the ordinary lay- 
man? These persons just on the line of sanity, as well as the admittedly insane, have 
rights, and the first and most important of all is the right to the best method of care 
and treatment which will promote cure. Almost always their own homes are not an 
aid to them. Very often they are unable to bear the expense of private care in retreats 
and sanitaria. For such there should be endowed institutions, accommodating a small 
number of patients, conducted on the family plan, where they could go voluntarily 
without the stigma of legal processes. The 'fear and dread which keeps so many 
from asylums and retreats too often leads to horrible tragedies that shock whole SECTION XVII-PSYCHOLOGICAL MEDICINE. 
339 
communities, and to the enormous number of suicides which bring dismay upon so 
many families. 
In institutions such as I have referred to, the number of patients being small, each 
could have the benefit of individualized treatment; the sense of freedom and moral 
restraint would aid much in their recovery. I by no means object to asylums, nor 
would I change the manner in which they are conducted. My object is to secure early 
treatment for a large mass of humanity on the edge of insanity. Neglected as they 
now are, they form the great recruiting-ground for our asylums, which have to be con- 
stantly enlarged and increased in number for their accommodation. If a halt can be 
called before the asylum gates are reached a great good may have been accomplished. 
As to the actual curability of insanity little may now be said. Dr. Earle feels con- 
fident that the proportion of cures is small. If such be the fact in developed insanity 
our only hope for brilliant professional success is before the mental break-up. Asylum 
reports seem to prove that the ratio of cures depends upon the length of time the disease 
has existed before admission to the hospital. When the disease has existed not more 
than six months before admission, the ratio of cures is 80 per cent., while the general 
ratio is less than 40 per cent. Taking our reports as a whole, in more than one-half of 
the admissions the disease had existed more than one year. For instance, in the Min- 
nesota. Hospital for the insane, out of 3449 admissions in only 1358 had the disease 
existed less than twelve months ; so in the Baltimore Mount Hope Retreat, of 615 
admissions 392 had been insane more than one year. So in 258 out of 497 admissions 
to the Danvers Asylum. 
The great question, then, is how to secure early treatment. The increasing prejudice 
against asylum care is one great obstacle. We must then have intermediate institutions 
between the home and the asylum, where the Borderland people can go voluntarily for 
rest and care. Should the treatment in such an institution in any case fail to secure 
the desired happy result of health, then they can be transferred to the asylum. 
Last, and not least, of the changes necessary for the wise care of nervous humanity 
is a better knowledge by the general practitioner of the early symptoms of insanity. 
Ask any of our superintendents how many of the cases of general paralysis they have 
received have been recognized by the first medical attendant. It may then be said that 
every general practitioner should be as familiar with the early symptoms of insanity 
as he is with those of ordinary bodily diseases. 
DISCUSSION. 
Dr. Gundry.-Dr. Russell has brought together the usual array of great per- 
sons with some single apparent departure from healthy mental action, who saw 
visions, heard voices, or suffered from a fit of some kind, and corraled them all in 
the border land of insanity. With these he has coupled the poet Cowper, who was 
really insane, who had many attacks of insanity with intervals more or less of perfect 
health, during which he wrote some of his poems-the last most beautiful and sad- 
dest of all written as his genius lighted up fitfully before sinking into final darkness. 
I allude to " The Castaway. " Now, Cowper certainly did not rest on the border 
land, but spent most of his life in the undisputed domain of insanity. Then Julius 
Cæsar and Napoleon had epilepsy which did not impair their intellectual power. 
So epilepsy is a part of the border land ! Now, where is the proof of the oft 
repeated assertion that they were epileptics? Suetonius, Cæsar's critic, if I recol- 
lect rightly, but I confess I am rather rusty in the classics, only mentions two instances 
of Cæsar fainting, swooning, or becoming unconscious, both from exhaustion after 
great fatigue. Supposing these were " fits," is it fair to call a person who has one 340 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
or two attacks of doubtful significance an epileptic, or say he suffered from epilepsy? 
Where is the evidence that Napoleon had epilepsy ? There is a tradition that on a 
certain occasion a lady said he had a fit, under peculiar circumstances, but that is all. 
Upon these bare assumptions is built up the theory that epilepsy produces no mental 
defect, and a false comfort infused into the friends of those who really suffer from 
such attacks. Now for the other "Borderers." If a man of great intellectual 
power happens to say or do anything different from what we, in our day, consider 
sound, we dub him by some bad psychological name, class him as insane, or at least 
relegate him to the border land. We forget that not by our standard, but by the 
environment which encompassed him and moulded his habit of thought and action 
must we judge him. What is to us a delusion, may have been the universal belief, 
accepted without hesitation and without any inquiry as to its probability. If Luther, 
tired by an exhausting period of study, isolated from his friends, in solitude and 
depression, saw some image which he took to be the devil, he simply adopted the ex- 
planation which accorded with the universal belief that the enemy of souls could 
appear to men-could talk to them and hold intercourse in various ways. He 
threw an inkstand at him and the spectre vanished-an allegory perhaps, after all, 
that the spirits of darkness are best dispelled by instruments that diffuse knowl- 
edge. Now an author in Boston apologizes for what he terms Luther's delusions, 
that he saw the devil, and threw the inkstand at him " at a time when the belief in 
a personal devil was required by the Canons of the Church of England." What 
Luther had to do with the Church of England is not clear, when we remember that 
Luther died before the Church of England took form as such. He died in 1546- 
the thirty-nine articles of belief of the Church of England passed the convocation 
1562-sixteen years afterward. Besides, Luther never had any relations with the 
Anglican Church. So about Pascal. A terrible accident had so impressed his sen- 
sory system, that he saw a yawning abyss before him, and fearing that when his 
attention was concentrated upon his extraordinary mathematical studies, he might 
unconsciously yield to the reflex influence of that impression, he had himself tied 
in a chair while engaged in such studies. He had no delusion about it-only his 
attention being absorbed by other objects, he could not always correct the impression 
made upon one of his senses, by calling up the evidence of the other senses. 
One learned author, I wish very much he were present to hear me, stigmatizes 
Dr. Johnson as a monomaniac-the most robust intellect of his age-because he was 
once seen reading a book for the amusement of some boys. Then, again, as he was 
putting his key into his college-room door he heard his mother (sixty miles away) 
call ' ' Sam. ' ' Some sound arrested him-he had been careless about his parents- 
now remorse interprets the sound as "Sam;", recalls him to his duty, and without 
investigation he accepts the solution-"his mother had called him." It was the 
popular belief that spirits, good and bad, thus ministered to mortals, and he believed, 
as the world believed, in ghosts and spiritual influences, accepted them thankfully 
and without such inquiry as he would have undertaken about doubtful matters in 
other regions of knowledge. 
Another author has fallen foul of John Bunyan, whose vivid imagination personi- 
fied the struggles between his lower and better nature, and in accordance with the 
popular belief of his time ascribed the evil suggestions of the former to the direct 
interposition of the devil, who voiced to his vivid imagination the words in which 
they are clothed. Such a mental struggle in such a nature was intense, but it was 
in accordance with the healthy development of his nature, and he was too grateful 
for the glorious outcome to scrutinize closely the grounds of his belief in the tempta- SECTION XVII-PSYCHOLOGICAL MEDICINE. 
341 
tions of the devil. They did not lead him out of his healthy course ; they roused 
his mental vigor, strengthened his better nature, and ennobled his life of thought and 
action. Such are not delusions nor the fruit of the border land. The same remark 
will apply to many other cases. To speak of these men as belonging to the border 
land, the recruiting grounds for the asylum, is a misapprehension of terms against 
which I protest. 
Dr. Porter.-Turning from the scientific to the practical side of the question, I 
think Dr. Russell has given us some of the best suggestions that have been brought 
before this Section. It is generally readily admitted that chronic insanity and epilepsy 
are but the expressions of organic disease of the brain. Before the grosser lesions 
appear, there is a nutritive defect that comes in advance of structural changes, and 
these nutritive defects of the brain occupy the border land as referred to by Dr. 
Russell. The time that the most benefit can be done to these patients is during the 
nutritive changes that precede the structural and organic defects. In calling the 
attention of the Section and of the profession to the best means of aiding these 
people who occupy the border land and go on, eventually making up the great body 
of insane and epileptic, he is educating the profession, and through them the people, 
to the better plan of caring for these people who are on the road to brain disease. 
All the Southern States are well provided with State institutions, but private insti- 
tutions, such as the Doctor suggests, are lamentably deficient. These patients are 
left at home among their friends until they become dangerous and must be secluded, 
when if cared for at the proper time and in the proper manner, by a relief from the 
environment which has developed and brought about the earlier manifestations, they 
could be cured and restored to society. 
Dr. Heber Ellis.-There is one point which thus far has not been considered 
in connection with this matter, and that is that nervous patients do not, unless com- 
pelled, go to any of these institutions. They may be very pleasant and cheerful, 
everything done to make them so, but it has very little effect upon their minds. 
These attractions can hardly be realized until they are there, and the trouble lies in 
getting them there. In England we think we hit upon a very good plan, by legally 
allowing medical practitioners, indeed any respectable householder, to take a single 
patient. These patients may be placed under certificate if it is necessary, and then 
they are regularly visited by commissioners, who see that there is no abuse. If they 
are in the house of a lay householder they must have a legal medical attendant ; 
that is to say, a medical attendant who must visit them at least once in a fortnight, 
and who, in a book kept for the purpose, must register the state of the patient at 
the time of his visit. Now, sir, I think that is an exceedingly useful system. The 
patient is removed from his unfortunate environment, is placed under altogether 
altered circumstances, and though these may not be more pleasing than his home, 
yet it constitutes a change of thought, of feeling, a change of air and diet, and such 
single patients do remarkably well. There is one great difficulty in the matter, and 
that is the question of expense. A single patient must necessarily be more costly, 
as such single patient, than where he would be one among many; but it is found that 
that may be gotten over very well by placing the patient in care of persons whose 
position corresponds to some extent with the class of society to which he belongs ; 
that is to say, the poorer patient may generally find some humble household where 
he may be placed, and be receives here better treatment even than he would in a 
better household, where the disposition might be to place such a patient out of the 
way. I myself have taken single patients, and they are very remunerative. They 342 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
are willing to pay exceedingly well, and under these circumstances the physician 
often finds this a very useful adjunct to his professional income. No more than one 
patient can be taken, and the consequence is one patient is not exposed to the influ- 
ence of the delusions of another. I can only say that that system of treatment in 
England is allowed to be the very best to be adopted in almost every case. It is only 
the question of expense, as I have said, that keeps it from being more generally 
adopted. I need not say that there is a great relief to the feelings of the patient, 
as well as to his family after he has recovered, to feel that he has been under treat- 
ment and has been considered as a member of the family, rather than returning from 
an asylum, which is, after all, an indignity, in its want of liberty. No matter how 
much people may talk about open doors, etc., it is absolutely necessary to deprive 
these patients of their liberty when they are sent to an asylum. 
NURSING REFORM FOR THE INSANE. 
AMÉLIORATION DANS LA MANIÈRE DE SOIGNER LES ALIENES. 
ÜBER REFORM IN DER PFLEGE DER IRREN. 
BY EDWARD COWLES, M.D., 
Somerville, Mass. 
It is a rare event when, in the cause of humanity, the gratitude of a great nation is 
earned, as it was by Florence Nightingale in the noble reform which she began, in 1854, 
in the Crimea ; the whole world acknowledges its lasting debt to her. No greater 
work has ever been done for the amelioration of human suffering and the saving of 
human life than this, which has been accomplished in the brief time of one generation. 
The history of hospital reform, and of nursing reform in the general hospitals, is well 
known. But it seems not to be known so well that when Miss Nightingale went to 
Kaiserswerth in 1844, to be trained in the art of nursing the sick under the instruction 
of a Protestant Sisterhood, Parson Fliedner only represented there the humane spirit 
which had previously, in Germany, inspired also Dr. Jacobi in his work on "Hospitals 
for the Insane." The world knows what was done in France, years before that time, 
by Pinel. Dr. Jacobi despaired of his ideal in the attendance he desired for his 
patients ; and since his book was republished in England in 1841, with Samuel Tuke's 
introduction, nothing has been written which sets forth a clearer or more humane con- 
ception of the needs of the sick, and especially of the insane, in intelligent and sym- 
pathetic personal attention, than came then from those two men. The leadership in 
these ideas of reform then belonged to those who had the care of the insane ; and those 
who have come after them in this work have constantly striven to put these ideas into 
effect. Dr. Brown, at the Crichton Institution, in 1854, the same year that Miss Night- 
ingale was in the Crimea, had as high a purpose and as humane desires, in giving his 
thirty lectures to his officers and attendants, and striving to get for his insane patients 
what so many have longed for-the ideal nurse. But the crying need of this has come 
down to our own times, through a series of lamentations that the boon could not be 
had, and of failures to gain it. In the meantime the way was opened for the general 
hospitals ; the opportunity came, and with it the woman. She has created an epoch SECTION XVII-PSYCHOLOGICAL MEDICINE. 
343 
for the hospitals, while the asylums were still groping to find the way in which they 
first felt the need of going. 
There were reasons for this failure of the asylums ; and now that, under the stimulus 
and example of the work in the hospitals, the former have made a beginning in nursing 
reform for the insane, it will be profitable to study those reasons, and to get as clear a 
view as possible of the best way to carry on the reform. The movement has been begun 
in America with a scope of purpose and an effectiveness of early results that furnish 
something to study, for improvement or approval. At this stage of progress it is import- 
ant that good foundations shall be carefully laid, and that the contingencies which 
endanger the success of the movement shall be guarded against. ' ' Slow and sure ' ' is 
a good motto in this, as in many other things, because failure, or even qualified success, 
means at least the misfortune of delay in a great reform that is certain to prevail. 
While viewing the subject in its larger aspects, it is the present purpose to say 
something of the apparent difficulties in establishing systematic methods of training 
nurses in our asylums-difficulties that disappear if properly provided against ; and 
especially to point out some of the real difficulties that will arise at the beginning and 
in the course of such a work, and threaten its failure. Something of warning and 
suggestion on my part may be justifiable, from its having happened to me, in the last 
fifteen years, to organize two training schools, one of them in a general hospital, and 
each requiring about five years for the preparation and establishment of the work. 
This must be the apology for assertions which it might require more extended discus- 
sion to sustain. Besides the difficulties that may be readily apprehended in making 
innovations in the usually well-ordered systems of asylum service, some other apparent 
ones, that seem to stand in the way of training nurses, may be mentioned as examples. 
It is thought by some that the educating and fitting of women in the asylums, for 
general nursing, will lead the nurses into this branch of the work for the public, and 
lose them to the asylums, for whose benefit the labor of training is primarily under- 
taken ; again, if to avoid this, they are trained simply for the especial nursing of the 
insane, they will find themselves without an occupation outside of the asylums, because 
there.is so little done in the country in general in the private and home care of the 
insane. This at once shows that in addition to the interests of the asylums and their 
inmates, there are, on the one hand, important questions concerning the interests of the 
public at large, and on the other, of the nurses themselves. 
To answer these questions and others let us take a large view of the subject, in order 
to include some of its less obvious bearings, and look first at the results of the reform 
in the general hospitals. Those in Boston furnish good examples of these results, both 
to the hospitals and to the public. Previous to 1873 the old order of things existed in 
all America. In that year, in Boston (and in the same year in New York and New 
Haven), there were imported the beginnings of that most beneficent work first organ- 
ized in its secular and effective form, by Florence Nightingale, at the St. Thomas Hos- 
pital, thirteen years before. At the Massachusetts General Hospital the work began in 
a few wards in 1873, and at the Boston City Hospital the formal organization of a 
school was complete in 1878 for the whole hospital. In 1873 the instructed nurse was 
an experiment and a cause of apprehension. It was said she would know too much, 
or would think she need not obey the physician in all particulars ; she would tam- 
per with the treatment ; she would want to be a doctor herself, etc. Now there are in 
this country few general hospitals of importance in which nurses are not carefully 
trained in their duties, according to well-established methods of instruction. 
In the short period of fourteen years, since the introduction of the reform in America, 
the following are some of the results of the work of the principal Boston Schools-the 
Boston Training School at the Massachusetts General Hospital and the Boston Ci ty 
Hospital Training School. The table shows the whole number of graduates, the average 344 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
number of graduates that remain in the service, and the average number of nurses, 
trained and untrained, on duty at all times :- 
Whole No. of 
Average No. of 
Whole No. of 
Graduates. 
Graduates remaining. 
Nurses on duty. 
Mass. Gen. Hospital, in 14 years 159 
10 
60 
Boston City Hospital, in 9 years 141 
14 
70 
1 
■ 
---- 
Totals, 300 
24 
130 
Only so many graduates are retained each year as will fill the few vacancies that 
occur in the relatively permanent staff of head nurses, of whom there are only a little 
more than enough to furnish one for each ward, and to provide for some special service 
like night duty. At the Massachusetts General Hospital the first class was graduated 
in 1875, of only three nurses ; the second class numbered eleven ; the third, five ; the 
fourth, twenty ; the fifth, six ; and the numbers have since ranged from fourteen to 
twenty-one graduates annually. The Boston City Hospital School has a similar his- 
tory, graduating its first class in 1880, and averaging eighteen graduates annually for 
the whole time. 
It is of interest here to notice what has become of the three hundred graduates 
from these two schools. The figures are approximately as follows:- 
Remaining in Parent Hospitals, as stated 24 
In other institutions « 30 
In District Nursing 8 
Total in institution and public work 62 
Engaged in private nursing 170 
- 232 
Total continuing as nurses 232 
Married 37 
Died 10 
Studied medicine 1 
Unknown as to abode and occupation 20 
68 
Total out of service 68 
300 
Thus it appears that more than three-fourths are continuing the work of their new 
profession. It is significant that only one has studied medicine; Florence Nightingale 
said that woman was made to be a nurse and not a physician. The most of those in 
other institutions, and a number of the private nurses, are in other States. The City 
Hospital, being the larger, has done about one-half of this work in nine years, against 
the fourteen years of the Massachusetts General Hospital. 
The Registry for Nurses in Boston has been in existence nine years; its work is 
represented in gross as follows:- 
Number of male nurses registered 84 
Non-graduate female nurses 408 
Graduate female nurses 245 
Total number registered 737 
But in the year ending November, 1886, these two hundred and forty-five trained 
nurses were represented in the registry by only one hundred and sixteen of their number 
who remained connected with it, and the proportion of trained nurses to the untrained 
is increasing every year. In the training of nurses for more special work mention 
should be made of the New England Hospital for Women and the Boston Lying-in 
Hospital. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
345 
The showing here given, from only one centre of this nursing reform, indicates how 
ready and active is the growing demand for the services of this profession, how quickly 
the product of the schools is scattered, what an immense agency for good is being 
evolved by this movement, and what a small proportion of those graduated from the 
schools is found to be enough to be retained in the hospitals, in order to perpetuate the 
invaluable advantages of the new system. It is noteworthy, also, that so large a pro- 
portion as nearly one-fourth has so soon fallen out of the work. The annual product from 
the two hospitals here specially mentioned is about thirty-five graduates, and of these only 
about five to eight are retained, in both together, to fill vacancies made by retiring 
head nurses. It is remarkable that these results have come in so short a time, from 
meagre beginnings ; for several years it was difficult to find enough women to undertake 
the work, but now, in contrast, the number of applicants is far in excess of the require- 
ments. All foreknown vacancies occurring from regular graduations are filled a year 
in advance at the Massachusetts General Hospital, and it often happens, in both hos- 
pitals, that fifty applications are received in a single month. 
The Boston Registry frequently sends the city-trained nurses to places in all parts 
of New England, and applications are constantly being received from all parts of the 
country for nurses to go and settle in the cities where there is no supply. There are 
now in this country more than thirty such schools, and yet the supply of graduates 
from well-organized schools falls far short of the demand. At the last annual meeting 
of the Massachusetts Medical Society a paper was read by Dr. Worcester, of Waltham, 
on "Training Nurses," advocating the importance and feasibility of doing this for 
country practice. His arguments were drawn from practical experience in a small 
country hospital. It is the trained nurse that makes practicable the extension of the 
cottage hospital system, in which there is, happily, such a growing interest in America, 
and in which a good proportion of the graduates of the schools is already employed. 
The demand for this special work must increase, and it is probable that, in time, trained 
nurses will become as common as physicians, even in country towns; there is evidence 
now that the physicians of Massachusetts, for example, are generally ready to employ 
such nurses when they can get them. 
It is really no loss to the movement that so many of the nurses fall out into other 
ways of living; the more there are who marry, the more generally will be distributed, 
in domestic life, an understanding of the use and value of their training. It will take 
time, of course, to attain such general results as are here indicated, but it must be 
always a simple question of supply, demand, and diminishing cost to an acceptable and 
equitable standard, just as it is for medical services. Any present evils, if such there 
be, of over-training or other errors of the system, are sure to be corrected in time by 
the repressing influences that must always exist. 
Any one who has watched the progress of this reform would undoubtedly say that 
from the beginning the demand for nurses has grown with the supply, and that it will 
be practically unlimited. In fact, in the country in general, it will be long before the 
present stage is passed, in which the supply must precede the demand, for the reason 
that the value and practicability of the common employment of such services cannot 
become generally known except by the gradual diffusion of their actual use, which 
must come by the distribution of persons enough to render them available. The estab- 
lishment of the Registry for Nurses, in Boston, in 1879, has had a large and important 
influence in this matter, by regulating and facilitating the employment of these nurses, 
thus aiding greatly in introducing among the public a knowledge of their value and 
making a market for the products of the schools. Were there no such market the 
manufactories, so to speak, would languish. 
These considerations lead to one of the points already mentioned, which needs to be 
especially emphasized, and it is the main proposition of this paper. One of the most 346 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
important requirements is, that there shall be an ample and continued demand, outside 
of the asylums, for the services of such a profession, otherwise the new system would 
have failed long ago. In the old order of things, with only exceptions enough to prove 
the rule, the attendant has been a make-shift for the asylums; her asylum work is a 
make-shift for herself also, and will always be so until such work fits her for, and 
leads her to, a respectable and more remunerative, or otherwise desirable, life-support- 
ing occupation. When this is done, the benefit of the asylums, as now of the hospitals, 
will lie in this very fact, and secondarily in the fact that not all graduate nurses will 
be so led away from institution work. Some will remain in it, precisely as do medical 
men; indeed, with a difference only in the grade of the work, the analogy in this 
regard is very close between the professions of the physician and the nurse. 
There is a direct relation between our need of kind and intelligent nurses, and the 
necessity, in their interest, for fitting them to engage in a desirable occupation outside 
of the asylums, as an offset to the undesirable character of the service. Samuel Tuke, 
in 1841, describing the often repulsive and trying character of the work of caring for 
the insane, says: " Can it be surprising, then, if it be so difficult to meet with persons 
to fill properly the post of attendant on the insane, that instances of neglect or abuse 
so frequently occur ?" He quotes Dr. Jacobi as saying: " I believe that this difficulty 
will never be surmounted till the spirit of the age becomes so far changed as to induce 
persons of cultivated minds and benevolent hearts to devote themselves to this employ- 
ment from religious motives." But Mr. Tuke's comment on this is, that "such attend- 
ants would indeed be invaluable; experience, however, in England as well as in Ger- 
many, does not lead us to expect a supply of this class." And, further, speaking of 
what we primarily want " in those who have charge of the insane " as being " a sym- 
pathizing, unselfish character connected with firmness and energy of mind, ' ' he says 
"these traits are, however, by no means commonly found in attendants." In 1876, 
Dr. Clouston still had to lament the unattainableness of the ideal asylum and attend- 
ants, which he feelingly and graphically describes; and in his paper before the British 
Medico-Psychological Society, he puts the practical sense of the situation into these 
words: "I know of few members of this association who took to asylum life from 
1 higher motives ' alone, however much these motives may influence the way our work 
is done. We cannot expect from others what did not influence ourselves." In 1883, 
Dr. Clark advocated the education of attendants for a permanent occupation, for the 
good of themselves as well as of the asylums. By this way, he said, we may advertise 
the asylums and attract to them the better raw material ; by bringing more elevating 
influences to bear upon our attendants-in raising their social and industrial status, we 
shall raise them in the estimation of the public and themselves, and may reasonably 
expect a more marketable article by and by; their work will become a life work worthy 
of the name. 
It is curious to notice how slowly these more practical views have been put into 
effect in the asylums-even in this country, where the most is being done. But these 
views were the mainsprings of the principles that governed the work of the reform in 
the general hospitals from the beginning, twenty-seven years ago, and made it success- 
ful. We cannot go against nature; we must take healthy human nature as we find it 
and make use of the common principle of wholesome self-interest as an instrument for 
our purpose. With proper regard for this principle we may expect our subjects to be 
able to afford the philanthropy we seek in them. This is not a theoretical matter. 
The analysis just given of the work of the Boston Training Schools and the influence 
of the Registry for Nurses proves every word here said, and that the application of these 
obvious business principles has already made the business success of this reform as far 
as the general hospitals are concerned. 
Now, the application of this to our immediate purpose teaches us not only what our SECTION XVII-PSYCHOLOGICAL MEDICINE. 
347 
first action should be in the premises, but also the reasons, to which allusion has been 
made, for the many failures of the asylums in their gropings for this object in the last 
forty or fifty years. The asylums, all the time, began at the wrong end of the problem, 
ignoring too much the larger view. The limited object of the immediate interests of 
the service and of the insane in the asylums, the ease of giving a few lectures which 
made a quick but deceptive show of " systematic training," the lack of the sustaining 
moral and business force of the outside organizations by which the first training schools 
were established in the hospitals, have led to disappointment and failure. The warn- 
ing is plain; the lesson is-lay a good foundation for your work and build upon it 
safely and surely. In the general hospitals the order of importance is reversed-lectures 
are regarded as of minor consequence, and true training as consisting of practical work 
in the wards and drill by teachers in class-room work in the text-books. Another of 
the prime causes of the failures was that no public demand had been created for asylum- 
trained nurses-the superintendents could not-and later did not when they could- 
set before the prospective attendant anything beyond the moderately paid asylum work 
as an adequate object of a reasonable self-interest. The general hospital schools met a 
more obvious want, thus having the advantage of the asylums; the hospitals have led 
the way; the asylums have only to recognize the fundamental principles which sustain 
the former, and to follow their methods now well-established and approved by experi- 
ence. There is no need of more " attempts " and " experiments. " 
Looking at this largest aspect of the movement, and on the basis of the proposition 
to which we now return-that it is essential to its success that there shall be a large 
and continued demand'for the product of our schools-certain practical questions arise, 
and the answer to these furnish the solution of our problem. The truth of the fore- 
going proposition was made plain in the first six years of the reform in America; and 
when, in 1879, it was determined to carry it into the asylum at Somerville, we found 
ourselves confronted by the questions just intimated. The use here of our experience 
may be pardoned, for the sake of clearer illustration; a few facts will be of more value 
than any theory. There was no uncertainty, with us, in regard to what the school 
should be, as to its methods-its needs, as to its organization and the provision of 
a suitable teaching staff, etc. It was to be no "attempt ;" all was clear enough on 
these points. But the first question was: "How shall we make a nurse that will 
be useful to the public, and command its patronage; in other words, how shall we 
best subserve the grand purpose of all our work-the public good-to which the 
personal interest of the nurse is incidental and complemental, and really a means to 
that greater good ? ' ' 
The specialist nurse, we knew, would be a failure; and upon the success of the 
individual nurse in the public service was believed to depend the ultimate success of 
asylum training. The precise question was: " Can we teach the asylum attendant to 
be a good general nurse, with the limited amount of ' bodily ' nursing there is among 
the insane?" (With respect to this, by the way, the large asylums, with their 
" infirmary wards," have an advantage over so small a one as the McLean.) A col- 
lateral question was: " If we put the work upon the basis of that of a general hospital 
-adopt hospital methods-hold the inmates in the attitude of being sick persons and 
as ' patients, ' will it be consistent with the best interests of the insane as to moral 
treatment-promoting home-like conditions, etc. ?" It was determined, however, at 
the outset, to call the patients " patients," as if to say, "You are sick, and may get 
well;" to make the attendants "nurses," and the place a "hospital." All the details 
of bedside attendance upon the sick were amplified as much as possible-the most was 
made of all opportunities. For example, nurses practiced in keeping a chart of the 
temperature, pulse and respiration, and taking other notes, could thus learn to perform 
these quite mechanical acts as understandingly as is necessary in any case. They 348 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
would be relatively on a par with many medical graduates, who see little of " cases" 
till they come to treat them. 
The practical questions resolved themselves, therefore, into one of getting proper 
instructors and laying a foundation for thorough work in the training, so that when 
this formally began there would be no half-way efforts that would invite failure by their 
inefficiency. At first a number of trained nurses from the general hospitals were invited 
into the service. Indeed, one employed as early as 1877, in a common ward for men, 
remained there five years, but with limited duty; still, she and her successors-the 
arrangement being extended to include other wards-demonstrated the admissibility 
and the great advantages of the daily presence of unmarried nurses and ward maids 
among male patients. From 1880 to 1885 nine other such hospital nurses were employed 
in female wards, with a view to gaining their aid in the establishment of our school. 
With one exception, the terms of service of these were only between one and six 
months ; they would stay no longer. One other was appointed Superintendent of 
Nurses in 1882, but withdrew after two years; and another, promoted to be supervisor, 
still remains after three years' service, doing good work also as a teacher. From expe- 
rience with these twelve nurses, there is ample warrant for saying that their general 
hospital training had, in some respects, actually unfitted them for ' ' mental ' ' nursing. 
They wanted to see some illness or inj ury, and to have something active to do; it was 
irksome to sit down and be companions to patients who did not do as they were told- 
as the nurse had been led to expect among those having only "bodily" illnesses. 
Therefore these nurses were slow to acquire the true asylum spirit. The outcome of it 
was, that our female supervisor, who had been nearly twenty years in the asylum, was 
allowed by the authorities of the Boston City Hospital to receive there a six months' 
special and comprehensive course of training. She was instructed, not only in the 
points upon which her experience was lacking, but she learned the technique of school 
methods. This done (our whole service having been, by that time, brought up to doing 
the work in hospital ways, and to the expectation and desire for being trained), we 
were then, at once, able to have a school in full operation. The system of lectures- 
the easiest part of it all to maintain-was supplemental ; this work, on the part of the 
medical staff, having been once prepared, there is afterward comparatively little trouble 
in revising and repeating the lectures to successive classes. 
In my judgment, the important thing is to make large account of the general 
nursing. In the two years of training the eight months' term of the first year is given 
almost wholly to this, in about thirty recitations, one each week, in several text-books, 
and in thirty lectures. Very recently the superintendent of the school at the Massa- 
chusetts Geheral Hospital said to me (of two of our graduates taking a supplementary 
course of a year, for a second graduation there), "They have been over this ground 
so thoroughly in their class work and lectures with you, that they do not need that 
kind of instruction with us." At the asylum, therefore, they are trained as " bodily " 
nurses the first year, and acquire the professional spirit that animates good work in 
that field, besides gaining some satisfactory practical knowledge of this business. At 
the same time they have been trained by practical example and exercise in " mental " 
nursing, which is further developed in the school-work of the second year, in another 
series of as many recitations and lectures as in the first year. 
The results now are that two classes, of sixteen and eight nurses respectively, have 
been graduated, and there is a senior class of fifteen pupils and a junior class of more 
than that number. Four only of the first class remain ; two of these will probably 
enter the hospital, and after graduation there will come back to the asylum. Two, as 
has been said, are already finishing the extra year there. Ten have been engaged in 
private nursing with great success and are in active demand, receiving fifteen dollars 
per week. None have been found wanting as ' ' bodily ' ' nurses, and some of the SECTION XVII-PSYCHOLOGICAL MEDICINE. 
349 
patients attended required a good knowledge of it. The second class of eight still 
remains with us. Ultimately we shall retain two or three of the first class, and so on 
of subsequent classes, and be entirely content to do only that.* 
On the basis of this experience, it seems proper even to urge the suggestions here 
made. The first thing is to make a good preparation ; there can be no doubt as to 
results, with a right beginning. Do not try to begin with a simple hospital-trained 
woman in charge, if better can be done, but regard it as imperative that, whoever it is, 
she shall have some general hospital training. This will avert great trouble and loss 
of time. About the second or third year, it will be discovered that the work is grow- 
ing harder,-that the zeal of all concerned is failing, and that petty difficulties arise 
which a woman experienced in a hospital school would get on with as a matter of 
course, without discouragement to the superintendent of the asylum. These drawbacks 
will be avoided, and the school will be self-perpetuating. In fact, the great point is, 
to keep clear in mind that the school system is a new and distinct department of asylum 
work ; provide it then with adequate and special officers, or specially train the existing 
ones, as teachers, and do not make its perpetuation dependent upon the continuous car- 
rying on of its details and extra work by the medical staff, as a material addition to its 
duties. The best way is, to begin with the women alone, and get well organized on 
that basis ; it is easier to get suitable assistance in teaching them. The men can be 
taken in afterward with less risk and labor, when it is only necessary to extend an 
established system. As a head for the school, take some suitable woman already in the 
service, used to the ways of that particular asylum and its superintendent, and send 
her to some general hospital, to be fitted for the new work ; a year's training might be 
enough. The hospitals are likely to be willing to help in this way ; such things were 
done for some of them in the beginning. Do this first, and time will be saved thereby 
in the long run. While she is away some minor details of the new system can be intro- 
duced. In default of having such a woman, get one, if possible, who has already had 
training in both a hospital and some other asylum. That such a preparation will lead 
to success has yet to be shown ; of course allowance must be made for the personal quali- 
ties, which training, cannot change. Another way is possibly practicable. There must 
be some hospital-trained nurses who will enter upon asylum work with the right under- 
standing and purpose when it comes to be known that there is in it an ample field for 
humane effort. Let such a woman be put into the wards, one after another, quietly 
keeping her own counsel, until she learns the peculiarities of the work, and gets the 
asylum idea and spirit if she can ; then promote her for the purpose in view. 
In regard to the training of men it is only to be said that we have been content to 
go slowly, and do one thing at a time. They do not lend themselves so pliably as 
women to the spirit of the work ; the inducements cannot as yet be made so strong for 
them. Last year we arrived at the point of beginning recitations and lectures, with the 
first class of fifteen men. All new comers now readily obligate themselves to take the 
full two years' course. The second assistant physician mainly conducts this class. 
This year there will be two classes of men in operation, and the male supervisor is 
expected to become qualified to do a part of the class-room teaching, which eventually, 
with the assistance of some future graduate, he may almost wholly do, relieving the 
assistant physicians from this part of the work. This is another way of providing teach- 
ers-made necessary because the general hospitals do not yet undertake the special 
training of men. The indications of substantial results are already good among the 
men. 
* A full account of the history of the school, with details of its organization, and courses of 
study, may be found in the Annual Reports of the McLean Asylum for the last six years-par- 
ticularly in that for 1885. 350 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It has seemed to me to be fair to hold out to young men and women, in our pros- 
pectuses and otherwise, the great advantages to be gained by them from this training, 
even if they have no idea of following the profession of nursing. The whole matter of 
instructing certain classes of people, as well as the public in general, by courses of what 
are called " emergency lectures," is becoming much in vogue and is precisely to the 
point in this regard. Young men and women, in an asylum training school, in addi- 
tion to the regular compensation for service, would get this kind of valuable informa- 
tion, useful in any walk in life, and in a way to amount to something. Again, the 
primary education of those who can make great success in this calling is defective in 
many cases, and can be improved in most by the educational means necessarily em- 
ployed in such school exercises as have been described. The study of the ordinary 
school text-books on ' ' Physiology and Hygiene, ' ' and other methodical class work ; the 
writing out of notes of lectures, with the criticisms thereon-the mental discipline in 
general, from all such exercises, are of themselves educational in the best sense, in the 
fundamental requirements of the common schools. There is, besides, the moral educa- 
tion. One only knows the full force of this who has seen the transformation, under his 
own eyes, of a company of earnest, excellent young women ; there comes into their 
faces-one feels as if he had " talked" it into them-the sure and pleasing signs of 
mental growth, as from girls they come to be thoughtful women, in so short a time. 
Some proof of this is shown, better than in words, by a composite photograph of the 
nurses of our first class, a copy of which may be found in the Century Magazine for 
November, in a second article by Professor Stoddard, on Composite Photography. 
These considerations have impressed me with a more general one as to the interest 
and duty of the State in this matter. It is, to my mind, clearly within its interest 
to foster, in the most efficient way, the progress of this reform ; the diffusion of a prac- 
tical knowledge of insanity, is, of itself, in the direction of prevention, and the wide 
distribution of persons well-instructed even in elementary but practical knowledge of 
the subject, must be of great good. Why then should not asylum schools be regarded 
as a part of the public school system, and as entitled to the fostering care of the State 
on this ground ? Among the ideas of the duty of the State now gaining recognition in 
regard to industrial education, cannot this work have its place, to a very direct end in 
the benefit of the State ? The last Massachusetts Legislature was asked to permit the 
annual use of a small part of the surplus of one of the State asylums for the foundation 
and support of a "Training School," but for want of appreciation of the importance of 
the subject, it was lost in committee. The "school" must come in the asylums, for 
the good is so great from the small outlay required. Two thousand to three thousand 
dollars should amply cover all additional cost, not only of increased salaries of the teach- 
ers, but to pay ten dollars per month extra, if necessary, to each of the ten or twelve 
graduates who will be induced to remain as head nurses. Not every ward will need a 
graduate head nurse ; to put advanced pupils in charge of some of them will be an 
advantage. The head of the school and her assistants as supervisors for the day and 
night (all as teachers), should have liberal compensation, for the work is of a higher 
order than it has been accounted, and the results are worth more than they will cost. 
The other expenses, besides these for services, will be insignificant. 
The part of the asylums in the general movement begun by Florence Nightingale 
may be made a large and proper one. The distribution of hospitals throughout the 
country is not general enough to do what the asylums can in this regard; these are so 
regularly situated as local centres. Thus each in its own locality may find sufficient 
demand for its products to stimulate their manufacture for the public service, and con- 
currently to supply its own wants. Every city of moderate size should have its registry 
for nurses, however humble it may begin ; it may finally serve the whole country of 
which it is the centre. In the preparatory years of the school at the McLean Asylum SECTION XVII PSYCHOLOGICAL MEDICINE. 
351 
fifty nurses were sent out to private cases-thirty-one women and nineteen men-many 
of them returning when the special service was ended ; the public was diligently led to 
understand that nurses would be so supplied, and for the sake of the ultimate greater 
good, the immediate convenience and economy of the asylum were often sacrificed by 
giving the best nurses the chances for the extra compensation. This was a strong, 
stimulus for the school. In like manner, let the public expect to find general nurses 
by applying to all the asylums. Again, under a similar policy, any one of its depart- 
ing graduate nurses is given employment at the McLean Asylum whenever she wishes 
to return, upon agreeing to stay at least three months. 
A word may be said in regard to the very large hospitals, with a corps of attendants 
that would be unwieldy in such school training. Classes of twelve pupils each year 
are quite large enough to be handled to the best advantage. It would seem that a 
working standard suited to the circumstances might be adopted, by which there could 
be two grades, one of attendants and one of nurses, selecting and promoting the most 
promising of the lower grade. Such a number of pupils would probably in time supply 
the needs of any large asylum. 
Another question arises in regard to the promotion of the private care of the insane; 
there is much that may be said upon this subject. In this country it is probable that 
we are to repeat the history of British Lunacy in this respect. This is said with no 
disparagement to the honorable gentlemen doing legitimate work in the private estab- 
lishments and in the home treatment of the insane. Of course such houses should be 
under governmental inspection and endorsement, even if for no higher purpose than 
the protection of their proprietors, while the "home care" of these unfortunates may 
be carried on in a particularly loose and irresponsible way in the present order of things. 
The deliberate sending out of trained asylum nurses is not to be considered as liable to 
foster any evil in this direction; that must be antagonized by the usual corrective effect 
of time and experience. Is not the truest corrective in this matter, also, in the seeing 
to it that all who have to do with the insane shall receive from us all that is in our 
power to give of whatever is right, and true, and honest, in all that goes to promote the 
intelligent and humane care of these unhappy people ? Our views in these matters 
will the sooner prevail, the more there are of the well-instructed missionaries that go 
out from us. 
Quite enough has probably been said, by way of warning, to redeem the promise in 
the beginning of this paper. Mention should be made, however, of a point of criticism 
of the new system, in New England, which may be instructive. There are conservative 
and intelligent physicians and surgeons who deprecate what they regard as the injudi- 
cious ideas of certain promoters of these schools, which beget too much of the mas- 
querading of "higher motives" and the "woman's mission." It is not likely that 
this will amount to a serious evil-in fact, the tendency has been to resolve the sensa- 
tional elements, at first not uncommon, into the plain common sense of simple good 
motives, and good conduct, and good work, in the seeking for an honest and respectable 
livelihood. It was a timely caution, however, recently given by an eminent surgeon, 
against training the woman so that she becomes a sort of hybrid, which is neither nurse 
nor doctor. In the beginning of a school, a few nurses, who know how to do acceptable 
work with no parade or nonsense, will do more to help on the cause, outside and inside 
of the asylums, than anything else. Of our graduates we should be able to feel content 
in saying, " By their works ye shall know them and us." At the McLean Asylum the 
nurses are not taught to write theses and the like ; they are quietly handed their 
diplomas when they are due, and there is rigid avoidance of promoting any other spirit 
than that of aiming at modest, quiet, unobtrusive devotion to honest work. In this 
we but imitate what is really the aim of the general hospital schools which have been 
established long enough to have settled down to the plain methods of solid business. 352 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The feeling is strong upon me that the importance of this nursing reform for the 
insane is not yet half realized. The keen psychological interest an intelligent nurse 
will take (when taught to do it) in the mental operations of an insane patient is some- 
thing beyond even my very sanguine expectations. This puts a power into our hands 
for the moral treatment of our patients that opens wide possibilities in promoting their 
comfort and cure. One must believe this when he finds his nurses methodically and 
intelligently fitting their manner and speech to different patients, and with womanly 
gentleness, as well as with an effectiveness that comes from an almost unconscious 
knowledge (so to speak) of power to manage the varying mental states of the insane. 
The acute intuition of women, when trained to this work, becomes a most valuable 
instrument in our hands. 
It is not the least of the advantages of this system, that it develops the personal 
relation between officers and the nurses. One cannot meet his people, even somewhat 
formally in the lecture room, every week for a series of months, without being more 
keenly moved by a sympathetic interest in each of them-in their troubles, their good 
efforts and their attainments. They discover this feeling, of course, and there is soon 
a community of interest, a unity of purpose and a mutual confidence that brings good 
to the common cause. Were no "graduates" to remain in the asylums, the value and 
comfort of this system would be so great, in the current benefit of carrying it on, that, 
once appreciated, no asylum superintendent would be deprived of it. 
Finally: Get ready before beginning; begin rightly; go slowly; do the work thor- 
oughly, and there will surely be good results. 
INSANITY AS A DEFENSE FOR CRIME. 
ALIÉNATION D'ESPRIT COMME UNE DÉFENSE POUR EXCUSER LE CRIME. 
ÜBER DEN WAHNSINN ALS VERTHEIDIGUNGSGRUND BEI VERBRECHEN. 
BY W. W. GODDING, M.D., 
Washington, D C. 
How far does the insanity of a man affect his responsibility ? In other words, is it a 
sufficient defense for crime to establish the insanity of the defendant? Happily solved by 
some of the Latin nations, among English speaking peoples this question has been cen- 
turies in the asking, and, in the apparently irreconcilable conflict between law and 
medicine, would seem to be as far as ever from a satisfactory answer. On the one 
hand are the authoritative replies of the English judges to the questions presented by 
the House of Lords, replies which shape the decisions of the courts to-day. On the 
other, is their masterly review by Ray, still matchless, though more than a generation 
old, and Maudsley's classic on "Responsibility in Mental Disease, '■ bringing the discus- 
sion down to the present time; two studies at once so exhaustive and complete as to 
leave little for us to add. But if there is nothing new-to be said, why take the time 
of this Congress in the saying? Because as scientific men, to whom the world is look- 
ing for authoritative utterance, we are bound to make answer to a question that, Sphinx- 
like, confronts us each day with a spectacle of the witless victims of its unguessed 
riddle mounting over scaffolds to their doom. It will not do for us to say that the 
answer is old and trite, and has been overruled again and again from the bench. Con- SECTION XVII-PSYCHOLOGICAL MEDICINE. 
353 
tent we may be to be overruled once more; we cannot be content to remain silent. This 
simple truth, that insanity is a disease and not a dictum, we proclaim anew and with 
all the weight which this world-congress can give to its utterance. For if words are 
symbols that rightly interpret thought, and not the veriest illusions which juggle with 
our brains, then insanity must be the mental manifestation of bodily defect or disease, 
and not a question of the knowledge of right and wrong; it can by no possibility become 
either a metaphysical conception or a judicial utterance; through all its changing types 
and varying infirmity of will it remains a disorder of the mind from somatic causes, a 
disease whose existence is to be scientifically determined by clinical observation, and 
which consequently cannot, any more than smallpox, take its limitations from the 
metaphysical answers of any judges. 
It is true that much of the seeming conflict between law and medicine comes from 
misapprehension of the situation. While the physician talks about a disease, the 
lawyer argues of the decisions of the court and the answers of the judges as if these 
constituted insanity. They are not proceeding from the same premises. In their 
rulings the courts have undertaken to establish, not as has been erroneously claimed- 
what insanity is, for that is not a legal question, but what degree of mental impairment 
constitutes an insanity which the law will recognize as a valid defense for crime. Con- 
ceding it to be a question of law and not of fact, this the court has a perfect right to do. 
Within her exclusive province who shall gainsay the majesty of the law? Like the 
Oriental princess, if she insists that her ice be warmed she must have it so; it is not a 
question of science, but of her personal comfort. But while as loyal subjects we bow 
to the mandate of law, we are not, as psychological experts, to warp our science to fit 
the legal formularies of the hour. When in the individual case before us we find 
insanity existing as a disease, and the legal definition takes no cognizance of that 
insanity, we are bound to object to the definition, and if as medical men we can agree 
among ourselves that the insane man, by reason of his insanity, is not responsible for 
his criminal acts, and, believing, teach men so, then, when public sentiment has taken 
shape in this direction, we may look to see the law in recognition of scientific truth 
" broaden down " by another precedent. 
It is not to be denied that among English-speaking nations there is at the present 
time a popular distrust of the plea of insanity as a defense for crime; in the newspaper 
parlance of the day it is the "insanity dodge." Here in America the plea has been 
scandalously overworked. The not too scrupulous advocate, finding in the case of his 
unfortunate client no opening for Mr. Weller's "alleybi," having no hope to establish 
the claim of self-defense, and seeing before him no stay of proceedings short of a halter, 
hunts up an eccentric grandparent in the direct line, some born fool in a collateral 
branch, the usual fall on the head incident to happy childhood, and with an imposing 
array of hypothetical expert wisdom he gravely interposes the plea of insanity. But 
this, which is only the lawyer's art, ought not to deceive the true expert or blind him 
to the real infirmity where it exists, and justice cannot permit that the disrepute 
resulting to the plea from its improper use shall in any way bar from its city of refuge 
the witless homicide fleeing before that avenger of blood, the too zealous prosecuting 
attorney. 
The plea of insanity, then, popular or unpopular, is a right of the accused, having 
both legal sanction and scientific basis. What is its status in our courts to-day ? We 
may take the great State trial of G-uiteau as fairly representing their position. With 
the sanity or insanity of that notorious criminal we have here nothing to do; it is the 
decisions of Judge Cox, as representing the present legal status of the plea of insanity, 
that concern us now. "The legal test of responsibility," says the judge, in the very 
opening of his charge, "where insanity is set up as a defense for alleged crime, is 
whether the accused, at the time of committing the act charged, knew the difference 
Vol. V-23 354 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
between right and wrong in respect of such act." This is the keynote to the whole, 
the point to which, from all the digressions by the way, his Honor continually returns. 
The man must, by reason of mental disease, be unable to distinguish between right and 
wrong in regard to the act in question, that it is contrary to human law or wrong in 
itself. 
This fairly states the present position of our judges on the question of the criminal 
responsibility of lunatics. I am not forgetting a far different ruling of the New Hamp- 
shire courts, to which I shall presently return, but which Judge Cox refers to in the 
charge under consideration only to reject, and in so doing is in accord with other judi- 
cial decisions. 
This, then, is the only insanity which our courts will recognize when presented as a 
defense for crime, i. e., the old, old doctrine of the knowledge of right and wrong. To 
the eye of the law, that broad domain of insanity, familiar to all medical men, lying 
outside of this limit, is invisible; in that judicial light these are the rays that fall out- 
side the spectrum. And the ancients pictured the goddess blind. 
We cannot overlook the question of irresistible impulse which Judge Cox, in his 
charge, recognizes only so far as to say that " it is a dangerous one alike for court and 
jury to handle," and then dismisses it as not relevant to the case in hearing. On this 
question the rulings from the bench are somewhat at variance, but where the fact of 
such impulse has been clearly established by competent medical testimony, there has 
been a disposition on the part of the court to recognize that overwhelming power as a 
tangible something higher than any sense of right or wrong, and in some plain case- 
say that of some poor woman struggling against the impulse in puerperal disease, who, 
at last, despite a full knowledge of right and wrong, has, in a frenzy, taken the life of 
the babe of her own bosom: With the facts all proven, when the judge comes to charge, 
somehow he forgets what was so familiar before, that a knowledge of right and wrong 
in reference to the act is the true test of responsibility for crime. Something like a 
tear stains the hitherto spotless ermine; he talks to the jury of the little we know 
about the inner workings of the human mind under the control of disease; that they 
are to consider, on their oaths, of the terrible tragedy whose details are before them, 
whether it was the act of an insane mother or not. And the jury, thus instructed, 
without leaving their seats, find her not guilty, by reason of insanity. How, in the 
presence of a real mental alienation appealing, in its extremity, for human sympathy, 
this bulwark of safety, this noble canon of the law about the knowledge of right and 
wrong in the insane man as the test of responsibility for crime snaps like a pipe stem ! 
The trouble with our courts is, that the study of insanity by the judges has been a 
metaphysical one. What they need is to spend a few months in an asylum, and make 
the personal acquaintance of a few crazy people. They would not then, as Dr. Ray 
has said, " be guilty of the absurdity of expecting an insane person to act reasonably in 
reference to his delusions." 
If the legal definition of insanity does not include that which is clinically observed 
by the physician, the fault is not with the disease, but with the definition. Our duty 
as medical men is to state the facts respecting mental disease and its limitations ; the court will 
make such rulings in regard to insanity in the abstract as it pleases. Those rulings do not 
concern us; when we have presented the facts our work in the case is done. If we have 
given only the truths of science, they will remain; the rulings of courts change. My 
Lord Coke said : " It is the knowledge of right and wrong. ' ' Lord Hailes said : ' ' Partial 
insanity is no excuse for crime." Then the judges listened to Erskine's brilliant plea 
for Hadfield-in some respects specious as it was brilliant-and the Court said: "Yes, 
delusion is the essential of insanity." So it has come down to our time, each genera- 
tion modifying somewhat the canons, but still clinging to the old essential dogma of 
the knowledge of right and wrong. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
355 
What is this New Hampshire doctrine which Judge Cox in the Guiteau case consid- 
ers only to reject as judicial heresy? Why simply this, " that all symptoms and tests 
of mental disease are purely matters of fact to be determined by the jury." Then all 
these so-called canons about a knowledge of right and wrong, these controlling delu- 
sions, this irresistible impulse, this infirmity of will, any or all of these conditions, 
whether fancied or real, are questions of fact in the individual case for the jury to pass 
upon ; they are not principles of law, and do not come within the province of judicial 
utterance or decision. 
Here then have we come to the very truth with which this paper started, that insan- 
ity is a disease and not a dictum. This New Hampshire doctrine, so consonant with 
scientific truth, so far in advance of the rulings of English courts, it was hardly to be 
hoped that it should find present acceptance of the judges. Yet who can doubt that in 
the coming time, among those fundamental principles, those foundation stones on 
which the temple of justice shall yet be builded anew, this decision, so clear in its truth 
as to be crystalline in its simplicity, and so a stone cut out without hands, that this 
stone which the builders of to-day have rejected, shall ere long become the head of the 
corner ! 
I shall not live to see it, but I expect that he who writes the judicial history of the 
twentieth century will record the abolition among English-speaking nations of my Lord 
Coke's venerable dogma of a knowledge of right and wrong as a test of criminal respon- 
sibility in the insane, and science and law will then have happily united, in the medical 
jurisprudence of insanity, on some such test question as this, to be left to the jury as a 
fact for them to determine after carefully reviewing the details in evidence of the crime 
and the insanity. Did the criminal act result directly from the insanity of the defend- 
ant? In other words, would the offence have been committed but for the unsound 
mind ? When the disease and the crime stand in the simple relation of cause and effect, 
and are so recognized by judge and expert alike, the result will be a brushing away of 
some legal and psychological cobwebs that now festoon the attics of many medico-judi- 
cial brains. 
There is room for only one or two cases illustrative of this need, although their num- 
ber might easily be indefinitely extended. I recall from the New York papers of two 
years since, that of young Barclay Johnson. A tragedy deliberately planned, the pistol 
purchased, the -walk arranged, and mother, brother, and sister go forth smilingly together, 
and seated on the rocks by the beach they look out over the pleasant waters and the 
sunshine on the bay. Then comes a pistol shot from the brother and the mother sinks 
back fatally wounded, the sister starts up to fly and tails dead with a bullet in her 
brain. One more shot from the assassin's hand and the three are weltering together. 
This letter is found on his person :- 
Greenwich, Conn., April 21, 1885. 
If I succeed in accomplishing what I think must be done, a word or two of explanation will 
probably be received with interest. I think I am saving my mother and sister from an unhappier 
fate. If there is a just and generous God, these two will go to the happiness they deserve. If 
there is no God, then they will simply find their restI am conscious of the enormity 
of what I have done and intend to do, but at the same time I have a suspicion that I have become 
insane. Why did not some one recognize my weakness, my great need of help, and help me 
while there was time? But to be fair, I suppose I should say why did I not help myself. 
There is said to have been a remaining portion of the letter, disjointed and almost 
unintelligible. The coroner promptly and properly found the man to have been insane, 
the act growing out of the insanity. 
But suppose the pistol when pointed toward himself to have unfortunately missed 
fire or its fatal aim, and Barclay Johnson had been arrested and tried for murder. 
Where would be your coroner's verdict then, righteous as it undoubtedly was ? The 356 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
letters and the preparation made show the crime to have been as premeditated as 
Guiteau's ; show that the enormity of the offence was recognized by him, and the im- 
pulse so far from being irresistible was reasoned about ; according to Dr. Hammond's 
studies of these impulses one, that, a crime being committed, should hang him. Ah, 
judges, doctors, and the "iron rule of the law," we should find you all concurring, con- 
senting, to his death on the gallows. Yet apply the common-sense rule that is com- 
ing-but for the insanity could he have done it? and the coroner was right, and Dr. 
Hammond and Judge Cox and the rest of us, the men of this generation, are all 
wrong. 
A single illustration more. A man who was for a short time under my care after 
putting or attempting to put belladonna in his wife's tea. His father placed him in 
my charge and in a few weeks took him away. He conducted himself well with me, 
and I was unable to detect intellectual delusions. The wife very naturally objecting 
to his variety of tea, left him and brought criminal charges. At his trial the principal 
evidence against him was a coherent letter to his wife, in which, with considerable fine 
writing and high-flown contrition, he confessed his crime, and begged her to condone an 
act for which he could offer no excuse or reasons. Other medical men testified to his 
insanity at the trial, from which I was unavoidably detained. My testimony would 
have been that I believed him insane and suffering from an obscure but incurable brain 
disease, with a mind weakened by the disease but having a knowledge of the criminality 
of the act, which act was the outgrowth of the disease. It would not have saved him, 
for the judge, a noble specimen of the old school, told me in conversation that the letter 
was proof to him of the man's capacity; as he said, it was a pretty sane letter. Charg- 
ing the jury accordingly they promptly brought in a verdict of guilty. So far as the 
insanity was concerned this was sound jurisprudence, at least of our day, but on some 
legal flaw in the proceedings he was granted a new trial at the next term. Pending this, 
dying of the brain disease, he took the case to a higher tribunal, where the dependence 
of the act on the insanity as a plea in defense for crime may not be barred. No motive 
for the crime was shown ; he had been both proud and fond of his wife. If he had not 
been insane, would he have done it ? 
The dependence of the criminal act upon the insanity of the individual, this is the 
pivotal fact on which responsibility turns. In whatever case that may happen to be 
before us, being satisfied on this point, we may rest content. The court may still rule 
otherwise, but in an age to come, better than ours, in justice to society no less than to 
the offender, insanity will be admitted as an extenuating circumstance to modify the 
sentence, even though it should not be received as a complete defense for crime. May 
we not hope, despite some recent illustrious examples to the contrary, that the courts 
have nearly done with hanging lunatics with or without the knowledge of right and 
wrong? The world may well dispense with protection that does not protect, with 
ghastly examples that do not deter other insane men from crime. Society is finding 
out less objectionable methods for the disposal of its cranks, and history will read bet- 
ter by and by without these impressive execution scenes. Then shall a humane justice 
arise, not timid and blind from instincts of self-protection, but courageous, clear-eyed, 
just in itself, and so divine. SECTION XVII PSYCHOLOGICAL MEDICINE. 
357 
ÜBER "MORAL INSANITY." 
ON "MORAL INSANITY." 
SUR L'ALIÉNATION MORALE. 
VON PROF. E. MENDEL, 
Berlin, Deutschland. 
1. Eine grosse Zahl von Geisteskranken zeigt als hervorstechendes Symptom un- 
moralische Handlungen, Vergehen, Verbrechen. 
2. Wenn dieselben in Fällen von Alcoholismus, Morphinismus, im Remissions- 
stadium der Paralyse, bei gewissen Manien u. s. w. auftreten, sind wir gewohnt, nicht 
von "Moral insanity," sondern von der zu Grunde liegenden Krankheit zu sprechen. 
3. Man hat in der neuesten Zeit vorzugsweise diejenigen Fälle als "Moral insanity" 
bezeichnet, bei denen von Jugend auf eine gewisse Schwäche der Intelligenz, häufig 
auch auf epileptischen oder epileptoiden Anfällen, und in der Regel auf gewissen 
ermitischen Abnormitäten und Difibrmitäten besteht, und die durch unmoralische 
Handlungen sich auszeichnen. Es liegt meiner Ansicht nach kein Grund vor, von 
diesen Fällen eine besondere Krankheitsform zu machen ; man bezeichne sie als Imbe- 
cille, bei denen ein Symptom, das aus der Imbécillités hervorgeht, besonders hervor- 
stechend ist. 
4. Äusser diesen Fällen giebt es jedoch noch andere, bei denen bei oberflächlicher 
Untersuchung lediglich das unmoralische Handeln als krankhaft erscheinen könnte. 
Genaue Untersuchung, längere Beobachtung zeigt jedoch, dass bei gut entwickelter 
und gut erhaltener Intelligenz doch krankhafte Vorstellungen bestehen, in der Regel 
Gefühl der Zurücksetzung Seitens gewisser Personen ; die Handlungen entwickeln sich 
auf diesem Boden als Abwehr, Rache, oder mit der Absicht, bestimmte Personen zu 
kränken. Dies sind Fälle von Paranoia, die sich öfters in der Pubertätszeit, im Puer- 
perium entwickeln. 
5. Nach Alledem liegt kein Grund vor, eine Anzahl von Fällen, lediglich wegen 
eines hervortretenden Symptoms, der unmoralischen Handlungen, als eine besondere 
Krankheitsform auszusondern. Es sind vielmehr die betreffenden Fälle, je nach der 
Genese der Handlungen, ob aus Imbecillitas oder aus Paranoia, diesen Krankheits- 
formen zuzutheilen. 
6. Eine solche, durch die psychiatrischen Thatsachen geforderte Beseitigung der 
" Moral insanity " als Krankheitsform wird gleichzeitig in forensischer Beziehung seine 
grossen Vortheile haben, da gerade hierbei durch Missverständnisse Seitens der Richter 
und falscher Auffassung Seitens der Aerzte viele Schwierigkeiten in allen Ländern ent- 
standen sind. 
DISCUSSION. 
Dr. Channing.-The view which Prof. Mendel has expressed here is one which 
is universally accepted in this country, that moral insanity should be thrown out of 
classification, and that either imbecility or paranoia, or something more tangible 
and definite, should be substituted, and if that were done we should be able to 
explain matters more understandingly in courts of law. 
Dr. Savage.-It seems to me that we are obliged to use some terms provision- 
ally that we do not intend to erect into titles for diseases. I think if we do not 
recognize such a term as moral insanity we are left in rather an awkward position, 
frequently. There are undoubtedly some who never grow to what may be called the 
moral standard of surrounding society, and those cases have been called cases of 358 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
moral imbecility. Now therefore, at once we should come to a confusion of terms 
if we class all cases of moral defect as imbecility or chronic insanity such as described 
as paranoia, and so referred to by Prof. Mendel. There also seem to me to be 
certain cases that are morally oblique ; who never grow up to the standard. Then 
there are péople who have moral scars, who do not seem to me to deserve the term 
paranoia and do not deserve the term imbecile, unless you unduly extend the term 
imbecile. Most of us, I suppose, are perfectly familiar with cases which seem to 
recover sufficient intellectual ability to perform all the functions they did before, but 
with some defect-with some moral scar ; at all events it is a common thing for me 
to see in England ladies who, having had an attack of puerperal insanity, have 
difficulty in keeping themselves from stealing; still others who are unable to control 
their lust for drink and other things; and we should be extending the term imbecile 
very far if we were to call all those who have just this moral defect imbeciles or 
drunkards. I quite think with Prof. Mendel that it is necessary that we should be 
very careful in courts of law not to make use of terms that we cannot define as we 
can imbecility or paranoia, but when we see a less definite influence we must still be 
careful in our definitions. Though I agree in the main with Prof. Mendel, I can- 
not help thinking that provisionally, at all events, we have need of the term moral 
insanity, though we do not erect it into a definite or definable form of disease. 
Dr. Hughes.-Prof. Mendel has evidently encountered in his country the 
embarrassment which we have met with in our own. He has encountered a popular 
prejudice against the term moral insanity, and he has also experienced the difficulty 
of explaining that term in a manner to have it comprehended by the public and the 
courts to mean something different from the insanity of deviltry. Now, I think 
that moral insanity as defined by Pritchard is a fact beyond question. I do not 
understand from what I heard Prof. Mendel say that he would obliterate the fact, 
but simply remove the use of the term. In order to do this I would substitute a 
state of imbecility, a state associated with congenital mental defect, rather than of 
acquired disease. While I am a firm believer in the existence of moral insanity, as 
understood and interpreted by Pritchard, as a form of mental aberration which dis- 
plays itself mainly in the disturbance of the affective life of the individual as distin- 
guished from his purely intellectual life, which need not, therefore, be associated 
with tangible and discernible delusions, I do not think that any process of reasoning, 
or efforts that we may make, will enable us to obliterate that clinical fact that we 
recognize in psychiatry, moral insanity as a form of mental disease. I do not think 
it is well for us to quarrel among ourselves about the use of terms, so long as we 
understand what each individual means. I am perfectly willing that Prof. Mendel 
should recognize that particular form of psychical aberration which Pritchard desig- 
nated as moral insanity, and explain it to the courts as moral imbecility. It means 
the same thing and is often a preferable method of explaining it before courts. But 
the fact remains the same that there is a condition of the brain in which, so far as 
standard delusions are concerned, disease is not manifest. Pritchard made a mistake 
in giving it this name, as before the courts it is considered to be the insanity of 
deviltry, while otherwise it is the effect of mental aberration ; an imbecile state of the 
cerebral organization, or an acquired disease. So far as my own experience goes it 
may result from both conditions. It may be a condition congenitally acquired, and 
it may be engrafted by a subsequent disease. I believe in the fact of moral insanity, 
without quarreling with any individual as to how he may choose to designate it. SECTION XVII-PSYCHOLOGICAL MEDICINE 
359 
DISCUSSION ON SYPHILIS AND ITS RELATION TO INSANITY. 
DISCUSSION SUR LA SYPHILIS ET SUR SES RAPPORTS AVEC L'ALIÉNATION 
MENTALE. 
DISKUSSION ÜBER DIE SYPHILIS UND IHRE BEZIEHUNGEN ZUM WAHNSINN. 
The following divisions of the subject were made :- 
I. IDIOCY, IMBECILITY, MORAL PERVERSENESS, DUE TO INHERITED SYPHILIS. 
II. INSANITY ASSOCIATED WITH ACUTE SYPHILIS (A), PHYSICAL (B), MORAL 
III. SYPHILIS PRODUCING EPILEPSY, WITH OR WITHOUT INSANITY. 
IV. SYPHILIS PRODUCING MENTAL WEAKNESS (A), WITH (B), WITHOUT PARALYSIS. 
V. SYPHILIS AS ASSOCIATED WITH GENERAL PARALYSIS OF THE INSANE. 
VI. PATHOLOGY, AS REPRESENTED BY COARSE CHANGES, LIKE GUMMATA, OR 
SLIGHTER ONES, AS SEEN IN ARTERIAL DISEASE. 
Dr. George H. Savage opened the discussion on each of the above divisions, and 
the discussion occupied the afternoon sessions of September 7th and 8th, 1887. 
Dr. Savage, in opening, said :- 
Gentlemen :-I feel the difficulty of my task very strongly, and also I feel that 
the subject which I have chosen is one of such wide range that instead of one there 
should have been a series of meetings for its special consideration. But here I 
and I must, with your help, make the most of my experience, hoping that the 
wealth of your knowledge will cover my deficiencies. Already the subject of the 
relationships of syphilis to other diseases has been so fully discussed that many will 
say, what more can you hope to add to the fact-heap ? I cannot hope to do more 
than give some facts, and suggest some relationships which may be of use in the 
treatment of a large and I fear increasing number of cases. 
We have to guard against being earned away by the fashion of the day. Every 
new fact in pathology is eagerly seized by the workers in medicine and is tried to be 
fitted to every possible condition ; we are too like the ignorant child with a puzzle, 
who taking each piece in succession, without reason, tries to fit the rounds into the 
squares and ovals as well as into the squares of varying dimensions. 
We are as subject to waves of thought as ever men were. Bacilli may reign to- 
day, but humors or chemical fancies may rule to-morrow. Every wave leaves some- 
thing behind ; it may have destroyed old landmarks, but it will leave a certain shore 
line of its own. The syphilitic interpretation of every nervous disorder was the high 
tide; now we have to take a just estimate of the shore line of the experience which 
has been gained. At first I intended that this should be my object, but I soon found 
that such work must be for less busy men than I ; so I am driven to take a kind of 
middle course, not neglecting the experience of others, but at the same time chiefly 
relying on my own, modified by what I have read in the works of the leaders in 
medicine. I give the digested results of reading and experience. When I began 
my work I circulated the papers showing the lines along which I wished the discus- 
sion to run. 
I shall myself take some special parts of the subject, and will, with your per- 
mission, introduce into their proper places contributions from others who have 
worked more specially at certain other branches. In my part I shall devote most of 360 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
my time to the clinical aspect, adding, where I have been able, the pathological con- 
clusion to the cases. 
As a preliminary step I wish to call attention to some well-known, established dog- 
mas which have special importance in the matter in hand. Dr. Wilks, among many 
of the older authorities on constitutional syphilis, pointed out that brain lesions fol- 
lowing syphilis are very frequent in cases in which the secondary symptoms have 
been but slight. My experience bears this out. Again I would say, that in my 
experience among the children of those who have formed my chief studies but few 
have suffered from any signs of constitutional syphilis. Among the cases to which 
I shall have to refer, there are many in which some local specific trouble has appeared 
to be the starting-point from which general degeneration of the nervous system has 
begun. In such cases the specific changes acted rather as local irritants than as con- 
stitutional causes. I hope to point out that, in my opinion, there is no possible line 
to be drawn between some cases of progressive nervous degeneration and general 
paralysis of the insane. I shall maintain, too, that true general paralysis may be 
caused by syphilis alone or combined with other causes. On the other hand I shall 
show that it is not true that all general paralysis must have a syphilitic history. 
I. IDIOCY, IMBECILITY, AND MORAL PERVERSION DUE TO INHERITED 
SYPHILIS. 
My experience-which has, however, been small, is fully borne out by that of 
such men as Drs. Ireland, Langdon Down, Shuttleworth, and Beach-is that but 
few cases of congenital weak-mindedness depend on congenital syphilis. Dr. Down, 
in some recent lectures, says not more than two per cent, among idiots show any 
signs of congenital syphilis. There are several points in such a startling statement 
to be considered. In the first place we have to remember that a very large number 
of the children of syphilitic parents die in utero ; many also die of early childish 
complaints, associated with convulsive seizures, which commonly end fatally. In 
one case, to which I shall have to refer later, of thirteen pregnancies only three 
brought forth living children ; these were never strong. Therefore we have to 
remember, of the children who might become idiots a large number do not survive. 
Yet with all this, it is a startling fact, and as a fact I must accept it, that few of 
the unstable offspring of syphilitic parents become idiots. I have to record one case 
of weak-mindedness following a steady course, in a woman whose symptoms depended 
on congenital syphilis. In this case the disease began by destroying some of the 
organs of sense, and the mental aspect of the case depended on the sense depriva- 
tion. I should have expected to have found more similar cases among the idiots 
with sense deprivation. 
I have another case to record, of a young lady whose mental symptoms were 
due in part to sense privation and in part to direct inheritance of intellectual and 
moral weakness ; or, to put it otherwise, to inherited want of power of control. It 
will be found from common experience that congenital syphilis interferes with brain 
development by causing disease of the organs of sense or by starting disease of the 
cranial bones, which in turn causes arrest of or injury to the young brain. Such 
disease, or some other disorder of the brain may set up convulsions or true epilepsy, 
which may prevent healthy mental growth. There is yet one other relationship 
which I should like to draw attention to, and it is this, that I have met with several 
cases of insanity occurring in adolescents, which had a great tendency to pass into SECTION XVII PSYCHOLOGICAL MEDICINE. 
361 
weak-mindedness. In these persons there had been a history of general paralysis in 
the father, and though the disease was not manifest for some time after the beget- 
ting of the child, yet in some I have reason to believe that syphilis had something 
at least to do with the causation of the general paralysis. In these cases, then, the 
degeneration of the parent depended on syphilis, and the instability of the offspring 
also had a similar cause. I want more facts to establish this last relationship. 
CASE OF CONGENITAL SYPHILIS, WITH INJURY TO SENSE ORGANS AND DEVELOP- 
MENT OF DELUSIONAL INSANITY. 
Sophia A. B. ; single ; thirty-six ; housekeeper ; sober and moral ; one sister 
deaf ; brother subject to some remittent inflammation of eyes. No history can be 
obtained of the parents. This was the first time she had been in an asylum. She 
is under-sized ; has a typical, specific head, with large frontal and parietal crosses. 
Both eyes have suffered from interstitial keratitis. Old deformity of the root of the 
nose ; old disease of both ears, with double deafness ; the incisors markedly of the 
Hutchinson type. This patient had hallucinations of both sight and hearing. She 
had suspicion about her food being poisoned. She heard voices directing her what 
to do. Her voice was indistinct and nasal. She was destructive, self-contained, and 
preoccupied. She chattered to herself, but could not be induced to do any work. 
Nothing could be done to rouse her, and for the twelve months she remained in the 
hospital she was solitary and deluded. She was in every respect a typical case of 
insanity depending on subjective sense impressions. She reminded me much of 
certain deaf mutes in her manners. I believe in her case the congenital syphilis 
chiefly acted by impairing the senses. Doubtless her whole nervous system, as well 
as her body, was defective from birch, and thus was predisposed to suffer more 
readily from the enforced solitude of deafness and blindness. 
INHERITED SYPHILIS WITH TYPICAL BODILY SYMPTOMS, AND WITH COMPLETE 
MORAL PERVERSION. 
A young lady aged eighteen, the daughter of a most abandoned father, who 
married a woman of immoral character. She had a syphilitic-shaped head, nose, 
teeth, and also keratitis. She was weak-minded and was treated as an idiot. At 
puberty she developed the most frantic sexual desires, and it was necessary to take 
special measures for her protection. She was placed under the care of Dr. Langdon 
Down, who will be able to give fuller details of her history. I can only say that his 
treatment of her was very satisfactory in its results, and she has become, though 
childish and weak, yet self-controlled and lady-like. Some defects were present in 
this case as in the last, but not to such a marked degree. The direct transmission of 
overpowering lust is the most interesting point in the case. I have met with a good 
many doubtful cases of the offspring of sexual paralytics, and though I have some 
ground for believing that some of them have come of syphilitic fathers, who at the 
time of their begetting were suffering from syphilis and not from marked general 
paralysis, yet I cannot vouch for this. In some of these cases fathers who have 
died of general paralysis have begotten children four or six years before they devel- 
oped the disease, and these children have either died of convulsions in childhood, 
have not developed normally, or have, at adolescence or at puberty, passed into weak- 
mindedness. In such cases the prospect has been very unfavorable. 
Discussing the first group, Dr. Savage said : " I have spoken of occasional idiocy 
depending upon general specific changes and general interference with the growth 362 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and nutrition of the body and brain together. I have had experience with other 
cases in which weak-mindedness has depended rather upon the loss of sight, loss of 
hearing, or these combined, occurring with young children and producing the form 
of idiocy that has been called the idiocy of deprivation. But one has a third class 
to note, though before I came to America I had no absolute facts to point to. Now, 
before I left London there were two boys, fifteen and sixteen years of age respectively, 
whose father had died of general paralysis. These two patients were suffering from 
typical weak-mindedness. In one of these cases there was very little doubt that he 
died of general paralysis associated if not caused by syphilis. Since I came to 
America I have met with one case in which Dr. Folsom was able to say definitely to 
me : "A case of mine died of general paralysis of the insane depending upon syphilis 
as clearly as a disease could be said to depend upon any other condition, and his child 
was idiotic, begotten when the father was suffering from constitutional syphilis, 
though he had not at that time shown the objective signs of general paralysis." My 
experience in that line, therefore, may be summarized in this way : We get but few 
idiots among the children of syphilitic parents; but we are to qualify that statement 
by remembering so many die in utero and in earlier life. 
IDIOCY AND IMBECILITY DUE TO INHERITED SYPHILIS. 
BY G. E. SHUTTLEWORTH, B.A., M D. 
[Read by Dr. Savage.] 
From all we know of the far-reaching constitutional effects of syphilis, we might 
fairly expect to find the inherited taint a potent factor in the production of congenital 
or developmental imbecility. Yet when we turn to statements by high authorities 
on this subject, or to the statistics of imbecile institutions, we are surprised to find 
how rarely syphilis is mentioned in the ætiology of idiocy. Thus, Dr. Langdon Down, 
the most experienced of British writers on the Mental Affections of Childhood,* 
states that in not more than two per cent, of his cases has he noted signs of inherited 
syphilis. That great syphilographer, Mr. Jonathan Hutchinson, mentions only three 
cases of juvenile imbecility among about 170 in which hereditary syphilis was the 
cause of specific eye and ear affections ( ' ' Syphilitic Diseases of the Eye and Ear, 
1883"), and in his Lettsomian Lectures (1886) he avers that "idiocy in connection 
with congenital syphilis is certainly not common." I note that in a lecture by Dr. 
Fletcher Beach, in the British Medical Journal of May 28th, 1887, on the "Influ- 
ence of Hereditary Predisposition in the Production of Imbecility, ' ' he does not even 
refer to syphilis, and think I may conclude that in his large experience at the Metro- 
politan District Asylum at Durenth it has not proved an easily traceable parental 
cause. In the tables of causes appended to the Reports of the Earlswood Asylum, 
inherited syphilis figures as but an infrequent item ; and many years ago the result 
of a visit by Mr. Jonathan Hutchinson to that asylum was to convince him that 
"only a very few" of the patients there could be reasonably suspected of being 
syphilitic. Dr. Kerlin, Superintendent of the Pennsylvania Institution for Feeble- 
Minded Children, found in carefully analyzing the parental and grand-parental ante- 
cedents of one hundred of his cases only two in which a syphilitic history could be 
traced, though from his table f it would appear that four of the patients exhibited 
* " Mental Affections of Childhood and Youth." 1887. 
f "Ætiology of Idiocy." Transactions of Association of American Institutions for Imbeciles, 
1880. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
363 
some evidences of syphilitic taint. At the Royal Albert Asylum for Idiots and 
Imbeciles of the Northern Counties of England, at Lancaster, 1170 cases are recorded 
in the case books, of which the history of perhaps 1000 has been fairly ascertained. 
In ten cases only is there reason for suspecting inherited syphilis, and in four only 
can the evidence be called satisfactory. This gives a proportion of one per cent, in 
which hereditary syphilis is a presumable factor, and only four-tenths per cent, in 
which it is an ascertained cause, of the imbecility. 
In spite of these figures, I am inclined to believe, with Dr. Judson Bury, that 
in fact inherited syphilis plays a larger part in the production of mental enfeeblement 
in childhood than institution statistics would lead us to suppose. Parental syphilis 
is not likely to be avowed in applying for the admission of a child to a charity, and 
questions bearing upon the infantile signs of congenital syphilis are often eluded if 
their drift be apprehended. I have indeed known mothers attribute the most char- 
acteristic marks of a syphilitic taint to some extraneous cause, as, for instance, that 
typical radiating scars from the angles of the mouth in a girl with interstitial keratitis 
were produced by an attack of smallpox ! Another reason why syphilitic cases are 
comparatively rare in institutions for imbeciles is the fact that, as mental impairment 
is not usually marked till the period of second dentition, and is often accompanied 
by paralytic and other degenerative symptoms, such cases are not readily received 
into training schools intended for more or less educable children, the mental charac- 
ters partaking rather of the nature of dementia than of simple imbecility. A certain 
number of cases primarily of syphilitic origin are, moreover, classified not as syphi- 
litic, but as the result of hydrocephalus, eclampsia, or epilepsy-affections them- 
selves sometimes springing from an inherited syphilitic taint. 
With these prefatory remarks I will now proceed to give brief notes of those of 
my cases in which the syphilitic etiology is fairly well ascertained. 
Case i.-M. A. L. (girl) ; aged fourteen. Parents not seen by me, but follow- 
ing history kindly furnished by Dr. Judson Bury, of Manchester : " Mother had ten 
full-time children and two miscarriages. First, dead born-(during this pregnancy, 
about eighth month, mother had brown spots all over body, which the doctor called 
"the bad disorder;") second died when four and a half years old, idiotic; third, the 
patient, M. A. L. ; fourth died in convulsions, aged six weeks; fifth, living, aged 
eleven, had "snuffles" when baby; sixth and tenth living; seventh, eighth and ninth 
died in infancy. Relatives on either side said to be free from neurotic weakness. 
Patient covered with spots when baby, and snuffled. Subsequently had fair health 
till ten years old, when mind became weak, and later the power of walking deterio- 
rated, also control of bladder. When admitted to Royal Albert Asylum (in Septem- 
ber, 1882) described as fairly nourished, with peculiar dirty brown skin; no scars 
about mouth, but some small white cicatrices at margins of lower lip. Upper central 
incisor teeth not characteristic, but have shallow notch in lower edge. Cornea clear; 
signs of well-marked disseminated choroiditis, most advanced in right eye. Slow, 
sometimes tremulous in movement; speech drawling; often repeats questions instead 
of replying; has forgotten letters, which she could formerly read correctly; cannot 
write, and counts only by rote. Superficial reflexes well marked; knee-jerk exagger- 
ated on both sides. This girl did not improve materially during her two years' resi- 
dence in the asylum, and was ultimately sent back to her Union. As Dr. Judson 
Bury remarks, in his excellent paper in Brain (April, 1883), to which I am indebted 
for some of the foregoing details-"the mental failure in this case, together with the 
choroiditis and other symptoms, suggest some thickening of the pia mater, and per- 
haps cortical change. ' ' 364 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Casé II.-A. D. (girl); sixteen years of age; admitted January, 1886. Father 
and mother said to be intemperate; family history as follows : Mother has had twelve 
children, of whom four were still-born; three only survive, inclusive of A. D., who 
was the first-born ; child had rash on face and chin when three months old (mother 
says smallpox /) and breathed curiously. Fairly healthy during childhood, and 
maae some progress at school ; information imperfect as to school attainments. On 
admission she was described as an odd-looking girl ; blind of left eye, from cataract ; 
speaks only in whispers ; when asked her age, replies " God knows ; I don't. ' ' Has 
linear radiating scars all round mouth, and the upper central incisors are decidedly 
notched. Subsequently it was noticed that the right cornea was somewhat opaque ; 
inflammatory symptoms set in later, and there were well-marked symptoms of inter- 
stitial keratitis of both eyes. She was treated with perchloride of mercury, and 
gradually the condition of her eyes improved ; mentally there has been but little 
change since her admission. There are no distinct paralytic symptoms, but she has 
shuffling gait. 
Case in.-A. B. (girl); aged thirteen ; admitted recently. Family history (kindly 
furnished by ordinary medical attendant) as follows : Father has had skin affec- 
tions of doubtful character ; mother healthy since birth of third child ; has had 
eight children ; first and second still-born at sixth and seventh months respectively ; 
third child had snuffles, rash, tetany (mother had severe eczema of breast and sore 
throat) ; fourth child died at fifteen months, wasting after convulsions ; fifth child, 
the patient, A. B., was covered with boils when six months old, and had laryngeal 
breathing ; sixth child had suspicious rash ; seventh, premature, died, aged nine 
weeks ; eighth and last, healthy. A. B. had whooping cough severely when baby, 
but was fairly healthy and intelligent up to ten years of age ; attended school and 
learned to read and write. About three years ago had attack of dizziness, followed 
by unconsciousness, attributed by parents to fall, of which, however, it may have 
been cause. From this time she had occasional slight paralytic seizures affecting 
right side, which is now feeble. She walks badly, dragging right foot. She has 
deteriorated mentally and cannot now read or write ; her speech is mostly interjec- 
tional. Cutting margin of upper incisors narrower than neck, but not grooved. 
Pupil of right eye constantly dilated ; no evidence of choroiditis on ophthalmoscopic 
examination. Latterly some physical improvement has resulted in this case, under 
mercurial treatment, followed by the administration of cod-liver oil. She is able to 
walk better and to lift up the right foot, so as to get up and down stairs without 
difficulty, which she could not do when admitted to the institution, and she is better 
conducted generally. She has not had any seizures, causing slight paralysis (as 
described by her parents) since she came under my observation ; these transient 
paralyses being probably such as Heubner attributes to syphilitic endo-arteritis. The 
first attack of dizziness followed by unconsciousness, which lasted several days, is 
attributed by her medical attendant to syphilitic meningitis. 
Case iv.-J. E. S. (boy); aged thirteen ; admitted November, 1885. Family 
history : father died seven years ago, of ' ' brain softening, ' ' aged thirty-eight. He 
was an unsteady and intemperate man, subject to frequent sore throat, pains in the 
bones, etc. Mother was a healthy woman till marriage, but constitution impaired 
since. Had three children previous to patient, two still-born, one lived only a few 
hours. J. E. S., the fourth and last child, not a strong baby ; had scaly eruption 
on buttocks and face when three weeks old, with soreness about anus. These symp- 
toms lasted about four months. Also had snuffles. Legs and arms always weak ; 
had numerous falls, and was run over on one occasion. Went to school up to eight SECTION XVII-PSYCHOLOGICAL MEDICINE. 
365 
years old, and though he did not learn much, his mental condition has become much 
worse since that age, and he has deteriorated in walking power. On admission he 
was noted to be a dull but irritable boy, sluggish in movement, and presenting a top- 
heavy appearance, his head being large, measuring 211 inches in circumference, and 
of hydrocephalic contour. Right pupil markedly larger than left ; speech indistinct, 
but can swear ! Teeth fairly good ; upper incisors not characteristically notched ; 
right side partially paralyzed. No educational attainments. During the two years 
he has been in the institution he has been gradually deteriorating in mental and 
muscular power, and is now quite unable to stand, and can only sit up in a chair 
when propped. Knee-jerk much exaggerated on each side. Sight apparently good; 
no evidence of choroiditis ; cornea clear ; right pupil constantly dilated. This boy 
has not had any " fits " since four years of age, and then only one ; but he is subject 
to occasional phenomenal flushings, attended with some amount of mental irritability. 
The four cases detailed above from our case books are the only ones in which a 
definitely syphilitic history is conjoined with distinctly syphilitic symptoms. It will 
be noticed that they present certain common characteristics, viz. : specific skin affec- 
tions in infancy, followed by a period of comparative health and intelligence in early 
childhood, and a break-down of bodily and mental power about the period of second 
dentition. In two of the cases there were signs of specific eye affections ; in the 
other two marked inequality of pupils. There is also a certain similarity in the 
mental condition of these patients ; all have lost whatever school attainments they 
acquired in early childhood, and there is a disposition to inertness, with easily excited 
reflex irritability, both muscular and mental. While Cases I and 11 may be described 
as stationary, some improvement has occurred in Case m, and gradual deterioration 
is going on in Case IV. 
I do not think it necessary to enter into details of the other six cases referred to, 
in which syphilis was suspected to be an ætiological factor, inasmuch as the evidence 
at present available is scarcely satisfactory. In three of these cases the family 
medical attendant alleges the existence of a syphilitic taint in the parent, but noth- 
ing specific has been detected in the condition of the children ; in the other three 
suspicious signs exist in the children, but there is no corroboration in what is known 
of the family history. 
Unfortunately I am unable to adduce pathological observations based upon post- 
mortem appearances, never having had an autopsy of an imbecile patient recognized 
as syphilitic ; but recently Drs. F. Warner and Fletcher Beach described, in a com- 
munication to the Medico-Chirurgical Society of London (April 26, 1887), a case in 
which chronic meningitis with false membrane adherent to the dura mater was found 
to exist, the symptoms having been those of ' ' progressive dementia, ' ' commencing 
between six and seven years of age. It seems probable that (as suggested by 
Heubner),* "the most important symptoms of the form of syphilitic cerebral dis- 
ease" observed in the case of imbeciles, " are to be referred to the affections of the 
cerebral arteries," the calibre of which becomes narrowed, owing to endo-arteritis, 
producing (unless influenced by early and vigorous treatment) more or less cerebral 
atrophy. In conclusion I may say that so far as my own limited experience of the 
matter extends, the relation of inherited syphilis to idiocy and imbecility would 
appear to be rather that of progressive pathological change than of original forma- 
tive defect. 
* Ziemssen's Cyclopædia, p. 332. 366 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CASES OF IDIOCY AND IMBECILITY DUE TO INHERITED SYPHILIS. 
BY FLETCHER BEACH, M.D., M.R.C.P. 
[Read by Dr. Savage.] 
This paper has been written to prove the negative rather than the positive propo- 
sition; to endeavor to show that imbecility is rarely the consequence of inherited 
syphilis. 
I am supported in this opinion by well-known authorities who have written on the 
subject, and though I intend to refer to only a few, those who wish for a full bibli- 
ography will find such given in a paper by Dr. Judson Bury in the sixth volume of 
Brain. 
Dr. Langdon Down, in his Lettsomian Lectures on some of the Mental Affections 
of Childhood and Youth, says : " Syphilis was not an important factor in the produc- 
tion of idiocy; in not more than two per cent, were there signs of inherited syphilis." 
Dr. Grabham, formerly superintendent of Earlswood Asylum, stated in a paper 
he published some time ago, "syphilis in the parents may account for a few cases. 
Information is not readily obtainable under this head. ' ' 
Mr. Hutchinson examined the teeth of the idiots at Earlswood Asylum some 
years ago, but did not find the specific character in any number of cases. It should, 
however, in fairness, be mentioned that he has pointed out that it is only when there 
have been attacks of syphilitic stomatitis that we are to expect to meet with changes 
in the teeth from their normal types. 
Dr. Ireland says: "Idiocy does not seem to be a frequent result of hereditary 
syphilis, though I have met with a few apparent instances of the kind. ' ' 
My friend Dr. Warner, who is one of the physicians to the East London Hospital 
for Children, tells me that he has met in hospital practice with cases of specific dis- 
ease in children leading to progressive dementia. In one there was gradual loss of 
mental function for three years, and then a stationary condition. The brother of this 
case had infantile hemiplegia and subsequent athetosis. Dr. Warner had found 
treatment with mercury and iodide of potassium useless. 
Probably the disease leads more often to juvenile dementia about the time of 
puberty than to idiocy or imbecility, and if of a mild type the case would not be sent 
to an asylum for imbeciles. In cases which are sent, hereditary neurosis will no 
doubt often be a predisposing cause. Of course, constitutional syphilis can only lead 
to idiocy or imbecility by causing some disease of the skull, brain membranes, or 
arteries, or all of these combined, and so affecting the nutrition of the brain, and 
though a priori, one would think idiocy should be a frequent result, yet practically it 
is not so. Exostosis of the skull, thickening of the brain membranes and arteritis 
are not commonly found in idiocy as far as my experience goes. I have never seen a 
case of exostosis of the skull in this asylum, although 1800 cases have passed through 
my hands, and have only found thickening of the membranes or arteries in seventeen 
cases post-mortem, and in only one of these cases was there a history of syphilis. 
The following cases are all that I have been able to find to illustrate the paper :- 
E. S., aged fourteen years, was admitted May 25th, 1875. She is of marked 
syphilitic type with depressed bridge of nose; keratitis of both eyes, so that she is 
almost blind; almost deaf; teeth ground. On admission she was fairly nourished, of 
fair complexion, quiet and well-behaved, could only say a few words. Her mental 
capacity was small, and though her powers of observation, imitation and attention 
were fair, she had little memory. She went to school in the asylum, but learned only 
a few letters and figures. She said little, but answered when spoken to. She was SECTION XVII-PSYCHOLOGICAL MEDICINE. 
367 
fond of sewing and was employed in the work-room until December 16th, 1886, when 
she was discharged to the adult asylum. No history could be obtained, as she was 
never visited. 
R. V., aged nine years; admitted April 18th, 1876. The relieving officer stated 
that the mother was a prostitute, and the child is said to have been an imbecile from 
birth. On admission she was well nourished, of dark complexion and lymphatic 
temperament. There was keratitis of one eye and the upper incisors were peg 
shaped. Her mental capacity was small. Power of observation and attention fair; 
memory slight; could say her name and a few words. After four years' training, 
she could only read the capital letters, spell a few words, count to 110, and recognize 
a few colors and forms. While under training, keratitis of the unaffected eye super- 
vened, and, notwithstanding mercurial treatment, some opacity remained, although 
the cornea in front of the pupil cleared up. She was discharged November 1st, 
1883, to the adult asylum. There is no doubt, I think, from the life the mother led 
and the low class from which she was drawn, that she had had syphilis before the 
birth of the child. 
T. A. H. B., aged fourteen; admitted November 6th, 1879. The mother had 
had syphilis before the father married her, and died of phthisis four years before the 
patient's admission. Paternal grandfather of patient also died of phthisis; paternal 
grandmother died paralyzed. The depressing influence of phthisis no doubt assisted 
in the production of imbecility. This was the second child; there had been ten, but 
all except the patient died soon after birth. T. A. H. B. was a well-nourished con- 
genital imbecile, of dark complexion, with loss of power on the right side, probably 
due to fits, from which he suffered when an infant. He had prominent eyes and a 
very highly arched palate, but his teeth were normal. He was of an irritable dispo- 
sition and masturbated a good deal. Mental capacity fair for an imbecile. After 
three years' training he could read well from the First Standard, transcribe and work 
sums. He could not work at a trade, being paralyzed on the right side. He was 
discharged to the adult asylum May 26th, 1882. In this case, beyond the imbecility 
there was no sign of congenital syphilis. 
E. B., aged seven years; admitted October 2d, 1879. The father had syphilis 
before marriage and communicated it to the mother. The family history is bad. 
Mother of very nervous temperament, maternal aunt epileptic, paternal uncle imbe- 
cile, maternal grandaunt insane. This is the third child. There have been five, of 
whom three are dead, one from hydrocephalus. The child is said to have been all 
right at birth, went to school and got on well until two years before admission, when 
she is said to have had a fright. She has since become very nervous and restless in 
her manner, and will suddenly stop while walking and scream out at the top of her 
voice. 
On admission she was fairly nourished, of fair complexion, and it was especially 
noticed that her features were good. Teeth normal. She was bright looking but 
very bad tempered. Her mental capacity was small. She had scarcely any memory, 
though she talked fairly well. She attended school for some time in the asylum, but 
learned nothing; was subject to violent fits of temper, when she would stop and pull 
out her hair. She has lately become very feeble in health, and so helpless that she 
has to be fed and fastened to her chair to prevent her falling out. I have no doubt 
that when the end comes thickened membranes will be found. 
In the next and last case a false membrane was found after death. As it has 
been previously reported, I will refer to it very shortly here. 
The case is that of a boy, aged seven years, who came under the observation of 368 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Warner in January, 1879. While an infant, he suffered from snuffles, thrush 
and sores on the nates. He never had fits. As he grew up he became a strong boy, 
and went to school, where he did his lessons fairly. He continued bright and well 
until about eight or nine months before he was seen. The first thing noticed was a 
certain difficulty in his movements, the boy at the same time complaining of head- 
aches, and crying out for slight causes. He was under observation until September, 
1880, when he was admitted into Dareuth Asylum, under my care. He remained 
there until his death, in January, 1882. At the autopsy, twenty-seven hours after 
death, the dura mater was found adherent to but easily separable from a subjacent 
false membrane, which had evidently been formed some time. It was attached here 
and there to the upper surface of the pia mater by thin membrane, and could be 
traced for a considerable distance along the floor of the skull. 
The family history showed that the maternal grandmother was epileptic, that the 
mother was liable to special illusions, and that the father had had syphilis. 
This case, which had been carefully watched for three years, was clearly one of 
acquired imbecility, due to chronic meningitis, probably syphilitic in its origin, and 
is representative of many others, where, owing to the influence of heredity, indicated 
here by the history on the maternal side, the child is born with an unstable brain, 
easily disturbed by any cause. As previously mentioned, syphilis is not a common 
exciting cause of imbecility, but according to Heubner, hereditary predisposition to 
nervous diseases appears to exert an influence in determining the syphilitic poison 
toward the nervous system. 
The brain weighed only twenty-seven ounces. Its growth had no doubt been 
interfered with by the chronic meningitis which had existed for some time. 
After presenting the views of Drs. Shuttleworth and Fletcher Beach, Dr. Savage 
continued : Although these gentlemen, speaking from the side of the asylum, say we 
do not recognize syphilis as a common cause of idiocy or imbecility, on the other 
hand, physicians who are largely connected with the treatment of diseases of children 
write differently. I hold in my hand a paper written by Dr. Judson Berry, of Man- 
chester, who was connected with the hospital for children, and he says it is not an 
uncommon thing for him to have weak-minded children with a history of congenital 
syphilis. So we have alienists and those connected with asylums on the one hand, 
who say these cases are very exceptional, some saying they have seen but one per 
cent, of idiots, some two per cent, with signs of syphilis, and on the other hand 
we have the general practitioner, who says he believes it is more common than we 
think. 
Dr. Down.-Mr. Chairman and Gentlemen : I wish to add my authority to the 
views here expressed. Not only do I believe in that small percentage of syphilis in 
idiots and imbeciles as derived from my clinical experience, but also from pathological 
investigation. In three hundred cases there were not more than two per cent, which 
gave any evidence of hereditary syphilitic disease, and in those cases the evidence 
was seen in thickening of certain bones. I commenced the investigation in the strong 
belief that I should find syphilis a very important factor, and it was only by thor- 
oughly investigating the cases, and by clinical methods, that I arrived at the conclu- 
sion that not more than two per cent, of idiots are the subjects of congenital syphilis. 
Dr. Savage referred to a case where he suggested the idiocy was owing to deprivation. 
I do not think that was entirely the case. I think the deprivation was a small factor, 
and that it was a case where syphilis was the important factor. It was the case of a 
young lady who had mental and moral perversion, due unquestionably, in myopinion, 
to syphilitic disease. Then the question in some cases where the children have been SECTION XVII-PSYCHOLOGICAL MEDICINE. 
369 
born in the presence of syphilitic disease-that is a point which makes it difficult in 
arriving at definite conclusions. 
As to the last remark by Dr. Savage, in regard to the divergence of opinion 
between alienists and general practitioners on this subject, I may say that I am an 
alienist in this department, but I am also a general practitioner and a physician to 
one of the largest hospitals in London, and my private work is very much with the 
class of children which would come under the hospital care, and by my experience, 
both in the London hospital and my experience also with private clinical work, my 
opinion is confirmatory entirely of the view which I have heard advanced; that 
syphilis is not an important factor in the production of idiocy. So that while I am 
averse to the gentleman last quoted, I am glad that I am in harmony with the 
large number of my colleagues who have here confirmed an observation which I 
made many years ago. 
Dr. Hurd.-Rather with the idea of adding to Dr. Savage's collection of cases 
than telling anything new, I would mention that on one occasion two imbecile boys 
were brought to the institution with which I am connected. One was twelve years 
old the other ten. The older had no notched teeth, and he was simply an imbecile. 
The younger had the characteristic notched teeth, and had I received him alone I 
should have had no hesitation in saying that the father or the mother was tainted 
with syphilis. I confess I was puzzled to explain the fact that one of these children 
presented evidence of congenital syphilis while the other did not. My explanation 
of the case was that in many instances the notched teeth were simply indicative 
of a defective physical organization. The older of the boys was the better developed, 
both physically and mentally. The deterioration of the stock seemed to have 
advanced another step in the other boy. The younger boy was more feeble-minded, 
and defective physically; and I regarded his notched teeth as the evidences of increasing 
physical degeneration. 
Dr. Gundry.-I have nothing very new to add to the discussion, but one or two 
facts and one or two doubts. First, the doubts. It is so difficult to isolate any factor 
in the production of disease, and especially such a factor as syphilis. Syphilis as a 
cause of disease, we have oftentimes among other causes which are more striking and 
which give the color, so to speak, to the causes assigned by the physician. In that 
way, oftentimes syphilis, which may have contributed to it, has not been sus- 
pected. Therefore, in many cases which were probably due to syphilis, some at least 
due to the syphilitic taint, it has not been recorded or suspected. There are a few 
cases in which syphilis stands out so prominent as to make it impossible not to discern 
it, and it has obscured the other factors. Occasionally we have syphilis so isolated 
that it cannot be confounded with other causes. One such case my memory recalls 
in this discussion. Many years ago I had a friend, a physician, as pure a man as 
ever lived, who contracted syphilis in his practice. The disease was not diagnosed; 
it was neglected. The moral aspect of the case negatived the presumption of syphilis 
in the minds of many whom he consulted, and it was a long time before he came 
under proper treatment. The disease went on and gradually mental symptoms arose, 
during which time I saw him. These symptoms gave rise to a fear of general paresis. 
There was a great deal that tended that way. About that time I left the State. I 
afterward learned that in two or three years he died, of what was supposed to be 
general paresis, or analogous thereto, resulting from syphilis. Two or three years 
ago, in revisiting my old home, I went to the Idiot asylum, and I was very much 
shocked when the superintendent pointed an idiotic child out to me as my friend's 
Vol. V-24 370 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
child. Calculating the time, I found it was born when he was suffering from these 
anomalous symptoms, which his friends had not recognized as syphilis, but were so 
treated afterward with apparent benefit. This man died from general paresis; I have 
no doubt of it. Now one fact like this, from which everything else has been 
excluded-there was no drunkenness, no dissolute habits, nothing at all but the 
syphilis in the case and the worry incident to the trouble he had been brought into- 
I think speaks more eloquently than a great number of cases in which there are many 
other factors involved. I have seen, too, not always so clearly shown as this, quite 
a number of cases-I won't say a great many-in which I thought I had traced the 
mental weakness, and especially the moral perversion of children, the feeble moral 
tone at any rate, and something of the feeble intellectual tone of children, to syphilis 
of the parents. Then again, if you go into the larger cities, where children are 
brought under treatment, you will find a general feeling prevalent among those phy- 
sicians who care for them, that a great number of anomalous mental symptoms, 
feeble-mindedness, especially weakness on the moral side, are to be attributed to 
syphilis. Probably they do not exclude other things, but, on the other hand, many 
other factors are credited with that which is due solely to syphilis; so that I should 
be rather slow in coming to the same conclusion that our friends on the other side of 
the water have, that syphilis is so slight a factor in producing moral weakness or 
imbecility in the next generation. 
Dr. Savage.-First of all I look upon Dr. Hurd as heterodox. I can have no 
communion with him when he talks about Hutchinsonian teeth as if they can be the 
outcome of anything but syphilis. This fact has been impressed upon me by Mr. 
Jonathan Hutchinson, that syphilitic teeth are syphilitic teeth, and that they are 
nothing else, and that no interference with second dentition, no struma, no scrofula, 
nothing can produce these teeth but congenital syphilis. This merely in passing. 
Hutchinson goes so far as to say that there are many other teeth that have been 
classed as his which are not his. 
In regard to what Dr. Gundry says, I have to agree with him very strongly in 
what he says of the moral perversion found in children of syphilitic ancestors. Dr. 
Maudsley Inis written largely upon the tyranny of our organization, and the tyranny 
of our organization is nowhere more marked than in our moral goodness or badness. 
One has seen syphilitic children who have shown moral perversion, and how could it 
be otherwise ? The fathers and mothers are dissolute, and it is from this cause that 
we have the moral perversion. I cannot accept the view that it comes from the 
syphilis. 
Dr. Down's case was that of a person whose father was an abandoned man and 
the mother nearly as bad. The patient was the only child, and had the syphilitic 
disease of both parents. Syphilitic corneitis was present and with it the most un- 
bridled lust that it was possible to have. 
II. INSANITY ASSOCIATED WITH ACUTE SYPHILIS. 
Dr. Savage.-I have here to say that the cases of insanity in which acute syphi- 
lis is the chief cause seem to me to be very rare. I have to communicate one case, 
kindly contributed by Dr. Wigglesworth, of the Rainhill Asylum, Lancashire. In this 
case acute syphilis was followed by insanity, and in the end the patient died. The 
remarks of Dr. Wigglesworth quite fall in with my experience. I have yearly 
cases admitted into Bethlem with some form of venereal disease fresh upon them, SECTION XVII-PSYCHOLOGICAL MEDICINE. 
371 
but as a rule the disease is the result of the insanity with its loss of care and self- 
control, and the disease has little or nothing to do with the insanity, or only is 
enough to color it. I have at present one case of general paralysis of the insane, in 
which a single man of irreproachable character developed uncontrollable lust, and 
managed to contract a chancre. This was treated on his admission into Bethlem, 
but has had no effect on him in one way or another. I very commonly, as I have 
said, receive general paralytics with some form of sore upon the penis. I have 
therefore felt it necessary to eliminate such cases from the really large group of 
cases of general paralysis, in which syphilis plays some part in the production of the 
disease. I do not believe that all general paralysis depends on sexual excess or on 
syphilis, but I recognize that sexual excess, and, as a consequence, venereal disease, 
are common in this disease. 
I cannot say that I have ever come across a case in which the febrile disturbance 
not uncommon with the early disorders of constitutional syphilis could be given as 
the starting point of an attack of mental disorder, but I have heard one or two sur- 
geons say they had seen delirium occur, and from this I feel sure that such cases will 
be found, and perhaps some here can assist me. 
INSANITY, WITH ONSET OF SECONDARY SYMPTOMS. 
I have one very interesting case to bring forward in this relation, and I would say 
that such cases are not so rare as the last group, though it is not often that one has 
the opportunity of tracing the growth of the bodily and mental symptoms so clearly. 
The patient whose case I give was a trainer of race horses, whose occupation led him 
to suspect every one who came near him, and when he got double optic neuritis, due 
to syphilis, the most troublesome symptoms depended on his natural suspicion, 
which became exaggerated in consequence of his imperfect sight. The rapid cure of 
the syphilis and the immediate removal of the mental symptoms leave no doubt as 
to the real connection between the two diseases. 
I have one other case which might be placed under this head, in which the mental 
symptoms developed directly with the ptosis, external strabismus, and mydriasis, 
that marked the constitutional disease, and which passed off with the relief of those 
symptoms. In this last case the syphilis remained present though latent, and 
reappeared in other parts of the body for three years after the mental recovery, 
though the patient has never since had any relapse mentally. 
INSANITY, WITH CONSTITUTIONAL SYPHILIS. RECOVERY. 
Martin J.; aged twenty-eight; single; trainer of race horses. No history of 
insanity in his family; has been strictly sober for the last four years. He held a 
position of great trust and responsibility, and was constantly on the lookout against 
touts and persons who might wish to injure the horses. He contracted syphilis some 
four or five years before, but had not suffered much since. He was admitted into the 
Bethlem Hospital for treatment of ptosis, external strabismus and other oculo-motor 
troubles due to syphilis, as well as loss of sight. In the hospital double optic neuritis 
developed, and with it great impairment of sight. With this he became more sus- 
picious and threatening. He believed persons stole his things, and he was violent. 
He thought the other patients were against him and wished to kill him. 
On admission into Bethlem he made no complaint of headache; he took food 
fairly, but slept badly; besides the right ptosis there was marked turgescence of 
retinal vessels and optic neuritis most marked in right eye. He was treated at first 
with iodide, and later had calomel baths and inunction of mercury. 372 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lie was slightly salivated a month after admission, and steadily improved after that 
time. At the end of two months from admission he was discharged perfectly cured 
both of his ocular and mental troubles; both seemed to clear up under the specific 
treatment. 
This patient has now remained well over eleven years, and is following his work 
as well as ever. 
The chief points of interest are that this patient, with the onset of marked con- 
stitutional symptoms, developed insanity of a type which was, to a great extent, the 
outcome of his calling-only exaggerated caution-and with appropriate treatment 
the bodily and mental symptoms all disappeared. Permanent cure has resulted. 
WEAK-MINDEDNESS AND STUPOR, ASSOCIATED WITH PTOSIS AND STRABISMUS. 
ULTIMATE PERMANENT RECOVERY. 
Henry P. ; admitted 1875; married; no family; no neurosis in family. Contracted 
syphilis six years ago. Had been sober and quiet. Eight or nine months before 
admission he had several fainting fits. Nine days before admission he began to talk 
incoherently; he was sleepless; he had exalted ideas; his memory was weak. On 
admission he was excited at first, but soon passed into a dull, preoccupied state. He 
was diagnosed not to be suffering from general paralysis. Within a month he became 
wet and dirty. There was ptosis and external strabismus of right eye; the discs 
appeared congested; no apparent loss of sight. Iodide of ammonium was given in 
ten-grain doses every four hours. He passed into a more pronounced state of stupor. 
After four months he had recovered power in his eyelid, lost the strabismus, but 
there was no mental gain. After six months' treatment he was so obstinate about 
his food, and so weak, that it was decided to leave him alone-as we thought, to die; 
but he soon after began to improve, and once having taken a turn he rapidly con- 
valesced; the only symptom remaining being dilatation of the right pupil. 
A year after his discharge he had symmetrical inflamed nodes on his shins; a year 
later a serpiginous ulceration of nose, rapidly spreading, and in 1879 a similar ulcer 
on his prepuce. Mercury relieved these symptoms, and a prolonged treatment by 
mercury and the use of Turkish baths appear to have completely removed all trace 
of syphilis, and he is fully occupied in business in the city. 
SYPHILIS, GREAT DISFIGUREMENT, NEUROTIC HISTORY, RECURRENT INSANITY. 
William H. L. ; single ; forty-two ; architect : brother insane, but recovered ; 
sober ; industrious. Admitted February, 1886. He had one previous attack eighteen 
years ago. He contracted syphilis twenty-four years ago, and was treated for 
two years ; he developed, some four years after contracting the disease, secondary 
symptoms of a very severe kind. He had ulcerations of throat and nose, and the 
whole of his face was disfigured, his mouth being contracted and misshapen. The 
first attack of insanity was coincident with the severe constitutional symptoms. 
He has felt the isolation caused by his appearance, but has worked steadily. He 
became depressed and unsocial, sleepless, then excitable. He thought his mother 
wanted to poison him. The immediate cause of this attack was said to be an opera- 
tion on his mouth which, besides being painful, was of no service to him. 
On admission he was suspicious, avoided others, but was at the same time excit- 
able. He said the scars on his face were due to explosions of cannon. There is no 
truth in this. He was tried on several occasions on leave of absence, but he appears 
to have passed, after eighteen months' treatment, into a state of mental weakness, 
and there is little prospect of cure, though he appears to be in good general health. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
373 
The above examples, with those of Dr. Wigglesworth, show that insanity may 
arise from the bodily disorders of syphilis in its primary or secondary stage, and may 
be relieved by the cure of these symptoms. Next I shall briefly refer to the mental 
effect of syphilis. 
Syphilis may by its physical symptoms cause insanity directly, but it is more 
common to find cases of syphilitic hypochondriasis in which syphilis is the explana- 
tion, not the cause. In a few cases I have met with persons who having had 
syphilis have felt the disgust, which is natural, in a very exaggerated degree, so that 
their whole lives became narrowed, and in the end they became distinct cases of 
hypochondriasis, with the syphilis as the primary cause. I recognize that most of 
the cases who accuse themselves of impurity and of having some contagious disease 
which they fear to communicate, are but cases of exaggerated self-consciousness, and 
that it is but an accident, whether they say they have syphilis, the itch, or are 
morally leprous. I think it hardly worth my while, in a meeting of this kind, to 
repeat the many examples of this kind which are daily being brought before us. 
I add one case, in which syphilis played a part, both moral and physical, in pro- 
ducing melancholia with dangerously suicidal symptoms. 
SYPHILIS, HEREDITARY NEUROSIS, DEPRESSION, MELANCHOLIA. 
Fred. J. D.; single; bar-man. Admitted February 14th, 1887. Uncle and 
cousin insane ; one uncle died of diabetes. Fifteen months before admission con- 
tracted syphilis and became very dull, but showed no signs of insanity. In October, 
1886, first showed symptoms of insanity ; he suddenly became emotional, noisy and 
excited. He became reasonable again, but had recurrences of this kind. On 
December 15th he cut his throat and had to be taken to a general hospital. His 
throat got well, but he said he should cut it again. He was much given to mastur- 
bation. He has always been sober. He was partly aphasic on admission. Pupils 
equally reacting ; memory good ; tongue normal. He worried for some time because 
he could not afford to marry. He had hallucinations of sight and hearing. After 
admission he improved greatly, but had several fits of depression, and one of great 
loss of self-control, so that he shrieked and rushed about saying he would kill him- 
self. 
In the above case the syphilis was, in my opinion, but a very slight part of the 
cause of his insanity, but yet was a distinct factor, and I have met several in which 
dread of syphilis, or dread of infecting a wife, has induced a man to refrain from 
marriage and led to masturbation and loss of self-control. 
A CASE OF INSANITY ASSOCIATED WITH ACUTE SYPHILIS. 
BY JOSEPH WIGGLESWORTH, M.D., LONDON. 
[Read, by Dr. Savage.] 
M. H, aged twenty-one; married four months. Was admitted into Rainhill 
Asylum, September 22d, 1885, suffering from an indurated chancre of one labium, 
and a small sore on the opposite side, at point of contact. Her insanity appeared to 
have been of about a week's duration. Mentally she was in a very dull, melancholic 
state ; rarely spoke spontaneously, and could seldom be got to reply to any ques- 
tions. She did not manifest any delusions, but it was stated that previous to admis- 
sion she had said that her food was poisoned. She resisted everything very strongly 
-not merely being examined, but being washed, changed, etc. Though seldom 
speaking she occasionally fretted or moaned. She remained in the above condition 374 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
for about six weeks, when she began to improve somewhat, the resistive character 
passing off, and the condition taking on the form of simple depression. She con- 
tinued very depressed and taciturn for another four months, but by the end of that 
time had become fairly cheerful and showed no intellectual aberration. Three 
months later she was quite cheerful and active, and might be considered convales- 
cent. 
The progress of the physical disease may be briefly summed up as follows : The 
chancre healed five weeks after admission ; two weeks subsequently a papular rash 
appeared all over the trunk and extremities ; this was soon succeeded by a pustular 
eruption, which produced broad, piled-up scabs, bearing a slight superficial resem- 
blance to rupia, on the falling off of which ulcers were in many cases left, which 
slowly healed. Ulcers of a serpiginous character also formed on all parts of the 
body and produced extensive loss of tissue in different regions. Seven months after 
admission the greater number of the sores thus produced had healed, and patient 
was much improved in health. Four months later all the sores bad healed with the 
exception of one or two on the scalp and one on the leg. Mentally, the patient was 
at this time quite convalescent, and might have been discharged had it not been 
thought advisable to detain her until all signs of physical disease had disappeared. 
Fourteen months after admission all the sores had healed with the exception of one 
on the outer part of the left leg ; this, however, now became worse, and necessitated 
confinement to bed. It had, however, almost healed by December 25th, 1886, and 
patient was again up. Four days later, however, this sore was attacked by erysipe- 
las, which assumed the phlegmonous character, rapidly spread upward and down- 
ward, affected distant parts by lymphatic infection, attacked the face, and producing 
great constitutional disturbance, caused the death of the patient in eleven days, viz., 
on January 8th, 1887. At the autopsy nothing was observed worthy of note ; there 
was a total absence of all signs of visceral syphilis, and the brain itself, including its 
vessels, appeared perfectly normal to the naked eye. 
The specific disease was mainly treated with iodide of mercury, dissolved in excess 
of iodide of potassium. 
Remarks.-In this case the connection of the insanity with the syphilis was 
probably twofold-both physical and moral. In the severe physical disease from 
which the patient suffered, there was indeed sufficient cause for mental depression, 
but this, nevertheless, assumed a distinctly pathological character. It will have been 
observed that there was nothing in this case to justify the term " Syphilitic Insan- 
ity, ' ' for though the insanity was undoubtedly caused by syphilis, there was nothing 
whatever in the character of the mental symptoms, taken by themselves, which 
would have raised any suspicion as to the cause of the insanity ; the case was, on 
admission, clinically, one of "resistive melancholia," and had it not been for the con- 
comitant signs of syphilis, the existence of this disease would not have been sus- 
pected. If the phrase " syphilitic insanity " is to have any place in our nosology, 
it must be shown that there is a form of insanity caused by syphilis which can be 
recognized by the mental symptoms alone. 
INSANITY IN RELATION TO SYPHILIS. 
BY RICHARD B. MITCHELL, M.D. 
[Extracts read by Dr. Savage.] 
Cases of insanity have been ascribed to syphilitic lesion of the brain since 1852. 
Less consideration has been given to the study of insanity as caused by such 
effects of syphilis as toxaemia and anaemia. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
375 
Blood changes may be brought about on the re-awakening (after years perhaps) 
of the syphilitic virus in the system ; blood changes that influence perniciously the 
functions of the brain cells. 
Many cases, anæmic and cachectic, admitted to asylums, doubtless have the 
explanation of their condition in an attack of syphilis many years before admission, 
an indisputable history of which cannot always be obtained. 
Syphilitic intracranial formations, exciting morbid mental phenomena, may and 
do disappear, during antisyphilitic treatment, leaving no trace to be found at the 
subsequent post-mortem. So, probably, more cases of insanity are due to actual 
intracranial lesion than would appear from statistics. A history of syphilis existed 
in the cases of 64 patients (51 men and 13 women) out of the 3740 cases (1821 men 
and 1919 women) admitted to the Royal Edinburgh asylum during the eleven years 
1874-1884. 
The average age of these patients was 36.6 (males) and 32.8 (females), being 
respectively two years and eight years below the average age of those admitted suf- 
fering from all varieties of mental disease. 
TABLE I. SHOWING, IN QUINQUENNIAL PERIODS, THE AGES ON ADMISSION, OF THE 
SIXTY-FOUR CASES. 
AGES. 
ADMISSIONS. 
M. 
F. 
Total. 
15 to 20 years 
1 
1 
20 to 25 " 
5 
4 
9 
25 to 30 " 
7 
1 
8 
30 to 35 " 
8 
2 
10 
35 to 40 " 
12 
2 
14 
40 to 45 " 
11 
11 
45 to 50 " 
4 
1 
50 to 55 " 
3 
3 
55 to 60 " 
1 
2 
3 
Total 
51 
13 
64 
The majority of the women were married, as shown in Table II :- 
TABLE II. SHOWING CONDITION AS TO MARRIAGE. 
• 
M. 
F. 
Total. 
Married 
Single 
24 
27 
7 
6 
31 
33 
Widowed 
Total 
51 
13 
64 376 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Of the 51 males, 16 (= 31.3 per cent.) were "head workers," while 21 belonged 
to the laboring classes (== 38.8 per cent.). Of the latter class, 8 had had falls on, 
or heavy blows on the head. All the women belonged to the laboring class. 
Of the males, 35 (= 68.6 per cent. ) were ' ' drunken, " or " profligate, ' ' or both. 
All the females (married) except one, were steady and well conducted. 
TABLE III. SHOWING THE PERIOD INTERVENING BETWEEN THE TIME OF INFECTION 
AND THE ADMISSION TO ASYLUM. 
PERIOD. 
M. 
F. 
Total. 
Six months or under 
2 
1 
3 
From 6 to 12 months 
1 
3 
4 
From 12 to 24 " 
2 
1 
3 
From 2 to 5 years 
3 
3 
From 5 to 10 " 
8 
8 
From 10 to 15 " 
1 
1 
From 15 to 20 " 
5 
5 
From 20 to 25 " 
2 
... 
2 
From 25 to 30 " 
1 
... 
1 
Unknown. 
26 
8 
34 
Total 
51 
13 
64 
TABLE IV. SHOWING DETAILS AS TO HEREDITARY PREDISPOSITION TO INSANITY. 
RELATIVE OR RELATIVES INSANE. 
M. 
F. 
Toial. 
Several near relatives insane 
4 
4 
Grandfather insane 
3 
3 
Grandmother insane 
Father (only) insane 
2 
2 
Mother (only) insane 
1 
1 
2 
Brother insane 
1 
1 
Sister insane 
1 
1 
Uncle insane 
2 
1 
3 
Aunt insane 
Cousins insane 
2 
2 
Relationship not stated 
2 
2 
Unknown or denied 
33 
11 
44 
Total 
51 
13 
64 
Hereditary predisposition was ascertained in 20 cases (18 males and 2 females) 
= 31.2 per cent. Of the 18 males, 12 had male relatives insane. Thus, father 
insane in 4 cases; grandfather insane in 3 cases; uncle or uncles insane in 3 cases; 
brother insane in 2 cases. Of the 2 females, mother in one case and uncle in the 
other. SECTION XVII-PSYCHOLOGICAL MEDICINE 
377 
TABLE V. SHOWING PREDOMINANT MENTAL FEATURES OF THE SIXTY-FOUR. 
M. 
F. 
Total. 
a. Enfeeblement the predominant feature 
19 
2 
21 
&. Depression the predominant feature 
19 
8 
27 
c. Exaltation the predominant feature 
11 
3 
14 
f Depression and exaltation alternating, the 
t predominant feature 
2 
2 
Total 
51 
13 
64 
Mental depression present in all the cases where there was mental enfeeblement. 
Depression (with irritability) and enfeeblement are the chief and most constant men- 
tal characteristics of insanity from syphilis. 
TABLE VI. SHOWING NATURE OF THE DELUSIONS OF DEPRESSION NOTED IN THE 
GROUPS a AND b. 
DELUSIONS AS TO 
|f. 
F. 
Total. 
Conspiracy against them 
13 
3 
16 
Poison in food 
9 
5 
14 
Death from violent means 
6 
6 
Unseen agency 
6 
6 
Being watched 
4 
~2 
6 
Total 
38 
10 
48 
37 (= 57.8 per cent.) were dangerous (34 men). The morbid irritability and 
insane suspicions common in ill-balanced anaemic brains, are, in syphilitic cases, the 
outcome of the specific toxaemia, or anaemia, the latter due to morbid changes in the 
haematopoietic system, or to obliterative changes in the cerebral arterioles. 
Delusions as to poisoning seem to have their origin in a tropho-neurosis of the 
root of the tongue and misinterpretation of the taste sensation. 
Of the 51 males only 3 were undoubted cases of general paralysis of the insane. 
Several others presented motor signs very closely resembling those of general 
paralysis. 
Sensory.-Headache severe, deep, nocturnal, chiefly frontal, noted in 14 cases 
(11 males). In one case, when a patient was pricked in left arm, he felt it in left 
thigh only. 
Sight was greatly impaired or destroyed in 7 cases (all males). Gross intracranial 
syphilitic lesion found in 3 cases of the 7 at death. Other senses impaired in a few 
cases. 
MOTOR. TABLE VII. SHOWING AFFECTIONS OF MOTOR SYSTEM. 
Ptosis 1 female. 
Paralytic affections.. 
Bell's paralysis 
right side 1 male, 
left side 2 females. 
right side 1 male. 
„ left side 2 males. 
Hemiplegia 
Paraplegia 4 males. 378 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
' Nystagmus 1 female. 
Chorea 1 male. 
Convulsive affections..., 
Epilepsy and epileptiform attacks 
18 males. 
4 females. 
(a) Right hemi-spasm 2 males, 1 female. 
(&) Lett hemi-spasm 3 males, 3 females. 
Convulsive commoner than paralytic affections. Both convulsive and paralytic 
affections were found much commoner on left side of body. 
SOMATIC TRACES OF SYPHILIS. 
In 14 cases (10 males) tertiary lesions were found. In 17 cases a cachectic, anae- 
mic appearance. In 39 cases (32 men) skin affections or their traces. Syphilitic 
lesions of some sort were found in over 70 per cent, of all the cases on admission. 
TABLE VIII. SHOWING THE DEGREE OF CUTANEOUS AFFECTION CONSIDERED IN RE- 
LATION TO THE MODE OF TERMINATION OF THE THIRTY-NINE CASES IN WHICH 
SYPHILITIC SKIN DISEASE WAS PRESENT. 
Discharged 
Recovered or relieved 
skin affection slight 
6 males, - .. 
1 female, = 7 sllShL 
" " extensive ■ 
7 males, extensive. 
5 females, 
Ä=4* 
Still resident 
skin affection slight 
" " extensive - 
7 males, extensive. 
no females, 
6 males, 
no females, 
Gross intracra- 
nial syphilitic le- 
. sions in 3 males. 
Died 
(post-mortem made) 
skin affection slight 
" " extensive • 
2 males, 
1 female. 
1. The most serious intracranial lesions were found, as a rule, in those cases 
where the skin disease was slight. 
2. Where the skin disease has been extensive, the prognosis as to the mental 
recovery of the patient is better than where it is not so. 
Prognosis.-Badin men, comparatively with women. Only 30.1 per cent, re- 
covered. (General recovery rate is 42 per cent, in Roy. Ed. Asylum. ) 25 per cent, 
died ; 29 per cent, are chronic cases. Good in women. 84.6 per cent, recovered. 
(General rate 40 per cent. ) 
TABLE IX.-SHOWING PERIOD INTERVENING BETWEEN TIME OF INFECTION AND 
ADMISSION TO ASYLUM, IN. THOSE DISCHARGED, DIED, AND CHRONIC. 
PERIOD. 
DISCHARGED. 
DIED. 
STILL RESIDENT. 
M. 
F. 
T. 
M. 
F. 
T. 
M. 
F. 
T. 
6 months or under 
2 
1 
3 
From 6 to 12 months... 
3 
3 
. . . 
1 
1 
« 12 to 24 " ... 
i 
1 
... 
... 
1 
1 
" 2 to 5 years 
i 
1 
... 
1 
i 
2 
2 
" 5 to 10 " 
4 
4 
3 
... 
3 
1 
1 
" 10 to 15 " 
1 
1 
... 
... 
... 
" 15 to 20 " 
1 
1 
1 
1 
3 
3 
" 20 to 25 " 
1 
1 
1 
... 
1 
... 
" 25 to 30 " 
1 
i 
Unknown 
12 
7 
19 
8 
i 
9 
6 
6 
23 
11 
34 
13 
2 
15 
15 
15 SECTION XVII-PSYCHOLOGICAL MEDICINE. 
379 
Ceteris paribus, the prognosis seems unfavorable in proportion to the length of 
the period of infection. It is more favorable in the educated than in the lower 
classes. An unsteady life does not of necessity act inimically to the chances of 
recovery. Over 50 per cent, of those recovered were "unsteady." Where the 
skin disease is extensive, the prognosis is good, and vice versa. 
TABLE X. SHOWING IN QUINQUENNIAL PERIODS THE AGES OF THE SIXTY-FOUR 
ADMITTED, RECOVERED, RELIEVED, DIEDj AND CHRONIC. 
ADMITTED. 
RECOVERED. 
RELIEVED. 
DIED. 
STILL 
RESIDENT. 
M. 
F. 
T. 
M. 
F. 
T. 
M. 
F. 
T. 
M. 
F. 
(T. 
M. 
F. 
T. 
15 to 20 years 
20 to 25 " 
5 
1 
4 
1 
9 
2 
1 
4 
1 
6 
3 
3 
25 to 30 11 
8 
1 
9 
4 
1 
5 
i 
i 
1 
i 
1 
1 
30 to 35 " 
8 
2 
10 
3 
1 
4 
1 
i 
2 
i 
3 
2 
2 
35 to 40 " 
12 
2 
14 
2 
2 
4 
3 
3 
3 
3 
4 
4 
40 to 45 " 
11 
11 
4 
4 
1 
1 
3 
3 
3 
3 
45 to 50 " 
4 
i 
5 
3 
i 
4 
1 
1 
50 to 55 " 
3 
3 
i 
1 
1 
1 
1 
1 
55 to 60 " 
1 
2 
3 
i 
2 
3 
51 
13 
64 
16 
11 
27 
7 
7 
13 
2 
15 
15 
... 
15 
SYNOPSIS OF THREE CASES. 
Case I.-Male; thirty-eight; originally healthy; clever, hard-working, temperate 
in drink, but very profligate. No hereditary predisposition to insanity. Six and 
one-half years before admission had an attack of syphilis; five months before admis- 
sion " convulsive fit; " deep-seated, intense left headache; dimness of vision; right 
hemi paresis; two months before admission developed delusions of persecution, deep 
despondency and sleeplessness. Admitted in a state of melancholic stupor. Cachectic; 
no hair on face; scar near frænum; syphilitic ulcers of leg. Death after six months' 
residence. 
Autopsy.-Left ascending frontal gyrus much shrunken, tough, hard and yellow. 
Minute arterioles with lumen more or less diminished or obliterated by proliferation 
of nuclei. Corpora amylacea numerous in left ascending frontal. Pia mater, nuclei 
much increased. 
Case II.-Male; fifty-two; intemperate; twenty years ago primary syphilis; five 
years ago heavy blow on head; two years ago intense nocturnal headaches began; 
fifteen months ago "convulsive fits" began; fourteen days ago an attack of mania. 
Dangerous to wife and children. Admitted in a state of dementia. Cachectic; tongue 
shaky; articulation much slurred; right hemi-paresis. Lucid interval for eighteen 
days, then for five days a succession of right convulsive seizures. Death on fifth day. 
Autopsy.-Small gumma in right frontal gyrus. All the membranes greatly 
thickened and adherent to each other and to the gray matter over the left " cortical 
motor area "-the discharging lesion in this case. Embolic softening in right frontal 
and temporo-sphenoidal. Yellow granular degeneration of brain cells. Small vessels 
near gumma greatly thickened and lumen diminished. Gumma composed of small 
cells or nuclei surrounding vessels. ê 
H 
<o 
en 
Age on admission. 
Nervous System. 
Symptoms and Signs Previous to, and 
on Admission. 
Mental Symptoms Previous to, and on 
Admission. 
Signs and Symptoms of Syphilis 
Noted on Admission. 
Termination 
of Case. 
Remarks. 
1 
F. 
35 
Pupils dilated and sluggish ; tongue 
tremulous. 
Confused; depressed; enfeebled; emo- 
tional ; cannot tell where she is or where 
she came from; not sure of her own 
name even; weeps without apparent 
cause ; no delusions expressed. 
Cachectic appearance; painful 
node on left tibia, and marked 
tenderness on pressing the bone; 
node on right clavicle; syphilitic 
ulcer on right leg. 
Recovered. 
Contracted syphilis several years ago: 
no other cause assigned for insanity; 
no other physical disorder present; had 
15 grains iodide of potassium thrice 
daily; duration of residence here was 
2% months. 
2 
F. 
55 
Pupils dilated and sluggish ; weak in 
the lower limbs; patellar-reflex in- 
creased ; articulation thick and " nasal " 
in character. 
Confused; stupid ; enfeebled mentally; 
incoherent; very restless; obscene in 
actions; memory seems impaired; unable 
to answer questions rationally. 
Pale and cachectic; hole in 
palate the size of a shilling (the 
result of syphilitic disease); 
tumor of skin (gummatous?) in 
posterior triangle of neck; cica- 
trix of old ulcer at left infra- 
clavicular area. 
Recovered. 
Date of infection unknown; assigned 
cause of insanity was "syphilis;" had 
the iodide in large doses during resi- 
dence here; duration of residence here 
was six months. 
3 
M. 
41 
Common sensibility impaired ; motor 
system normal. 
Depressed; taciturn; delusions that 
his landlady was in the habit of poison- 
ing his food, and that other persons had 
' drugged" him; imagined that a cica- 
trix which wss on his tongue, and an 
eruption on his body were due to his 
being "drugged." 
Anæmic; cachectic: syphilitic 
psoriasis on arms, legs and trunk ; 
copper-colored cicatrix in left 
groin, and on right side of scro- 
tum ; cicatrix of ulcer on side of 
tongue. 
Relieved. 
Duration of residence here was two 
months. 
4 
M. 
28 
Plantar skin-reflex and patellar ten- 
don-reflex increased. 
Depressed ; suspicious ; somewhat 
facile in manner; delusions that certain 
persons watch him and plot against him 
to prevent his succeeding in anything; 
that others poison his food. 
Glands in right groin enlarged 
and indurated ; syphilitic disease 
of right testis, and node on right 
tibia. 
Relieved. 
Duration of residence here was one 
month. 
380 5 
M. 
31 
Intense headache sometimes, and a 
feeling of heat in the head ; taste im- 
paired; right pupil dilated; patellar- 
reflex exaggerated. 
Irritable; suspicious; sometimes con- 
fused and sometimes depressed; very 
violent at times; some mental enfeeble- 
ment; delusions that poison is put in 
his food, and that certain persons " work 
upon" him by magnetism. 
Sallow and anaemic ; one white 
preputial scar, and one on corona 
glandis; glands in groin indura- 
ted ; hair scanty ; cicatrix of ulcer 
on left pillar of fauces. 
Still under 
treatment. 
Has been married seven years; has 
one healthy boy six years old; was in- 
fected three years ago; admits having 
had chancre, rash, bubo,ulcerated throat 
and lossof hair; iodide, ten grains, thrice 
daily; has been two years in asylum; 
is slightly improving. 
6 
M. 
38 
Complains of intense frontal headache 
at times, worst at night, and especially 
about 4 a.m. 
Very irritable and suspicious; some- 
what confused frequently; delusions 
that certain persons influence him by 
some unseen agency, and that others 
plot against him ; threatens violence to 
persons. 
Pale and sallow ; hair very thin. 
Still under 
treatment. 
States that he had chancre, bubo and 
sore throat, 20 years ago; but does not 
recollect any eruption on his skin at 
that time; has had the iodide pretty 
regularly since his admission about 18 
months ago ; slightly improving. 
7 
M. 
44 
Intense frontal headache, worst at 
night; eyesight impaired; pains in back 
and joints, worst at night, and accompa- 
nied by rise of temperature; epilepti- 
form attacks ; tendency to vomit at 
times. 
Previous to admission was very violent 
and excited; afterwards became de- 
pressed and imagined he was to be 
killed; hypochondriacal; thought he had 
only one lung; is now considerably 
demented. 
Yellow cachectic look ; inguinal 
glands enlarged and indurated ; 
syphilitic eruption on trunk and 
legs; syphilitic sores and coppery 
blotches on legs; pains in, and 
tenderness of, right tibia. 
Still in an 
asylum. 
Was believed to have become infected 
through a wound on his finger while 
dressing a syphilitic patient; the case 
was complicated by alcoholism ; has been 
11 years insane. 
8 
It. 
43 
Intense headache at night; sight be- 
came impaired at thirty-four years ; 
smell defective ; taste impaired ; hearing 
and common sensibility normal; 
ophthalmoscope reveals atrophy of both 
optic nerves; left disk has a "filled in" 
look, and the veins around are dilated 
and tortuous; tongue shaky and pro 
truded toward left; internal squint of 
left eye, which began five years ago; 
right pupil dilated; tendon reflex dimin- 
ished on left side; a degree of left hemi- 
paresis; peculiar rhythmical movements 
of head and neck. 
Melancholia gradually deepening, then 
becoming intense and accompanied by 
strong suicidal impulses; attempt at 
suicide; great mental depression con- 
tinues; dementia advancing; disregards 
calls of nature; imagines he is "lost," 
and cannot be saved; is irritable, suspi- 
cious, greatly depressed, and is becoming 
gradually more and more demented. 
Three white cicatrices on the 
glans penis ; one coppery cicatrix 
in right groin. 
Still resident. 
Contracted syphilis 15 to 20 years ago ; 
only two cases (both males) out of the 
64 attempted suicide, this man was one 
of them; tumor of the brain, believed 
to be syphilitic, has been diagnosed by 
an eminent physician; no improvement; 
dementia deepening ; has been two years 
here. 
381 382 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case hi.-Male; forty-two; temperate in drink. Grandfather insane and mother 
paralytic. Ten years ago primary syphilis; two years ago intense nocturnal headache 
and pains in arms and back. "Alteration in conduct," then exaltation, followed 
soon by depression, enfeeblement, and irritability and violence. Progressive dementia; 
chorea of face and neck; abscesses on head, left shoulder and sternum. Death after 
six and one-half years here. 
Autopsy.-Syphilitic carious perforation at middle of right parietal bone, one inch 
by three-fourths of an inch. Remains of caseating tumor at same spot. Some small 
vessels thickened by nuclear proliferation. 
CONCLUSIONS. 
1. Syphilis may cause insanity, either by lesion of the brain, or by perverting the 
blood, without there being evident brain lesion. 
2. Syphilis is not recognized as a common cause of insanity (only five per cent, 
of the cases admitted here in nine years were diagnosed as " Syphilitic Insanity," all 
having lesion of brain). 
It is probably a more common cause of insanity than is generally believed-as, 
when it operates many years after infection, and has its re-awakening accompanied 
by anæmia and toxaemia. 
3. Syphilis alone is probably very seldom an exciting cause of insanity. It is 
probably one of the exciting causes in many cases. In some the principal exciting 
cause, in others an exciting cause of second-rate value, and so on. 
4. Men are more liable to cranial and intra-cranial syphilis, and to insanity caused 
by syphilis, than women-the former being more exposed to the determining causes 
than the latter. 
5. Insanity from syphilis is, as a rule, a dangerous (not suicidal) form of insanity 
(fifty-seven per cent, were dangerous lunatics). 
6. Prognosis in insanity from syphilis is worse in males, and worse also where 
there is grave organic lesion of brain, especially where there are obliterative processes 
in the cerebral vessels. 
7. Lastly, syphilis may simply co-exist with insanity, and bear no causal relation- 
ship to it. 
Dr. Savage continued : I have had many cases in which, with the ptosis, with 
the external strabismus, and with the other oculo-motor or ocular trouble, insanity 
has developed. One of the best cases that ever came before me in that relationship 
was that of a jockey who trained for the Duke of Westminster, and who when he 
recovered said that he had never gone to bed with less than twenty pounds of horse- 
flesh under his pillow, and was therefore an extremely anxious man. He contracted 
syphilis and five or six months after the development of it got double optic neuritis 
with impairment of vision, and from that at once the character of the insanity was 
developed. He saw vaguely and with uncertainty, and owing to his education his 
suspicions made him believe that every one who came near him was coming with the 
idea of injuring or tampering with him in some way. He became pugilistic, knocked 
people about and had to be sent to the asylum, where specific treatment cured him 
rapidly. That man is now training race horses for another nobleman. I have seen 
other cases in which, associated with optic disc trouble or with the onset of ptosis and 
strabismus, and double vision with temporary hemiplegia, there was a development 
of either weak-mindedness or of some insanity which has been recovered from with 
the anti-syphilitic treatment; and this is, as it were, an introduction to a case to which SECTION XVII-PSYCHOLOGICAL MEDICINE. 
383 
I shall refer later, in which these local troubles, instead of being recovered from, 
seemed the foci from which general degenerations occurred, as general paralysis and 
dementia. Besides that, I have had one or two cases in which the presence of 
syphilis, the constitutional syphilis in its most advanced type, has had something to do 
with the development of insanity. One case is described by Wigglesworth, in which 
acute syphilis is associated with acute insanity, and one has had acute syphilis with 
oculo-motor troubles with insanity. One has had great disfigurement of the face, a 
great amount of ulceration; I have at present a patient who lost almost the whole of 
his nose, with immense ulceration about the nose, and with it a steady and progressive 
weak-mindedness. I shall point out that these cases are not at all unique, and that I 
have recorded at least a dozen of them. 
Dr. Ferguson.-A portion of Dr. Savage's paper has called to my mind an 
instance under my personal observation, of insanity resulting from syphilis. The 
subject was a man whom I saw several times in consultation with his physician, 
and whose personal history was intimately known to that physician. He was a 
man of the utmost rectitude of habits; a man who was believed to be perfectly virtuous 
during his entire life. Three or four days after his marriage and during the festivi- 
ties connected with that event, an improper sexual intercourse occurred and syphilitic 
infection resulted. The moral effect upon the patient was very severe indeed. He 
could not forget what he considered the moral taint, and during the first portion of 
the secondary symptoms he became a victim to a form of insanity which might fairly 
be attributed to moral causes. He recovered from that after a comparatively brief 
time,, but the syphilitic infection was a striking instance of those virulent forms which 
we occasionally see, and which show that however specific and active our medication 
may be, it is decidedly impotent as far as malignant syphilis is concerned. This man 
was put upon most thorough anti-syphilitic treatment, and the most approved methods 
brought into play, but each and every one of the manifestations of the syphilitic 
poison seemed to march onward in its course uninfluenced by treatment. Somewhere 
between two and three years after the first appearance of the disease there began to 
develop evidence of cerebral trouble, and he again became insane. This was preceded 
-I will not go into the special symptoms-by a period of severe pain in the head. 
The diagnosis was made perfectly satisfactory to the attending and consulting physi- 
cian, of syphilitic disease of the brain, and was confirmed by the autopsy, made in an 
institution near by, but at which I was not present ; there being found gross lesions 
of the membranes of the brain and bones of the skull. The case was to me a very 
striking illustration of the dependence of insanity upon syphilitic lesion, as well as of 
the powerlessness, in some cases, of anti-syphilitic treatment. 
Dr. Hurd.-Mr. President: I have no doubt in my mind but that a true 
syphilis will produce the simpler psychosis, like mania and melancholia. I have in 
mind a patient who came to the asylum with which I am connected suffering appar- 
ently from acute mania. Shortly after admission it was discovered that she had 
syphilis. She had a syphilitic rash, an elevation of temperature and a regular course 
of symptoms, which lasted several weeks. She was promptly put upon treatment, 
with the effect bf subduing the syphilitic disease, and there was a corresponding 
improvement in her mental condition. In her case, however, a certain tendency to 
relapse was present, which was associated invariably with an accession of the syphil- 
itic trouble. The disease finally became constitutional. After two or three years' 
treatment the syphilitic trouble was in such a state of abeyance that the girl was sent 
home on trial and has now been at home nearly a year. I have no doubt that sooner 384 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
or later I shall receive her back, in consequence of the fresh lighting up of the syphil- 
itic disease. 
Dr. Hughes.-Mr. Chairman: The most numerous cases of syphilis that have 
come under my observation have been associated with a latency in the most prominent 
early manifestations, and I think the point which Dowse makes on that subject will 
probably be borne out by further clinical observation. In the institution at Fulton 
the recorded history of most of these cases gave a history of a previous, long-continued 
duration of syphilitic poison and an apparent cure of the gross lesions so far as per- 
ceptible, disappearance of the chancre, disappearance of the syphilitic indurations 
and all of the gross symptoms perceptible to the eye, and at a later period in the 
case was the setting in of symptoms of mental aberration, which were probably due 
to that peculiarity which syphilis manifests in the neural tissue, to produce abneural 
changes rather than changes within the structure of the nervous texture itself, and I 
think this definition which Dowse has made between these two complications of 
syphilis is one which is very valuable for us to consider with reference to our prog- 
nosis, and which explains to us the facility with which syphilitic mental aberration is 
removable under adequate and vigorous specific treatment-probably to reappear, as 
we sometimes see it in the life history of the individual, again and again before its 
close, sometimes reappearing in another portion of the cerebro spinal axis, attacking 
the spinal cord, as you know, and giving us the symptomatic expression of locomotor 
ataxy, as I have seen in some of my patients. 
For a long time, in my clinical experience at Fulton, I concluded that it was only 
the insidious and chronic forms of insanity that were the most likely to be engen- 
dered by the syphilitic poisoning ; those cases which come on slowly and insidiously, 
beginning with syphilitic melancholia and passing into mania, etc., in those forms of 
general paresis with which we are so familiar. But one case, as far back as 1867, 
made a profound impression upon my mind as to the power of the venereal virus to 
engender acute mania in its most virulent forms. That was the case of a lawyer 
who about six or twelve months previously had had an attack of syphilis which had 
apparently disappeared under treatment. The patient came to the institution suffer- 
ing from an attack of acute mania excited by a slight debauch ; I believed this to be 
the exciting cause. A similar case of general paresis occurred in the chief clerk of 
the House of Representatives about that time, in which syphilis was the predispos- 
ing and the pathologically determining cause, in all probability, so far as the history 
was concerned, and a debauch, which was not common to the individual, I regarded 
as the probably exciting cause. I suppose the vasomotor disturbance caused by that 
one spree had brought about the localization of the subsequent pathological changes. 
Now we know that there is such a thing as syphilophobia ; that it may exist without 
the preexistence of any syphilitic poison, and we know that it may exist concomi- 
tantly with that and yet not be a syphilitic affection ; and this syphilophobia may 
pass into melancholia, which has no connection at all with syphilis, and it may or 
may not be associated incidentally with the syphilitic virus, with the person's vene- 
real virus in the system. We have to make these distinctions, and we all of us do, 
in determining the existence of syphilitic insanity. Syphilitic general paresis, I 
have no doubt, is exceedingly common as the result of this poison. 
Dr. Godding.-Mr. President and Gentlemen : If this is the proper point in 
the debate, I would like to emphasize a point that has already been made, and that 
is that while we have insanity undoubtedly resulting from the specific poison of 
syphilis, it has not been my good fortune to be able to identify any mental symptoms 
whereby I could diagnosticate it as syphilitic insanity. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
385 
I shall give briefly the case of a girl who came under my observation about nine 
months since, in apparently the most advanced dementia, drooling, almost aphasic 
dementia. But for something in the history of the case that pointed in the direc- 
tion of syphilitic poison I should undoubtedly have passed it by for a case of hope- 
less dementia. After a short time she was placed upon syphilitic treatment, and 
almost simultaneously there came out the most extensive rupial sores with loathsome 
abscesses. The effect on her general health was such as to render it doubtful at one 
time if she survived. How far that low condition of general health may have 
affected the brain I am unable to state, but she was put upon the usual remedies, 
and to-day there is almost a complete restoration of her physical health. She is 
rosy, plump, and although she has some evidences of rupia left she is apparently as 
intelligent as any other girl in her station. She is happy and pleasant, and I shall 
take great pleasure in showing her to the gentlemen who may visit me. If she had 
suffered with this apparently hopeless dementia, and it had come from any other 
cause, I should have abandoned all hope at once. The case, however, presented at 
first no lines which would enable us to identify it as syphilitic insanity. 
Dr. Spitzka referred to a condition in the secondary stage of syphilis in which a 
febrile state was complicated by an acute mental disturbance. This is exceedingly 
rare. The only case he had seen reported was one seven years ago. He did not know 
of any such case having since been reported where exact methods of observation had 
been applied. The discovery had been made by Finger that during the roseola 
eruption there is abolition of the knee jerk. The knee jerk finally reappears with 
the remission of the fever ; then again it disappears. This shows how profound an 
effect upon the nervous structure this virus must have. The question seems to be 
an open one, whether this form of delirious mania is a febrile insanity or a specific 
syphilitic one. Of course the treatment in all cases has been anti-syphilitic, because 
in treating the case we strike at the root of that fever. The symptoms resemble 
those of scarlet fever and measles. 
Dr. Russell reported the case of an active young man who came under his 
charge for melancholia, the leading delusion being that of unfaithfulness to his wife. 
The actual fact of his infidelity was microscopic. He was of an intensely neurotic 
family, the male branch being almost exterminated by suicide. He made a good 
recovery. 
After one year of intense business activity, during which he had cleared one 
hundred thousand dollars, he returned. He was again the victim of his idea of 
unfaithfulness with syphilophobia. Careful and repeated examinations gave no 
proof of any primary lesion, nor had the patient ever seen any, though exposure 
was a fact. 
Suddenly he developed a beautiful macular syphilide with marked febrile disturb- 
ance and great intensification of his mental symptoms, which, however, varied in no 
way from the first attack. He recovered from this second attack only to break down 
again in a year, when he nearly lost his life in an attempted suicide. 
Dr. Brush.-Some years ago, before I was engaged in the treatment of insanity, 
I was so situated 'that I saw a great deal of syphilis. Unfortunately then I knew 
very little of neurological science, or I should have been more careful to observe one 
or two cases of delirium in the second stage that I saw, in reference to the point 
Dr. Spitzka has made as to the abolition of the kneejerk. We have now in the 
hospital at Philadelphia two cases, recently admitted, in both of which the knee jerk 
is entirelv absent, and as confirmatory of Finger's observations, one of these cases 
Vol. V-25 386 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
had a short time ago a remission of symptoms of acutely maniacal excitement. He 
had been quiet and coherent, had had parole of the grounds and did nicely for five 
days. About the middle of that period there was a very slight return of the knee 
reflex. Previously it had been entirely absent. He tore his clothing and had hallu- 
cinatory disturbance of sight and hearing. 
In reference to this question of syphilitic insanity, or rather insanity produced 
by syphilis-I do not like the term syphilitic insanity, I do not think we can call it a 
special form-there was last winter, at the female department of our hospital, a 
patient in very much the same condition as this man. She suffered from acute 
maniacal excitement, with a very high grade of mania, and being a married woman 
there was no suspicion of syphilis. After she had been in the institution a few 
weeks the attendants, on bathing her, noticed a peculiar and suspicious eruption on 
one of her legs. The physician's attention was called to it immediately. She was 
put upon specific treatment and in a week her symptoms had grown less marked, 
and in a month she went home and has remained, according to her friends, perfectly 
well ever since. 
Dr. Fisher.-I will quote a single case in my experience. Twelve or fifteen 
years ago a young officer in one of the hospitals in Boston contracted syphilis. He 
had, of course, the best medical treatment. He was very much mortified at the 
occurrence, and after a time went into a state of great apprehension, was sleepless 
and developed some delusions of suspicion. It is necessary to state that his father 
was insane : he had melancholia and committed suicide. This young man was sent 
to the Concord Asylum, where he remained two weeks. The syphilitic symptoms 
disappeared, and under treatment in the asylum he recovered his mind and was dis- 
charged. I have no further knowledge of the case. 
Dr. Brown, of Barre.-I want to add a word in confirmation of the position 
taken by Dr. Savage and Dr. Down in reference to the effect of syphilis upon imbe- 
cility and idiocy, not that I have anything at all to add, except to say that in an 
an experience of thirty-five years injconnection with the care and training of idiotic 
people I have not had, in the whole number of people I have seen, more than five 
where I had good evidence that there was a syphilitic inheritance ; about one and 
one-half per cent 
Dr. Savage.-With Dr. Godding I feel there is no such thing as syphilitic 
insanity. I forget which of the London teachers it is who is always asserting that 
each organ has its ways of expressing its illness. You have no more right to talk 
of specific insanity than to speak of a specific cause of asthma. I think the less we 
talk about specific insanity the better. 
Dr. Spitzka's observation interested me extremely. First of all, that the delirium 
which occurs with syphilis-that may occur with it-a mere extension of it may 
become acute delirious mania; then the next thing, that with that there maybe a loss 
of the reflexes, which we know is not an uncommon result of the disease syphilis in its 
last end, locomotor ataxy ; the whole thing seems to be a consistent whole, and we 
have thereby a consistent physiological process that is of extreme value and interest. 
The cases that have been brought forward also seem to me to show that many others 
have been observing in the same way, and that if these cases are recorded, as they 
will be in the Transactions, I have no doubt that we shall find that this condition of 
acute mania following the febrile disturbance of constitutional syphilis is not, after 
all, so uncommon, although I believe it has hardly been recognized hitherto. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
387 
III. SYPHILIS PRODUCING EPILEPSY, WITH OR WITHOUT INSANITY. 
Dr. Savage.-The general physician needs not to be reminded of the many cases 
which are to' be met with under this heading; at every out-patient clinique we meet 
with them, and among the cases of cured epilepsy probably the largest numbers come 
from among the syphilitic. There are just one or two points to which I should like to 
refer under this head. 
First. I think I find that in many of these cases mental degeneration is very often 
unusually rapid. 
Second. That though there seems to be a definite cause it does not follow that 
this is certainly curable. 
Next, that in nearly all these cases some mental loss is certain to appear if the fits 
continue. 
Aid last, though the symptoms point clearly to some local lesion, we are not 
certain to find any correspondingly distinct lesion within the skull. 
The epilepsy maybe the one chief symptom, or it maybe but one sign of a widely 
spread disease. Thus epileptiform fits occurring in these patients may mean the first 
sign of general paralysis, or one of the signs of locomotor ataxy, or recurring epilepsy 
due to tumor cerebri, or to some more intangible changes in the central nervous system 
producing motor instability. I subjoin these typical examples. (See also Dr. 
Warner's cases.) 
SYPHILIS PRODUCING SIMPLE EPILEPSY. 
P. A.; formerly railway guard; married; aged forty-nine; attendant in an asylum; 
steady; trustworthy and hard-working. He rose steadily until he became the head of 
a ward; there were at this same time nodes and other evidences of old syphilis which 
he had contracted when about twenty-four years old. He had very bad ulceration of 
his throat. Without any warning symptoms, five years ago he suddenly lost con- 
sciousness and had a true epileptic fit. He was placed under constant treatment, but 
fits recurring he had to be pensioned. After removal from care and responsibility he 
improved in every way, and had no more fits. His wife, who had been an attendant 
at Bethlem, had many children who were all very healthy, showing no sign of syphilis. 
For some five years no fits recurred, but they then reappeared, and will doubtless end 
in mental weakness, though at present he remains trustworthy and sane. In this case 
the fits are generally without cry or warning, they are of rare occurrence, but may 
have marked effect in producing mental weakness sooner or later. 
SYPHILIS, LOCOMOTOR ATAXY, FITS, INSANITY. 
In tne next case the symptoms were more mixed. A married man contracted 
syphilis in his early youth, and after about five years developed ptosis and other signs 
of cranial-nerve implication. Under treatment he recovered. He had little or no 
other local troubles from his syphilis, but he showed signs of locomotor ataxy, and 
later fits recurred at irregular intervals. These fits had a marked effect on his mind, 
chiefly shown by loss of memory, but beyond this there was no loss of business capacity, 
nor was there loss of control. He had loss of power in lower limbs and over bladder; 
he also became all but impotent. In this case the changes are widespread, and are not 
to be localized. There seems some ground for thinking that the syphilitic disease of 
the central nervous system has made it very unstable, so that irritation about the 
bladder may be the efficient cause of a nervous discharge. 
In the next case the epileptic fits are associated with marked mental disorder, and 
thus we have given a case of simple syphilitic epilepsy not cured by treatment. A 388 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
case of widespread syphilitic disease, with epilepsy as an epi-phenomenon, and lastly, 
epilepsy associated with coarse brain disease. 
SYPHILIS, MISCARRIAGE, HEADACHE, VOMITING, JACKSONIAN EPILEPSY, 
AND OPTIC NEURITIS WITH MELANCHOLIA. 
Alice W. ; married; aged forty; admitted April, 1887. No neurosis in family. 
Has had thirteen pregnancies; first four miscarried at seven months; fifth survived, 
but is weakly; sixth miscarried at three months; seventh living and healthy; eighth 
and ninth miscarried at three months; tenth still-born at seven months; eleventh 
is a boy, living, has fits. History of cancer in brother and sister. 
In December, 1886, began to be suspicious and saw strange things. Heard 
people calling after her. She had twitchings in her left foot, and her first fit, starting 
in the left foot, occurred in December. On admission she was described as small, 
feeble and depressed. She was preoccupied and dull, feared something was going to 
be done to her, or that her children or relatives were being killed. She had a fit 
January 15th, and another March 23d. The fits are preceded by restlessness, head 
and eyes turned to right, convulsions starting in left foot become general, uncon- 
sciousness is complete, and after the coma she suddenly awakes in terror; greater loss 
of power in left side after the fits. She bites her tongue; the left pupil is the larger; 
both react. There is double optic neuritis, but no vomiting, and any local pain is 
referred to the forehead on right side. She was treated by liq. hyd. perchlor, gj; 
potassa iodi gr. v. t. i. d. 
June 19th, another fit of the same kind. Since this date fits have been more 
frequent, and she has become more emotional; though mentally weak and emotional 
she has been allowed to go home. 
Her husband had syphilis nearly thirty years ago, and has syphilitic laryngitis at 
present. 
My experience is that there are epileptic cases with a syphilitic history with very 
definite lines, so that one is able to say, from a Johnsonian point of view, compared 
with Ferrier and Hitzig's observations, there is a definite lesion there. 
Dr. Hughes.-I would like to ask the Doctor one question in regard to his post- 
mortems. He has stated that he failed to find the asserted syphilitic gummata in 
the motor points in his cases of unilateral epilepsy, etc. I would like to ask him if 
he failed to find foci of irritation there, either vasomotor or vascular deposits, 
microscopically ? 
Dr. Savage.-I would at once say that in these cases there have been definitely 
no coarse lesions, and that although one got evidences of arterial disease, yet the 
evidence of the arterial disease was so general that I was not able to say that on the 
left side there is definitely more arteritis than on the right, and I give that as my 
experience up to the present day. There is no reason why I should not be moved 
by future experience, but I have been so frequently disappointed at the post-mortems 
that I think it well to record this negative experience. 
Dr. Spitzka.-My experience regarding anatomical findings is in complete accord 
with that of Dr. Savage, as to the absence of gummata. I have seen the case of a 
young quadroon who died with the most intense symptoms indicating rapid acute 
syphilis of the nerve centres, the patient dying in coma, where there was no lesion 
of any kind whatever that I could find. The question of the existence of tabes 
dorsalis interests me a great deal. I have had under observation the interesting case 
of an actor, who is still under my treatment, and whose disease is arrested, as it were, SECTION XVII PSYCHOLOGICAL MEDICINE. 
389 
who has abolition of both knee jerks, the characteristic Argyle-Robertson pupil, 
unilateral ptosis (which is occasionally influenced by treatment and occasionally recurs), 
and this gentleman has had, in the course of the day, fifty or sixty attacks of a pecu- 
liar kind of petit mal, in which he first loses consciousness for a moment, sometimes 
while going upon the stage, but so briefly that he could recollect himself. On one 
occasion he had to cross a foot-bridge in the scene, and while he was going across he 
had an attack of this kind, but went on as though nothing had happened, the petit 
mal losing its character as a loss of consciousness and becoming replaced by a peculiar 
sensory disturbance. He found that, accompanied by the prodromal feeling, all the 
faces in the audience were exactly the same; this sensation passed like an electric 
flash. He still has these peculiarities, though they are rarer, and they have become 
a matter of interest to him, and he studies their course and peculiar symptoms. 
IV. SYPHILIS PRODUCING MENTAL WEAKNESS-(A) WITH, (R) WITHOUT 
PARALYSIS. 
Dr. Savage.-The group to which I now wish to refer is the most difficult to 
handle, and I fear my experience is largely gleaned from watching the life histories 
of those whom one has known as friends or as fellow students. I think most of us 
must have experience of men who between thirty-five and fifty become almost suddenly 
old. We may know that they have suffered from constitutional syphilis and have 
had more or less secondary troubles, but for years little or nothing has given cause 
for alarm. As a rule most of these cases have some other complications, but some 
run a straightforward course to mental degeneration. In these latter my experience 
leads me to think that the signs of mental senility are the most common and note- 
worthy symptoms: Repetition of small anecdotes of only personal interest; childish 
interest in trivial matters, and weakness of will ; while there is irritability of temper 
and self-assertion, there is often some appearance of exaltation and neglect of the sim- 
pler conventional rules of society. I own that these are but slight outlines to give of a 
special disease, but any one who has watched cases of this kind will recognize them 
as not uncommon. 
Such symptoms as I have described may gradually increase and leave the patient 
childish, to die after several years, of dementia, or what is more common in my expe- 
rience, a single fit may lead to rapid degeneration, or a fit may give the case the 
aspect of one of general paralysis of the insane. There are no hard and fast lines in 
pathology, and we meet with every phase of ruin in the degenerating nervous system. 
In one the fabric tottering to its fall after one shock, in another remaining a wreck 
of itself, yet bearing in outline its old form through years of a kind of calm. 
SYPHILIS, HEMIPLEGIA, MENTAL WEAKNESS. 
John S. S., admitted November 30th, 1886; widower ; aged forty. No neurotic 
history; had syphilis about three years before admission; business worries for a year 
or more. In July he had loss of power in his left side. His walk was feeble. His 
mind at the same time became confused, his memory failed, he was irritable and 
attempted violence. On admission left pupil enlarged, reflexes dull, left leg thrown 
unduly forward; he was markedly weak on one side; he had a quiet, dull aspect; he 
would sit for hours appearing to be reading the same page. He had no knowledge 
of his surroundings. His appetite was fair, bowels regular, rectal and vesical control 
normal. He was placid and contented. He had some swelling of his left foot, which 390 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
became ulcerated, but this in no way seemed to affect him. Memory for recent 
events almost completely destroyed; no tremor of tongue or lips and no clipping of 
words. lie was treated with iodide with no beneficial effect. The sore on the left 
foot had a specific aspect, and was cured by mercurial treatment, local. He remains 
quiet, contented, and weak-minded. 
We have frequently similar cases, and though we may get a similar series of 
symptoms in other patients with hemiplegia, whether due to syphilitic lesions or not, 
we cannot pass over the fact that such cases follow syphilis, and may be due to vas- 
cular disease, to local softening, or to local gummata in one or two cases. I have 
met with local minute softenings which have produced serious symptoms from their 
occurrence in the pons or medulla. 
Under this head it is well to consider some other cases to which detailed reference 
will have to be made later. I am quite used to seeing cases in which some local 
cranial nerve lesion follows syphilis in due course, and which in its turn may be fol- 
lowed by progressive mental weakness, but besides these cases I wish to call attention 
to those in which some sensory trouble of a like nature is followed by mental weak- 
ness. This part of my subject passes quite imperceptibly into the part devoted to 
general paralysis of the insane, and so naturally finds its place there. 
I would only say now that we appear to have some cases in which a local syphilitic 
change suffices to disturb the mental balance more or less permanently, but the pro- 
cess is not a steadily progressive one; on the other hand we may have similar changes 
setting up a degenerative process which cannot be arrested. In each of these cases 
the history and the early symptoms may be the same, and we can only guess as to 
whether there is to be weak-mindedness associated with a tendency to sudden out- 
breaks of disease, or if the process will be more uniform and follow the course which 
is called that of general paralysis. 
In some cases I have seen, the patient becomes old prematurely, in consequence, 
I believe, of syphilis, and he rapidly degenerates. In other cases a paralysis, a mono- 
plegia, a loss of sight or some sensory trouble, may be the starting-point of a simi- 
lar degeneration. There has come to me to be a good group of cases in which 
progressive weak-mindedness follows constitutional syphilis. There is another group 
in which it is confounded with general paralysis which has been preceded by some 
motor symptoms, by either the oculo-motor trouble, a monoplegia, a hemiplegia, in 
one by aphasia and in another by some other motor trouble, and there is still another 
group in which some sensory trouble, some temporary loss of vision, some temporary 
loss of taste, of hearing, some aphasia which may be purely muscular or may be 
more, some temporary giddiness-these may be the first symptoms, which are fol- 
lowed by progressive degeneration, which is not of the same kind and not to be 
grouped with true general paralysis of the insane depending upon syphilis. 
Dr. Channing.-I would like to ask Dr. Savage one question. How would he 
classify these cases which he has just described? Where would he put them? 
They are not general paralysis, yet where should they appear ? 
Dr. Savage.-Organic dementia, I suppose, would be as good a classification as 
any. 
Dr. Channing.-Should the term syphilitic dementia be used ? Are there 
enough cases of that sort to warrant the use of such a term ? 
Dr. Savage.-I should object to the term syphilitic. I should prefer to stick to 
the dementia. Organic dementia of a syphilitic origin. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
391 
Dr. Gundry.-I think if there is any one thing characteristic of mental and 
moral manifestations of syphilitic origin it is that there seems some mighty agent 
behind very slight apparent agencies at work, and that the fact of these very slight 
agencies producing such anomalous symptoms, which cannot be referred to those 
ordinary causes, are the indications of something behind, which we do not see, we do 
not feel, but of which we vaguely have a knowledge, and that something is usually 
syphilis in its course. That is, I think, the bond of union between the cases that 
have been described. We have very marked maniacal symptoms apparently from 
very slight causes, so far as we can ascertain, if we exclude the hypothesis of syphi- 
lis. But when we find this capable of being brought in, then these very slight 
causes and very great effects seem to go very naturally together. I remember very 
many years ago being called in consultation to see a lady who had some anomalous 
cerebral symptoms which defied all treatment. Among other things which her 
mother related to me was that her tone of conversation was so changed ; it did not 
pass beyond the range of propriety, but there was a constant recurrence of topics 
that were alien to her ordinary current of thought ; little double entendres, slight 
suggestions of smuttiness, and this so foreign to her natural tone that it worried her 
mother. I suggested to the attending physician that there was syphilis in the case. 
I believe politeness alone prevented him from calling me a fool, to insinuate that 
there could be syphilis in such a family. I told him to look out for symptoms and 
to turn to specific remedies. In the course of events he discovered something which 
seemed of a syphilitic character and immediately put her upon treatment as I had 
suggested. After some years I had evidence in my hands how she had contracted 
the syphilis. I think I have met many cases in my life, just these anomalous cases, 
sometimes showing a little melancholia, which do not improve under the ordinary 
treatment for depression, which defied treatment until treatment of a specific charac- 
ter was applied, when it gradually disappeared. So I think I have seen things of 
the same nature in which you cannot make out a case which the books will classify, 
and it is just this very thing, this very great variation from trivial causes, which in 
my mind characterizes the ordinary mental disease from syphilis. So with epilepsy 
in the same way. As Dr. Savage has remarked we have a more rapid mental deteri- 
oration where syphilis is present than when absent, and I think I may add a deterior- 
ation which is not regained ; that if there is a temporary improvement there is a 
retrogression afterward very much greater, apparently making up the loss of time 
for the improvement. I think in all of these cases that is the characteristic thing. 
LA SYPHILIS CAUSE DE FOLIE AVEC OU SANS PARALYSIE.'X 
PAR LE DOCTEUR LOUIS FRIGERIO, 
D'Italie. 
Prenant pour base la statistique et étudiant les rapports intervenants entre la folie 
et la syphilis pour les aliénés accueillis dans cet Asile Royal de l'année 1881 à l'année 
1887, et cela sur un nombre de 492 aliénés nous sommes arrivés aux conclusions sui- 
vantes :- 
De cinq femmes, chez lesquelles parmi les causes de folie opéra la syphilis, s'était 
affectée de folie circulaire, trois de démence sans paralysie et un de folie syphilitique. 
Cette dernière guérit parfaitement moyennant la cure sous-cutanée du proto-chlorure 
de mercure. Deux des cinq aliénées, dont il est question, auraient été prostituées 
clandestines. 392 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
De 17 individus chez lesquels la syphilis opéra, soit seule soit en concurrence à 
d'autres causes il y eut :- 
Sept cas de folie paralytique, quatre cas de démence sans paralysie, un cas de folie 
alcoolique, un cas de folie épileptique, un cas de folie morale, un cas de mélancolie 
simple, un cas de mélancolie stupide, et un cas de Lue cérébrale. 
En trois cas existait en même temps l'hérédité. 
Dans le cas enfin de Lue cérébrale on nota le plus obstiné refus de tout aliment 
lequel étant subordonné à une cause insolite, nous croyons digne d'intérêt de le dé- 
crire avec détail. 
Il est question d'un militaire qui ayant contracté, il y a quelques années, un ulcère 
syphilitique, tomba en proie à des idées fixes, quand il fut confié à nos soins, les 
manifestations de l'infection vénérienne étaient très remarquables chez le sujet et 
disparurent par suite de l'usage prolongé de l'iodure de potassium et moyennant les 
injections sous-cutanées de proto-chlorure de mercure. 
Les hallucinations acoustiques et la sitophobie continuèrent, au contraire, à être 
rebelles à tout traitement ; cette dernière précisément subordonnée à une cause très 
étrange, laquelle, autant que nous croyons, n'a pas été décrite jusqu'à présent; le 
patient dont nous parlons, bien que montrant la bonne volonté alors que nous l'ex- 
hortions à se nourir, s'y refusait constamment disant que les mets étaient volumi- 
neux d'une manière énorme et extra-grands les vases qui les continaient, était 
même singulier l'étonement qu'il montrait ensuite de notre insistance ne pouvant 
comprendre que nous ne pussions nous rendre compte de l'impossibilité dans laquelle 
il était de ne pouvoir suivre nos conseils. A la vue des éléments qu'on lui apportait 
il se sentait dégoûté par leur volume si bien qu'il en prenait toujours en petite quan- 
tité, la croyant toujours supérieure à la réelle. 
L'examen ophthalmoscopique nous révéla ce qui suit : rétine ombragée de cou- 
leur de plomb, vases veineux gonflés et variqueux. 
On n'obtient aucune amélioration ni fonctionnelle ni organique de l'application 
répétée des gouttes de sulfate neutre d'atropine. 
Voulant donner une interprétation convenable au phénomène nous croyons être 
dans le vrai, en l'assignant à une illusion physiologique la mégalopsie qui fut jugée 
jusqu'à présent, non autrement que comme caractéristique de la rétenite parenchy- 
mateuse. 
Même du côté pratique le présent cas nous parut instructif tenant compte de la 
possibilité de recourir avec quelques succès à la thérapie spéciale quand il est donné 
de pouvoir opportunément constater la vraie cause de la sitophobie, complication 
toujours grave et souvent fatale pour les aliénés. 
V. SYPHILIS ASSOCIATED WITH GENERAL PARALYSIS. 
Dr. Savage.-This part of my subject will be the one about which there will be 
the most difference of opinion. At the very foundation of this subject there is this 
question, which has been debated over and over again, as to whether general paraly- 
sis is a definite disease. I, for one, would say that in the true acceptation of the 
word disease, it is not one. We have learned that albuminuria and degeneration of 
the kidneys are not equivalents. We know that with degeneration of the kidneys 
albumen is pretty sure to occur, and we know that certain mental symptoms, specially 
those which show marked and progressive loss of mental power, are commonly asso- 
ciated with general paralysis. There are many causes which may set the kidneys out SECTION XVII-PSYCHOLOGICAL MEDICINE. 
393 
of order, and almost any of these may start a progressive disease in these organs 
which will incapacitate them from performing their functions. And similarly there 
are many conditions which will interfere with healthy action of the brain and the 
whole nervous system, and these may lead to degeneration of the brain and nervous 
system. It used to be supposed that general paralysis was a disease with very defi- 
nite mental symptoms, but we must all now acknowledge that this fatal progressive 
disease of the nervous system may begin at any part of the nervous chain, and as a 
result may exhibit any symptoms, mental, motor or sensory. Disease, disorder, or 
malnutrition of any organ may each have the same symptoms. It is not surprising 
that the hysterical patient should have the same symptoms as the person suffering 
from organic disease of the nervous system. The whole body is built up on certain 
lines and will break down along similar lines of least resistance; and not only will 
these lines of least resistance be the lines of breakdown but of general instability. 
So far, then, I have given in my support to those who think that general paralysis 
is but a progressive degeneration affecting the nervous system. 
Syphilis in one way or another has a distinct power over the nervous tissues, as 
has been seen by the constancy with which its effects have been traced in the produc- 
tion of certain distinct degenerations of these tissues. We all know the weight 
which is given to it as a cause of locomotor ataxy. I shall have a word or two to say 
on this subject presently. I do not think we are always able to distinguish between 
this disease and its special treatment by studying the causation of some of the symp- 
toms. Degeneration is degeneration, whatever its cause may be. I shall begin by 
stating that I find the differences between observers so great, when considering the 
part played by syphilis, that I have felt bound to take my own cases and examine 
them as fairly as I could. 
NEGLECT OF OTHERS' OBSERVATIONS AS TO SPECIFIC GENERAL PARALYSIS. 
First, I feel confidence in saying that a certain rather large proportion of cases of 
general paralysis have not only a syphilitic history, but a true syphilitic origin. I can- 
not go so far as some who would say that general paralysis is a syphilitic disease. 
My first difficulty arose in discovering the number of patients suffering from ordinary 
nervous disorders who had also suffered from syphilis. I hoped to have been able 
in some way to compare the two classes, those,, with and those without syphilitic 
histories, suffering similarly. I found that very few, certainly not five per cent., of 
the ordinary insane male patients in Bethlem had any history of the disease, while 
of the general paralytics I found that at least twenty-five per cent, had such a history. 
And the more carefully I was able to go into their histories the more frequently I 
found syphilis as one of the factors. In many cases I obtained the history of the 
infection from the patients themselves during periods of remission. I have, how- 
ever, two or three conclusive arguments against the universal causation of general 
paralysis by syphilis. Thus, at present there is in Bethlem one of twins suffering 
from general paralysis. His brother also having suffered from the same disease, 
starting a little before this twin and ending a little before my patient. The two have 
lived in different parts of the kingdom, and have neither any history of syphilis nor 
have they any other symptoms of the disease. I had under care two other brothers 
who, at the same age, thirty-two, both became general paralytics, though they had 
led utterly different lives, one being sober and industrious, while the other was intem- 
perate and licentious. In these and many other cases a tendency to break down pre- 
maturely along the nervous lines was part of their inheritance and had nothing to do 
with any acquired cause of degeneration. Next, I do not know any means of dis- 394 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tinguisliing between ordinary general paralytics and those coming of neurotic parent- 
age or developing from syphilitic disease. 
GENERAL PARALYSIS FOLLOWING SYPHILIS MAY START EITHER IN BRAIN OR CORD. 
I shall have to give cases in which the brain symptoms were first marked, and 
others in which the cord symptoms began first, and it will be for you to decide 
whether you think in some of the latter the disease was widespread from the first or 
whether it was propagated from one to another part of the nervous system. I purpose 
giving examples of some of the groups of cases with which I have met, for though 
I do not accept any case as having a right to be called, from their symptoms, syphi- 
litic, yet I have met with certain arrangements of symptoms which may for con- 
venience be studied together. We have some cases which, with histories of syphilis 
of very long standing, have been followed by acute symptoms which have rapidly 
run their course. I have two well-marked cases which I will give in brief, one a 
gentleman who some seventeen years before had contracted syphilis, and had been 
under careful medical treatment by a leading London surgeon. He recovered, and, 
after long waiting, was considered fit to marry. He married and lived a perfectly 
healthy life, having no special causes for worry or anxiety. He began, however, 
though still only a little over forty, to consider himself an old man. He complained 
of inability to write as he did before. His memory failed and his will power and 
energy were wanting. It was decided that he should consult some leading physician. 
This he did and the doctor saw no signs of any danger. Within a fortnight the 
patient was suffering from all the most marked symptoms of acute general paralysis. 
He was sleepless, restless, irritable, extravagant, with great tremor of his lips and 
tongue. The condition of his pupils was difficult to detect, as he was blind of one 
eye. His handwriting was very shaky. Knee phenomena wanting ; in every way, from 
his greasy skin to his exalted ideas, he was a general paralytic, and he died within a 
few weeks of the outbreak of acute symptoms. 
In the next case similar acute symptoms occurred, but were arrested. 
Joseph T. B., admitted December 31st, 1886; butcher; married; aged forty-five; 
father at one time melancholic. Had syphilis as a young man and right side cho- 
roiditis since 1876. He was said to be sober, but this is doubtful. A week before 
admission he became excited; he rambling and incoherent, with the most extrava- 
gant ideas. Pupils minute, not reacting to light or accommodation. Restless and 
noisy at night; tongue tremulous; speech hesitant; walk shaky; can't stand with 
eyes shut; knee reflexes brisk. He refused his food though he talked of the banquet 
he would give, but he appeared to have no appetite or feeling of necessity for food. 
He improved up to this point and was discharged uncured at the end of a few 
months. 
GENUINE PROGRESSIVE GENERAL PARALYSIS IN A SYPHILITIC MAN WITHOUT 
SIGNS OF LOCAL TROUBLE. 
In the next case the syphilis had been acquired many years before, and had not 
in any way affected the family of the patient. The first symptoms were such as I 
have frequently seen with syphilitic general paralysis, especially when it occurs in 
medical men, namely, a consciousness that they were breaking down with some spe- 
cific intracranial degeneration. I can call to mind two who have in early general 
paralysis come to me with the same expression, that they were '1 going to die of 
brain syphilis. ' ' This symptom of marked consciousness of failure in bodily and 
mental vigor was the earliest sign of the disease, which within four months had SECTION XVII-PSYCHOLOGICAL MEDICINE. 
395 
become well marked general paralysis. In this case there was no sign of any other 
visceral trouble, and therefore I bring it first under notice, as being one of the cases 
in which general and not special degeneration seemed present. 
William H. E. ; married; admitted October, 1885; age forty-two; surgeon; 
father died insane. He showed signs of mental failure eighteen months before 
admission, but these were so slight that he followed his profession up to July. He 
became excited, talkative, with great and constant restlessness. He had very great 
exaltation of ideas ; aspect worn and thin ; tongue tremulous ; pupils equal but 
small, reacting ; walk firm ; writing scratchy ; reflexes normal ; he was very aetive, 
at times destructive ; he rubbed his hair off ; his writing, at first very voluminous, 
got less and less legible. His face was almost always flushed, and over the malar 
bones the fine capillary network was very marked. He lost power in flexors of right 
foot, and this gave him a peculiar gait. Toward the end he refused food ; he was 
fed artificially, but sank and died in May, 1887. Brain wasted ; membranes water- 
logged ; convolutions small ; general excess of fluid and no adhesions to cortex ; cord 
wasted ; no coarse signs of syphilis in any viscera. 
SYPHILIS. NO LOCAL TROUBLES. GENERAL PARALYSIS. 
M. T. S. ; single ; age thirty-seven ; admitted July, 1883. Mother died of 
hemiplegia. In childhood had scarlet fever and chronic albuminuria. Had syphilis 
when about twenty. Two months before admission he became excited and extrava- 
gant in his dress ; he also was excitable and wandered from home ; he got the most 
extravagant ideas about his powers ; great tremor of tongue and lips ; hesitation in 
speech ; handwriting shaky ; some loss of expression, but his face of florid color ; 
malar capillaries well marked ; left pupil larger, both sluggish in reaction ; memory 
fair ; patella reflex very excessive at first, later absent on left side and exaggerated 
on the other. This patient passed through all the ordinary stages of general paraly- 
sis. In 1885 he had some general convulsions; later he had slight ptosis of left 
eyelid. He had some vomiting, and later he passed several ounces of bright blood 
from his bladder. He had some swelling of glans and more bleeding. He slowly 
sank and died October, 1885. 
Brain wasted, most marked about frontal region ; very great excess of fluid in 
lateral ventricles, and also in the water-logged membranes ; a few adhesions at apex 
of left ascending frontal convolution ; kidneys with pyelitis, bladder with signs of 
very acute cystitis. In some other cases I have met a tendency to hemorrhage in 
syphilitic general paralysis, in the course of inflammations in which such an occur- 
rence is not common. Thus, in cystitis and in laryngitis. 
In the above cases we have seen general paralysis developing in young patients 
who have had no cranial nerve trouble, and I am used to meet with a good many 
such cases among the unmarried. And though there is nothing characteristic about 
these cases, I have noticed that in many there is a worn aspect with bright capillary 
stigmata on the malar prominences, that the reflexes are often very brisk indeed, and 
that the speech is unusually interfered with. In these cases it is common to meet with 
great contraction of the lower extremities before the end, and post-mortem to find 
little beyond great wasting of brain and excess of fluid. In the next group, it is 
remarkable to see the frequency with which the same history is given. And I shall 
only need to give one case as an example, though I think I should have no difficulty 
in providing dozens of similar instances. 
The pathology of these cases deserves very careful study. We seem to have a 
damage done to a brain. This is recovered from, but there is either some weakness 396 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
left or there is some start given to degeneration which, from some cause or another, 
at a later date spreads and finally ends by destroying the patient, as I said when 
speaking of weak-mindedness following local cerebral lesions. The degeneration may 
follow either a motor or a sensory lesion, and I shall submit two cases, in one of 
which the motor and in the other the sensory loss was the starting point. 
SYPHILIS, PTOSIS, INTERNAL STRABISMUS. RECOVERY UNDER TREATMENT, FOL- 
LOWED BY ONSET OF GENERAL PARALYSIS. 
Walter W.; admitted May 12th, 1886; married; agent; uncle insane. Had 
syphilis many years ago. He has recently been under treatment by Mr. Bader for 
ptosis and external strabismus, and recovered entirely. He remained well for a few 
months and then became changed in his character ; he became irritable and exacting, 
at the same time was careless in his business affairs. He became sleepless, restless, 
and extravagant a month before his admission into Bethlem. On admission he was 
a splendidly built man, very restless, constantly writing letters ; he had the greatest 
ideas of his capacity; he played the piano constantly with great vigor; he was 
irritable. 
Tongue clear, fairly steady ; pupils unequal, right the larger ; reflexes deficient ; 
writing tremulous; speech hesitant. He remained in a restless, excited state for 
nearly a year, when he gave up writing and became weaker in every way. With 
this the facial and lingual tremors became more marked ; he became self-negligent 
and at times wet and dirty. His memory failed and he appears to be rapidly pass- 
ing into a demented stage ; his music is now very defective, and his evening rubber 
at whist very trying to his partners. 
SYPHILIS, BLINDNESS, GENERAL PARALYSIS. 
Admitted October, 1886; married; age thirty-five; twin children, age twelve. 
Had syphilis when about twenty. No neurotic history ; had brain fever as a child ; 
was delirious eight years ago for three or four days ; used to be very intemperate, 
but has been sober for two years. In April, 1885, had a delusion that he was dying, 
and was depressed for three months ; he improved but has a great deal of business 
worry ; in June, 1886, wanted to preach the gospel ; he became irritable ; took dis- 
like to wife and family, and struck people. Impairment of vision began three years 
ago, and has steadily increased, so that at present he can hardly detect light from 
darkness. On admission he was excited and emotional ; great tremor of lips and 
tongue ; considerable exaltation of ideas ; pupils equal, reacting ; gray atrophy of 
discs ; numerous pigmented patches of disseminated choroiditis and pigmentation of 
retina ; vessels much diminished ; patellar reflexes brisk ; sleep interrupted. This 
patient has recently had epileptiform fits. 
In addition to these cases I think it right to record those in which syphilis had 
occurred years before and has been apparently recovered from, and the earliest mental 
symptoms, pointing to the onset of general paralysis, was fainting fits or severe 
attacks of giddiness, or attacks of aphasia of a temporary character. 
In one of two cases this aphasia has occurred four, five, or even nine years before 
general paralysis was suspected. 
SYPHILIS, FAINTING FITS, GENERAL PARALYSIS. 
J. M. ; admitted June 10th, 1887; married; age thirty-eight ; grandfather died 
of paralysis ; has been sober ; had syphilis thirteen years ago. Three of his children 
suffered from hereditary syphilis and died. He has suffered from a specific rash for SECTION XVII-PSYCHOLOGICAL MEDICINE. 
397 
some time past, recurring yearly. Two years ago he had some syncopal attacks ; he 
was unconscious, and he had drawling speech after these attacks for some hours. 
Six weeks before admission he had another similar loss of consciousness, followed by 
much more marked loss of memory and of other powers. He failed to do his work 
right and had to be looked after by his fellow clerks. It seems, from the evidence 
of these clerks, that he has failed slightly for nearly two years. A fortnight before 
admission he became restless, amorous, noisy, and extravagant. On admission he 
was anaemic, restless, given to endless letter writing. He was grand and bountiful. 
He was irritable, and liable to outbreaks of violence if opposed. Tongue clean, 
tremulous ; pupils small, equal, reacting slightly ; reflexes normal ; his writing is 
shaky and his speech clipped ; he is restless, and has every form of exaltation of 
ideas ; is benevolent and emotional. He rapidly passed into a more quiet state, 
though his ideas of grandeur are unchanged. 
CASES OF GENERAL PARALYSIS, WITH SYPHILITIC HISTORIES, IN WHICH TIIE FIRST 
OR THE CHIEF SYMPTOMS FIRST TO ATTRACT NOTICE WERE SPINAL. 
Here we have two distinct groups. Those with ataxic symptoms and those with 
symptoms of lateral sclerosis. 
And here it is well to notice that among our cases we not infrequently meet with 
mixed cases, such as have normal or exaggerated reflexes on one side and absence of 
reflexes on the other. (I here refer to the knee phenomenon.) In the case of M. 
T. S., we have one in which the reflexes differed on the two sides of the body. In 
reference to these cases I must say that the greater number of the young cases of 
syphilis with general paralysis, to whom I have referred above, were suffering with 
marked exaggeration of all the reflexes, and in these cases the speech was early and 
markedly affected and the gait was also of the spastic type. The tendency was early 
to get feebleness, and later the muscles wasted, the patient became bed-ridden, and 
dying often with large bed sores and with greatly contracted limbs. In these cases I 
failed to find any very general post-mortem signs. As a rule the brain was much 
wasted, the adhesions were few, and the lateral ventricles filled with fluid, while 
secondary degeneration was seen in Turck's columns as well as in the lateral columns. 
SYPHILIS, BRISK REFLEXES, GENERAL PARALYSIS. 
Alfred E. ; admitted January, 1887; single; twenty-seven; no neurosis in family; 
tailor; sober; had syphilis a few years ago; at present has rupial sores. He had 
rheumatic fever two years ago, but his heart is healthy. He has had fainting fits 
since. He had convulsions in infancy; recently he has had chorea and was in a gen- 
eral hospital for six weeks; he became odd and his memory was weak; he became 
irritable and depressed alternately. He then became maniacal and had to be brought 
to Bethlem. On admission he was very excitable and very confused; he did not in 
the least appreciate his position or his state. He had hallucinations of sight-saw 
rats, also of hearing-fancying his employer whistled to him; he fancied his food 
was poisoned, and he talked about bad smells. There was slight divergence of eyes, 
some swelling and pallor of discs, and neuritis; pupils equal, reacting; knee phe- 
nomenon brisk; there was great tremor of tongue, and speech was markedly affected. 
There was loss of expression and some greasiness of skin. He had extravagant 
ideas and wrote many letters, which showed change in handwriting. He was treated 
with mercurial chloride and potassium iodide, but for a time was more stupid than 
excited. He was both wet and dirty. In March he tried to kill himself, and was 
very emotional. He gradually roused up and became fat. Dr. Sanford again exam- 398 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ined his eyes and said the vessels were diminished in size, and that other appear- 
ances indicated neuro-retinitis and hyalitis. He had some herpes frontalis, and at 
the same time some sub-conjunctival hemorrhage. He recovered sufficiently to go 
out on leave, but I consider this but another evidence of the specific origin of the 
disease. 
Among the ataxic cases I have several very good examples. In the first the 
patient was not discovered to have locomotor ataxy till after he had been sent to 
Bethlern suffering from melancholia with delusions that he would be hanged. It was 
found that he had been for a year or more behaving in a very excited way, and that 
his passions had, as is so often the case with these cases, been beyond his control. 
He was noticed to be peculiar in his gait. He had pains in his limbs which were 
considered to be rheumatic. The symptoms of ataxy were well marked, and though 
he managed to get his discharge from the asylum, I fear the result will be sad. In 
any case his is one of the interesting examples of ataxy which connects the three 
groups : (a) the simple ataxic with specific history and delusion; (6) the specific gen- 
eral paralysis with ataxic symptoms, and (c) cases of specific history with ataxic 
symptoms beginning years before any signs of general paralysis are to be detected. 
In the other two cases the syphilis was recognized and treated years before the 
ataxic symptoms showed themselves, and these latter lasted some years before the 
confirmed general paralysis developed. 
The chief point of interest being, as I said before, whether the symptoms are 
produced by a general lesion working its way at a different rate, or whether there is 
a true propagation of the disease from one part to another. 
SYPHILIS. STRONG HEREDITARY TAINT, LOSS OF FORTUNE, LOCOMOTOR ATAXY, 
INSANITY, TEMPORARY IMPROVEMENT. 
James S. C. ; married; forty-two; admitted March, 1884; father eccentric; brother 
insane. Had lived a great deal within the tropics; had been doubtfully sober. Had 
a sore on his penis when about twenty-one; this was cauterized, but for some time 
was unhealed. Had very slight secondary symptoms. He became insane three 
months before admission; he believed he had leprosy; he accused himself of all sorts 
of crimes. He had been very lascivious of late. He believed he was the subject of 
a plot, and that some one was going to poison his wife, and that he would be accused. 
He was very wretched and full of contrition for the past. He developed the idea 
that he was in the power of the devil. His gait was slightly ataxic; he had pains 
in his legs and some swelling about both ankle joints. Several bullæ appeared about 
his feet, and cutis anserina was very marked. Patellar reflexes both absent. Pupils 
small, reacting to accommodation, but not to light; some slight changes in right optic 
disc, the outline of which was indistinct and the disc rather opaque; retinal veins 
tortuous. For fifteen months the patient was every day coining some new fancy to 
interpret his uneasy feelings, but his general health improved and at times he was 
more cheerful. He was discharged uncured and transferred to another asylum. He 
was discharged from this as recovered, and proceeded to take legal action against his 
wife to recover some of his property. His mental balance was not really restored, 
but he was fit to be at large. The ataxic symptoms are less, and he is hopeful that 
nitrate of silver treatment will restore him. 
In the above case we have the common history of syphilis, small secondary 
troubles, and after many years associated with worry, locomotor ataxy developing 
the insane tendency, giving insane interpretation to the symptoms. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
399 
SYPHILIS. HISTORY OF PARALYSIS IN THE FAMILY, LOCOMOTOR ATAXY, GENERAL 
PARALYSIS. 
Frank B. F. ; single; thirty-one; clerk; admitted February, 1887; grandfather 
died of paralysis; he contracted syphilis twelve years ago. He had been carefully 
treated and had suffered from secondary troubles. He had been treated at Aachen. 
He had complained of pains in his legs for some time past. A few years ago had a 
severe fall on to his back. For a year or more he had been very irritable, and at 
times not fit for his work, but for a few months before his present break-down he was 
very remarkably bright and clear-headed. About six weeks before admission he 
became sleepless, excited, and developed very grand ideas; he chattered and was 
hilarious; his appetite became very ravenous, and he ate whatever came in his way. 
He believed he was very strong, notwithstanding his constant falls. He said he 
knew one side of his head was mad. On admission his gait was very ataxic; he had 
retention of urine; bowels confined; left pupil larger, both react to accommodation 
but not to light; he had double vision; knee reflexes absent. 
This patient rallied a great deal, but all the time he was under observation he 
was ravenous, extravagant, and boastful, while he steadily lost power. 
In the above case, syphilis, locomotor ataxy, and general paralysis form the 
sequence. 
SYPHILIS, LOCOMOTOR ATAXY, GENERAL PARALYSIS OF THE INSANE. 
Alfreds.; single; forty-five; admitted April 16 th, 1887. No neurotic history. 
Contracted syphilis sixteen years ago ; no serious secondary troubles. About six years 
ago locomotor ataxy developed and was treated by Dr. Althaus. Symptoms of mental 
disorder have already shown themselves during the past week. He had been exposed 
to wet and cold a good deal of late. He became excitable and irritable ; he was 
sleepless and noisy at night. He wrote endless letters, tore up books ; he was going 
to reform the world, to suppress the House of Commons, to blow up every one with 
dynamite. He has had hallucinations of hearing for a month and shooting pains in 
his legs. He had frequent erections and emissions ; pupils at times equal, small, at 
others the left larger. Six years ago he had convergence and diplopia, which was 
cured by the use of mercury ; general and color vision normal ; pupils reacting both 
to light and accommodation ; patellar reflexes absent ; walk ataxic. This patient on 
admission had all the most marked symptoms of ataxy and of general paralysis of 
the insane, and no treatment seems in any way to affect him. 
Before proceeding to consider in brief the pathology of these syphilitic changes, 
I wish to call attention to the subject of the course cases having their origin in 
syphilis run. It is a generally accepted dogma, that whether the general paralysis be 
due to syphilis or to any other source, it is a matter of almost indifference, and that 
though when you hear the case is a specific one you order mercury or the iodides, as 
your fancy leads you, yet you have no hope. I agree with the general principle 
that whatever has caused the degeneration matters little if it is certainly started ; 
but yet I think I have some grounds for hoping that in specific cases cure may from 
time to time occur, and that at any rate remissions of unusual length may often be 
expected. I recall the only case of general paralysis that I ever saw which appar- 
ently recovered, and in that case one symptom-cranial nerve paralysis-pointed to 
syphilis, though there was no other proof of the disease obtained. The man got well 
and remained well for years, but died of obscure nervous disease, which was certainly 
looked upon as specific by the eminent neurologist who attended him. In another 
case with specific history, prolonged remission has occurred, and it is noteworthy 400 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
that in both these cases excessive suppuration was the immediate cause of relief. 
In a case, the particulars of which I submit, the recovery has been so far remarkable, 
and the patient, who was undoubtedly suffering from early general paralysis, seems to 
have recovered sufficiently to be trusted as second in command of a ship. In another 
case the symptoms, which were of weakness and depression, but unmistakably those 
of general paralysis, passed off, and allowed the clergyman to perform his duties 
perfectly for some months before he again broke down. I do not for one moment 
claim anything special for cases of general paralysis with syphilis, but I think I 
ought to take note of any facts which have struck me in their history. 
SYPHILIS, GENERAL PARALYSIS, REMISSION ; CURE. 
William II. S. Mac.; admitted July 6th, 1885; male; thirty-four; married; 
no children ; father insane, mother phthisis ; no injuries ; syphilis. First symptoms 
of first attack twelve months ago. Change in temper toward wife five months ago ; 
depressed ; then he got command of a vessel-this excited him ; next he became very 
amorous, then disagreeable and dogmatic ; fancied all were against him and wanted to 
wander away ; then fancied he had a mission to relieve the poor ; next, extravagance ; 
purchases things recklessly ; very variable ; red colors irritated him while white 
soothed ; thought he possessed great wealth and was a great musician. Pupils unequal; 
both small, right larger. Exalted and pleasant until July 21st, then morose ; rapidly got 
worse. July 23d. Better again. July 28th. Alternating. August 9th. Exaltation 
and given to masturbation ; thought he could kill people by looking at them ; very 
destructive ; getting thinner. November 20th. Pot. iod., gr. v. t. in d.; smeared 
fæces around room. December 10. Very variable; tremors of lips and tongue; 
pupils unequal, right larger ; getting stout. March, 1886. More quiet ; leave of 
absence. March 31st. Appears well. April. Still on leave ; tremors and twitching ; 
stout ; sleeps too much ; change in temper-more docile and mild ; acknowledges 
mental attack. June 1886. Discharged, " well. " May 4th, 1887. Hear he is chief 
officer on board ship in the east. 
Dr. Savage read only portions of the paper he had prepared, and then continued, 
extemporaneously, the discussion, as follows :- 
In regard to cases of syphilis of long standing which had been followed by general 
paralysis with acute symptoms, he gave two illustrations. He said : Under this 
group of acute cases I have seen several in which after 17, 18, or even 30 years' 
standing of syphilis there has been a sudden outbreak of general paralysis, and in 
several cases ending very rapidly. Even in the best cases I have been able to exclude 
evidences of intemperance or of other exciting causes ; in fact, I was able to exclude 
almost every other cause of general paralysis with which I was familiar. 
Speaking of another group, Dr. Savage continued :- 
A man contracts syphilis, suffers comparatively little from constitutional symp- 
toms, but when he is about 30 or 40, he begins to get weak, his memory is impaired, 
there is alteration frequently in his reflexes, sometimes defective ; later on he has 
some eye trouble, such as loss of sight, or impairment of vision on one side or both; 
later greater tremulousness in speech, a change in his handwriting, and the man 
proves to be a case of ordinary general paralysis. Of course, of all the people who 
have syphilis, a certain natural proportion would die, I suppose, of general paralysis 
in any case, and I would therefore lay less stress upon these cases than upon many 
others. I would simply say that I have a considerable number of cases under my 
care, of ordinary general paralysis of the insane, running a perfectly ordinary course, SECTION XVII-PSYCHOLOGICAL MEDICINE. 
401 
with no longer and no more frequent remissions, with fits and sometimes without 
fits, in fact, in no way separable from ordinary general paralysis, but with very defi- 
nite histories of syphilis. 
I suppose every one of us who sees a patient with cranial nerve paralysis, asks, 
almost automatically, of the patient, when did you have syphilis ? I know that directly 
we get ptosis, external strabismus, and dilatation of the pupils the most common 
cause of these symptoms we suspect is syphilis. Well, I have seen many cases with 
the following history. Ptosis, external strabismus, and dilatation of the pupil, in men 
who, from five to five and twenty years have had constitutional syphilis and thought 
very little about it. They then become alarmed, go to an oculist; he recognizing the 
specific symptoms, treats them, generally pretty freely, with mercury, and the symp- 
toms all pass away. I have seen in four years from twelve to twenty patients who, 
having recovered from the local lesion, sooner or later became weak-minded and be- 
came so in the ordinary sense of the term, as I referred to it yesterday, but developed 
symptoms of general paralysis of the insane. A German merchant now in Bethlem 
had that history. This man, a successful and hard-working merchant, a married man, 
entirely sober, without a family, developed ptosis and external strabismus ; was 
treated by a London oculist and recovered. He went back to business, and every- 
thing seemed to be going on very well, but his friends noticed that he seemed to 
take things a little more easily. Twelve months ago he began to drink more than he 
should, and this had an unusual effect upon him. He was extravagant, his hand- 
writing was changing, he was dropping letters from his words, his speech was losing 
its crispness, his tongue had become expressionless and tremulous, his skin had 
become greasy, and he passed from the stage of paralysis with great exaltation into 
the half weak-minded state, and was in this condition when I left town. There are 
several cases in which general paralysis of the insane has followed temporary aphasia; 
a man has had an attack of syphilis, and following that syphilis there has been a 
temporary attack of aphasia, which has been recovered from, and later on there has 
been a development of true general paralysis. To sum up, as time is of importance 
this afternoon, I am quite used to seeing cases that have been diagnosed as suffering 
from syphilis, develop after they have been treated, and appeared to have recovered 
from the local specific lesion. I have seen them repeatedly break down with general 
paralysis of the insane. I have seen also patients in whose cases there has been 
motor loss or sensory loss. Cases in which there has been ptosis, cases of monoplegia, 
cases of hemiplegia, cases in which there has been a simple aphasia, cases of aphasia 
with hemiplegia, some with paraplegia in which there has been simple sensory dis- 
turbance, such as loss of sight in one eye, or loss of sight associated with loss of hear- 
ing and giddiness. I would like to refer in parenthesis to one group of cases that 
has greatly interested me. I have already spoken of the general paralysis which may 
start in the brain. I would also like to say a few words as to general paralysis start- 
ing in the cord. In introducing the subject I would say that there are a number of 
writers who recognize the fact that those patients who suffer from locomotor ataxy, 
if we call that a disease and not an assemblage of symptoms, the largest number of 
them have got some syphilitic history : and one finds that among cases suffering 
from general paralysis of the insane, a very fair proportion of them begin with loco- 
motor ataxy. Well, of course, there are two or three groups ; those who begin with 
locomotor ataxy and develop into general paralysis of the insane, and those who begin 
with the ataxy and the general paralysis develops about the same time. One man 
at Bethlem was a most marked case of locomotor ataxy, with general paralysis, both 
symptoms starting together and keeping a perfectly parallel course. Besides those, 
Vol. V-26 402 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
one gets more frequently, I think, cases of general paralysis in which syphilitic his- 
tories are present, with what I have called spastic symptoms, more for convenience, 
and in contrast to the ataxic symptoms and implying a general likeness. 
My experience is that general paralysis which depends upon syphilis may run a 
somewhat unusual course in so far as the remissions may be more frequent and more 
prolonged. One patient at Bethlem, under my care, with typical symptoms of 
general paralysis of the insane, after about six or eight months' treatment recovered 
sufficiently to be discharged on leave. After twelve months' leave of absence I 
heard from his wife that he was in command of a ship, and that his former 
employers cannot detect any loss of his faculties whatever. Another case is that of 
a clergyman, recently under my care, who had so complete a remission that he per- 
formed all the duties of a chaplain in the south of Europe during the whole of the early 
spring. This man hardly came under the class of complete or short remissions, for 
in four months he had fresh outbreaks, and these I think will terminate fatally. I 
believe that if one could only see those cases of reported cure of general paralysis of 
the insane, it would be found that nearly all of them belonged to these cases of syphilitic 
general paralysis. My own experience is that I have seen only one thoroughly well- 
marked case of general paralysis of the insane appear to get well ; that is, he was 
able to administer his affairs for some years, but he died ultimately, of some obscure 
nervous disease, under Dr. Ferrier. Unfortunately no post-mortem was allowed, and 
I am still inclined to think that, though apparently cured, it was only a case of 
syphilitic general paralysis in which there was a prolonged remission. My belief is 
that general paralysis of the insane is a degeneration which may be set up by many 
causes. There is no special form of general paralysis which depends on syphilitic 
changes ; we may have quite a large number of cases of general paralysis in which there 
is a syphilitic history, yet not every case of general paralysis with syphilitic history 
depends upon syphilis. But I feel quite sure that there are one or two definite 
groups in which there is no doubt whatever, and my belief is that the most import- 
ant one is that in which local lesions of the nervous centres are present-I fear I am 
not able to say what these lesions may be. In speaking of the pathological changes 
yesterday, I said there were no gummatous changes found. I belieye if any cases 
are certainly dependent upon syphilis they are those where the symptoms are first 
of local nerve cranial lesion, followed by more or less recovery, followed later by 
degeneration ; and my belief is that in the majority of these cases the old lesion has 
formed a focus of degeneration. The only other group generally syphilitic are those 
ataxic cases in which the ataxic precede the paralytic symptoms by considerable 
time. 
Dr. Mendel discussed the subject, in German, as follows :- 
Ich stimme mit Herrn Collegen Savage darin überein, dass unter dem Symp- 
tomenbilde der progressiven Paralyse sehr verschiedene Processe verlaufen, dass wir 
während des Lebens Paralyse diagnosticiren und bei der Autopsie multiple Sclerose, 
ausgebreitete syphilitische Ilirnarterienerkrankung oder andere Processe finden. 
Ich spreche hier nur von denjenigen Fällen, die äusser den Symptomen im Leben 
den bekannten Befund post mortem zeigen. 
Die Ansichten über den Zusammenhang dieser Erkrankung mit der Syphilis sind 
im Wesentlichen folgende drei : 
Ein Theil der Psychiater glaubt, dass die Syphilis mit der Paralyse überhaupt 
nichts zu thun hat, ein anderer Theil, dass die Paralyse fast immer eine syphilitische 
Erkrankung des Hirnes ist, und ein dritter Theil endlich, dass die Syphilis das prä- 
disponirende Moment ist, das in einer sehr grossen Reihe von Fällen die Entstehung SECTION XVII PSYCHOLOGICAL MEDICINE. 
403 
der Paralyse ermöglicht. Der ersten Ansicht gegenüber steht der von den verschie- 
densten Forschern erhobene statistische Nachweis, dass in einer ganz unverhältniss- 
mässig grossen Anzahl von Fallen von Paralyse anamnestisch Syphilis festzustellen 
ist. Meine Zahlen sind weit grösser als die des Herrn Savage : ich finde in ca. 70 
bis 75 Procent aller Fälle vorangegangene Syphilis. Diese Statistik, die an den ver- 
schiedensten Orten erhoben ist, ist bisher durch eine andere, die das Gegentheil 
beweisen könnte und durch Genauigkeit Anspruch auf Berücksichtigung verdiente, 
nicht entkräftet worden. 
Der zweiten Ansicht gegenüber ist daran festzuhalten, dass in einem Theile der 
Fälle echter Paralyse in der That keine Syphilis nachzuweisen ist, und dass bei den 
Autopsieen verhältnissmässig selten bei Paralytikern unzweifelhaft syphilitische Pro- 
ducte in den inneren Organen gefunden werden. Der Einwand gegen jene Ansicht, 
dass die specifische Therapie keine Erfolge aufzuweisen hat, erscheint mir nicht 
erheblich. Wenn wir die Paralytiker in Behandlung bekommen, dann hat der Pro- 
cess in der Regel schon ein Narbengewebe gebildet, und vir verlangen auch sonst 
nicht von der specifischen Therapie, dass sie Narben beseitigt. 
Ich selbst huldige der dritten Ansicht und glaube, dass, wenn zwei Menschen den 
unzweifelhaft als ätiologische Momente auszusprechenden psychischen Processen, 
wie Kummer, Sorge, gekränkter Ehrgeiz, getäuschte Erwartungen u. s. w., ferner 
ausschweifendem Lebenswandel, Abusus in Venere et Baccho ausgesetzt sind, der- 
jenige, der vorher syphilitisch war, mit drei-bis viermal grösserer Wahrscheinlichkeit 
Paralytiker wird, als der vorher nicht Inficirte. Die Sache verhält sich nach meinen 
Untersuchungen folgendermaassen : Wenn man die Hirne der Paralytiker in den 
verschiedensten Stadien untersucht, so findet man zuerst Austritt von Blutkörper- 
chen über die ganze Rinde zerstreut. Sie liegen nicht selten in dichten Reihen 
neben den Gefässen ; in einem zweiten Stadium haben diese ausgetretenen und als 
Reize wirkenden Blutkörperchen eine Entzündung des interstitiellen Gewebes her- 
vorgerufen, und in einem dritten bringt das wuchernde Bindegewebe Ganglienzellen 
und Nervenfasern zur Atrophie. Es beginnt der Process also mit einer activen 
Hyperämie, welche die Blutkörperchen durch die Wendungen der Gefässe treibt. 
Ich war so fest von dieser Form des physio-pathologiscben Vorganges überzeugt, 
dass ich glaubte, man müsste durch Anwendung einer starken Gewalt, welche das 
Blut durch die Gefässwände treibt, auch bei Thieren die Symptome der progressiven 
Paralyse erzeugen können, und meine Versuche bei Hunden, bei denen durch Wir- 
kung der Centrifugalkraft auf den Schädelinhalt (Drehen auf einem Tische) eine 
symptomatologisch, wie pathologisch-anatomisch der Paralyse beim Menschen gleich- 
zustellende Erkrankung hervorgerufen wurde, bestätigten dies. 
Bei normalen Gefässwänden werden in der Regel jene oben erwähnten ätiologi- 
schen Momente mit ihren - auch physiologisch beim Menschen - nachgewiesenen 
Hyperämien, ohne dauernden Schaden zu erzeugen, vorübergehen ; sind dagegen 
die Gefässwände krank, haben sie nicht mehr die normale Widerstandsfähigkeit - 
und es ist wohl unzweifelhaft, dass solche Veränderungen durch die Syphilis hervor- 
gebracht werden können - dann werden jene Hyperämieen zum Austritt von Blut- 
körperchen, vielleicht auch Blutserum, in übermässiger Weise führen und damit 
die paralitische Erkrankung des Hirnes einleiten. Die Syphilis ist also meiner 
Ansicht nach in der grossen Mehrzahl der Fälle das Moment, das im Gehirne die 
Bedingungen setzt, welche späteren auf dasselbe schädlich einwirkenden Einflüssen 
die Hervorrufung der Paralyse gestattet. 
Diese meine Auflassung leitet auch mein therapeutisches Handeln. Ist man in 
der Lage und im Stande, die Krankheit in ihren Anfängen zu behandeln (die Diag- 404 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nose wird ja allerdings sehr oft keine sichere sein können), dann wird man zu einer 
specifischen Behandlung zu schreiten haben, um, wenn möglich, durch die Einwir- 
kung derselben den Zustand des Gefässsystemes zu bessern und damit dem Weiter- 
schreiten des Processes entgegenzutreten. Ist bereits erhebliche Dementia da, dann 
sehe man von jeder Behandlung ab, denn man kann ebensowenig ein atropisches 
Hirn durch die Behandlung wieder normal machen, wie man etwa einen syphilitischen 
defectiven Gaumen durch eine anti-syphilitische Behandlung mit normalem Gewebe 
ersetzen kann. In den Fallen aber, die noch nicht so weit vorgeschritten sind, ver- 
suche man bei der Aussichtslosigkeit jeder anderen Therapie die anti-syphilitische 
Behandlung (Inunction und Jodkalium) nach dem Grundsätze : Remedium anceps 
melius, quam nullum. 
Dr. Mickle.-The first group mentioned by Dr. Savage is one in which I have 
seen very few cases. But the other two he mentions I have often seen ; cases in 
which the syphilis was a cause of general paralysis. I have seen these cases ; cases 
in which the patient has constitutional syphilis, later on has general paralysis, and 
there is nothing in the course, the duration, or the complications of the case to make 
one think that it is in any way different from the ordinary every-day case of general 
paralysis. All that you can say is, that the man has had constitutional syphilis and 
now has general paralysis, and that neither through life nor at the post-mortem is 
there anything different from ordinary general paralysis. Then the other group, in 
which there was, at the beginning of the case, local motor symptoms ; the patient 
suffers from some local motor paralysis or sensory symptoms ; also from nocturnal 
headache sometimes, and such a symptom as anaemia is prominent in these cases. 
In the cases where the local unilateral spasms and local spasms are followed by 
paralyses, these paralyses usually clear up, but they usually cause this condition of 
things-the patient gradually takes on a hemiplegia which steadily progresses and 
becomes more and more complete. From time to time there are paralyses following 
convulsions, but the condition usually terminates in a more or less extended hemi- 
plegia, accompanied by contortion or rigidity of the affected limbs of one side. 
Then you have often the occurrence of ocular paralysis, and I have often found very 
distinct evidence of neuritis of the nerve trunk itself. As regards the mental 
symptoms dementia predominates very strongly. Of course you have cases of 
general paralysis that take on a demented form, but in these it is more than usually 
prominent. Then when you come to the necropsies there is in these cases a pachy- 
meningitis, a local one, affecting the dura on one side. The thickening of the soft 
meninges is not so diffuse in very many cases as usual. The thickening is found on 
the one side, and on the other side such adhesion of the meninges and the surface 
of the convolutions and erosion of the convolutions, as is so often found in general 
paralysis. Not only so, but one side frequently undergoes an unusual degree of 
atrophy. Together with that, also, there is often a somewhat diffuse yet a circum- 
scribed sclerosis affecting a greater or less tract of the cortex of the brain, that I 
have frequently found existing upon one side chiefly, or upon one side only, affecting 
usually a large portion of the frontal lobe, but not strictly limited. Of course, this 
is found sometimes in cases of general paralysis. 
There is another group of cases which, I think, forms a link between cases of 
brain syphilis and general paralysis. The patient often takes on the form simulating 
the demented form. He has probably epileptiform convulsions, a local paralysis 
more or less marked, a paretic condition of the muscular symptoms and often a 
monoplegia. Such patients often die of epileptiform seizures-in epileptic status. 
At the necropsy you find the cerebral blood vessels, particularly those of the circle SECTION XVII-PSYCHOLOGICAL MEDICINE. 
405 
of Willis, with their coats enormously thickened Then, sometimes, there are 
growths that are really syphilomatous, really a gumma of the arterial coat. In some 
such cases there is a diminution or encroachment of the lumen of the vessel and 
often the smaller arterioles of the vessels are affected. This explains the degenera- 
tion which does ensue in these cases. In consequence of syphilitic arteritis affecting 
the walls of the large blood vessels, and in consequence of the syphiloma affecting 
their coats, and the thickening of the walls, there is an obstruction of the circulation 
and a tendency to thrombosis. As a result we get local softenings, and these give 
symptoms of ordinary paralysis. In these cases there are gummatous infiltrations 
affecting other than arterial walls, and in these cases we often find, besides the 
softenings, a more or less extended area of adhesion of the pia to the cortical convo- 
lutions. 
I wish to express my general concurrence with the views of Dr. Savage. 
Dr. Down.-I have had a great deal of experience in London hospitals in loco- 
motor ataxy cases, and I think they are nearly all of a syphilitic character ; that 
they all respond to anti-syphilitic treatment, and that they are, as a rule, syphilitic. 
I am very strongly inclined to the belief in the syphilitic nature of locomotor ataxy. 
Is there any connection between locomotor ataxy and general paralysis of the brain ? 
I have had the opportunity of following out several cases very closely. One was 
that of a chaplain in a Welsh prison who came under my care with locomotor ataxy 
of very marked and progressive character. There was not the slightest lesion. No 
anxiety was felt upon that score. He kept his appointment in the prison for several 
years. After ten years it was observed that he had some signs of exaltation. These 
became progressive, he began to run down rapidly, went into general paralysis and 
died in about eighteen months after the first attack. 
Dr. Yellowlees.-We are all apt to have, and do have constantly, cases of 
general paralysis with constitutional syphilis running its ordinary course and without 
anything exceptional whatsoever about it. I think we want to be careful in our 
deduction as to the effect of syphilis on the history of the disease. They unques- 
tionably coincide and concur in the same individual without the general paralysis 
being at all perceptibly modified thereby. That being so, I think we want to be 
careful about our deductions. I concur, however, emphatically with what Dr. Down 
and Dr. Savage have said about the probably syphilitic origin of those cases which 
begin with spinal symptoms. The result seems to be that in cases of general paraly- 
sis occurring in patients with a history of constitutional syphilis, however, that we 
have the disease modified to a greater or less extent by local paralyses-and by a 
greater tendency to local paralyses than in the ordinary cases, and that this is the 
whole of the matter; at least I don't know that our present knowledge gives us 
further light than this gives us. 
Dr. Nichols.-Mr. President : I will only take the time of the Section long 
enough to say that I treat a good many cases of general paralysis of the insane, and 
have the misfortune to lose from fifteen to twenty by death every year, and I have 
studied as carefully as I have been able to the cause of the disease. In my expe- 
rience I have only been able to trace the existence of a syphilitic disease or hereditary 
taint in about half the cases, and allowing for some uncertainty, in other cases it has 
been my opinion that about two-thirds of our cases have had or may have had 
syphilis. In respect to the remaining third it seems to me that it is pretty clear 
that they have not. I sympathize with what fell from Dr. Yellowlees. I have 
really doubted whether syphilis was an essential cause of general paralysis of the 406 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
insane. It seems to me that those cases that I have not been able to trace to syphilis 
run their course more regularly than those that I can. I have never been able to 
benefit a patient who has not had syphilis by anti-syphilitic treatment, but I have 
retarded the disease in many cases in which I knew the patient had had syphilis. 
My opinion upon the subject of the specific character of general paralysis as a disease 
is not worth much. I think my friend, Dr. Spitzka, is perhaps the best American 
authority. I think he is really very much the best American authority upon this 
subject, and if there is time I should be glad to hear from him. 
It has appeared to me, I might add, that in some way the mental degeneration 
of the brain did take on a specific character, although it is accompanied undoubtedly 
by gross lesions that are common to other forms of brain degeneration ; and I may 
add that I have supposed that excessive venery, excessive intellectual labor and loss 
of sleep were the most efficient causes of general paralysis of the insane. These 
causes, it seems to me, will cause this form of mental disease independently of 
syphilis. It has seemed to me, and does seem to me, that syphilis is not an essen- 
tial cause of general paralysis of the insane. 
Dr. Spitzka.-While agreeing with every material point advanced by the dis- 
tinguished superintendent of Bethlem, I feel constrained to differ regarding the 
subsidiary question of nomenclature. In matters of nomenclature we are apt to 
strain at a gnat and swallow the camel. We use the terms post-febrile, post-epileptic 
and senile insanity every day. In every asylum we are shown cases of puerperal 
and masturbational insanity. In reply to the challenge made here yesterday as to 
the existence of any specific single symptom that distinguished syphilitic insanity, I 
would like to ask what specific symptom characterized any other ætiological form. 
The clinical grouping of symptoms could be pointed to as being as specialized in the 
one as in the other case. 
There does seem to me to exist a group of cases in which, with a background of 
progressing dementia, the suddenness of development of certain motor symptoms 
and the suddenness of their disappearance, as also a peculiar lacunar disturbance 
of the memory, separates them from ordinary paretic dementia. Pathologically I 
think they are characterized by two sets of changes, first a peculiar form of endymal 
granulation in the ventricles. In ordinary hydrocephalus, paretic dementia, and 
epilepsy, the granulations are warty. In syphilitic dementia I have found them 
reticular like the ridges of butter left in separating the halves of a sandwich. In 
the central tubular gray, particularly of the mesencephalon-and this accounts for 
the oculo-motor troubles-small hemorrhages are common. I have brought with me 
and have shown to some of the members present, specimens in which the exact 
localization of a combined internal rectus and accommodation paralysis was possible. 
Both anatomically and clinically this disorder differed from ordinary paretic dementia 
of syphilitic origin. Among the accessory causes of the latter complaint tobacco is 
a most important one. One constantly growing evil seen in large capitals is the 
habit of imperfect coitus indulged in for the prevention of conception. This has a 
most deleterious effect upon the spinal apparatus. Another is the vicious habit 
indulged in by those who are losing sexual power. These certainly are causes of 
locomotor ataxy. I believe that the three w's-wine, women and worry-are the most 
potent factors in causing general paresis. 
Dr. Hughes.-Before the discussion closes, lest the subject should be over- 
looked, I should like to ask Dr. Savage or Prof. Mendel, or any of the other gen- 
tlemen who have paid special attention to post-mortems in cases of general paralysis, SECTION XVII-PYSCHOLOGICAL MEDICINE. 
407 
whether they have had opportunities of making post-mortems in any of these cases 
which have died during a remission-of intercurrent disease. I have a conviction 
that there is something-a vascular condition, a microscopic vascular condition-which 
will ultimately be discovered to have preceded the coarser structural microscopic 
changes which we see in the arachnoid vessels in general paralysis. Now I have in 
mind two clinical cases which, so far as I was able to discover by a close watch of 
the patients, have apparently recovered from what-if my experience at Fulton was 
sufficient to enable me to judge-was general paralysis ; whether they are going to 
stay recovered or not is a question which I cannot answer. I suppose the only way 
we can get at the facts is to be careful to make investigations of these cases which 
die of intercurrent disease during a remission. As you know, we are now at a 
stage in regard to general paralysis of the insane-we stand much as our ancestors 
did in regard to phthisis pulmonalis and in regard to Bright's disease and other 
affections which have been classed as incurable, but which may yet be proven to be 
curable in certain stages and under certain circumstances. I believe general paralysis 
will yet be classified as a form of curable disease if taken early enough for treatment, 
not after they are sent to asylums, but those cases which come under the observation 
of the neurologist and psychiatrist before they become fit subjects for the asylum. I 
have a conviction that the paralytic stage is one of capillary hyperæmia, and the 
question to be gotten at is one which our pathologists must study out for us. 
Dr. Savage.-As to the question of vascular changes I have quite thought, 
with Dr. Hughes, that if any cure is to take place it is to be when the case is taken 
early. The longer we have experience with the disease, and the more we get the 
early history, the more extended the length of time the prodromal symptoms have 
existed. I have within the last five or six years made it a rule, when a patient 
became certainly and undoubtedly a general paralytic, and was recognized as such by 
his friends, then to issue a form of questions as to the very earliest changes in char- 
acter, in handwriting, in vision of one kind or another, and in a very large number 
of cases, eight, nine, ten, or even twelve years before the patient became fit for cer- 
tificates there were signs of the disease, but I think that not in one case out of ten 
thousand would we be able to persuade the patient that he required rest or treatment. 
Especially in some cases with syphilis, I think early treatment will do good ; but I 
am afraid the time is very far distant when we shall be able to persuade those who 
break down with general paralysis that they required treatment years before. 
Dr. Mickle.-Dr. Savage has hardly replied to Dr. Hughes' question. There 
are always found lesions in paralytics who have very extreme remissions and then die 
without the symptoms ever recurring ; for example, they take a severe convulsion 
and die, and the lesions are seen in these cases as in general paralysis. 
Dr. Hughes.-Dr. Mickle has not quite answered the question I asked, whether 
there were ever found cases where there was no appreciable lesion found after death 
when the patient died during a remission ; from pneumonia, for instance. 
Dr. Mickle.-The cases I speak of were insane enough to have come under my 
care, and they died during a remission. Those were precisely the cases to which I 
did refer. 
Dr. Brush.-So far as one case will answer Dr. Hughes' question, I might cite 
that of a general paralytic who died of phthisis during the first remission without 
any return of the mental symptoms. It was a question in my mind at the time 
whether the phthisical trouble did not act like the carbuncular affection which Dr. 408 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Savage reported yesterday as bringing about a remission. The characteristic lesions 
of general paralysis were found at the post-mortem. 
Dr. Hurd.-I would like to ask Dr. Savage a brief practical question. Granting 
that we have cases of general paresis of unmistakably syphilitic origin-I think we 
all agree that we do find them-is there any reason to anticipate benefit from anti- 
syphilitic treatment ? 
Dr. Savage.-Some patients undoubtedly with syphilitic histories, who are suf- 
fering from general paralysis of the insane, rapidly pass, under such treatment, into 
conditions of temporary remission. The only cases of prolonged remission that I have 
seen, or nearly all the cases that had syphilis and had prolonged remissions, were 
treated very definitely anti-syphilitically. 
To take one case under this head, an acute case of general paralysis springing up 
very suddenly in a case of chronic syphilis ; it was that of a patient who had other 
complications, but there was no doubt about the syphilis. He had constitutional 
syphilis at the time. He had a very acute attack of maniacal excitement, refused 
his food and looked as if he would die rapidly with exhaustion. He was treated 
anti-syphilitically, and instead of getting worse, so far as the stomach was concerned, 
he began in two days to take his food freely, and within ten days or a fortnight 
passed into a state of remission. It seems to me that if not cured, these cases are 
relieved-chiefly those cases in which we have got a history of syphilitic lesion. The 
consensus of opinion seems to be that I was right in saying that some cases of gen- 
eral paralysis undoubtedly come from syphilis. There is considerable difference of 
opinion between Prof. Mendel, Dr. Mickle and myself, but this I expect will be 
found to be cleared away in time. We are cautioned by Dr. Yellowlees, and I take 
the occasion of saying that I agree with him when he says we have reached in the 
syphilitic tide of pathology the highest point, and that it is now time to mark a shore 
line. I think the border land that Dr. Spitzka has referred to, the cases of syphilitic 
dementia, are the ones about which we shall always have the greatest difficulty. I 
do not pretend for a moment to be able to say, when a case is brought before me ; 
this is a case of syphilitic dementia, that will live for years, and which might fairly be 
called dementia organica. I do not pretend to be able to say that, nor to say this 
demented case will not take on a more acute process and end as a general paralytic. 
I do not believe there are any defining lines in these cases. I think we are, perhaps, 
too prone to be definite in these matters, especially since we know comparatively so 
little of the relationships between syphilitic dementia and syphilitic general paralysis. 
Accept dementia in these cases, and if they end in this way, let us say they are cases 
of general paralysis of a demented type starting with syphilis. 
VI. PATHOLOGY AS REPRESENTED BY COARSE CHANGES, LIKE GUM- 
MATA, OR SLIGHTER ONES, AS SEEN IN ARTERIAL DISEASE. 
First I recognize a moral element; it is not at all uncommon to see the worry of 
the disease set up melancholia. It is quite easily to be understood how the fear of 
propagating a disease to offspring may modify the life of the individual, and I have 
seen several conscientious men, refraining from marriage on account of an attack of 
syphilis, pass into hypochondriasis. 
Next, the. fact of having givçn a wife or children syphilis may be enough to 
destroy rest and produce nervous exhaustion ; and I here wish to record one case in 
which general paralysis occurred in a man who had had no signs of local intra-cranial SECTION XVII-PSYCHOLOGICAL MEDICINE. 
409 
disease, but who had suffered terribly from the distress caused by the infection of 
his wife. 
SYPHILIS COMMUNICATED TO WIFE, GREAT WORRY, GENERAL PARALYSIS. 
William B. J. ; married ; age thirty-six ; photographer ; admitted February, 
1886. No neurotic history, first attack. He contracted syphilis before marriage ; 
had but slight secondary symptoms and married two years later. His wife had no 
children, but developed secondary syphilis in a very marked way, and has for years 
been a martyr to all sorts of troubles due to this source. 
She is now suffering from syphilitic laryngitis. The patient has had no symp- 
toms of cranial nerve paralysis, but has been greatly distressed by his wife's suffer- 
ings and also by business worries. 
Eighteen months before admission he began to lose his memory ; he had severe 
headache four months before admission. He had hallucinations of sight. Right 
pupil larger ; walk feeble, tottering ; knee reflexes brisk. 
On admission he was suffering from confusion and weak mind ; he was restless 
and incoherent ; pupils unequal ; skin greasy ; labial tremors and twitchings ; great 
physical weakness ; loss of vesical control ; some exaltation noticed in his incoherent 
babble ; optic discs hazy, probably due to old syphilitic retinitis. He was ordered 
potass, iodid., gr. x. Fie had cystitis and once hemorrhage from the urethra, and 
haematoma occurred in right ear. After a year he was discharged uncured. 
Next, I have to note that several cases have been admitted suffering from a most 
cachectic state, with rupial sores and general anaemia as the result of syphilis, and in 
these I feel inclined to think the mental aspect, which was generally melancholic, 
was chiefly due to the bad state of nutrition of the nervous system. Besides this, 
there is a widespread idea that in syphilis there may be general vascular changes 
which may interfere with the general and special nutrition, and that in such cases 
the nervous system, which needs such constant supplies of fresh, healthy blood, 
suffers early and seriously. In support of this I have referred to certain cases in 
which capillary stigmata were present on the face. I have referred to this else- 
where, and shall be glad to hear if it is a fact or only a fancy begotten by a few 
coincidences. 
In many cases I could record the marked changes present in the vascular system, 
and, though simple atheroma is not more frequent in cases of general paralysis with 
syphilis than others, yet it is often found. 
I do not think that I can too often repeat that I do not find anything special in 
these cases which would not have been found in any other cases of general paralysis. 
I do not find any specific overgrowth of fibrous tissues either about the vessels or 
elsewhere. 
Next, as to gummata. I can only say that though in Bethlem we have a fair 
opportunity for making post-mortem examinations, I can hardly recall a single case 
in which there was to be found a gumma to account for the symptoms. I have often 
diagnosed them, but have not found them. It seems to me that the changes, such as 
ptosis and external strabismus, which we so frequently meet with, are not so com- 
monly the result of coarse changes as we were led to expect. My own opinion is that 
in many of these cases local causes of interference with nutrition arose, and were much 
more easily removed than would be a solid growth like a gumma. In fact, I feel 
that the rapidity of the cure of these cases is against their being due to gummata. 
Next, as to the general results of these local changes. Whether the changes be in 
the vessel walls or not, there appears to be a local interference with nutrition which 410 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
may be recovered from, but which is rarely cured without a scar, and this scar may 
be the starting-point of degeneration. In nearly every case in which we have gen- 
eral paralysis following on these local troubles we have some other active cause for 
the break-down, thus, over-work, worry, sleepless anxiety, drink, injury, or excess. 
There is one other factor deserving, nay, demanding notice-hereditary predisposi- 
tion to neuroses. In these cases the weak point is the nervous system, and here we 
get the first evidence of the general degenerative changes. I cannot go so far as 
some have, and say that with heredity you are almost always sure to find syphilis 
selecting the nervous tissues. 
I believe in most cases there has been some vascular and tissue change in the 
nervous system, and that this may be quite general; that the selective nature of the 
disease affects certain parts more than others, and that though recovered from there 
is vascular weakness; or there is some exudation material which is not perfectly 
absorbed, and which will under some conditions begin to act as a fresh cause of irri- 
tation, and, in some cases, may set up a rapid change which runs its course in a few 
weeks, while in other cases the process is slow in the extreme if we are to consider 
it as allied to inflammation. 
I cannot believe that a poison is locked up for so long a time-ten, fifteen, twenty, 
or even thirty years-and then in the shape of bacilli invades the tissues. Once 
more, I would suggest that in some cases the treatment may have something to do 
with the symptoms. 
I have been struck by the number of patients who, having been thoroughly well 
treated with mercury, have become general paralytics, and in many of these cases 
there was very great tremor, in some cases recalling mercurial tremor. I have no 
proof of this, but I have grave suspicions, especially since I have found so many 
victims among medical men who have kept themselves for years on a course of mer- 
cury. As to the general pathology of these cases, I can only repeat that it is that 
of general paralytics generally. 
LEFT HEMIPLEGIA FROM DESTRUCTION OF THE RIGHT 
PARIETAL CONVOLUTIONS, SUCCEEDING TO A 
VEGETATIVE ENDARTERITIS. 
HÉMIPLÉGIE GAUCHE PAR SUITE DE LA DESTRUCTION DES CONVOLUTIONS 
PARIÉTAIRES DROITES SUCCÉDANT A UNE 
ENDARTÊRITE VEGETATIVE. 
LINKSSEITIGE HEMIPLEGIE DURCH ZERSTÖRUNG DER RECHTEN PARIETALEN HIRN- 
WINDUNGEN, IN FOLGE EINER WUCHERNDEN ENDARTERITIS. 
BY LOUIS FRIGERIO, M.D., 
Alexandria, Italy. 
The importance of the subject rather than the special merits of the following case, 
encourages me to contribute what may be of value in the engaging, but not always 
stable, theory of cerebral localization. 
Rose F. deB.; age sixty-four years; midwife; no insane relatives; of an uneasy and 
crabbed disposition, though she had discharged commendably the duties of her vocation 
during ten years of married life she had one miscarriage and bore one child that she 
nursed ; she had not been addicted to bad habits. SECTION XVII-PSYCHOLOGICAL MEDICINE. 
411 
About seven years ago she manifested evidence of mental disorder in exaggeration 
of religious sentiment, fear of damnation, etc., induced or promoted by hallucinations 
of sight. 
Insomnia and sitofobie developed and aggravated the sad condition of F., and this 
was followed, but at an undetermined time, by an attack of apoplexy, of which the 
effects disappeared spontaneously. 
When she was brought to the asylum she was very much disordered in mind and 
body, easily irritated and quarrelsome, perfectly free and correct in her movements, but 
with notable feebleness and emaciation. There was manifest rigidity of the temporal 
arteries, the pulse was full, and there was a diminution of the first sound of the heart, 
with a blowing murmur. 
A few months thereafter she was again attacked with apoplexy with loss of motion 
and sensation on the left side of the body; contemporaneously she was taken with con- 
vulsive movements, and at the same time an obstinate itching in the paralyzed mem- 
bers. Thereafter the left leg was attacked by a gangrenous erysipelas which recovered 
in a short time, but there remained the lesions of motion and sensation -the stipsie and 
the sitofobie. 
Mentally the condition remained nearly unchanged; she wept and groaned, being 
always disturbed by hallucinations and illusions of the sense of hearing; and quite fre- 
quently during a period of relative calmness she would use, in speaking, the phraseology 
belonging to her vocation-the dim and confused remembrance of a remote experience. 
Thereafter the emaciation continuously increased, and each day rendered more 
marked the suggillations on the left side of the body; after some months the scene ter- 
minated in a last attack of apoplexy, to which F. succumbed. 
The calvarium was of quite uniform thickness, rich in supplementary grooves along 
the lambdoidal suture. The right hemisphere measured 18.5 cm., the leit 18 cm. ; the 
former weighed 486 grm., the latter 478 grm. The cerebellum, isthmus, and bulbe 
weighed 236 grm. Total, 1200 grm. 
The right parietal convolutions were lost, being replaced by a cyst filled with a 
limpid serum, of a lemon-yellow color, in quantity equaling a hen's egg. This cavity was 
bounded by a membrane of appreciable thickness, which was adherent to the white 
substance. In addition, the first temporo-sphenoidal convolution along the fissure of 
Sylvius, and the lobe quadrangulaire were involved in a process of softening, which 
lesion was limited, in a well defined manner, by the seconde circonvolution occipitale 
postérieure. 
The lesion of the parietal lobe penetrated to the roof of the left lateral ventricle, 
the walls of which were covered with a layer of gelatinous material, so that the 
vessels were scarcely visible. The lateral ventricle itself was greatly dilated, and the 
vessels in its walls were extraordinarily distended. 
A second centre of softening was found in the posterior lobe (separated from the 
former by the thickness of a convolution) of the diameter and form of a centime défraie; 
and a third centre of softening, more superficial, was found at the inferior free border 
of the same lobe-circonvolution occipitale externe postérieure. 
The arteries supplied to the involved parts were atheromatous, more especially the 
following: the anterior cerebral; the middle cerebral; the ascending parietal, which, to 
the unaided eye, seemed normal, but, when examined by the microscope, fatty infiltra- 
tion of the middle coat was found. Of the branches proceeding from the basilar the 
right posterior cerebral was of irregular calibre, due to the presence of atheromatous 
patches. 
The heart was large, covered with fat; the arch of the aorta thinned, the internal 
surface covered with vegetations of a yellowish-red color, which, by microscopic exami- 412 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nation, appeared composed of fat and a material of the nature of granulation tissue 
(nouvelle formation}. 
Nothing notable in the other organs was found. 
CONSIDERATIONS. 
By the general result of the microscopic evidence it is not difficult to go back to the 
origin of the pathological changes sustained by our patient, and, by inference, to recon- 
struct the history. 
It is not improbable that the first symptoms of insanity, occurring at about fifty- 
seven years of age, had their cause in the irregularity of the circulation induced by the 
diffuse endarteritis, the physical results of which were manifest at the autopsy; we 
believe the endarteritis to have caused-by embolism, through the transportation of 
detritus from the vegetations which had successively formed in the arch of the aorta- 
the first attack of apoplexy not followed by persistent motor lesions, and which sponta- 
neously recovered by the establishment of the collateral circulation. 
The disorders of sight, which manifested themselves in hallucinations, were possibly 
only another effect of the disordered circulation through the atheromatous posterior 
cerebral artery of the right side, which, later, induced the softening of the right poste- 
rior occipital convolution, as previously described. 
The left hemiplegia which followed is to be considered as undoubtedly produced by 
the large centre of softening that constituted the lesion destructive of the convolutions 
of the parietal lobe, which lesion was dependent on the failure of the circulation induced 
by the pathological condition of the anterior and middle cerebral arteries-the arterial 
supply of the parietal lobe. 
Three apoplectic attacks, three centres of disease, three orders of trouble are noted 
in the case described. As to the centres of softening found in the occipital lobe, would 
it be proper to attribute to them the gangrenous erysipelas and the cutaneous suggillations 
that appeared on the left inferior extremity? According to the opinion of Geoffroy, who 
considered the occipital lobes as trophic centres, that explanation seems reasonably 
plausible if it should be confirmed by a larger number of facts. 
HOSPITAL AND ASYLUM CONSTRUCTION FOR THE INSANE. 
SUR LA CONSTRUCTION DES HÔPITAUX ET D'ASILES POUR LES ALIÉNÉS. 
ÜBER DIE KONSTRUKTION VON HOSPITÄLERN UND ASYLEN FÜR DIE IRREN. 
• BY P. M. WISE, M.D., 
Of Willard, N. Y. 
The location, plans, and environment of hospitals and asylums for the insane have 
such a near relation to the treatment and care of the insane that they may properly be 
considered medical questions of sufficient importance to receive the earnest attention of 
the profession. There has been no factor of the marked changes in the treatment of 
the insane during the past quarter of a century, particularly in America, that has been 
of greater importance than the asylum aspect; and the last decade has been a period of 
departure from monotonous asylum construction as wide as any feature of the modifi- 
cation of treatment and care of the insane in asylums. These changes are not only a 
result of a better knowledge of the nature of insanity, and the abolition of dogmatic SECTION XVII PSYCHOLOGICAL MEDICINE. 
413 
requirements in its treatment, but they have also, in part, outgrown from a liberal and 
comprehensive study of the relations the dependent insane bear to society and the 
public welfare. 
The tendency has been away from a rigid classification and inflexible grooves of 
treatment and care of the insane, toward the recognition of an individual measure of 
responsibility, and the greatest flexibility of classification and treatment. It has been 
found expedient and advantageous to conform asylum life to domestic conditions in a 
greater degree than was previously considered possible, and the influence of such expe- 
rience is exhibited in recent asylum plans. 
It is a fair assumption, based on the century's experience, that the mass of the 
insane will continue to be dependent on public support, and will require treatment and 
care in organized institutions-hospitals and asylums. For the present purpose it may 
also be assumed that the progressive increase in the numbers of the dependent insane, 
and the consequent burdens imposed upon the public, will, for reasons of economy, if 
for no other, lead to the creation of large institutions. The tendency toward larger 
hospital and asylum capacity has been a progressive one in nearly all countries. In 
America it was the recorded sense of the Association of Medical Superintendents, less 
than forty years since, that the preferred maximum number for an institution for the 
insane was two hundred, while to-day there are approved asylums that have eight-fold 
this capacity. 
The aggregation of the insane in hospitals, due to the retention of the chronic class, 
transforms them into asylums, and in very few instances has it been found possible to 
preserve a distinctively hospital character in our public institutions for the insane, 
however great such a desideratum might be sought. An analysis of the population of 
the average lunatic asylum in America will show a large preponderance of cases that 
have passed the hospital stage, and are retained for custodial care; and, as far as I am 
acquainted, this will apply to the public asylums of Great Britain and the continent. 
If, then, by virtue of public policy or expediency mixed asylums with a large 
capacity are unavoidable; or, if, for purposes of classification and as a provision for the 
varied conditions that are highly desirable as a means for the moral or mental treatment 
of the insane, the large hospital asylum is the most subservient, then the asylum struc- 
ture should be made conformable to its probable requirements. 
This proposition is self-evident, but until recent years asylum plans have presented 
a monotonous uniformity, and the linear gallery with its dormitories was their constant 
characteristic. That the asylum structure of the past is not now approved by the pro- 
fession, is shown by the voluminous correspondence of the Commission to locate and 
plan a State asylum in New York. The counsel received by the Commission from the 
highest authority in this and other countries, urged that the construction should con- 
template a more liberal, intelligent and flexible classification; greater subdivision, and 
variety of situation; separation of the classes; a nearer approach to domestic construc- 
tion for convalescents and patients with normal sensibilities, and an avoidance of dull 
uniformity of aspect. 
The danger to be apprehended in a departure from old methods is, that errors 
escaped may be multiplied in a new form. Reform movements, like the swinging 
pendulum, rarely stop at a centre before reaching extremities, and the tendency that 
now exists, favorable to subdivision of structure, may be carried too far. Several asy- 
lums in America present recent examples of extreme views relating to subdivision, and 
they are consequently not calculated to accomplish their purpose in one direction any 
better than the old linear plan failed to accomplish in another. 
It may be held, primarily, that the central building and its wings, in some form, is 
indispensable. There is no practical substitute for the hospital plant, as it is ordinarily 
understood, but even here there can be a healthy departure from linear building, and 414 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the corridor plan is not a necessity. The New York Commission so interpreted the 
prevailing opinions of the experts consulted, and prepared plans for a hospital for two 
hundred and fifty patients, with eight subdivisions, in addition to the residential and 
official buildings. These buildings, separated about one hundred feet, can be practically 
isolated by a ligneous growth, but they are connected by corridors in a manner that 
renders them as effective for administrative purposes as if the hospital was a congregate 
structure. The elevation of this street of two-story houses is devoid of uniformity and 
entirely free from the institutional aspect, and might be taken for a street of suburban 
villas. The classification of hospital cases only was contemplated in the arrangement 
of interiors. Three of the buildings for either sex are two-story, with parlors and day 
rooms on the first floor and dormitories on the second floor. The terminal building of 
either wing is one story in height and arranged for the care of the most disturbing ele- 
ment of the hospital, in a manner that isolates the rooms from the main hospital, while, 
at the same time, they are within easy reach of the resident physician. Ninety per 
cent, of the dormitory accommodations are single rooms, and there is ample provision 
for night attendance. After the policy of the asylum at Alt-Scherbitz, there is a recep- 
tion ward, an observation and hospital ward for either sex, the latter calculated also as 
a residence for a physician. The day accommodations are as diversified as it is possible 
to make them, without disturbing the ease and cost of administration, or the hygienic 
requirements. 
The Commission considered this hospital plant adequate for an asylum of at least 
one thousand patients, based upon the average proportion of acute insane in existing 
public hospitals in this country. The remainder, or the chronic insane may be pro- 
vided for in a diversified manner, but objection to their segregation is not valid, pro- 
viding it does not increase the cost of construction, maintenance or administration ; 
while the advantages of an entire separation of certain classes of the insane are too 
great to be overlooked. Above all in importance is construction for the special care of 
the suicidal and epileptic, and for the separation of the grossly demented and filthy 
patients from others. These classes demand night care and the attendance should be 
continuous. To provide a constant surveillance for these classes, construction must 
specifically contemplate such care, and the pity is that it seldom does. At the Willard 
Asylum, in New York, a short experience with one-story buildings, containing large 
day rooms and dormitories surrounded by wide verandas, and organized with equally 
efficient forces of day and night attendants for the care of terminal dements and epilep- 
tics, has changed the character of its chronic insane population to a degree that cannot 
well be expressed without statistics, besides affording marked and grateful relief to 
other portions of the asylum. 
With a due allowance for climatic conditions, the additions to a hospital where the 
chronic insane are to be received and retained, can be better adapted for the various 
purposes of classification, and more economically provided, by detached buildings of an 
inexpensive character, than by the congregate system. Buildings accommodating from 
twenty-five to fifty patients can be grouped to afford united kitchen and dining arrange- 
ments ; or, what seems to me preferable, the segregation may be more than nominal, 
by a division of the domestic arrangements. The nearer the approach of accommoda- 
tions for the chronic insane to ordinary home life, the fewer coercive measures will be 
required for their retention, and contentment will be gained. This will apply as well 
to the milder cases of recent insanity. With the ordinary class of insane dependents, 
the kitchen with its labors supplies a home feeling that cannot be otherwise acquired, 
and its multiplication should not therefore be discouraged, even should it add triflingly 
to cost of operation. 
Sanitary and constructive details that apply to general hospitals, are of like conse- 
quence to hospitals for the insane, but fire prevention has an extraordinary importance SECTION XVII PSYCHOLOGICAL MEDICINE. 
415 
that cannot be too strongly emphasized. It may be impracticable to build so-called 
fire-proof structures for all the insane, but it is not unreasonable to hope that buildings 
can be provided with ample means for escape in case of fire, and such holocausts of 
insane that have been only too frequent in the last few years may be prevented. It 
should be a cardinal rule to construct no building for the insane higher than two stories, 
and to have not less than two stairways leading from the upper story of each division, 
convenient and easily accessible from all the rooms. Lighting by incandescent electric 
lamps, where the plant is carefully installed, will lessen danger from fire. Statistics 
of asylum fires show that many of them start from the gas flame. Where buildings are 
heated by steam or hot water medium, the necessity for the use of matches in the 
wards will not exist. 
The prevailing methods of ventilation in asylums are all effective, but one natural 
means of air circulation that is almost wholly neglected in America, is by open fires. 
Where they are built the flues are usually contracted and the capacity is small. Large 
fine areas with an ample fire surface effect a triple purpose, in increasing in a very 
marked manner the cheerfulness of a ward, in adding a quota of heat, and in affording 
a most valuable means of forcible ventilation. 
Preliminary to asylum construction, questions are submitted that have an important, 
and sometimes a vital, bearing on the future usefulness of the institution, and relate 
chiefly to site, aspect, elevation and agricultural area. It is unfortunate that these 
questions should so frequently be submitted to non-professional bodies, who are unable 
to comprehend their full significance, either as factors in the administration of the 
institution or as they relate to the treatment and welfare of the insane. A mistake in 
location, like an error in construction, cannot be corrected during the existence of the 
asylum. No rule is applicable to asylum location, but a pleasant environment, natural 
and uninterrupted drainage facilities, a bountiful water supply and a sufficient agri- 
cultural area should be gained at the expense, if necessary, of removal from the prox- 
imity of populous centres. Facility of access is a matter not always fully considered, 
even in countries that are densely populated. An asylum visitor in Great Britain, as 
well as upon the Continent and in America, will find suburban asylums that cannot be 
reached as easily or as cheaply as those in the more distant country. Contracted prem- 
ises for an asylum should be avoided. The asylum superintendent who has been 
embarrassed by a narrow domain can fully appreciate the relief afforded by a large 
agricultural area. In addition to supplying employment of an agreeable kind, whether 
the patients are drawn from an urban or agricultural district, it offers innumerable 
advantages in walks and drives upon hospital grounds, and the necessity for enclosures 
is obviated. Based on the American asylums' experience, the minimum area should 
not be less than one-half acre per patient. 
The importance of a bountiful water supply and facilities for drainage and sanitary 
filth disposal cannot be overestimated. The selection of a site near a river or lake, 
where this is possible, furnishes each, besides adding to the capabilities for attractive 
environment. These trite conditions are too frequently disregarded, and in this country 
there are asylums whose usefulness is crippled from a neglect to obtain these funda- 
mental requirements in location. 
The location of State or public asylums in America, to which my remarks should 
chiefly be applied, and usually the preparation of plans for construction, are questions 
submitted to Commissions which are subject to appointment upon political grounds ; 
and, although they may be conservative and intelligent, they are frequently, I may 
safely say usually, devoid of knowledge of the requirements of hospitals for the insane, 
as such requirements relate to site and construction. Unfortunately, and because they 
are otherwise unprepared for judgment, such bodies act on syncretic advice, and follow, 
if not desultory, then plans of existing asylums that may be poorly adapted to any but 416 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
their particular location. Dr. Bucknill furnishes an illustration of this fact, in his 
graphic description of a Swedish pavilion asylum, which was adopted on foreign 
recommendation, that proved an abnormity in that particular climate. Anomalism in 
asylum structures should not be discouraged, if it is controlled by an expert knowledge 
of requirements, but a departure from established methods of provision for the insane 
for the mere sake of producing an anomaly, and without any other specific purpose, 
may be regarded as an unwise policy. 
Each State, in fact, each individual commission, acts upon its own laws, and seeks 
its own counsel. Where there is an honest endeavor to befit the commission for its 
official functions from existing asylum experience, the difficulties that are encountered 
are discouraging. Tedious and expensive journeys have to be undertaken and various 
asylums have to be visited. In the confusion occasioned by the problem before them, 
it is too frequently the case that immature suggestions are favorably received and acted 
upon. There is no bureau of information to which they may resort, and even in the 
several States, Boards of Charities cannot supply the complete data that such a body 
should require. 
In view of these difficulties and the fact that millions are annually expended for 
asylum and hospital structures, it is suggested that there might be added by the central 
governments a department devoted to all that appertains to hospital and asylum loca- 
tion, sanitation, construction, organization and management, not only in its own, but in 
foreign countries. Information can be obtained by a central government through its 
ministers that cannot otherwise be practically reached, and by the home government 
may be diffused or made available to the largest numbers. An illustration of the 
effectiveness of such a process is presented in the Report of Parliament on the working 
of Lunacy Laws in various countries, by her Majesty's representatives abroad, in 1885. 
Such a department, if properly organized and equipped, could be maintained at an 
expense that would appear trifling compared with the effective purposes it might serve. 
It would tend to unify the best features of asylum construction in all countries, as well 
as to diffuse a better understanding of the progressive changes in asylum practice and 
management. With an efficient department of the government of this nature, it 
would not require a quarter of a century for us to appreciate the position of British 
alienists on the subject of non-restraint. 
EXAMINATION OF THE BRAIN CONDITION OF CHILDREN. 
EXAMEN DE LA CONDITION DU CERVEAU DES ENFANTS. 
ÜBER UNTERSUCHUNG DES GEHIRNZUSTANDES BEI KINDERN. 
BY FRANCIS WARNER, M. D., F.R.C.P., F.R.C.S., 
Of London, England. 
Many reasons may be given, showing why we should be interested in examining 
the brain condition of children. At an early age the nerve system is more mobile, and 
more impressionable than in the adult, and its action is more spontaneous. In the 
clinical examination of a young child, whatever its condition may be, the state of the 
nerve system forms an element which we can never afford to omit from our diagnosis 
and prognosis. Again, the clinical study of the physiological brain is a simpler matter 
in the child than in the adult, the expression of psychological action is simpler at the SECTION XVII-PSYCHOLOGICAL MEDICINE. 
417 
early age. In prosecuting such studies, observations should be made among well- 
developed children and then compared with cases presenting defects ; the contrast 
throws each into greater relief ; in studying the nerve system of children it is not neces- 
sary to go far to find specimens of imperfections, the percentage of defective cases is 
greater in children than among adults, on account of the high mortality among those 
of feeble brains. 
There is another reason for the special study of the brain condition of children ; it 
is among the young that we find the greatest scope and opportunity for improving the 
brain by the processes of a wise educational training. If we wish to study children as 
subjects for education, it is probably desirable to see them in school as well as under 
other circumstances, and observe the outcome of brain conditions as affecting the moral 
and intellectual faculties of the individual. Such considerations may well serve to 
draw the psychologist into the school to study as well as to advise. 
Is it practicable to observe the brain condition of children in schools without inter- 
fering with lessons ? The answer is best given by describing the method pursued. ' 
The principles involved in the methods of observation suggested must first be 
explained. Observe the signs of nutrition ; the signs of development ; the passive 
motor signs and the actual movements. All expression of mind is by movements, and 
these are the direct outcome of the action of nerve centres. The nutrition of the body 
should be observed, not only in the face, but also in the limbs ; note the form, size and 
proportions of the body and its parts, including the separate features, as well as the 
make and color of the skin. The brain is an integral part of the body, and the general- 
ization may be given, that when one or more of the visible parts of the body are defective 
in development the brain is likely to be defective also. 
Let the child stand up and hold out his hands, opening the fingers. The postures 
of the head, the spine, the upper extremities and the digits, as produced by the nerve 
system, may thus be determined. The movements in the body should be observed at 
the same time. Postures are due to balance of nerve-muscular action, or the ratios of 
action in the respective nerve centres. Movements are the direct outcome of nerve 
stimulation of muscles; we observe the parts moving, the time and quantity of the 
movement. 
I must not engage your time in repeating work given elsewhere; typical postures of 
the various parts of the body have been given as aids to descriptions of brain states, and 
various nerve-muscular conditions of the face, eyes, and hands have been described. 
Eight typical hand postures have been suggested; that named the "nervous posture " 
is very characteristic, the wrist being drooped, the knuckles over-extended; this posture, 
associated with finger twitching and a relaxed condition of the orbicular muscles of the 
eyelids, is commonly significant of liability to recurrent headaches. 
The average cerebral development and brain power of children is a point worth 
determining. We should like to have some exact knowledge concerning the cerebral 
and psychical condition of children of various social classes under various conditions. 
For this purpose it is very desirable to examine 10,000 children in schools in England, 
America, and other countries. 
A method of examining children has been sketched, the principles involved and 
some of the signs to be observed have been briefly indicated. Having visited many large 
schools in London and elsewhere, I can assure you that teachers, especially women, 
show an eager desire to study children and to understand the make and condition of those 
placed under their care. It also appears quite possible to give teachers some knowledge 
of what they may observe for themselves. Nurses have taken better and more intelligent 
care of our patients in hospitals since we have taught and trained them. 
Our system of compulsory education has created a public responsibility to see that 
all children in our primary schools are trained, and none neglected, or allowed to pass 
Vol. V-27 418 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
from the schools to mental degradation because they are not understood and properly 
cared for. 
I would submit that children can be classified in schools by scientific observation as 
to their brain power. Feeble-minded children are not suitably trained in large classes, 
but can be educated in small classes under special teachers in day-schools: such children 
should be trained in the interest of the public. 
Appended is a list of signs which may be looked for in making observations. Typical 
hand postures; similarity or assimilarity on the two sides; finger movements; tremor. 
The balance and symmetry of the spine, lateral or antero-posterior bendings. The 
position of the hand and its movements, flexion, extension, rotation and inclination. 
The face, the upper, middle, and lower zones, looking for symmetry in each area. The 
eyes, their movements, whether spontaneous or controlled by sights and sounds. 
EXPERIMENTAL AND CLINICAL OBSERVATIONS OF COCAINE. 
OBSERVATIONS EXPERIMENTALES ET CLINIQUES SUR LA COCAINE. 
EXPERIMENTELLE UND KLINISCHE BEOBACHTUNGEN ÜBER DAS COCAIN. 
PROF. DR. M. ROSENTHAL, 
Of Vienna, Austria. 
The excellent results obtained from the use of cocaine in the different departments 
of medicine induced me to make investigations on the physiological and clinical effects 
of this remedy. A large number of experiments were made on dogs, in the laboratory 
of Dr. Basch. The solution of cocaine was introduced in the vena jugularis externa 
(1:100). The experiments tended to illustrate the pressure of the blood, not only as 
hitherto in the arterial, but also in the venous system (especially in the vena axillaris), 
under the influence of cocaine and other remedies combined with it. According to 
these investigations the clinical effects of cocaine should be shown in forms of central 
diseases. I will here give the principal phenomena of the experiments and of the 
clinical observations :- 
1. The injection of small quantities (0.01 grm.) first produces a considerable increase 
of the pressure of blood in the arterial system and acceleration of the pulse; the pressure 
of blood in the veins is not altered. The injection of larger doses (0.04-0.05) 
induces a rapid fall of the pressure of blood in the arteries; the pressure in the veins 
is often lowered to the negative. In such cases the injections of strychnine have no 
stimulating power on the pressure of blood vessels. 
2. The slowness of the pulse after injections of cocaine is most combined with 
increase of the venous pressure. The same phenomena is to be observed, if larger doses 
provoke a rapid decline of the pressure of blood in the arteries. It is evident that there 
is not always a parallelism in the action of the two representants of the vascular system. 
The same different effect I observed also in the employment of morphine. 
3. The injection of larger doses of cocaine is very soon followed by a rapid collapse of 
both vascular pressures (after the use of 0.1-0.15). The action of the heart is stopped. 
Even by the injections of greater quantities of strychnine no benefit is obtained. The 
cocaine, employed in large doses, is an active cardiac poison. 
4. If the pressure of blood is not yet much lowered by cocaine, the injections of SECTION XVII-PSYCHOLOGICAL MEDICINE. 
419 
strychnine may often bring a recovery. The changes of vascular pressure are propor- 
tionate to the quantity of the injected matter. 
5. Experiments upon dogs prove also the good effect of the injections of cocaine in 
cases of first tetanizing action of strychnine. The cocaine stimulates the cardiac and 
vascular functions. 
The interesting results of experimentation on animals may also be taken into con- 
sideration for the purpose of interpretation of symptoms in some nervous diseases and 
other organic affections. In several cases after the employment of cocaine, the phe- 
nomena revealed to us an increase of pressure in the vascular system. In other cases 
the local effect of anaesthesia prevailed. 
In several forms of neurasthenia, associated with periodic anxiety, pallor of the face 
and upper limbs, small pulse and lessened arterial tension in the radialis, I could ob- 
serve a good effect of the methodic employment of cocaine; increasing doses of the 
alkaloid (0.02-0.03 twice a day) administered for some weeks, contributed to calm the 
abnormal impressionability and anxiety. The pulse becomes stronger, the arterial 
tension more vigorous, the mind more energetic. 
In two cases of affection of the posterior columns of the cord (tabes dorsalis) I 
obtained temporary good results, if the lancinating, shooting pains were combated by 
hypodermic injections of cocaine. In both patients the violent neuralgic pains were 
associated with subjective sensations of cold, with discoloration of the integument of 
the limbs, and with local cutaneous hyperæsthesia ; the pulse small and feeble. After 
the hypodermic injection of cocaine (3-5 : 100) in 15-20 minutes the warmth returned, 
the skin of the limbs was without any hyperæsthesia, well colored, and the seat of an 
agreeable perspiration. The pulse stronger and of higher arterial tension ; very soon 
also recovery of the motor power. But the long employment of the cocaine produced 
anorexia, dyspepsia, nausea, dizziness, headache, and general exhaustion. The remedy 
was in such cases no longer efficacious. 
In chronic diseases with dropsy, hypodermic injections of cocaine (0.03) are of good 
effect. But no permanent benefit is obtained. The dropsy returned after the omission 
of the remedy. The diuresis is produced by the increase of the pressure of blood and 
of the cardiac action. 
The local effect of anaesthesia is manifest, if the cocaine is introduced by the ways 
of digestion. For instance in cases of nervous cardialgia, frequently observed in 
anaemic and hysterical individuals, the occasional administration of cocaine constitutes 
an efficient remedy during the attacks themselves. The solution of cocaine is to be 
given (0.15-0.2: 150) by the coffeespoonful every fifteen minutes, till the pain is 
calmed. 
In the painful sensation of hunger, occurring with unusual frequency, in boulimia, 
the hyperæsthesia of the pneumogastric is also appeased by the longer employment of 
cocaine (0.01-0.02 three times a day). In a hypochondriac, who had been benefited by 
the treatment with cocaine, I was obliged to omit the remedy, as digestive disorders 
appeared. The patient was afraid he would entirely lose his appetite. 
Finally it may be mentioned, that the annoying noises in the ears produced by 
larger doses of quinine or the salicylates, are very much mitigated by the combination 
of the drugs with small doses of cocaine (0.01 : 1.0). SECTION XVIII-DENTAL AND ORAL SURGERY. 
President: JONATHAN TAFT, M. D., Cincinnati, Ohio. 
OFFICERS. 
VICE-PRESI DENTS, 
W. W. Allport, m. d., Chicago, Ill. 
Frank Abbott, New York, N. Y. 
S. W. Dennis, m. d., San Francisco, Cal. 
C L. Ford, m. d., Ann Arbor, Mich. 
Dr. Kuhn, Paris, France. 
Dr. W. Bowman McLeod, Edinburgh, Scotland. 
Dr. A. T. Metcale, Kalamazoo, Mich. 
Dr. H. J. McKellops, St. Louis, Mo. 
Dr. A. L. Northrop, N. Y. 
Dr. W. H. Morgan, Nashville, Tenn. 
Dr. L. D. Shepard, Boston, Mass. 
Dr. W. W. H. Thackston, Farmville, Va. 
Dr. T. D. Harding, England. 
A. M. Dudley, m. d., Salem, Mass. 
F. H. Rehwinkel, m. d., Chillicothe, Ohio. 
SECRETARIES. 
Dr. E. Brasseur, Paris, France. 
Dr. E. Foerberg, Stockholm, Sweden. 
Dr. Jaul Schwarze, Leipsig, Germany. 
COUNCIL. 
Dr. F. Abbott, New York, N. Y. 
R. R. Andrews, m. d., Cambridge, Mass. 
W. C. Barrett, m.d., Buffalo, N. Y. 
C. F. W. Boedecker, m. d., New York, N. Y. 
Dr. C. A. Brackett, Newport, R. L a 
Dr. J. S. Cassidy, Covington, Ky. 
B. H. Catching, m. d., Atlanta, Ga. 
Dr. George H. Chance, Portland, Or. 
E. S. Chisholm, M. d., Tuscaloosa, Ala. 
C. C. Chittenden, m.d., Madison, Wis. 
Dr. D. M. Clapp, Boston, Mass. 
Dr. W. R. Clifton, Waco, Texas. 
E. T. Darby, m. d., Philadelphia, Pa. 
Dr. K. B. Davis, Springfield, Ill. 
Dr. A. M. Dudley, Salem, Mass. 
Dr. Geo. L. Field, Detroit, Mich. 
M. W. Foster, M. d., 
C. E. Francis, m. d., New York, N. Y. 
George G. Freiderichs, m. d., New Orleans, La. 
F. J. S. Gorgas, m. d., Baltimore, Md. 
Dr. Geo. W. Keely, Oxford, Ohio. 
Dr. C. E. Hill, Brooklyn, N. Y. 
A. 0. Hunt, m. d., Iowa City, Iowa. 
Dr. R. Finley Hunt, Washington, D. C. 
Dr. P. G. C. Hunt, Indianapolis, Ind. 
Dr. E. E. Kirk, Philadelphia, Pa. 
James Lewis, m. d., Burlington, Vt. 
C. A. Marvin, m. d., Brooklyn, N. Y. 
James McManus, M. d., Hartford, Conn. 
Dr. T. T. Moore, Columbia, S. C. 
J. Hall Moore, m. d., Richmond, Va. 
Dr. W. N. Morrison, St. Louis, Mo. 
Dr. Edgar Palmer, La Crosse, Wis. 
Dr. S. B. Palmer, Syracuse, N. Y. 
Dr. J. H. Plomteaux, San Francisco, Cal. 
Dr. A. O. Rawls, Lexington, Ky. 
Joseph Richardson, m. d., Terre Haute, Ind. 
C. W. Spalding, m. d., St. Louis, Mo. 
W. A. Spaulding, m. d., Minneapolis, Minn. 
C. S. Stockton, m. d., Newark, N. J. 
Dr. A. H. Thompson, 'J'opeka, Kansas. 
Dr. James Truman, Philadelphia, Pa. 
Dr. E. V. Turner, Raleigh, N. C. 
W. C. Wardlow, m. d., Augusta, Ga. 
J. W. White, m. d., Philadelphia, Pa. 
W. G. Younger, m.d., San Francisco, Cal. 
421 422 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met at 3 P.M., in the Universalist Church, corner of Thirteenth and 
L streets. 
Dr. J. Taft, m.d., d.d.s., of Cincinnati, Ohio, President of the Section, called 
the meeting to order, and said that, as there were many brethren of the profession 
present from other countries, it was proper that, in the outstart, they should have a 
word of welcome. He therefore asked that Dr. W. W. II. Thackston, of Farm- 
ville, Va., should express that welcome. 
W. W. H. Thackston, m.d., d.d.s., of Farmville, Va., said:- 
Gentlemen, Brethren of our Craft from abroad-To me has been dele- 
gated, unexpectedly, the grateful duty and the high honor of welcoming you to 
this Hall, to our land and to our country. We, dentists of America, know you, and 
have known you, from your labors, your professional achievements, your advances in 
the science, and we have profited by them. We have honored you abroad in your 
native lands, and we have longed for the opportunity of meeting you on America's 
shores. (Applause.) 
And now that you have signalized your devotion to the cause of science and 
your regard for the need of such an assemblage as this, by your willingness to scale 
mountains, to brave the perils of the ocean, and to meet us here, we honor you all 
the more and love you all the more. And now, in behalf of the Dental and Oral 
Section of the Ninth International Medical Congress, it is my proud privilege to 
welcome you to our country and to its proud metropolis. More than that, my 
foreign brethren, we welcome you to our roof-trees, to our hearth stones, to our 
firesides, and to our hearts. (Applause. ) And our only hope, our highest hope, is 
that your visit, and the scenes and associations with which you are brought in con- 
nection, may be as gratifying, as enjoyable, to you, as your presence is honorable and 
grateful to us. 
Fellow-Members of the Dental and Oral Section of the International Congress, 
I shall not consume your valuable time. I feel that I have given expression to the 
feelings of every American dentist, of every one whose name is identified with the 
progress and improvement of the science. I regret that I have not words to give 
full expression to all that I feel ; and I shall be most happy to have my remarks 
supplemented by what my venerable friend and cotemporary, Professor W. II. Mor- 
gan, of Vanderbilt University, can so much better say than I; and, if it be his 
pleasure, I hope he will finish what I have imperfectly attempted to perform. 
(Applause.) 
Professor W. H. Morgan, of Vanderbilt University, Tenn., said:- 
Mr. President, our brethren from abroad-I feel that it is entirely unne- 
cessary that I should attempt to say anything on this occasion, after the hearty wel- 
come tendered you by my venerable friend on my right (Dr. Thackston). Indeed, I SECTION XVIII DENTAL AND ORAL SURGERY. 
423 
am so hoarse as to be hardly able to make myself heard. From the early settle- 
ment of this country we have been accustomed to look to the East for light. We 
have been taught to look in that direction for light in science and for light in many 
other matters ; and when we see the stars from that side of the water making 
their appearance in our skies, our hearts become glad. We are very glad to see 
them. (Applause.) Gentlemen, we are very glad to welcome you to our shores. 
We feel that you cannot come among us without greatly benefiting us. We feel 
that we are to be the beneficiaries on this occasion. I am here, therefore, to bid 
you welcome to our shores, welcome to our firesides, welcome to our arms and hearts. 
We are glad to see you, and we hope that when you leave this goodly city, the 
capital of our confederacy, you will feel pleased and benefited by your visit. Again, 
in the name of my professional brethren of America, I bid our foreign brethren 
welcome to our shores and welcome to this platform. (Applause.) 
The President.-This meeting will not be content, I am sure, without having 
a word from our foreign brethren. I will, therefore, first call on Dr. W. B. Mc- 
Leod, of Edinburgh, Scotland, for a word from the profession in his country to the 
profession in this. I now introduce Dr. McLeod. 
Dr. Wm. B. McLeod, of Edinburgh, Scotland, said :- 
Mr. President and Gentlemen.-As a representative of the dental profession 
in Scotland, it affords me very great pleasure, indeed, to be permitted and honored 
on this occasion to express the feeling of gratification and pleasure which we, from 
distant parts, have in visiting your country. We come here, not only from an innate 
love of the profession which we follow, but from a love of the people who inhabit 
this country. And I trust that we may soon have an opportunity, at some future 
International Medical Congress, to show you that we fully reciprocate the warmth 
of kindness and good feeling generally which has met us on every hand on this occa- 
sion. It is supposed, Mr. President, that the Scotch people are a cold, hard lot of 
people ; and that, in that respect, they resemble the mountains, the winters and the 
floods of that country. But I assure you that such is not the case. I assure you that, 
if any of you gentlemen ever visit our shores, the fact that you are an American 
dentist, and that you have been a member of this International Congress, will be a 
sufficient lever to open our hearts and to make you welcome to every good thing 
which our land can afford you, whether it be professional, social or otherwise. I 
trust you will accept these words as an expression of the warmth of our feelings. 
And however inadequate these words may be, I trust that before the week is out, 
we will have many occasions (better than can be done in any public performance) of 
showing our appreciation of the country which we are visiting and of the kindness 
with which we have been received. (Applause. ) 
The President next introduced Dr. J. von Metnitz, of Vienna, Austria, who 
addressed the meeting in German, a translation of which is as follows :- 
Mr. President and Gentlemen.-In response to your kind invitation, lam 
sent to you as a delegate of ' ' The Society of Austrian Dentists of Vienna. ' ' Allow 
me in this manner to present to you my most sincere thanks for the kind reception 
tendered and the many acts of friendship everywhere shown me as your brother 
colleague. Please accept the most hearty greetings from your German and Austrian 
brothers. 424 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. John E. Grevers, of Amsterdam, Holland, said:- 
Mr. President and Gentlemen-Prof. Morgan, in his speech of welcome to 
the foreign members of this Section, referred to the East, whence, in former times, 
scientific light did come. 
I embrace this opportunity with pleasure, as a countryman of the discoverer of 
the dental tubuli, Loewcnhoeck, of expressing the great interest the Odontological 
Society of Holland takes in the proceedings of the Eighteenth Section of the Ninth 
International Medical Congress, and I doubt not but that there will be ample occa- 
sion for me to take home proofs of the great advance America has made in the 
scientific as well as in the practical bearings of our specialty of medicine. 
Dr. Ernst Sjoberg, of Sweden, said:- 
Mr. President and Gentlemen-As a representative from Sweden, I have 
the honor to receive the kind compliments you have just given to the foreign visitors 
who have come here to learn and to witness the progress which dentistry has made 
in the last few years. 
There are few departments of the healing art which have to show such a sound 
and rapid development as dentistry. And, Mr. President, it is a well-known fact 
that the sons of America have been the most zealous, the most enthusiastic, and the 
most successful workers of the scientific, and still more of the practical, part of 
dentistry. 
I assure you that in our far North we have followed your efforts and your 
studies with constant and hopeful interest, and I am glad to state that the Swedish 
government has been anxious to send a delegate to this great meeting, to get the 
benefit of your instruction. 
Mr. President, please to receive a hearty congratulation from Sweden to the 
work of this Section, which will certainly give a strong impulse to continued progres- 
sive scientific investigation, and will mark an epoch in the history of dentistry. 
Dr. J. Taft, of Cincinnati, Ohio, President of the Section, then delivered the 
following address on- 
f 
THE FACTORS AND FORCES IN THE DEVELOPMENT AND 
PROGRESS OF DENTISTRY. 
LES FACTEURS ET LES FORCES DANS LE DÉVELOPPEMENT ET LE PROGRES 
DE L'ODONTO-THÉRAPIE. 
DIE FAKTOREN UND KRÄFTE IN DER ENTWICKELUNG UND DEM FORTSCHRITTE DER 
ZAHNHEILKUNDE. 
Members of the Section, Ladies and Gentlemen : - One hundred years 
ago the germ out of which Dental science and art have grown possessed no 
special significance. It showed but little, if any, promise for the future. There 
was apparently no soil in which it could grow; no environment from which any 
remarkable product could spring. It had up to that time attracted no considerable SECTION XVIII-DENTAL AND ORAL SURGERY. 
425 
attention on the part of the public, nor even of those who were engaged in the 
general practice of the healing art. The elements of progress were not visible ; and 
the only instrumentality prior, and up to that time, that was operative, or exerted any 
influence for the development of dentistry, was a meagre and desultory literature, 
exhibited for the most part in monographs, largely the product of Continental Europe, 
chiefly of Germany and France. Somewhat more of the former than of the latter. 
No marked and decisive step was taken until the time of John Hunter. He, 
with a more penetrating and out-reaching vision, and fuller and more just apprecia- 
tion of the value and importance of the teeth, wrote his work " Natural History of 
the Human Teeth," in 1771. This challenged not only the attention, but the 
admiration of the medical men of the world; and not only those of that day, but to 
the present time this is regarded as one of the standard works of our literature. No 
work upon dental science and art of equal importance to this had appeared sixty 
years ago. 
During the decades from 1830 to 1850, the wheels of progress were set in motion. 
In 1829 a system of Dental Surgery, by Samuel Sheldon Fitch, was published. This 
up to that time was the only work in the English language presuming to cover the 
entire field of dental science and art. 
1 ' The Principles of Dental Surgery, ' ' by Leonard Koecker, was published in 
1826. This work was less pretentious in its aim, as the scope is clearly indicated on 
the title page by the words, "Exhibiting a New Method of Treating the Diseases of 
the Teeth and Gums ; Especially Calculated to Promote their Health, Beauty, 
etc." 
A new interest was awakened and a fresh inspiration seemed to pervade the lead- 
ing men in the profession about that time. For within ten years after the publica- 
tion of Fitch's system of dental surgery, there were published in the United States 
about twenty new works on dental surgery, and ten or twelve new editions and trans- 
lations were issued; and in Great Britain about thirty, most of which were new works. 
A part of these, at least, possessed such interest and value that they have been 
accepted as standard text-books. During this period was established the first peri- 
odical devoted to the science and art of dentistry, The American Journal of Dental 
Science, in 1839. This was the beginning of the journalistic literature for dentistry, 
in the world. This publication having demonstrated its value, and shown the 
probability of permanency, others were established, both in this and foreign countries, 
so that not less than one hundred and fifteen periodicals have been established, and 
have, in a more or less marked degree, rendered service in the development and 
establishment of this highly important department of the healing and restorative 
art. 
The influence of our special periodical literature as a factor in giving form and 
character to dentistry, cannot, even prqximately, be estimated. Upon it the other 
instrumentalities have depended greatly for their influence and efficiency. The 
periodical literature of our profession is increasing in influence and power continually, 
and to-day it is more potent than ever before. 
About the year 1840 the first association of dentists was organized. The Ameri- 
can Society of Dental Surgeons was the pioneer in association work, though prior to 
it two efforts were made to establish societies, but without any apparent result. 
The American Society, after a varied career of sixteen years, disbanded. It demon- 
strated some valuable points to be attained by association, and as clearly indicated 
some points of danger that should ever after be avoided. In both of these respects 
it accomplished a valuable service. 426 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
So generally was the value of associative work recognized that other organizations 
were soon established. The Virginia Society of Surgeon Dentists was formed 
December 12th, 1842 ; The Mississippi Valley Association of Dental Surgeons, 
August 13th, 1844; The Pennsylvania Association of Dental Surgeons, December 
14th, 1845 ; The Society of Dental Surgeons of the State of New York, November 
17th, 1847 ; The American Dental Convention was established August 2d, 1855 ; 
The American Dental Association was organized in August, 1859. The following 
States, in the order named, were the first to establish State organizations; viz., Vir- 
ginia, Pennsylvania, New York, New Hampshire, Vermont, North Carolina. 
State and local organizations were from this period on, established in rapid succes- 
sion, till now almost every State and territory in the Union has put into operation 
this means of progress, and each city of a few thousand inhabitants and more can 
boast its dental society. So fully is the importance of association work now regarded 
that no one of any professional ambition, or true comprehension of the trend of the 
times, can afford to stand aloof, or refuse participation in it. 
In England, Scotland, France, Germany and Sweden very efficient systems of asso- 
ciative work have been inaugurated and carried forward with most signal results. 
The Odontological Society of Great Britain was organized in 1856, and has con- 
tinued in active operation to the present time. It has not been excelled, if equaled, 
by any dental association in the world, in the amount of systematic and valuable work 
accomplished. Ample evidence of this is presented iu the twenty-five published 
volumes of its transactions. 
This is not a matter of wonder when we consider that such men as Sir John 
Tomes, Sir Edwin Saunders, Samuel Cartwright, A. Rogers, C. Spence Bate, Robert 
Nasmith, and eighty-five others of noted ability and reputation, united their efforts 
in the formation and support of the Odontological Society of Great Britain. To these 
noble men the profession of the world owes a debt of gratitude upon which it will 
never be able to pay more than a reasonable interest. 
The chief object of this body was the advancement of the Science and Art of 
Dentistry, and the execution of this purpose has been most rigidly observed to the 
present time. 
The British Dental Association was organized in 1879. This body embraced at 
the beginning a large number of the leading men of Great Britain. Sixteen months 
after the organization it had enrolled three hundred and eighty-three members ; of 
these three hundred and thirty were resident in England, thirty-three in Scotland, 
and four in Ireland. It has now six hundred active members. The care exercised in 
the formation of this body is clearly shown in the following extract from its by-laws : 
"A person who is registered in the Dentist's Register shall be eligible for election as a 
member of the association, provided that he be of good character ; that he does not 
conduct his practice by means of the exhibition of dental specimens, appliances or 
apparatus in an open shop, or in a window, or in a show-case exposed to public 
inspection ; or by means of public advertisement, or circulars, describing modes of 
practice; or patented or secret processes, or by the publication of his scale of profes- 
sional charges. 
" Any registered dental practitioner who can subscribe to a declaration (provided 
by the association) embodying the preceding by-law, and who shall be recommended 
as eligible by any three members of the association, may be elected a member by the 
Representative Board, or by a committee appointed forthat purpose by that board." 
This association has for its aim the promotion and fostering the ethics of the 
profession ; and the giving aid and encouragement in the formation of societies of a SECTION XVIII-DENTAL AND ORAL SURGERY. 
427 
more local character-branches of the parent stock. In the organization of and care 
for these, it has outstripped all others. 
Dental associations have been established in almost every civilized country, at least 
where dentistry is practiced. In Germany there are twelve; in France, four; in 
Sweden, one ; in Norway, one ; Denmark, one ; Australia, one ; Scandinavia, one ; 
Russia, one. In the very general adoption of association work there is a strong evi- 
dence of its importance and value as a developing and sustaining force. 
In 1840 the first institution in the world was established for imparting a regular 
and systematic course of instruction in dental surgery. Hitherto the instruction 
available for the dental student had been very meagre, circumscribed and defective. 
Medical colleges were appealed to in vain to assist in supplying the need. The 
proposition to establish a dental college was a bold one, and its execution required a 
courage stronger, and an ability much above that possessed by the average man. It 
was to enter upon an untried field-an unbroken way. There were no antecedents ; 
the way had to be opened wholly anew. Success, the attainment of which was 
uncertain, would involve arduous labor and be attended with sacrifice of strength and 
means; the prospects of emolument were hopeless, at least to the pioneers; and failure 
would engulf all concerned in irremediable disaster. 
What then were the incentives that urged forward these founders of our special 
educational scheme ? Nothing save the great, crying need that existed-for ignorance 
rested like a dark and deadly pall upon the childhood of our profession, threatening 
suffocation-and the almost divinely prophetic vision, unseen by others, that was to 
the comprehension of these men almost a reality. Whether that vision came to them 
in the fullness and richness of the realization of to-day, I leave you to imagine. Thus 
did they go forward with an almost superhuman strength, influenced by a more than 
human impulse, to the accomplishment of an untried work. 
The Baltimore College of Dental Surgery was conceived by and was the result of 
the efforts of Horace H. Haydon, M.D., C. A. Harris, m.d., Thomas E. Bond, m.d., 
and H. Willis Baxley, m.d. These men constituted the first Faculty. The first 
graduating class consisted of two persons, Robert Arthur and R. Covington McCaul, 
both of Maryland. These were the first in the world to receive the degree of D.D.S. 
-the first mature fruit of this grand conception. 
After the first experiment had been on trial for five years, and success and prac- 
ticability had been well nigh demonstrated, another institution of like character was 
projected, and in 1845 the Ohio College of Dental Surgery was established, under the 
guidance and leadership of James Taylor, M.D., of Cincinnati. 
The first faculty consisted of Jesse W. Cook, m.d. ; Melancthon Rogers, M.D.; 
James Taylor, M.D. ; and Jesse P. Judkins, m.d. 
These two pioneer Colleges, one in the East and the other in the West, 
have pursued their work uninterruptedly from their organization to the present 
time. 
In 1850 the Transylvania School of Dental Surgery was organized at Lexington, 
Ky. In 1852 the New York College of Dental Surgery was established at Syracuse, 
and in the same year the Philadelphia College of Dental Surgery was organized, and 
the Pennsylvania College of Dental Surgery in 1856. 
Since that time dental colleges have been established in the United States on an 
average of one every two years. And now there are in operation twenty-two legally 
established dental colleges in this country, thirteen of which have been organized 
since 1880. 
A variety of opinion exists as to the need or utility of so many schools; but really 428 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
there is no well-grounded objection, except, perhaps, the possibility of an unhealthy 
competition, and even this might exist with the few as with the many. 
In foreign countries, especially Great Britain, Germany, France, Sweden and 
Canada, have dental colleges been established. The first of these was the Dental 
Hospital of London and the School of Dental Surgery, established in 1858. The 
following gentlemen constituted the first corps of teachers; viz., John Tomes, 
Charles Rogers, W. A. Harrison, S. Cartwright, Robert Hepburn, and Thomas 
Underwood. 
In 1860 the College of Surgeons of England opened its doors and instituted the 
L. D. S. examination-a significant fact, to which we of this day may look with 
interest. 
Other dental colleges and hospitals have been organized in Great Britain, till now 
they number ten. In France there are two-"The Paris School of Dentistry" and 
"The Dental School and Clinic of France." In Germany there have been for a 
number of years Dental Institutes connected with the Universities of Leipzig, Halle 
and Breslau. 
Originally, the treatment of oral and dental diseases was part of the surgical 
clinics of the Department of General Surgery, and was attended to by the surgeons. 
The University of Leipzig was the first institution in which a dental surgeon was 
appointed to superintend the treatment of the diseases of the mouth and teeth, and 
to conduct a special clinic of this branch. 
Dr. Julius Parreidt took charge of it in 1876, and, until within two or three 
years since, has had the direction of it. 
Halle has a similar Institute, under the direction of Prof. L. Hollander. Dental 
students hear the lectures on branches collateral to dentistry at the departments of 
the University. The practical instructions in operative and prosthetic dentistry are 
given in the clinics of the University, and also privately by Prof. Hollander. 
The Institute connected with the University at Breslau, which is under the 
direction of Dr. Brack, is conducted upon nearly the same principle as the two 
above named. 
The University of Berlin has an Institute which is modeled more after our own 
dental departments of universities. It opened its doors at the beginning of the winter 
course, October, 1884. This dental college-the only one in Germany-is under the 
direction of Prof. F. Busch, M. D. All the practical branches are taught in this college. 
The lectures on some subjects of general medicine are heard in common with the 
medical students at the University. A number of other dental schools have been 
established in Germany. One dental college has been established in Russia, and one 
in Switzerland. In Sweden, in 1861, a scheme of dental education was inaugurated 
by a royal decree ; it was modified at various times, as condition seemed to require. 
In 1879 an academical education was required for admission to the study of dentistry. 
It is now a well-established department and is supported by the State. 
About the year 1866 the subject of regulating the practice of dentistry by legal 
enactments began to receive attention. A number of years before this, however, 
laws were enacted in perhaps two States of the Union, framed for the purpose of 
exercising a healthy control over the practice.- At that time, however, public senti- 
ment was not alive to the subject, and it attracted very little attention up to the time 
above indicated. It is true, however, that as early as 1840 to 1845 legislative bodies 
had granted charters to dental colleges, this being the first point at which legislative 
bodies had done anything for dentistry. 
During the decade from 1860 to 1870 empiricism and false practice so much SECTION XVIII-DENTAL AND ORAL SURGERY. 
429 
increased, and became so active in mischief, that some method of restraint seemed 
to be a necessity, and attention was especially directed to legal enactments having in 
view the encouragement of the competent and honest, and the restraint of the incom- 
petent and dishonest. 
When laws for regulating the practice of dentistry were first suggested, their 
utility and propriety were much questioned by many. However, after testing the 
matter, several States secured laws, and from time to time having them improved as 
experience indicated, their value was no longer a question. The desire for such laws 
has been for a number of years almost universal ; so that now about thirty-six 
States and Territories of this Union have laws regulating the practice of dentistry. 
Perhaps the most efficient, and certainly the most elaborate, law for this purpose 
is that of Great Britain, for the framing and securing of which Sir John Tomes has 
the honor, and for which he should-and, doubtless, does-receive a tribute of grati- 
tude from every honorable and true dentist in the world. 
They have also been enacted in almost every European country, and in most 
instances are quite stringent in their requirements. 
Legal enactments as a factor in the support and protection to the practice of our 
profession has been fully and clearly demonstrated, and, in fact, must be largely 
relied upon. 
Your attention has now been directed to the four great forces or factors that have 
been especially operative in the development and progress of dentistry throughout the 
world. And now, it may be asked, have these agencies, all or any of them, been 
exhausted ? Have they accomplished everything of which they are capable ? The 
great influence that each has exerted cannot be questioned. But has any one of 
them reached the maximum of usefulness ? 
To these questions, as a matter of necessity, various answers will be given. But 
no one who has been familiar with or instrumental in operating these forces, or, it 
may be, has been only an observer, can arrive at any other conclusion than that they 
are capable of accomplishing far more than has, as yet, been attained. 
While it is admitted by all that the progress of our profession for the past twenty- 
five years has hardly had a parallel in any other department of human occupation, yet 
to-day these developing forces are in better condition than ever before for promoting 
and building up that specialty or department in whose behalf they were instituted. 
Never has the literature of our profession made so full and perfect record of 
progress as to-day. Never has it been appreciated and utilized as now. Never so 
many readers nor so thorough. Our literature is a persistent propelling force for 
the practitioner, without which he must of necessity fall behind. Indeed, it is his 
daily guide and helper. It is the practitioner's source of constant growth and 
strength. No one can hope to attain great ability and eminence without it. 
The association work as an influence for the promotion of the art and science of 
dentistry was never so efficient nor so highly valued as at present. But it is an 
agency whose limit for usefulness is very far from being as yet attained. It is a 
matter of great encouragement to note the growing interest in this work. There is 
a rapidly-increasing sense of responsibility in this direction. The value and import- 
ance of this work is shown clearly in the fact that nowhere is marked progress made 
where this instrumentality is not employed. 
Our educational institutions, though they have accomplished so much, and are, 
in a sense, on a high tide of prosperity ; yet no one who is familiar with the results 
accomplished, the methods adopted, and can forecast their possibilities in the future, 
can arrive at any other conclusion than that they have entered upon a career which 430 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
shall be upward and onward to a far grander realization than was ever conceived by 
their founders. 
And now, under the influence of the conditions and forces that exist to-day, are 
we not warranted in anticipating more rapid progress than has yet been realized ? 
The effort for higher attainments and the outreach for perfection was never so 
active as now, and this activity is becoming more and more intensified ; the demand 
at every point is for something better, and this pervades the profession throughout 
the world, indisputable evidence of which we have here this day. 
We can look with pleasure upon many things pertaining to our profession, but 
none for which we should be more grateful than for the unity and absence of schism 
in its ranks ; there are no isms or pathies ; there are no elements of discord and 
faction. Now and again agitations have occurred, but have soon passed away. Our 
profession moves forward in solid column to the accomplishment of its legitimate 
work ; and while each individual is an independent thinker, and capable of shaping 
his own opinions and forming his own conclusions, yet whenever important questions 
affecting the whole body arise, then there is such an unanimity of views and concur- 
rence of action as can hardly elsewhere be found. Nowhere can a body of men be 
found so free and yet so firmly united. 
In this assembly is the largest number of dentists ever witnessed in the world, 
coming from almost all countries, brought together for a common purpose, with a 
common sympathy and strong fraternal feelings. And thus do we occupy enviable 
ground, which should be utilized in discharging the duties that devolve upon us. 
We have no factious struggles in which to spend our strength and divert our ener- 
gies, and nought to do but press forward to the fulfillment of the high behest before 
us. 
Is it, then, a wonder that such great and rapid progress should be made, and 
that in the race for high achievements dentistry should be abreast of even the fore- 
most? Let us see to it that our work does not falter. The dental profession is one 
of the battalions of the great army in the warfare against disease and the ruin it 
works. 
A just expectation is entertained that from this Section, composed of representa- 
tive men of the dental profession from all parts of the world, a great impetus will be 
given for the progress and elevation of dentistry. Let us see to it that this expecta- 
tion is answered to the full. 
On motion of Dr. J. S. Marshall, of Chicago, a vote of thanks was given to 
the President for his able address. 
Dr. H. L. Cruttenden, of Northfield, Minn., then addressed the Section as 
follows :- 
Dr. J. Taft, President :-During the recent session of the Minnesota State 
Dental Association I presented a gavel to that body. It was voted by the Associa- 
tion that it be tendered to the President of the Dental Section of the International 
Medical Congress, for use during its session. 
Our Association numbers ninety active members; it is but five years old,is young and 
composed principally of young men, filled with young blood. Many of our members 
have come from the Northwest to meet with you. 
The gavel is entirely dental, it being made in a dental office, by a dentist, for a 
body of dentists, is made from material most common in dental practice-gold, rubber 
and cement. SECTION XVIII-DENTAL AND ORAL SURGERY. 
431 
Gold might be emblematical of that intrinsic worth and richness of thought which 
should actuate our deliberations. Rubber, the elasticity of thought and unbiased 
judgment. Cement emblematically unites us into "one common band or brother- 
hood, among whom there should be no contention. " It is made to represent some- 
thing that a dentist prizes, and which they, as well as the rest of the human race, 
are pained to part with. 
It being placed in the hands of the presiding officer, it should actuate us to the 
dentist's true and highest aim-to save the teeth. It is with much pleasure that I 
present this gavel; if it is accepted by you, our Association will consider it a great 
honor. 
Therefore, as the President of the Minnesota State Dental Association, I present 
it to you for your use. 
The President, in accepting the gavel, remarked that he was sure the proceedings 
of the Section would go on smoothly, and that all the members would defer to the 
pronouncements of this gavel. He also took the liberty, he said, of extending the 
thanks of the Section to the Minnesota State Dental Association for furnishing so 
useful an instrument for the meetings of this Section. 
Dr. R. Finley Hunt, Washington, D. C., of the local Committee of Arrange- 
ments, made a report as to his intercourse with the municipal and school authorities 
of Washington on the subject of obtaining a suitable place of meeting, and offered 
the following resolutions, which were adopted :- 
Resolved, That the thanks of the Section of Dental and Oral Surgery, collectively 
and individually, are due to the Board of District Commissioners and to the Board of 
School Trustees for their generous liberality in granting the use of the Franklin School 
Building to that Section on the occasion of the meeting of the Ninth International 
Medical Congress, and are hereby tendered, a cordial invitation to attend the meetings 
and clinics whenever it may suit their pleasure. 
Resolved, That our thanks are tendered not only to them, but to all officers con- 
nected with the school building with whom we have been brought into contact, for the 
uniform courtesy with which they have given us every facility to carry out our objects, 
and that they be invited to attend our clinics and meetings. 
Resolved, That a copy of these resolutions be transmitted to the President of the 
Board of District Commissioners and to the President of the Board of School Trustees. 
CHRONIC PYAEMIA OF DENTAL ORIGIN. 
PYOHEMIE CHRONIQUE D'ORIGINE DENTAIRE. 
CHRONISCHE PYÄMIE DENTALEN URSPRUNGES. 
BY R. J. PORRE, D. D. S., 
Of Cincinnati, Ohio. 
In November, 1882, the writer read before the class of the Ohio Medical College, 
by request of Prof. W. W. Dawson, a paper giving a description of a case of pyæmic 
suffering extending over a space of thirty years, and of a character so protean and alto- 
gether extraordinary as to baffle the diagnostic and therapeutic skill of many of our 
best surgeons. Patient and careful investigation, from what may be termed a dentist's 432 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
standpoint, disclosed an abscess caused by a concealed suppurating wisdom tooth. 
After removal of this tooth and proper treatment, the patient's health was speedily 
restored. This paper was subsequently published in the Cincinnati Lancet and Clinic, 
November 25th, 1882. It was extensively copied into American and foreign medical 
journals, and excited considerable interest, eliciting comments both favorable and, to 
some extent, unfavorable ; a majority congratulating the author upon having discovered 
a heretofore unsuspected cause for many obscure and grave disorders, and others, while 
admitting the general facts and conclusions, affecting to believe that the varied terrors 
and protean phases of the symptoms described were, perhaps, exaggerations on the 
part of an extremely nervous patient or a highly imaginative dentist. 
No one could possibly be more anxious than the "dentist " to be able to verify the 
accuracy of the symptomatology and correctness of the conclusions. 
The latter may certainly be disposed of briefly with the remark that whatever may 
have been the cause of the long train of varied tissue and functional disorders, they all 
disappeared after the removal of the supposed offending tooth and obliteration of the 
local abscess. 
It may be of interest to state that up to the present time the patient enj oys absolute 
immunity from the previous complications. 
In regard to the pyæmic symptomatology suggested by the history of the case, the 
author is now able to demonstrate, as the result of four years' additional experience, a 
complete medical syllogism, from verified premises to an assured conclusion. 
In order to do this, it will be necessary to refer to the remarkable train of symp- 
toms in that case, compared with the admitted results of pyaemia by surgical authori- 
ties, and, if possible, verify the conclusions by the testimony of other and similar cases. 
It will be remembered by those who read the details of the case named, that its 
startling features consisted in the vast variety and persistent development of lesions in 
so many tissues, apparently so very discrepant with any theory of dental origin. The 
patient, it may be well to state, inherited a powerful constitution, of active habits from 
his youth, an athlete, possessed an iron will and an irrepressible spirit, all of which 
sustained him in his struggle with this hydra-headed monster of disease. He remem- 
bered that thirty years before he had a facial swelling, which had subsided after a 
week's diet and treatment. Since that time he had never been quite free from neuralgia 
and pains in some other parts of his organism. He had been the victim of constantly 
recurring furuncles and eruptions in various parts of the body, which would often for 
months become running abscesses. He experienced burning and itching eruptions of 
the hands and feet, which would finally change to stubborn ulcerations. 
His throat was subject to frequent and painful inflammations. His bowels were 
either stubbornly constipated or exhaustingly loose. He suffered from frequent rigors 
and febrile attacks of varying intensity, profuse night sweats, retention of urine, serious 
constriction of the bowels and urethra. Lancinating pains like electric shocks darted 
from maxilla of the right side to diaphragm, bowels, bladder, limbs, hands and feet, or 
to whatever part that was locally affected at the time. It was this latter peculiarity, 
together with the discovery of a little pus exuding from the locality of the wisdom 
tooth, that led to a finally correct diagnosis of his case. He had been treated in turn 
for nearly every local lesion, and for over a score of years for syphilis. It is not neces- 
sary to repeat the treatment adopted and final relief of this patient. It has been given 
in detail. 
The important point is to establish the relations of cause and effect between these 
apparently trivial local abscesses from diseased teeth and the numerous and diversified 
symptoms of pyæmia. 
Surgically considered, pyæmia expresses that class of morbid effects produced by 
animal products upon the system. SECTION XVIII-DENTAL AND ORAL SURGERY. 
433 
It will be interesting to observe the curious resemblance between the diversified 
effects of the almost innumerable phenomena produced by the distribution of the mor- 
bific matter among different tissues under varying circumstances and the cases we have to 
offer for investigation. The conditions may be primary, that is, directly produced by the 
poisonous matter, or secondary, when complications occur from the systemic infection. 
They may be general and rapid, as the virus is absorbed into veins and lymphatics, 
attended by fever, rapid pulse, heat, vertigo, rigors, perspirations, etc., modified in 
intensity by the extent of the abscesses or reservoir from which the supply of the virus 
is drawn. The general demoralization of the system in such cases is indicated by 
changes in the ulcer or source of inoculation. 
' If from a wound, granulation is arrested, and sometimes the cicatrix is broken down, 
the margins become dusky and indurated, the integument becomes distended with 
serous fluid, a sanious discharge takes the place of pus. Purpura and ecchymoses occur 
in different parts of the body as the morbid effects disseminate ; the patient becomes 
anxious and delirious until prostration, sinking and death close the scene. Or if the 
morbific supply is arrested before the utter demoralization of the vital functions, typhoid 
symptoms supervene, the system labors to eliminate the poison by fluxes of various 
kinds, and, if successful, convalescence is slow and feeble. 
Or the effects may be modified by various circumstances-disease, age, temperament, 
state of health, habits and idiosyncrasies. For example, the influence of scarlatina, 
diphtheria, phthisis, cancer, shock, wounds, etc., aggravate and increase the action of 
the virus. 
The symptoms vary also with each new organ affected, and nothing is more usual, 
amid the general symptoms of depression and prostration, attended with anorexia, 
sweetish taste in the mouth, distaste for food, sallow or tawny skin, than to note dis- 
charges from the nose, ears, or uterus, or effusions into serous cavities, and cellular 
tissues, boils, abscesses, etc., in parts distant from each other. The gravity of all such 
complications being determined by the quantity of infection and resistance of the vital 
forces to its influence. 
Now if all of these pathological conditions may follow some mysterious local change 
or decomposition of the animal substance, perhaps the case cited may not seem so 
improbable or exaggerated. 
It is an axiom in mechanics that the strength of a piece of machinery is only equal 
to its weakest place, and any intelligent surgeon will tell you that it is the only explana- 
tion he is able sometimes to give to his curious patient of the capricious action of general 
diseases upon certain local organs. 
Suppose a wandering pus corpuscle, or several of them, should find their way into 
the circulation from some suppurating tissue, a vigorous vitality would be able to elimi- 
nate and dispose of them. Or the globules might in succession pass the lungs, liver, 
spleen, and kidneys, and finally get entangled in some debilitated capillary of the 
skin, and so soon as its progress is arrested its work of degeneration begins, and a local 
abscess or furuncle is the result. But the keen and tireless investigations of science 
have demonstrated that the pus globule, while in the exercise of its wonderful task in 
the process of waste and repair, is not the dangerous enemy it has been represented, 
but must itself be demoralized, if we may use such a word to signify the condition of 
decomposition and chemical change produced in animal substances by varioqs causes, 
among which may be named microorganisms and certain chemical products of the putre- 
faction of proteid substances, alkaloidal in their character, and of peculiarly virulent 
and destructive nature; to which Gauthier, in 1870, gave the name of ptomaines, to 
distinguish them from certain alkaloid principles found normally in animal excretions, 
as urine, saliva, etc., to which the name of leucomaines is given. 
Gauthier also demonstrated the presence in the secretions, even in health, of certain 
Vol. V-28 434 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nitrogenous extractive compounds of a highly toxic nature, to which the bites of animals 
often owe their poisonous character. 
It is not necessary at this time to discuss the various theories of chemical, microbic, 
or fermentative origin of these insidious morbid elements in the system, since we are 
too frequently rendered painfully aware that life is a continued series of deaths and 
resurrections, and while we carry about with us the elements of death, and the corpse 
of dead protoplasm in every tissue, we retain life and resist the infection from morbid 
chemical changes and a thousand inimical inferior organisms only by our superior vital 
powers, whereby we eliminate the poisonous substances and promote their destruction 
by oxygen. 
Our present affair is with known results rather than with the discussion of theories 
concerning the origin and influence of microbes or the ptomaines and leucomaines of 
dead or living tissue upon the body. The remarkable analogy between the admitted 
pathology of known pyæmic diseases and the train of symptoms presented in the case of 
dental lesions already described may now be so fully confirmed by subsequent experi- 
ence that the relation of cause and effect is no longer in doubt; as in all toxic diseases, 
when the system becomes affected by depraved secretions, as phthisis, tonsillitis, and 
diphtheria, ulcerations of the ears and throat, and abscesses of the viscera, etc. It is 
well understood that the gravity of the effect is determined by the strength of the vital 
forces to eliminate the infection, and the rule obtains in the class of disorders produced 
by diseased and carious teeth, the morbid results, as from other forms of vitiation being 
proportioned to the magnitude of the cause, the idiosyncrasy of the patient, and the 
amount of vital resistance. 
It must also be remembered that the oral cavity is subject to other diseases whose 
morbid secretions are capable of vitiating healthy action of other functions, among 
which may be named scurvy, of whose terrors it is not necessary to remind the reader. 
And when the disease is cured not unfrequently the consequences, as diseased gums, 
loosened teeth, etc., become prolific sources of future general vitiation. 
Pyorrhea alveolaris is another local lesion from which the gravest pyæmic disorders 
may be feared, all the more so as diagnosis is often obscure and the mischief is quietly 
going on without the cause being suspected. The disease consists in inflammation, 
ulceration, and caries of the investments of the teeth, and often the discharge of pus 
is phenomenal in quantity. The gums waste less at their borders than at the margins 
of the alveola. The deposits around the neck and roots of the teeth, in some cases, 
are unlike salivary calculi, being dark, hard, and so adherent as to almost defy removal. 
This deposit is regarded as produced in some manner from elements of the blood; 
therefore it has been named calculus sanguinarius. 
The etiology of this disease has not been satisfactorily settled, as to whether it is of 
local or constitutional origin. 
Another serious disorder of this class is alveolar abscess, which, although most 
frequently caused by carious teeth, producing periosteal inflammation, is often variable 
in its forms of development. A suppuration may begin around the root, absorbing the 
bony walls; pus burrows its way sometimes along the tooth to the edge of the gums, 
generally through the gums opposite the apex of the root, not unfrequently opening on 
the cheek, chin, jaw, and points remote from the place of beginning. 
Ofteq the antrum is implicated, and a series of painful and grave results occur with 
which dentists and surgeons are familiar. 
The process and effects of caries is both suggestive and interesting in this connec- 
tion. The periosteum thickens and becomes highly vascular, beside the ovoid tissue 
cells rows of spindle-shaped cells, forming bundles of wavy connective tissue, appear ; 
small nerves and vessels in the vicinity atrophy, and large vessels expand, tissue under- 
goes a retrograde metamorphosis, fatty granules appear in and between the cells of SECTION XVIII-DENTAL AND ORAL SURGERY. 
435 
protoplasm, and germs of proliferation are excited. The root is absorbed, the plastic 
exudation elevates and loosens the tooth. Suppuration begins in the lymph around 
the tooth and in the cavity formed by absorption, and is often very rapid and always 
painful. 
Although only a toothache, readily cured by a pair of forceps, the carious process 
may extend by means of the absorbents and lymphatics, which convey the infec- 
tious matter to other and distant organs, and by a little stream, whether of decom- 
posed pus or ptomaines, too small to destroy life outright by pyaemia, but enough to 
vitiate the health of the whole body, is able to produce a degree of physical suffering 
wholly incommensurate with its inconsiderable origin. 
The symptomatology of pyaemia and methods of dental disease have been given 
somewhat in detail in order to compare with the following cases now offered in corrobo- 
ration of the theory of pyaemic poisoning suggested by the history of the one described 
in 1882. 
CASE I.-CELLULAR INFLAMMATION OF NECK, SIMILAR TO MALARIAL FEVER. 
In July, 1881, Mr. K. was sent to me for diagnosis and treatment by Prof. W. W. 
Dawson, of the Ohio Medical College. 
The patient was thirty years of age and of good physical history and habits. He 
was suffering under a fourth repetition of an excessive swelling of the left side of the 
face, extending downward quite to the clavicle. The first attack had occurred a year 
before, and he had been continuously under treatment of some kind, and suffering 
great local and general distress of body and mind, under the conviction that the disease 
was malignant. He came to Prof. D., who opened the buccal wall into a cyst, which 
discharged a teacupful of yellowish sanious fluid at intervals during a week or so, 
gradually diminishing in quantity and the symptoms subsiding into an apparently 
normal condition. As symptoms of malignant or constitutional disease were absent, 
and as effects do not exist without causes, it became necessary to seek for some occult 
source of irritation sufficient to account for such results. The mouth was carefully 
explored. The first and second bicuspids on that side were missing. The three molars 
exhibited no tenderness, and had but slight superficial caries on their grinding surfaces. 
No evidence of roots or appearance of inflammation in the gums were visible on 
that side. 
With less experience, or less firmly-established convictions of the dental origin of 
such disorders, a correct diagnosis seemed like a forlorn hope. But in accordance with 
a custom born of experience, not to rely too much upon appearances, I began a system- 
atic search for concealed roots, and finally found .the remains of the first bicuspid. It 
was not easy to determine whether doctor or patient was most pleased when the proba- 
bility dawned upon them that the cause of the long suffering had been found. Upon 
removal of the root the stench was intolerable, although the exudation was but slight. 
A free opening with the dental engine revealed the sinus impacted with a cheesy 
deposit. This was broken up and the cavity washed out with an antiseptic lotion of 
the following formula : Carbolic acid, oil eucalyptus, chlor, zinc., alcohol, aq. destil. 
This treatment was continued daily for ten days, and a complete cure effected, and 
the patient relegated to the care of his physician to recuperate his general health, which 
had been much deteriorated by absorption of the vitiated secretions, combined with 
local pain and a wearing dread of malignant disease. 
It is not difficult in this case to trace the array of pyæmic symptoms directly to a 
dental origin, the obscurity and apparent unimportance of which had led to the gravest 
misapprehension in regard to both diagnosis and treatment. 436 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CASE II.-SERIOUS INVOLVEMENT OF THE EYE-GREAT GENERAL PROSTRATION. 
In May, 1885, Dr, McDermott brought to me for diagnosis and treatment Mr. S., a 
young merchant from Kentucky, twenty-eight years of age, who had consulted Dr. 
McDermott for severe pains of the right side of the face and eye. Suspecting some 
obscure dental origin, and observing symptoms of oral abscess, the doctor referred the 
case to me. The patient was of good physical ancestry, and with the exception of an 
interregnum about the age of twenty, had enjoyed excellent health until eighteen 
months before, when it began to fail. He suffered from loss of appetite, indigestion, 
and unaccountable mental depression and general nervous prostration, for which his 
physician had recommended sea air and bathing. The fatigue of the journey to New 
York had so exhausted him that he returned with some difficulty, and only after a 
severe illness of two months and skillful tonic treatment was he sufficiently recuperated 
to resume business. For a time his general health greatly improved, with the exception 
of occasional severe facial pains, involving the right eye, for which he had finally sought 
the advice of an oculist. 
Now certainly no diagnostic symptoms could have been more obscure, and his 
medical attendants would most naturally be disposed to seek for causes in functional 
disorders of the digestive system. Yet the predominance of a typhoid tone and the 
persistent neuralgic symptoms indicated plainly the presence of some vitiated secretion 
as a far more probable origin of the vital deterioration. 
I found an abscess occupying the entire right half of the roof of the mouth. 
Seeking to detect its origin, I suspected a right upper bicuspid, the plug of which 
was leaking, but upon investigation found the pulp alive, and I capped and refilled the 
cavity. 
Percussion revealed no tenderness in any tooth. Fluctuation in the abscess was 
unmistakable, but the outlet of the secretion under quite hard pressure was obscure ; 
but Upon patient and careful investigation I finally discovered a detachment at the 
margin of the gum back of the right upper cuspid, presenting no evidence of disease, 
but through which, by hard pressure, I obtained a small exudation of sanious fluid. 
I made a free opening at this point, and was surprised at the quantity of purulent 
matter which was forced out, by a pumping motion, with pressure upon the sac. I 
washed the sinus out freely with the "antiseptic lotion " and put in a drainage tube. 
Further investigation for cause discovered caries in the alveolus, at the base of the 
cuspid mentioned ; no caries in the tooth. The secretion had been retained until the 
soft tissues lining the roof of the mouth became detached and distended, and every 
morning the patient could, by hard pressure, force out small quantities through the 
valve-like margin of the gum. The free opening I made facilitated the complete 
evacuation of the sac and sinuses and enabled me to treat the abscess, and in a short 
time I turned the patient over to his medical advisers, and as I have not since heard 
of him, I presume that the cure was complete. 
CASE III.-GENERAL PROSTRATION, WITH TRAUMATIC LESION OF THE TONGUE. 
I extract from my notes the following pronounced case of pyæmia from dental origin. 
The patient was one of Dr. Thrasher's, who had diagnosed well-marked symptoms of 
pyæmia, and requested me to call with him to examine the mouth for cause. The 
patient, Mr. W., aged sixty-eight, had a good physical history. For some years had 
been suffering from a general failure in health. A few months before my visit, Dr. 
Thrasher had obtained the history of the case, and he found the patient's condition was 
of a low typhoid character, great mental depression, cough and expectoration, indurated 
patches detected over lower lobe of the left lung, tongue coated and aphthous, anorexia, 
irregular bowels, and pulse quick and feeble. Under a tonic treatment he would react 
for a time and then relapse. We found his mouth in bad condition, teeth covered with SECTION XVIII-DENTAL AND ORAL SURGERY. 
437 
tartar and gums ulcerating. Two of his few remaining teeth were ulcerated and dis- 
charging septic fluid. I desire at this point to call especial attention to a method of 
propagating infection that is, perhaps, too frequently overlooked. In this case one of 
the ulcerated teeth, reeking with ptomaines and purulent virus, was a right lower molar, 
which, inclining inward and worn to a sharp edge, continually cut into the tongue, and 
thus actually distributed the virus by inoculation. The wound in the tongue had 
formed a sinus, running obliquely backward toward the base one and one-fourth of 
an inch. The two ulcerated teeth were extracted and the usual antiseptic lotion 
applied, and Dr. Thrasher informs me that the patient's health is now better than for 
years. 
CASE IV.-INFLAMMATION OF THE THROAT. 
Another of the varied expressions of dental pyæmia I find in the case of a lady brought 
to me by Dr. A. for consultation and treatment. This patient had been treated by 
several prominent physicians during a series of years for a disease of the throat, involving 
at times the pharynx and fauces, inflicting very serious local distress and a general 
deterioration of health, both mental and physical. The doctor recognized the effects 
of some septic infection, and, upon consultation, after extracting several ulcerated teeth, 
and especially the root of a left lower wisdom tooth, the lady's health rapidly improved 
under the most simple remedies. Her throat disease disappeared, as the cause was 
evidently the ulcerating third molar root. 
Case v.-As an example of the surprising rapid and complete recovery of persons 
afflicted with pyæmia from oral lesions after proper attention, I will mention a case 
which is representative of many. 
Mr. W., aged sixty-four, had enjoyed the best of health until four or five years 
previous, during which time he had received medical attention, but to no avail, evi- 
dently for reason of failure to discover the cause of his disorders. He became the 
patient of Dr. Thrasher. The doctor, after obtaining the history of his case, examined 
for the cause of his long train of ills, recognizing plainly aggravating symptoms of 
pyæmia, and, as in instances before, he examined the mouth for cause. Finding several 
ulcerating teeth and roots and badly-diseased gums, he brought the patient to my office 
for the operation very plainly indicated. Ether was administered, and seventeen teeth 
and roots were extracted. 
In ten days he had gained in weight six pounds, indisputably proving that the septic 
poison generated by the diseased condition of his teeth and mouth was the cause of his 
seriously-disordered system, as his rapid and complete restoration to health after the 
cause was removed attested. 
CASE VI.-EXTENSIVE CARIES AND NECROSIS OF THE ALVEOLUS. 
In 1885, Mr. B., aged sixty-four, history good, called for consultation. I found the 
left superior maxilla from the lateral incisor to the second bicuspid and to the base 
of the sinus, with almost all of the alveolus investing the teeth, involved in caries. 
Over the cuspid and the space of the first bicuspid, as it was gone, there was an open- 
ing through the gums into a cavity in the alveolus, caused by necrotic disintegration, 
that would receive a filbert. Three or four years before he experienced an abscess over 
the cuspid which spontaneously opened, and had continued to discharge a sanious secre- 
tion afterward. He first applied for, and had been under, treatment, more especially 
to be relieved from the unpleasantness and offensiveness of the excessive discharge 
from the fistulous opening, as there was no pain. Having been under local treatment 
a year, with the promise of a cure, and no change, he began to think his case a serious 
one, and decided to seek other advice. The treatment was plainly indicated, namely, 
the extraction of the three teeth mentioned. This was accordingly done, and the 438 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
carious bone cut away and washed out with warm water and the septic lotion, and the 
patient was requested to call daily. It was apparent after ten days' treatment that a 
condition still prevailed that was antagonistic to the reconstruction of bone. Examina- 
tion with the probe revealed extended ramifications of carious bone. So after drying 
the cavity with absorbent cotton, the nozzle of a syringe charged with a drachm of 
sulphuric acid was introduced into each of the several ramifications and a few drops 
discharged, and also a few drops were deposited upon surfaces of bone still exposed on 
the walls of the cavity. (The acid was successfully used in the first case mentioned in 
this paper for similar conditions. ) 
At the end of a week there was a decidedly favorable change. The walls of the 
lesion became rapidly covered with granulations, with the exception of two deep-seated 
points of caries. With two or three applications of the acid to these, and the daily use 
of the lotion as usual, the reconstruction of bone was complete in thirty days. The 
health of the patient, which was deteriorating with marked symptoms of pyæmia, was 
speedily restored to its former excellent standard, and is still unusually good for a 
gentleman of his age. 
CASE VII.-GRAVE GENERAL DEBILITY, WITH SERIOUS COMPLICATION OF THE 
UTERUS. 
Mrs. G., widow, aged thirty-five, of good personal and family history, had been an 
invalid for years, and for a year or two before I saw her had been under the care of a 
gynaecologist. Circumstances required that she should give daily personal attention to 
household duties. Consequently, at times her sufferings were severe and exhausting, 
until finally compelled to surrender to her couch and receive special attention for a week 
or two, when she would resume the dragging and, to her, hopeless life of agony. She 
called to consult about the painful and unpleasant condition of her teeth and mouth. 
Upon examination there was but one course suggested, namely, the extraction of fif- 
teen teeth and roots, as they were hopelessly decayed, and the gums and alveolus were 
seriously involved in ulceration and caries, with an excessive secretion and discharge 
of septic fluid. Being abnormally nervous, she deferred the operation for some two or 
three months, when she finally returned to obtain the relief confidently promised, as 
she received no permanent benefit otherwise. An obtundant lotion was applied to the 
gums, and the operation was at once successfully completed. The nervous shock was 
singularly light. After the lapse of a week, the improvement was astonishingly rapid, 
and in the course of two months her recovery was complete, declaring herself in perfect 
health, and having regained to the maximum her lost weight. The uterus is, perhaps, 
the most sympathetic organ, to septic causes, of the entire organism, let the generation 
of septic matter originate or be produced by whatever source or cause. An involve- 
ment, it may be observed, either in ulceration, congestion and falling, or what not, 
adds, as a secondary cause of aggravation, to the constitutional derangement. The 
above case is representative of many that have been noted by the writer, and is worthy 
of especial attention by gynaecologists. Where traumatic causes are not present, an 
examination into the condition of the oral cavity will, perhaps, reveal, in a majority of 
cases, the source of vitiation and cause of organic lesion. 
A few words in behalf of our little ones in this connection cannot but be appropriate, 
especially for the reason that the fact may not be generally known that the temporary 
teeth of a majority of children, perhaps, from causes unnecessary, for the purpose of 
this paper, to discuss, between the ages of three and twelve years, are more or less 
extensively affected with caries. Therefore, as there is rarely a limit to its ravages, 
distressing toothache prevails, the nerves devitalize, then follows in time the death of 
the teeth, when nature, through her unvarying methods, proceeds by inflammation and 
suppuration to dispose of them ; and if they are neglected and allowed to remain, not SECTION XVIII-DENTAL AND ORAL SURGERY. 
439 
only interfere with the eruption of the permanent teeth, but will inevitably afflict the 
unfortunate victim with this most insidious and relentless of diseases. 
There is a class of cases with which observing dentists are becoming more familiar, 
where you have only to repeat some of the varied manifestations of pyaemia to 
describe your patient's case. For example, a lady calls for consultation in regard to 
diseased and painful teeth. She has a pallid and clayey color and is extremely ner- 
vous and weak. After careful examination of her mouth, and you find one or more 
ulcerated teeth, you may say confidently: ''You must have suffered greatly; you have 
no appetite, your digestion is very bad, you spit up your food, your bowels are consti- 
pated, your nervous prostration is sometimes so extreme that you suffer from night 
sweats, rigors, and fever, your uterine troubles have become chronic and serious, you 
have darting pains through various parts of the body. Often you cannot sleep from 
unrest and nervousness ; you have had, perhaps, paroxysms of hysteria ; sometimes 
you have burning of the hands and feet ; your temper is variable, and makes you at 
times very unhappy and depressed, etc." 
The chances are ten to one that she will assent to all you have said, expressing the 
greatest astonishment that you have read her case so well. 
Her happiness and confidence in you are rendered complete when, after the removal 
of the exciting cause and simple treatment for a few days, she finds her aches and 
pains all gone and her health returning. 
Physicians are awakening to the importance of exploring the mouth in all cases of 
pyæmic and neuralgic symptoms of obscure origin, and, having long regarded all dis- 
eases of the teeth as the special province of the dentist, are now bringing ten such 
cases to him for diagnosis and consultation where one was brought before. 
My own experience is to the effect that but few cases afford greater satisfaction to 
physician, dentist, and patient than such as I have described, selected from notes of 
many similar ones. I am also quite certain now of the correctness of my conclusions, 
as expressed in 1882, in regard to the pyæmic results of obscure dental lesions. 
I leave the facts and theories with my dental brethren and the medical profession, 
with entire confidence. 
DISCUSSION. 
The discussion of Dr. Porre's paper was opened by Dr. J. Frank Lydston, 
of Chicago, Ill., in the following written criticism, which, in the absence of Dr. 
Lydston, was read by the Secretary, Dr. A. M. Dudley. 
Mr. Chairman and Gentlemen :-While duly appreciative of the honor con- 
ferred upon me by the invitation to discuss the excellent paper to which we have 
just listened, I am yet free to say that I wish the privilege had been placed in abler 
hands. In a paper of clinical facts presented by a careful observer there is often very 
little room for discussion and absolutely no opportunity for criticism ; this, to my 
mind, is especially true of the paper in question, but as the subject is one in which 
all general surgeons should become interested, I have formulated a few ideas which 
occurred to me in looking over the cases and remarks presented by Dr. Porre. 
It is high time that both dentists and physicians appreciated the important rela- 
tion which morbid conditions of the mouth and jaws may bear to different general 
conditions, and especially those which may be produced by septic absorption. I 
believe that our author has struck the keynote to the explanation of many obscure 
ailments, and the sooner both the profession and general public can be brought to 
understand that septic matter is quite generally found about the roots of the teeth, 440 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and may, under favoring circumstances, be absorbed into the blood, and there produce 
disturbances of greater or less degree, the better it will be for the reputation of the 
one and for the health of the other. Why may not many slight ailments be dependent 
upon such septic absorption without the intervention of purulent processes ? 
The mouth is a veritable hot-bed for bacterial culture, and presents all of the 
favoring circumstances for their growth, development and differentiation. Very 
slight lesions, indeed, may be followed by fatal results. A few years ago I reported 
a case of acute and fatal septic glossitis due to the absorption of decomposing food 
by a small tertiary syphilitic ulcer at the root of the tongue. The rapidity of the 
fatal result in this case was something marvelous. Dr. B. W. Richardson relates a 
case of fatal acute septicaemia due to the absorption of poison from a small portion 
of "high" potted hare, by a small ulcer in the roof of the mouth. ("Diseases of 
Modern Life. ' ' ) 
Dr. Porre's third case is another illustration of the serious results which some- 
times follow slight oral lesions. As for the relation of alveolar abscess to blood poi- 
soning, my own recent experience has afforded two cases of the kind. One of these 
was reported at the last meeting of the American Medical Association, in a paper 
before the Dental Section, on "The Co-relation of Dentistry and General Medicine." 
{Dental Register, July, 1887. ) In this paper I called especial attention to the dangers 
of sepsis from morbid conditions of the oral cavity. I was not at that time cogni- 
zant of Dr. Porre's observations. 
The other is at present under my charge, and as the patient is old and feeble, 
and the jaw extensively necrosed, death will probably ensue. 
Dr. Porre is evidently perfectly familiar with the symptoms and clinical history 
of what he is pleased to term pyaemia, and there is little to add to his description. 
It will be observed that the special symptoms of furuncles and small dermic abscesses 
are not alluded to by most writers, who fail to recognize a form of septic infection so 
chronic as some of the cases our author has just related. In two cases of chronic 
"pyæmia" under my own observation I was enabled to make a correct diagnosis 
and prognosis by the existence of an extensive crop of boils and erythematous pus- 
tules, the diagnosis being verified post-mortem. The varying results of septic 
absorption, as set forth by Dr. Porre, are too little appreciated. Thus, I recall a 
case of a woman who died four months after confinement, from the exhaustion con- 
sequent upon an enormous gluteal abscess, which foimed while she was supposed to 
be convalescing from puerperal septicaemia. 
There can be no question as to the relation of cause and effect in the cases recorded 
by Dr. Porre, in spite of the prolonged duration of some of them. The case of 
facial paralysis resulting from a diseased tooth quite closely resembles some of the 
cases reported by Dr. Samuel Sexton, of reflex paralyses and neuralgias due to simi- 
lar causes. 
It is to be regretted that the author of the paper felt constrained to pass over 
the pathology of blood poisoning so briefly ; for if his clinical reports are a fair cri- 
terion, he would certainly have added something new to our knowledge of the 
pathology of the disease. As far as he has discussed the subject I can see nothing 
to which exception can be taken, save the nomenclature, and I am free to say that 
the term "pyæmia" is to me very obnoxious. I will take the liberty of presenting, 
in this connection, a short abstract of a paper upon " The Relations of Pyæmia and 
Septicæmia," which I published several years ago. ( Western Medical Reporter, 
July, 1883.) 
As pyæmia and septicæmia are usually described by surgical authorities, they SECTION XVIII-DENTAL AND OK AL SURGERY. 
441 
constitute a very confusing subject. The two diseases are usually differentiated, and 
have been supposed to depend upon different pathological conditions ; e. g., it was 
long held that pyaemia consisted in blood poisoning by pus, hence its name ' ' pyae- 
mia," or "pus in the blood," while "septicaemia" consisted in a peculiar blood 
poisoning by a product of putrefaction, termed "septin." At the present day; some 
pathologists claim that in pyaemia we have a peculiar condition of the blood, with 
certain resulting pathological changes, dependent upon bacterial organisms absorbed 
from some suppurative inflammation, while in septicaemia we have an infection of 
the blood due to the absorption of the poisonous products of decomposition, and in 
which no bacteria are present. The idea that pyaemia depends upon simple absorp- 
tion of pus and its presence in the blood is, of course, no longer tenable, and we now 
know that the pus corpuscle per se is not infectious, and is nothing more nor less 
than a dead or dying blastemic cell. Now it is true that bacteria are always present 
in the blood in pyaemia and are not necessarily present in septicaemia, but this does 
not constitute an essential difference between the two diseases, inasmuch as in the 
light of our present pathological views both are dependent upon the same cause, 
viz., putrefaction of pus or wound discharges, which putrefaction is dependent upon 
bacterial organisms introduced from without, and which gives rise to poisonous 
principles, whose introduction into the blood produces blood poisoning. Septin, first 
isolated by Bergmann and Schmiedeberg from putrefying brewer's yeast, will, when 
introduced in the blood, after having been separated by filtration from all bacterial 
organisms, produce septicaemia ; but this same septicaemia is dependent upon bac- 
teria none the less, for it is by their action that ' ' septin ' ' is primarily produced. So 
that we may assume that the cause of pyaemia and septicaemia is precisely the same ; 
and as this cause is always the absorption of the poisonous products of decomposition, 
or septic materials, they may be classed under one head, and preferably the term 
"septaemia," or, if you prefer it, "toxaemia." But it may be said that "these 
diseases run a very different course, and exhibit marked differences as to their 
•pathological manifestations. ' ' Very true ; but does every case of variola, scarlatina 
or any blood disease run the same course? If we consider for a moment, we will see 
that they do not, and can readily appreciate the fact that their local manifestations 
differ markedly in certain instances, and that constitutional peculiarities, as well as 
the intensity of the infection, determine their occurrence to a great extent. Thus 
we meet with different grades of severity of variola, in some cases observing a fatal 
result before any local manifestations appear ; in others, the occurrence of abscesses 
in various situations, hemorrhages, and so on ; and in still others, slight constitutional 
symptoms without local disturbances or eruption. The same holds true of scarlatina. 
The analogy of these diseases to septæmia is, of course, not perfect, but is suffi- 
ciently marked to permit of our applying it to the explanation of that disease. We 
have, primarily, the entrance of bacteria into wound discharges; these multiply, 
increase in activity, and are absorbed into the circulation. In certain instances they 
produce a condition of mild septæmia; in others, a severe form in which the patient dies 
in a few days ; in others, again, a well-marked form in which abscesses and diffuse 
suppurations in various situations occur, and which, though usually fatal, may end 
in recovery. Now, what determines these grades of severity? In the first place, 
the discharges of a wound in a perfectly healthy person do not afford a favorable 
nidus for the development of bacterial organisms, and consequently they neither 
multiply rapidly in such wounds nor acquire very great virulence. Then, too, in 
healthy persons the cut extremities of the veins are usually occluded with firmly- 
organized or organizable thrombi, and the admission of bacteria is thereby prevented 442 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
more or less perfectly. In case the bacteria should enter the blood, their effects 
would be modified by the degree of resisting power possessed by the patient. If the 
person be in only fair systemic condition, the blood is still quite readily coagulable, 
and thrombi form in the wounded vessels. These thrombi may become infected by 
the micrococci, or bacteria, and, becoming softened, enter the circulation. But they 
do not remain in motion, for they must necessarily lodge in some part of the system, 
and at every point of lodgment must form a new focus of suppurative inflammation 
and infection, yielding the local manifestations classed under the term "pyaemia." 
In certain persons this tendency to suppuration is, of course, more marked than in 
others. Now, supposing the bacteria enter the blood, but are not very virulent, and 
there are no thrombi in the circulation, those at the wound being too firmly organized 
to become infected and separated. In such cases we generally have favorable circum- 
stances, due to the excellent physical condition of the patient as well as to the mild- 
ness of the infection, and consequently have merely slight or moderate constitutional 
manifestations of septicaemia, with no local pathological evidences, and which are 
followed by recovery. 
Now, it remains to consider those cases of profound septaemia in which death 
occurs in a few days, the system being speedily overpowered by the septic poison. 
We will allow that acute septaemia may occur in persons apparently healthy, as seen 
in operation wounds, but, in such cases, we can easily claim the existence of a large 
surface for absorption, or a very virulent bacterial infection. Such cases are most 
apt to occur when the bacterial development is going on within closed cavities, and 
deprived of oxygen, for it has been demonstrated that under such circumstances bac- 
teria develop rapidly and become increased in virulence; cases of this kind occur after 
operations, as ovariotomy or various obstetrical operations, or, in certain instances, 
after simple labor. As for the reported cases of rapid septic poisoning, say within 
twenty-four hours after laparotomy, I believe them to be instances of death from 
profound shock, or excessive reaction therefrom. It must be acknowledged that 
cases of fatal septæmia are most apt to occur in cachectic individuals. Now for their 
explanation. We have already seen that cachexia predisposes to an unhealthy con- 
dition of wound discharges, and that this is favorable to the development and to 
increased virulency of the bacteria-producing decomposition. This we may accept 
without any qualification, as a fact, and this very condition of the system tends to 
prevent the formation of thrombi in the veins, and also tends to promote a rapid 
alteration in the composition of the blood, which produces a fatal result many times, 
before a large number of bacteria have had time to develop in the system. This 
same fatal change in the composition of the blood occurs as a result of snake poison, 
in which there are no bacteria present, and, in fact, we see the same hæmatogenous 
jaundice, produced by the venom of snakes, that is observed in septæmia. This, of 
course, favors their analogy, and, reasoning from this same analogy, and from the 
fact that "septin" will, when isolated, produce septæmia, we may conclude that this 
is the substance which destroys the nutritive properties and oxygenating function of 
the blood corpuscles in septæmia. But one is apt to say "the changes in pyæmia 
do not depend upon septin, but upon bacteria." Very true; but this same septin is 
primarily produced by bacterial organisms, so here we are again at the same point of 
departure that we have in pyæmia, viz., bacteria. Now, the cause being the same, 
we must conclude that its effect ought to be the same, and so they would be, but for 
the fact that they are modified by the local conditions of the wound, and the consti- 
tutional condition of the patient. The bacteria produce "septin," and this depends 
upon local conditions for its malignancy; if no thrombi are present, the septin enters SECTION XVIII-DENTAL AND ORAL SURGERY. 
443 
the blood, alters its composition and may destroy life. If thrombi be present, it may 
dissolve them, and, as it produces a plasticity of the blood, no more are formed. As 
no thrombi exist to act as carriers of bacteria, and thus form new foci of inflamma- 
tion and abscesses, none of the so-called "metastatic" changes occur. In some cases, 
perhaps, abscesses might result, just as in any condition of debility or systemic 
poisoning, if the patient lived long enough, but he does not, for he is destroyed by 
profound blood changes before local results have time to occur. It may be seen, 
therefore, that ' ' pyæmia " and " septicaemia ' ' are undoubtedly the same disease, there 
being a difference in degree and not in kind, and there being, probably, in certain 
cases, a blending of the two apparently different types of disease. Now, as for the 
difference in the manifestations of the two phases of disease : We have, as is well 
known, a condition of toxaemia in both, which gives rise to certain disturbances of 
nutrition and various local and constitutional manifestations, which are modified by 
the degree of virulency of the virus, the amount and rapidity of its absorption, and 
lastly, and most powerfully, by the constitutional condition of the patient. On the 
one hand, we have the effects of the poison manifested by more or less febrile move- 
ment with adynamia, and greater or less vital depression, merging into a typhoid 
condition, while on the other we have successive chills, fever and perspirations, not 
unlike malarial fever, and merging also into the typhoid state. Why is it that we 
have this marked difference between the two forms of disease? On examining the 
case closely, we discover the explanation in the presence of more or less generalized, 
diffuse or circumscribed suppurations, which are characteristic of the so-called "pyæ- 
mia, ' ' and which give rise to symptoms proportionate to their extent, the importance 
of the tissues involved and the resisting power of the patient. In these suppura- 
tions we have the cause of the characteristic features of pyæmia. What do we look 
for, as indicating the formation of pus in various situations, particularly in chronic 
suppurative processes? Simply chills, febrile movement, and, perhaps, sweating, or, 
in short, "hectic fever," the severity of which depends entirely upon the importance 
of the diseased structures, the extent of the process, and the systemic condition of 
the individual, and all this, too, independently of any morbific or poisonous principle 
in the blood, for we have the same phenomena in deep-seated suppurations when no 
bacteria are present. The difference between these manifestations of the existence 
of simple purulent processes and those of pyæmic deposits and inflammations is 
simply one of degree and not of kind. The peculiar features of pyæmia, then, are 
only the ordinary sequences of suppuration intensified. 
In applying this theory to such cases as those described by Dr. Porre, it is suffi- 
cient to say that the same local and constitutional conditions which modify the 
severity of septæmia also modify its duration, hence these cases are by no means sur- 
prising results of blood poisoning. The slight çxtent of the local process, the other- 
wise fair health of the individual in dental lesions, and the relative slowness of the 
process of absorption of the poison, explains their chronicity. To the general sur- 
geon, their analogy to carious and suppurative processes in bone, of a chronic char- 
acter, is very striking. Their symptoms and results are a modified and, at the same 
time, prolonged representation of those which occur in chronic hip joint disease, 
spinal caries, etc., in which chronic septæmia plays a by no means unimportant part. 444 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SECOND DAY. 
The Section met at 11 A.M., and, after some preliminary business, proceeded to 
the discussion of the paper read yesterday by Dr. Porre, on the subject of Chronic 
Pyaemia. 
Dr. George II. Chance, of Portland, Oregon, said that he was very much inter- 
ested in that paper, and that he was gratified in being able to endorse it. He held 
in his hand a specimen of pyogenic membrane which he had removed from the 
superior maxilla, growing out of such a case as indicated in the paper read yesterday- 
The history of the case was this : A banker residing in his city had been partially 
treated in New York, but had returned home, in consequence of not being able to 
remain in New York, and had placed the case in his (Dr. Chance's) hands. The 
roof of the mouth was all open, and the process of the maxilla was entirely invaded. 
There was a thick coating on the tongue ; the patient suffered from insomnia and a 
generally debilitated condition. He had removed as much of the carious bone as he 
possibly could without passing through the palatine arch. The cavity had been 
packed, and (to use the patient's own language) he had expectorated enough to fill 
seven heads. The disease had been running about two years. After three months' 
treatment he (Dr. Chance) was happy to say that the patient was perfectly well. 
Dr. W. C. Barrett, of Buffalo, N. Y., asked Dr. Chance what he meant by a 
pyogenic membrane. 
Dr. Chance replied that he understood it to be the product of inflammation or 
(to put it in plain language) a scab. 
Dr. Joseph Walker, of London, said that it had given him great pleasure to 
hear, yesterday, the reading of Dr. Porre's paper on so important a subject as 
"Chronic Pyæmia from Dental Origin,'' but that he was surprised at Dr. Porre's 
recommendation of the practice of extraction. So far as he could gather from the 
paper, he learned that Dr. Porre's general treatment in his clinical cases was the 
extraction of teeth, mentioning as many as seventeen teeth which he had extracted 
in the case of one diseased condition of the membrane. It had given him great 
pleasure, also, to hear the paper by Dr. Lydston, of Chicago, read by Dr. Dudley, 
on the same subject. It seemed to him that that paper treated the case very 
scientifically. The subject had received great attention on the other side of the 
water. Doctors Bartholomew and Underwood had made very thorough experiments 
in that direction for the last three years. It seemed to him that the case reported 
by Dr. Porre was simply a formation and development of microbes and bacteria, and 
if the germs of the microbes and bacteria were destroyed, the condition of the patient 
would be improved, and finally the pyæmia alveolaris would be eradicated. That was 
the treatment which they were adopting in London. He would not trouble the 
meeting any further, but he simply wished to express his surprise at the treatment 
of the disease by Dr. Porre, by eradication and extraction of the teeth. 
Dr. A. E. Baldwin, of Chicago, asked Dr. Porre if he understood him correctly SECTION XVIII-DENTAL AND ORAL SURGERY. 
445 
as recommending a treatment consisting of one gramme of carbolic acid in a mixture 
with a pint of water. 
Dr. Porre replied in the affirmative. 
Dr. Baldwin asked Dr. Porre what effect he expected from carbolic acid used in 
a solution of that strength. 
Dr, Porre said that it acted as a disinfectant, and that it sufficiently stimulated 
the tissue. He varied the lotion according to circumstances. He used it to wash out 
the cyst in some instances. He used it as a disinfectant and antiseptic lotion, with 
strength varying to suit the case. He had simply given the facts in the case which 
he had described, and would expect gentlemen to deviate according to the circum- 
stances of the case. He had mentioned that as a moderate lotion, as one containing 
a strength which he thought sufficient, and which would not do any harm. The 
Strength might be increased, of course, to suit the case. 
Dr. F. II. Kehwinkel, of Chillicothe, Ohio, said that he rose, almost from a 
sense of duty, to state the impression made upon him by a conversation with Professor 
Dawson, of Cincinnati, on the subject presented by Dr. Porre. They were all familiar, 
not so much with the symptoms described as with the pathological conditions. All 
present, particularly from the West, know who Professor Dawson is. He is 
Professor of Surgery in the Ohio Medical College, a man of large experience, and 
who is looked upon in his own locality as an authority. Professor Dawson said : 
"The idea of chronic pyæmia ! Who had ever heard anything about chronic pyæ- 
mia? If, five years ago, a dentist had told the medical faculty of chronic pyæmia, 
the faculty would have said: 'What is the man thinking about? He is a fool.' 
Who has ever heard anything about chronic pyæmia? But we in Cincinnati (he 
said) have seen these cases which have passed through the hands of twenty or thirty 
of our best physicians and surgeons, myself among the rest. We have had these cases 
and treated them until we got tired of them, and we c'ould not do anything with 
them. But here comes a dentist, and in the first and second examination of the 
case he diagnoses the case, and goes to work and cures it in a remarkably short 
time. ' ' 
These, Dr. Kehwinkel continued, were facts. Nobody could get over them. 
They could not be controverted. He and all of them had been struck with the 
importance of the paper and with the revelations made in it. It had opened their 
field of vision. For himself, he had never thought of inquiring into the general 
condition of health whenever he had a case of that kind. He and others had gener- 
ally contented themselves with merely giving local treatment. The subject of pyæ- 
mia alveolaris had been alluded to. It was, in some respects, very similar to chronic 
pyæmia. It was not exactly the same, but it was similar in its tendencies and in its 
general effects. He would not take up any further time now. The field of inquiry 
had been opened, and he had no doubt that the seed would bear its fruits. 
Dr. C. A. Brackett, of Newport, R. I., expressed the opinion that if in their 
practice gentlemen would look out for carious bones and necrosed bones, they would 
find them in the future much offener than they had recognized them in the past, 
and would treat them properly. 
Dr. W. J. Younger, of California, suggested the use of lithic acid in dissolving 
callous bone, and also the use of corrosive sublimate, with a strength of from two to 
four per mil. 
Dr. D. Genese, of Baltimore, said that in all the remedies mentioned there was 
the possibility of harm. There were, however, two substances which he had used 446 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
successfully. One was a diluted aromatic sulphuric acid. The. other was one to 
which he attached more importance, and which had frequently given a patient 
immediate relief. Besides, it could be used frequently without fear of the injurious 
effects that often attended ordinary preparations of opium. That was the solid 
extract of white poppies. In all operations of the mouth where incisions were made, 
a pellet of this extract placed immediately over the part gave almost immediate 
relief; while a gramme of it dissolved in half a pint of hot water made an excellent 
mouth wash, both as an antiseptic and soporific. 
Dr. Younger, of California, explained, in answer to an inquiry, that when he 
used the expression "two to four per mil.," he meant two to four per thousand. 
He added that lithic acid had a very strong affinity for lime salts, while it did not 
affect soft tissues. It attacked the lime salts and the necrosis, while it did not affect 
the healthy tissues around it. 
Dr. Geo. W. Whitefield, of Evanston, Ill., described and recommended the 
use of an electrical process, which, he said, not only destroyed the necrosed bones by 
decomposition, but also stimulated the tissues to healthy action. 
Dr. J. C. Storey, of Texas, inquired of Dr. Porre *in what way the toxi-pysemia 
was produced ; in what way the pus entered the circulation and contaminated the 
blood. Was it by direct or immediate absorption from the wound, or was it by the 
pus entering the stomach ? 
Dr. Porre replied that he left that to be decided by gentlemen themselves. The 
blood was unquestionably vitiated through both methods. If the septic matter 
thrown off from diseased gums (amounting often to a tablespoonful in twenty-four 
hours) was taken into the stomach, what became of it? If the patient had a strong 
vital force he could throw it off, and keep doing so for years, perhaps, before it 
would produce any deleterious influence on the organism. But eventually it would 
make inroads, and in proportion to the inroads made would be its cumulative action. 
Finally, the individual affected would suffer from indigestion and the train of symp- 
toms which he had mentioned yesterday-constipation, nervous prostration and 
insomnia. Gentlemen were left to draw their own conclusions. A patient with a 
feeble organization would be very readily affected by septic matter through the 
stomach, and also through direct absorption. As he had not been in the hall when 
Dr. Walker spoke, he would like that gentleman to repeat what he had said about 
extraction and about sacrificing too many teeth. 
Dr. Walker, of London, said he had merely expressed his surprise at Dr. Porre's 
frequent resort to the extraction of teeth, and at his extracting as many as seventeen 
teeth from one head. That was entirely different from the treatment they were now 
adopting in London. They were using new preservative means rather than extrac- 
tion, and were doing so successfully. 
Dr. Porre said that he stated in his paper that the teeth extracted were all past 
salvation. The teeth and the roots were too much diseased to attempt to save them. 
Consequently he had extracted them. In one of the cases which he had mentioned, 
the patient was a charity patient. The teeth and roots which he could not save he 
had extracted, and others he had filled, some of them with gold, not expecting any 
return, rather than sacrifice them. He only extracted those which he could not 
save. He was emphatically opposed to sacrificing any teeth which could possibly be 
saved. 
Dr. W. C. Barrett, of Buffalo, N. Y., said that the general tone of the discus- SECTION XVIII-DENTAL AND ORAL SURGERY. 
447 
sion seemed hardly up to the present development of science and of medical knowl- 
edge. He objected most seriously to the consideration of such a thing as a " pyogenic 
membrane," and he objected to the statement that the swallowing of pus must 
necessarily produce injurious effects. Pus could be digested in the system precisely 
as anything else. According to the later developments, there was no such thing as 
pus without microorganisms. If the microorganisms were destroyed, there could be 
no such thing as pus. There could be no such thing as the migration of pus cor- 
puscles from one centre to another. Pus had to be produced in its own centre, and 
that had to be the focus of inflammation. That inflammation might proceed to such 
an extent as to form septic organisms and a new focus for the production of pus. 
But the idea that pus might be absorbed into the system and carried to a certain 
definite point, and that there that same pus might be eliminated, he most seriously 
objected to. There might be such a thing as the transfusion or transference of septic 
organism from one point to another, but he did not think that pyaemia necessarily 
resulted from what was usually understood as the absorption of the pus. It might 
arise from a new focus of inflammation, which of itself might be called entirely septic, 
and in that way, from infection of the organism, there might be a new focus for the 
development of pus. But the idea that pus proceeded from anything like a pyæmic 
membrane had been, as he supposed, entirely abandoned by advanced students. 
Dr. A. M. Dudley, of Salem, Mass., then proceeded to read (in the absence of 
its author) an English translation of a paper prepared by E. Brasseur, entitled Sur 
T Emploi de T Air dans la Thérapeutique Dentaire. 
At the conclusion of the reading, the usual recess was taken to three o'clock P.M. 
The following is the original of Dr. Brasseur's paper. 
SUR L'EMPLOI DE L'AIR DANS LA THÉRAPEUTIQUE DENTAIRE. 
ON THE USE OF AIR IN DENTAL THERAPEUTICS. 
ÜBER DEN GEBRAUCH DER LUFT IN DER ZAHNTHERAPIE. 
PAR LE DR. E. BRASSEUR, 
De Paris, France. 
Messieurs:-Depuis longtemps l'air chaud comptait au nombre de nos agents thé- 
rapeutiques ; dans ces derniers temps on l'utilisait même sous pression, afin d'en aug- 
menter son action ; ce n'est donc pas une idée nouvelle que je viens préconiser. 
En vous entretenant des applications de l'air chaud à notre thérapeutique, je veux 
seulement attirer l'attention de mes confrères, en leur démontrant l'utilité et les avan- 
tages de cet agent, en indiquant, d'après mon expérience, les cas où l'air nous rend de 
grands sendees ; enfin en signalant plusieurs appareils perfectionnés qui en facilitent 
l'application. 
En raison de la sensibilité exagérée dont jouissent les dents, le plus souvent nous 
dûmes avoir recours à l'air chaud plutôt qu'à celui de la température ambiante, la 
thermot'hérapie doit don? être à juste raison considérée comme un de nos meilleurs auxi- 448 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
liaires dans le traitement des dents et dans les opérations qu'elles comportent, particu- 
lièrement dans les cas suivants :- 
1° NETTOYAGE DES CAVITÉS. 
Dans le nettoyage des cavités, pour enlever les détritus de la carie résultant de 
l'emploi des fraises et des excavateurs, à la place des injections d'eau, il sera plus 
avantageux et plus prompt de se servir désormais d'un vigoureux coup de piston d'air 
chaud. 
L'air sera moins douloureux pour le patient que l'eau qui souvent n'étant pas à la 
température convenable impressionne désagréablement, quelquefois même douloureuse- 
ment la dentine. 
Chaque fois que la digue de caoutchouc sera appliquée sur les dents, l'air envoyé 
avec force devient indispensable car l'eau ne saurait être employée puisque précisément 
la sécheresse absolue est recherchée. 
2° SENSIBILITÉ DE LA DENTINE. 
Nous savons tous par expérience combien la résection de la dentine cariée, dans les 
caries du deuxième degré, est douloureuse, l'hyperhestésie est parfois tellement vio- 
lente, qu'il est impossible de continuer l'opération. 
Cette hyperhestésie de la dentine peut tenir à trois causes différentes : 
1° A la congestion de la pulpe. 
2° A l'acidité buccale. 
3° A la présence de quelques prolongements nerveux venus du plexus pulpaire, ou 
d'une substance intermédiaire mettant en relation directe l'ivoire et la pulpe. 
Il sera le plus souvent assez facile, par des moyens de thérapeutique habituellement 
employés en pareille circonstance, d'obvier aux deux premières causes ; cependant si 
vous venez à rencontrer un de ces cas où le contact de l'ongle sur la superficie lisse 
d'une dent provoque de la douleur, c'est qu'il existe, soit une érosion, soit une carie du 
collet. 
Une autre fois ce sera un patient dont les superficies interstitielles des incisives supé- 
rieures seront cariées et d'une telle sensibilité qu'il sera impossible de les toucher avec 
un instrument. 
Or si on applique la digue sur les six dents antérieures, qu'on enlève l'humidité 
avec l'alcool absolu et qu'on dirige sur les dents un peu d'air chaud bien sec, elles 
seront d'abord moins sensibles, puis peu à peu dépourvues de sensibilité. 
Après avoir bien nettoyé de cette façon toutes les cavités, on pourra, s'il n'y a pas 
d'autre complication, procéder de suite à leur obturation sans aucune douleur. 
Les uns n'ont pas craint de conseiller comme remède Vacide arsénieux, prétendant 
qu'une très-légère application agissait alors comme astringent et non comme caustique 
(Magitot, Combes) ; c'est là, suivant nous, une grave erreur; la dose si minime soit- 
elle agit toujours comme caustique et escharotique. S'il est vrai qu'une légère couche 
d'acide arsénieux enlève pour le moment de l'opération la sensibilité exagérée de la 
dentine, il est vrai aussi que dans un avenir plus ou moins éloigné, la dent perdra sa 
vitalité et si elle a été obturée même loin du voisinage de la pulpe, un jour sans cause 
connue, une fistule conséquence d'un abcès alvéolaire apparaîtra et à la trépanation de 
la dent, on trouvera une pulpe morte. 
Heureusement que cette théorie aussi fausse que pernicieuse n'a pas été admise par 
les praticiens soucieux de conserver avant tout un organe pouvant répondre à ces fonc- 
tions physiologiques. 
D'autres conseillent des escharotiques moins énergiques. 
D'ailleurs plusieurs théories ont été émises au sujet de cette sensibilité, Fomes Père 
et Fils attribuent à la présence de fibrilles qui seraient contenues dans les canalicules, SECTION XVIII-DENTAL AND ORAL SURGERY. 
449 
la sensibilité de la dentine, et donnent comme preuve de leur théorie, la cautérisation 
ignée qui fait cesser la douleur en détruisant ces mêmes fibrilles. 
Les fibrilles sont pour d'autres anatomistes, une chose difficile à définir, car suivant 
la théorie de Fomes, ces fibrilles seraient de véritables organes nerveux, or nous savons 
tous, qu'aucun nerf n'a été jusqu'ici trouvé dans la dentine, aussi s'est-on servi d'un 
terme plus général, celui de matière vivante, qui en relation directe avec les vaisseaux 
de la pulpe entretiendrait la vitalité dans la dentine et transmettrait même la sensibi- 
lité à la pulpe elle-même. 
En effet, on peut entendre et nous comprenons sous le nom de matière vivante, un 
proto-plasma qui serait contenu dans les canalicules dont il est impossible de nier l'exis- 
tence et circulant dans la dent en vertu d'une force osmostique ; la sensibilité dès lors 
pourrait être transmise à la pulpe à travers cette couche plus ou moins liquide dont la 
densité nous est inconnue, tout aussi bien que par des fibrilles nerveuses restées jus- 
qu'ici invisibles aux regards et recherches de bien des observateurs et que beaucoup de 
dentistes ont admises pour en avoir constaté l'existence dans leurs différents manuels. 
Quoique Fomes avance qu'il n'y a pas d'exemple de sensibilité à travers les liquides, 
le contraire cependant nous est démontré par le liquide de Cotunio, lequel sert à trans- 
mettre les sensations au nerf auditif et par celui du globe de l'œil, et d'ailleurs il est 
précisément d'observation de chaque jour que la sensibilité dans une dent varie surtout 
suivant son état hygrométrique. 
Peut-être a-t-on pu saisir au milieu d'un très-grand nombre de préparations et de 
coupes diverses quelques filaments partant des odontoplastes et pénétrant jusque dans 
les canalicules, en tout cas ce serait là une exception qui pourrait appliquer heureuse- 
ment pourquoi dans une carie de deuxième degré, alors que l'on se trouve assez éloigné 
de la chambre pulpaire on rencontre un ou deux points représentant la surface d'une 
pointe d'épingle, sur laquelle il est impossible de mettre l'instrument sans provoquer 
une vive sensibilité. 
Cette manière de voir se trouverait corroborée par l'opinion de Colman qui dit : les 
odontoplastes semblent avoir pour fonction principale non pas de créer la formation de 
la dentine mais bien une propriété sensorielle spéciale semblable à celles des corpuscules 
du tact (corps de Pacini), des bâtonnets et des cônes de la rétine, des cellules olfactives, 
qui comminuquent tous avec des nerfs. 
Des odontoplastes dans ce cas, seraient de véritable cellules ganglionnaires termi- 
nales qui recouvriraient le bulbe dentaire et enverraient des prolongements dans les 
canalicules, où se trouve un liquide (ou des fibres terminales suivant quelques auteurs) 
et dont les vibrations transmettraient la sensibilité à ces corpuscules, qui doivent être 
dès lors regardés comme des cellules de renforcement. 
Cette explication anatomique rend les dents capables d'apprécier très-exactement la 
nature des corps soumis à leur action et leur permet de distinguer nettement la diffé- 
rence des diverses substances qu'elles doivent broyer. 
Ce sont d'abord des sensations purement refexes se produisant sans l'effort du cer- 
veau, puisqu'elles se manifestent chez les monstres amonocéphales. 
Quoiqu'il en soit de l'une ou de l'autre de ces explications physiologiques, il reste 
prouvé que la dent est douée d'une très-grande sensibilité, puisqu'à travers cette couche 
si dure, l'ivoire, elle sait distinguer les diverses substances qu'elle est destinée à broyer, 
ce qui la constitue pour ainsi dire, la gardienne du canal alimentaire ; qui de nous en 
effet, n'a pas éprouvé sur les dents, une sensation différente selon qu'elles rencontrent 
dans la mastication, du gravier, de la craie ou du charbon ; les liquides eux-mêmes les 
impressionnent différemment, le sucre, les acides, les corps gras, ont une sensation dif- 
férente qui leur est propre. 
Il n'est donc pas surprenant qu'un organe de tact aussi parfait puisse acquérir une 
hyperhestésie très-grande à l'état pathologique. 
Vol. V-29 450 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
D'après cette texture anatomique nous croyons dangereux d'appliquer des cscharo- 
tiques, des caustiques présents comme l'acide arsénieux. 
Il est certain que si la sensibilité a été éteinte, c'est que le médicament a agi et 
nous savons de quelle façon. 
La lésion a été légère sans doute, mais elle n'en existe pas moins et tous ceux qui 
ont pour eux l'expérience des années n'ont pas été sans voir des dents à peine cariées, 
causer par la suite des abcès alvéolaires, des fistules, sans cependant pouvoir reconnaître 
la cause de la mortification de la pulpe. 
Qu'ils interrogent leurs malades, ils leurs répondront : Ma dent était très-sensible, 
le dentiste m'a fait un pansement et çà été fini. Ce pansement vous l'avez reconnu, 
c'est à n'en pas douter l'acide arsénieux. 
Du moment que nous admettons que les médicaments pénètrent à travers les cana- 
licules de l'ivoire et à l'état ordinaire, nous croyons qu'ils pénétreront encore bien 
mieux au moyen de l'air chaud qui, après avoir desséché momentanément les canali- 
cules et en avoir refoulé le liquide qu'ils peuvent contenir, facilite le phénomène d'im- 
bibition par le médicament, c'est pourquoi nous rejetterons l'emploi de l'acide phénique 
cristallisé et de tout agent caustique, car il n'est pas douteux qu'en arrivant ainsi dans 
les canalicules, ils ne provoquent tôt ou tard certains troubles du côté de la pulpe. 
Nous savons en effet que l'acide phénique coagule l'albumine des tissus et déter- 
mine, si l'emploi en est continué la formation d'une eschare qui ne Peut disparaître que 
par voie d'élimination, lors donc qu'on badigeonne et que même comme nous l'avons 
vu, on cherche à faire fondre des cristaux d'acide phénique pur dans la cavité de la 
dentine, afin d'avoir une action plus énergique encore, on détruit la matière vivante de 
la dent. 
Il est vrai qu'à cette action énergique, il se joint, parait-il une autre action bienfai- 
sante cette fois, comme l'a écrit un dentiste en parlant de l'application de l'acide phé- 
nique. Plus loin ce même dentiste, à propos de la dévitalisation dit : nous employons 
concurrencent avec Z' acide phénique d'autres caustiques plus puissants, l'acide arsénieux, 
la potasse caustique, lorsque nous avons à détruire des pulpes sèches en filets nerveux. 
Comment se fait-il que dans un cas l'acide phénique cristallisé, pur par conséquent, 
soit simplement anesthésique et antiseptique, alors que dans un autre cas il est cau- 
stique, capable de détruire la pulpe, le tissu vivant. 
Nous avouons ne pas bien comprendre une semblable théorie, et quant à nous, nous 
ne recourrons à l'acide phénique cristallisé et fondu à l'aide de l'air chaud dans la dent, 
que dans les caries arrivées au troisième degré, dépourvues de pulpe, en un mot dans 
des dents mortes, nous cherchons alors à imprégner tout le tissu dentaire d'un antisep- 
tique puissant propre à détruire en même temps les parcelles de tissu vivant pouvant 
encore exister, l'acide phénique fondant à 42°, pénètre alors tous les canalicules, allant 
désinfecter la couche péricémentaire qui à cette époque de la carie se trouve elle-même 
envahie par des micro-organismes. 
Mais en se servant d'un médicament aussi énergique pour détruire la sensibilité de 
la dentine il s'en suit que l'acide phénique pénétrant par imbibition les canalicules, 
arrive en contact avec la matière vivante et la pulpe, laisse sous l'obturation des parties 
escharifiées dont l'organisme ne peut se débarrasser, que plusieurs mois, plusieurs 
années même après cette application, nous pourrions vous en citer bien des exemples. 
Nous bannissons donc l'emploi de cette médication et nous conseillons dans le cas 
d'hyperhestésie dentinaire d'entourer la dent de la digue de caoutchouc, afin de la main- 
tenir complètement à l'abri de l'humidité, puis de pratiquer simplement des insufla- 
tions d'air chaud, car tous nous savons par expérience que l'état hygrométrique de la 
dent développe une plus ou moins grande sensibilité. 
Si l'hyperhestésie était trop grande, et que l'air chaud ne soit pas suffisant pour 
rendre l'opération, non pas complètement insensible, mais supportable, on aura tou- SECTION XVIII-DENTAL'AND ORAL SURGERY. 
451 
jours un moyen certain de faire pénétrer au sein du tissu de la dentine un médicament 
.calmant comme l'huile de girofle ou un mélange de chloral et de camphre. 
Voici encore deux autres procédés qui paraissent donner de très-bons résultats :- 
1° Eugénol 10 gramme. 
Chlorhydrate de cocaïne 1 gramme. 
2° Vératrine 0.10 centigramme. 
Alcool absolu vi gouttes. 
Faites dissoudre, agoutez :- 
Tannin 0.35 centigramme. 
Glycérine 8 grammes. (Bogue.) 
Une goutelette sur du coton qu'on appliquera sur la dent et qu'on fera pénétrer 
dans les canalicules grâce à l'intervention de l'air chaud. 
Ces médicaments à la fois antiseptiques et calmants agissent sur les canalicules qui 
à la superficie forment un réseau plus abondant. 
Un de nos confrères les plus distingués et dont l'autorité ne saurait être mise en 
doute, Monsieur le Docteur Bogue nous racontait qu'une patiente lui avait assuré que 
sans le secours de l'air chaud elle n'aurait pu supporter la vive douleur que lui causait 
la résection de la dentine pour la préparation d'une cavité. 
Il n'est donc pas étonnant qu'en employant des caustiques comme l'acide arsénieux 
et même l'acide phénique si largement employé de nos jours, que la dentine ne soit 
plus sensible, puisqu'elle a été atteinte dans sa vitalité et c'est là ce que certains prati- 
ciens, ignorants sans doute de l'action des médicaments appellent le pouvoir anesthé- 
sique de l'acide phénique. 
Nous avons été témoins des effets désastreux de cet acide sur une dent de première 
dentition dans laquelle, pour éviter la douleur on avait mis des pansements en coton 
imbibé d'acide phénique, il se forma à la suite un abcès qui plus tard détermina la 
nécrose de la partie alvéolaire. 
D'ailleurs ne savons nous pas que ce que nous avançons sur le pouvoir escharotiqu3 
de l'acide phénique se trouve confirmé par la conduite des praticiens qui ne voulant à 
aucun prix entendre parler de l'acide arsénieux pour la dévitalisation de la pulpe, 
s'adressent précisément à cet acide, qui par une action plus lente, il est vrai, arrive 
cependant au même résultat. 
Entre le passage de la carie du deuxième degré au troisième degré, on rencontre 
souvent de la dentine décolorée ayant subi un commencement de ramollissement. 
Si nous enlevons cette couche, nous mettons la pulpe à un, or tous les efforts d'une 
bonne chirurgie conservatrice doivent tendre au contraire à ne pas découvrir la pulpe ; 
vous connaissez en effet les réactions pathologiques survenant du côté du périodonte et 
du cément à la suite d'une dent morte après quelques années, le peu de résistance 
que de telles dents peuvent opposer à une nouvelle carie, leur changement de couleur, 
etc. 
Aussi a-t-on considéré cette couche déjà ramollie comme devant le mieux protéger 
l'organe vital de la dent. 
D'un autre côté, il est bien certain que cette dentine contient des micro-organismes 
en voie de pullulation, que ces derniers continueront leur travail de destruction et de 
décalcification, dont la pulpe ressentira les effets morbides, or vous savez quelles sont 
les conséquences d'une pulpe congestionnée, suppurant sous une obturation. L'inflam- 
mation se manifeste rapidement, un abcès alvéolaire apparaît avec tout son cortège de 
complications. 
Nous conseillons pour se mettre à l'abri de tels accidents, de stériliser complètement 
cette dentine pathogénique; au moyen de l'air chaud on chassera toute l'humidité pour 452 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
la saturer ensuite d'un antiseptique puissant tel que la solution de bichlorure de mer- 
cure au 1000me. 
On injectera de nouveau de l'air chaud pour badigeonner ensuite à l'acide de l'huile 
de girofle ou d'Eugénol, substances qui à leur propriété antiseptique ajoutent l'avan- 
tage d'être un calmant excellent et non irritant des hyperhestésies pulpaires ; après 
cette application on dirigera de nouveau quelques jets d'air chaud et une fois la cavité 
redevenue sèche on enduira les parois d'un vernis antiseptique composé de : 
COPAL. 
Ether, quantité suffisante pour dissoudre. 
Ce vernis s'évaporera facilement sous l'influence de quelques jets d'air chaud dirigés 
toutefois, à une certaine distance de la cavité (deux centimètres environ). L'air envoyé 
trop près occasionnerait des bulles d'air qui soulèveraient le vernis par place ; pour 
obvier à cet inconvénient nous employons un mélange de gomme copale et de paraffine, 
parties égales. 
La cavité ainsi préparée on appliquera au fond, un corps mauvais conducteur de la 
chaleur, comme la gutta-percha, la pâte de Hill, ou mieux encore, une de ces petites 
rondelles d'amiante, que nous trouverons toutes préparées dans nos dépôts dentaires ; 
après avoir trempé l'une ou l'autre de ces substances dans l'huile de girofle, ou dans de 
l'acide salycilique dissout dans de F Eucalyptol ou toute autre substance antiseptique 
et non caustique. 
Cette précaution d'un corps isolant est indispensable, car les obturations définitives 
sont ou métalliques ou à l'oxyphosphate ; métalliques : elles se composent d'or, d'étain 
ou d'amalgames, elles sont alors dangereuses par Faction thermique qu'elles déve- 
loppent ; à l'oxyphosphate elles sont hygrométriques et n'assurent pas une obturation 
complètement étanche, ces deux causes suffisent pour, à la longue il est vrai, irriter la 
pulpe et déterminer les accidents que nous avons signalés lors de la mort de cet organe. 
C'est particulièrement sur d'anciens amalgames que nous avons souvent constaté les 
effets que nous signalons en ce moment. 
Arrivé au troisième degré, la carie a pénétré dans la chambre pulpaire et la pulpe 
peut présenter diverses conditions pathologiques. 
Premièrement. Elle est mise à un par suite de la carie sur un très-petit point 
intentionnellement ou accidentellement ; pendant la préparation de la carie, elle n'a 
fait que peu ou pas souffrir, elle est saine, apte par conséquent à continuer ses fonctions 
physiologiques. 
Deuxièmement. Elle est enflammée très-douloureuse, mais encore vivante quoique 
commençant à secréter. 
Troisièmement. Elle suppure et subit les effets de la fonte purulente qui est la 
désorganisation, la gangrène et la mortification. 
Ces trois stades, le patient les indique de la manière suivante :- 
Dans le premier, douleur persistante au contact de l'eau froide. 
Dans le second, c'est-à-dire la formation de l'exsudât, le chaud et le froid lui font 
mal. 
Au troisième stade correspondant à la suppuration, le chaud seulement. 
Nous avons donc, suivant ces trois états, un diagnostic sérieux à faire pour diriger 
notre thérapeutique. 
La première période est la plus délicate à traiter pour le dentiste dont le devoir est 
de diriger tous ses efforts en vue de la conservation d'un organe aussi important que 
l'est la pulpe dentaire, dont l'état pathologique, à ce moment, réclame un traitement 
spécial pour le ramener à son état physiologique. 
Le patient de son côté, ne considérant que la douleur, réclame d'être débarrassé de 
suite d'un traitement qu'il croit souvent inutile. SECTION XVIII-DENTAL AND ORAL SURGERY. 
453 
Que de fois ne nous dit-on pas : mais Docteur, tuez-moi le nerf ! parole bientôt dite 
et qui se répète à chaque sentiment pénible ou à chaque pansement, sans se rendre 
compte de la cause de l'élément douleur pas plus que de la nature de la lésion. 
Si dans une dent atteinte de pulpite par exemple, après un ou deux pansements faits 
par un dentiste habile, précisément dans le but de conserver la pulpe, un sentiment 
douloureux persiste, surtout lors du toucher de la dent par l'opérateur, le malade ne 
manquera pas de dire : mais Docteur ! ne pouvez-vous donc pas mettre quelque chose 
de bien-fort pour tuer ce nerf et me boucher ma dent, s'imaginant ainsi qu'une fois le 
nerf tué, suivant son expression, dévitalisé suivant la nôtre, que tout est fini. 
Ne vous semble-t-il pas surprenant comme à nous d'entendre des malades souvent 
intelligents parler de détruire si vite ce que la nature a fait de si merveilleux ; n'est-il 
pas de notre devoir de leur faire comprendre comment un nerf, une pulpe dans une 
dent est nécessaire pour lui assurer sa propre vitalité, que la dent privée de cet échange 
de matériaux nutritifs ne tient plus à l'économie que par le ligament alvéolo-dentaire, 
le périodonte, mais ne pourra plus lutter contre les causes de détérioration auxquelles 
elle est exposée, que dans un temps plus ou moins éloigné, la nature ayant horreur de 
ce qui ne vit plus fera un effort pour s'en débarrasser soit par des complications du côté 
des racines dont le cément s'hypertrophie ou se raréfie, soit du côté de l'alvéole ou le 
ligament intra-alvéolaire, etc., vous le voyez nous devons par tous nos efforts tenter de 
conserver un organe aussi précieux. 
C'est donc dans cette première période qu'il importe plus que jamais, puisque la 
carie a pénétré dans la chambre pulpaire, de tenir cette chambre à l'abri de l'humidité 
et de toute cause septique pendant l'opération. 
Nous considérons, en effet, comme une cause de septicité non douteuse le passage 
de la salive dans les canaux radiculaires, et nous ne saurions trop insister sur une pré- 
caution que beaucoup de praticiens ne considèrent pas comme indispensable. 
En nous appuyant d'un exemple tiré de la chirurgie comparée, nous demanderons 
si l'oculiste, alors qu'il pénètre dans les tissus du globe oculaire et qu'il s'entoure de 
toutes les précautions antiseptiques, pêche par un procédé opératoire complètement 
inutile? Non, sans doute, puisqu'il sait que c'est en agissant ainsi qu'il se mettra à 
l'abri des inflammations, des suppurations consécutives ; pourquoi alors en serait-il 
autrement pour le dentiste quand il se trouve en présence d'un organe aussi délicat que 
la pulpe dentaire, d'ailleurs ceux qui ont pour habitude de suivre la règle que nous 
indiquons savent combien les périodontites, les Kystes péridentaires, les abcès alvéo- 
laires, complications autrefois si fréquentes, sont rares aujourd'hui entre leurs mains, 
du moment qu'ils assurent à la plaie intra-dentaire la même antisepticité qu'à la plaie 
intra-oculaire. 
Il sera donc sage, même pour un pansement, d'appliquer soit la digne en caout- 
chouc, soit des petites serviettes de papier ou de linge maintenues en place par des 
crampons spéciaux que vous connaissez, puis de dessécher délicatement la cavité à 
l'aide d'amadon et d'air sec légèrement chaud. 
En principe ne doit-on pas admettre et dire que la cavité la plus sèche et la plus 
aseptique sera celle ou l'opération réussira le mieux. 
La cavité ainsi préparée, on pourra pratiquer le coiffage de la pulpe, si l'on désire 
conserver cet organe. 
Cette petite opération si répandue aujourd'hui dans notre pratique est, vous le savez, 
fort délicate et réclame comme dans toute manipulation dentaire une grande légèreté 
de mains ; pour continuer la comparaison de tout à l'heure, la légèreté du toucher de 
la part du dentiste doit être semblable à celle de l'oculiste retirant une cataracte de la 
chambre de l'œil, nul doute que si le dentiste s'habituait à considérer la dent comme 
un organe aussi délicat que celui de la vue, qu'il n'obtiendrait un résultat plus satis- 454 
. NINTH INTERNATIONAL MEDICAL CONGRESS. 
faisant dans la grande majorité de ses opérations, toute compression est ici inévitable- 
ment funeste à un organe aussi riche en vaisseaux sanguins et en nerfs. 
L'action de l'air légèrement chaud permettra d'éviter cette compression, en faisant 
rentrer la pulpe dans sa chambre, si comme cela arrive souvent, elle fait légèrement 
hernie au dehors, par suite de l'afflux sanguin. 
Cette action a été parfaitement démontrée dans un travail du Docteur Rose. 
Selon ce praticien, l'humidité fait gonfler le tissu de la dentine et amène une com- 
pression très-douloureuse des nerfs de la pulpe. 
D'ailleurs, dit-il, cette action de la chaleur sur la dent, est tellement vraie, que, si 
l'on vient à projeter de l'air chaud dans l'intérieur d'une carie où la pulpe est mise à 
nu, on la voit, si on l'observe attentivement, rentrer dans la chambre qu'elle occupe 
ordinairement au milieu de la dentine à la façon d'un ver de terre. 
Pour procéder au coiffage de la pulpe on peut se servir de petits disques en platine 
concaves sur une face, celle qui regarde la pulpe. 
Si ces coiffes rendent des services, nous pensons que l'on peut avantageusement s'en 
passer, car leur application n'est pas toujours très-pratique vu la nombreuse variété de 
la forme des caries. 
Nous nous servons d'un procédé que nous n'hésitons pas à recommander vu les 
résultats satisfaisants qu'il nous a donnés. Ce procédé consiste dans l'application 
d'un médicament indiqué par Rosenthal (de Liège-Belgique) et connu sous le nom de 
P alpine. 
Cette préparation consiste en un mélange d'huile de girofle et d'oxyde de zinc 
anhydre ; on fait une pâte de consistance, de crème épaisse, qu'on applique très-délica- 
tement sur la pulpe préalablement séchée à l'air chaud, on en facilite l'adaptation à 
l'aide d'un léger tampon de ouate que l'on retire ensuite. 
Par dessus la Pulpine on fera une obturation plastique, afin de la mettre à l'abri 
des liquides de la bouche et des efforts de la mastication. 
Puis si on le juge utile on pourra sur cette couche d'oxyphosphate faire une aurifi- 
cation ou un amalgame afin de donner plus de durée à la dent. 
Dans le second cas nous suivons le même traitement après avoir réséqué la partie 
secrétante de la pulpe, à moins que par trop enflammée elle n'ait déjà déterminé de 
violentes odontalgies, auquel cas nous procéderons à la dévitalisation, après avoir toute- 
fois calmé l'hyperhestésie pulpaire. 
(Nous ne décrirons pas le procédé de la dévitalisation, ce serait sortir du cadre que 
nous nous sommes tracé). 
A la suite de la dévitalisation nous entrons alors dans la troisième période. 
Dans le troisième cas. La pulpe est tombée en gangrène, soit naturellement, soit 
par suite des progrès constants de la carie, soit artificiellement par suite de la dévitali- 
sation et là, dans l'un ou l'autre cas, il s'est formé des produits morbides de décompo- 
sition qui répandent une odeur caractéristique se percevant rien qu'à l'ouverture de la 
bouche et le coton mis dans la cavité confirmera de suite le diagnostic. 
Les canaux radiculaires sont donc remplis de pus produit par un organe en complet 
état de putréfaction. 
Le produit de cette putréfaction est-il un ferment spécial de la putridité de la pulpe ? 
Voilà ce que jusqu'ici nous ignorons, et il en sera ainsi tant que nous n'aurons pas dé- 
couvert le microbe pathogène de la carie dentaire. 
Mais si nous considérons que l'infection d'une dent peut provenir de la plaie du petit 
organe en suppuration il y a dès lors une septicémie traumatique et nous serons portés 
à penser que le ferment de putridité de la pulpe est le ferment putride de toute putré- 
faction de matière animale (foyer sanguin, collection purulente, plaies en suppuration 
en communication avec l'air). SECTION XVIII-DENTAL AND ORAL SURGERY. 
455 
Nous laisserons aux spécialistes éminents toujours en observation au-dessus du foyer 
du microscope, ouvrant tous les jours des horizons nouveaux à la pathogénie, le soin de 
nous instruire d'une façon précise sur cette identité putride dont la connaissance nous 
permettrait d'indiquer d'une façon plus précise la nature du médicament antiseptique 
spécial pour la circonstance. 
En attendant, plus que jamais la méthode antiseptique s'impose, car il importe de 
débarrasser les canaux dentaires des micro organismes qui ont pénétré jusque dans les 
canalicules de l'ivoire, ou en désséchant complètement cette cavité au moyeu de l'air 
chad, nous éviterons sûrement ces pansements interminables que beaucoup de praticiens 
font encore, ainsi que les complications qui surviennent presque infailliblement du côté 
du ligament intra-alvéolaire et du cément. 
En général, nous avons remarqué qu'on n'attache pas assez d'importance aux pan- 
sements des dents malades. 
Selon nous, dès l'instant où. nous pénétrons dans la chambre pulpaire nous devons 
suivre la méthode antiseptique la plus sévère et enseignée dans la pratique de la chirur- 
gie en général. Pourquoi en serait-il autrement ? 
Est-ce que les dents, organes si délicats, ne font pas partie intégrante du meme 
organisme ? 
Les dents ne correspondent-elles pas aux nerfs de la cinquième paire qui sont tous 
si sensitifs et dont l'irritation produit ces névralgies rebelles, ces accidents secondaires 
et sympathiques du côté des yeux, des oreilles, du nez ; c'est donc faire preuve d'une 
profonde ignorance que d'agir différemment. 
Partant de ce principe que nous ne saurions trop répéter, dans cette monographie, 
on doit appliquer la digue et dessécher la dent par l'alcool absolu, la solution au bichlo- 
rure de mercure au 1000 me ou au biiodure qui selon le Professeur Gosselin serait la plus 
puissante comme action. 
Dernièrement. M. R. Dubois faisait une communication fort sérieuse à l'Académie 
des Sciences sur l'influence des vapeurs anesthésiques sur les tissus vivants.* 
Ses recherches ont porté principalement sur l'action exercée par les vapeurs de 
chloroforme, d'éther, de sulfure de carbone, d'alcool, sur le protoplasma des tissus 
végétaux et animaux. 
Il a montré par des exemples nombreux et variés que les vapeurs de ces liquides ont 
la propriété de pénétrer dans l'intensité des tissus et de se substituer sans changer la 
forme colloïdale des protoplasmes à l'eau qu'ils renferment normalement. 
Il ne s'agit pas ici d'un phénomène de déssication, de dessèchement comparable à 
ce que l'on connaît. 
Ce n'est pas non plus un phénomène d'osmose s'exerçant entre les liquides de 
nature différente entre lesquels est interposée une membrane. 
Il y a une véritable affinité mise en jeu. 
Les protoplasmes absorbent les vapeurs des liquides anesthésiques et rejettent une 
certaine quantité d'eau à l'état liquide. Ainsi se trouve expliquée l'action antiseptique 
des vapeurs anesthésiques, car les spores et tous les organismes ont besoin d'absorber de 
l'eau pour se développer. 
De petites portions de ces vapeurs suffisent pour éliminer une portion d'eau relati- 
vement considérable. Enfin, il est à noter que l'action de ces vapeurs est d'autant plus 
rapide et puissante que la vapeur des liquides considérés est plus anesthésique. 
Il résulte de cette note que les vapeurs de chloroforme, de l'air, de l'air chaud sous 
pression seraient un excellent moyen pour agir d'une façon antiseptique au troisième 
degré de la carie et même comme anesthésique au deuxième degré ; de plus il est proba- 
ble que ces vapeurs n'auraient pas l'inconvénient de ternir l'éclat de l'émail comme le 
* Académie des Sciences. Séance du 7 Juin, 1886. 456 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
font : la créosote, l'acide phénique, qualité précieuse surtout pour les dents antérieures; 
c'est donc là une étude à faire, que nous n'avons pas encore faite mais qui est digne 
d'être prise en sérieuse considération. 
Le tissu dentaire bien imprégné de l'une de ces solutions au moyen de l'air sur- 
chauffé, nous ferons pénétrer dans les canalicules les médicaments que nous aurons 
choisis : acide phénique, créosote, iodoforme. 
Ces médicaments pénétreront dans l'intimité des tissus morbides en même temps 
qu'ils en chasseront toute matière septique et au bout de deux ou trois pansements 
nous assisterons à une véritable transformation de ces cas regardés trop souvent comme 
incurables, nous pourrons conserver un organe toujours si précieux, en reculant de plus 
en plus les limites de l'extraction, nous prouverons que notre chirurgie est avant tout 
conservatrice. 
Etant admis que les dents obéissent aux mêmes lois pathologiques que les autres 
organes du corps humain, il est bien certain, tant qu'il existera des détritus pulpaires 
gangrénés en voie de suppuration, que les accidents continueront leur marche ascen- 
sionnelle et souvent même s'aggraveront. Des phénomènes locaux et généraux appa- 
raîtront, la gencive se tuméfiera en vertu même de la production des gaz putrides et 
de leur pouvoir d'expansion, le pus pénétrera au delà de l'apex dans l'alvéole pour y 
former ces abcès alvéolaires souvent accompagnés d'un trajet fistuleux inguérissable. 
Il convient donc dans les abcès alvéolaires, après avoir bien nettoyé la cavité, de 
déposer une ou deux gouttes d'acide phénique aussi profondément que possible dans la 
chambre pulpaire, on placera l'extrémité du chalumeau à l'orifice de cette cavité et on 
tassera autour du tube un peu de gutta-percha ramollie, puis on pressera sur la soupape 
du thermo-injecteur et l'air sous pression entraînera la solution phéniquée jusqu'à l'apex 
de la racine ; lorsqu'une fistule s'ouvre sur la muqueuse gingivale ou palatine, on voit 
quelques bulles sortir par cette ouverture, preuve évidente que le liquide antiseptique 
a pénétré de part en part l'organe dentaire, le traitement est donc très-énergique et 
donne des résultats inespérés. 
Une fois la poche de l'abcès et le trajet fistuleux ainsi débarrasés de tout élément 
putride, nous pensons que l'on doit diriger tous ses efforts en vue d'obtenir une séche- 
resse presque absolue de la cavité pulpaire et radiculaire, pour cela il sera bon d'ouvrir 
légèrement l'apex de la racine à l'aide d'un équarrissoir. 
Une fois cette petite opération faite, ou insuflera au moyen de l'air chaud sous pres- 
sion une poudre astringente et antiseptique. 
La formule suivante nons a paru devoir remplir les conditions réclamées :- 
Tannin. 
Iodoforme, quantité suffisante. 
Nous plaçons cette poudre dans la canule de l'extrémité du thermo-injecteur, nous 
ouvrons la soupape et immédiatement la poudre est projetée au-delà de l'apex sur 
toutes les parois du sac de l'abcès, par dessus ce pansement nous conseillons d'appliquer 
un petit tampon de onate un peu comprimée, un petit morceau de feutre conviendrait 
parfaitement, et par dessus comme dans tout pansement antiseptique, nous obturons à 
l'aide de la gutta-percha, nous renouvelons le pansement jusqu'à cessation de tout 
écoulement ; la guérison sera accomplie quand le coton sortira complètement sec, sans 
odeur, que tous les symptômes inflammatoires de la gencive et des racines auront cessé, 
alors il ne reste plus qu'à procéder à l'obturation définitive. 
L'air chaud sous pression est un aide puissant dans les périodontites chroniques sous 
l'apparance d'une véritable petite douche que l'on promène sur le bord gingival, il fait 
pénétrer la substance médicamentaire du collet des dents jusqu'au fond du décolle- 
ment. 
L'air chaud et sec devient le complément indispensable de toutes les obturations, 
non seulement il est permis de dire que la cavité la plus sèche sera celle qui réussira le SECTION XVIII-DENTAL AND ORAL SURGERY. 
457 
mieux, mais encore dans les obturations à la gutta-percha elle assurera une plasticité 
plus grande ; le docteur Fr. Chapein, de Philadelphie, disait dans une note récente au 
sujet des amalgames que la chaleur en augmentait également la plasticité, dans les 
aurifications où l'humidité est une cause absolue de non réussite, il sera très-utile de 
pouvoir déssécher la surface de l'or déjà condensé qui viendrait à être humecté, soit 
par la salive, soit simplement par l'haleine de l'opérateur, afin de pouvoir obtenir une 
nouvelle adhérence et de ne pas perdre le bénéfice de l'opération commencée. 
Dans les obturations à l'oxyphosphate de zinc de Weston, l'air chaud assure un 
durcissement très prompt et une meilleure combinaison chimique. 
Ce genre d'obturation terminé, nous faisons fondre à la surface un mélange de 
paraffine et de gomme copale qui pénétrant dans les porosités de cette matière, toujours 
légèrement hygrométrique, empêche les fluides alcalins de la salive de la désagréger 
aussi promptement ; en effet ce sont bien plus les alcalis qu'il faut redouter que les acides 
pour ces obturations, la preuve nous en est fournie tous les jours quand nous voyons 
ces obturations se si bien comporter dans les bouches où toutes les dents ne sont plus 
que des ruines. 
Au moyen du thermo-injecteur on aura encore un excellent moyen d'investigation 
pour établir un diagnostic certain dans quelques cas pathologiques où le doute pourrait 
s'élever sur la vitalité de la pulpe, car alternativement on pourra projeter sur la dent 
de l'air chaud ou froid qui est sans contredit le meilleur moyen de s'assurer si la pulpe 
est encore vivante ou morte. 
Enfin, pour la même raison, le thermo-injecteur, en fournissant de l'air froid sous 
pression, sera utile si l'on désire faire durcir plus promptement le Godivo ou le Stent 
qui introduit chaud dans la bouche, pour la prise des empreintes, demande quelquefois 
à être retiré presque froid. 
Dans le blanchiment des dents, la cause du changement de coloration est due à la 
complète oxydation de l'infiltration des canalicules. Il importe de ne imprégner la 
dent, de créosote, d'acide phénique, d'alcool, ni d'aucune autre substa. ce capable de 
coaguler l'albumine, si on s'est servi de ces substances, il conviendra de laver la cavité 
avec une solution de biborate de soude. 
Après avoir appliqué la digue, de laver parfaitement la cavité à plusieurs reprises 
avec du peroxyde d'hydrogène, puis on déssèchera soigneusement à l'acide d'un courant 
d'air chaud comprimé. 
On mettra dans la cavité un peu de chlorure d'alumine, ou humecte de peroxyde 
d'hydrogène et on le laisse séjourner cinq minutes environ. 
On débarrasse alors la cavité du chlorure d'alumine, avec une solution claire de 
biborate de soude, et on la déssèche complètement de nouveau à l'aide de l'air chaud. 
On remplit ensuite la dent avec de l'oxychlorure. 
Le rapide dégagement de chlorure de A12C16, en présence de H2O2 qui amène la for- 
mation de HCl et H2O en laissant l'oxygène et du chlore libres, explique la destruction 
rapide des matières dorantes qui renferme la dent dépourvue du pulpe. 
Ainsi que nous l'avons déjà vu, le thermo-injecteur quand il est mis en communica- 
tion avec de l'air comprimé un atmosphère J à 2 atmosphères est un excellent insufla- 
teur pour faire pénétrer les poudres médicamentaires dans les cavités. 
Ainsi dans le traitement des abcès du sinus ou de l'éclat catharal de cette région, il 
sera préférable d'employer une poudre très-ténue qui en tapissant la muqueuse aura 
plus d'action que les liquides, les poudres se dissolvant plus lentement au contact des 
cavités de la muqueuse, dans ce cas nous conseillons la poudre d'iodoforme et de tannin, 
ou d'iodol, ce dernier est beaucoup moins désagréable que l'iodoforme. 458 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DES APPAREILS. 
Nous venons de voir les principaux avantages que nous pouvons tirer de la thermo- 
thérapie, mais pour cela il fallait que nous eussions le moyen pratique d'avoir, toujours 
sous la main, de l'air à une température variable suivant le besoin du moment. 
Vous connaissez tous la simple seringue composée d'une poire en caoutchouc et 
d'une tubulure métallique au milieu de laquelle se trouvait une petite chambre à air 
formant ainsi un réservoir pour l'air chauffé. 
Cet air chaud s'obtenait en tenant pendant quelques instants l'instrument au-dessus 
de la flamme d'une lampe à alcool ou d'un bec de gaz ; après quoi en pressant sur la 
poire, avec la paume de la main, ou faisant sortir de l'air chaud d'abord, puis bientôt 
Fig. 1. 
Appareil dit Thermo-Cautère du Docteur Paquelin converti en Thermo-Injecteur. 
p. Récipient en verre contenant du pétrole rectifié, pp. Poires en caoutchouc chassant l'air dans le 
récipient, t. Tube conduisant l'air dans le récipient, t'. Tube conduisant les vapeurs du récipient 
au cautère, o. Orifice d'échappement des vapeurs, c. Pointe en platine, d. Douille en cuivre 
recouvrant le cautère et laissant passer l'air chauffé à son contact, m. Tube conduisant de l'air qui 
se chauffera au contact du cautère sans se mélanger avec les vapeurs du pétrole. 
tiède, la température diminuant d'intensité calorique à chaque nouvelle pression ; en 
effet, à chaque nouvelle pression répond une nouvelle entrée d'air frais, à la tempéra- 
ture ambiante, dans l'intérieur de la poire, en un mot nous avons un mouvement inter- 
mittent, l'un qui envoie de l'air chauffé, l'autre qui fait rentrer de l'air froid. 
Cet instrument utile quand on n'avait pas mieux, est tout à fait insuffisant aujour- 
d'hui, de plus il se détériorait très-rapidement, si, par malheur, l'exposition à la flamme 
de la lampe se prolongeait, ce qui arrivait dans une opération un peu longue; ainsi pour 
avoir de l'air toujours chaud, il fallait de toute nécessité chauffer à nouveau l'instru- 
ment ; pendant ce temps la dent refroidissait, l'opération était rendue plus longue et SECTION XVIII-DENTAL AND ORAL SURGERY. 
459 
plus incomplète, par conséquent plus fatigante et moins satisfaisante pour le patient et 
l'opérateur. 
Ce moyen primitif fut cependant le point de départ d'un nouve agent thérapeu- 
tique et suffit à attirer l'attention des praticiens. 
Le premier qui, à notre connaissance, chercha à appliquer l'air chaud fut le Docteur 
Bing qui, au moyen d'appareils dont nous parlerons plus loin, s'en servit sous pression. 
Plus tard, quand le thermo-cautère du Docteur Paquelin se fut répandu dans la 
pratique chirurgicale, un mécanicien-dentiste, moyennant une légère modification, l'ap- 
pliqua à la production de Pair surchauffé. (Par l'air surchauffé, nous entendons l'air 
plus chaud que la température ambiante, entre 45° à 50°). Une plus forte chaleur serait 
inutile et surtout douloureuse, car il y aurait alors brûlure. On peut cependant obte- 
nir une température plus élevée en vue de la destruction de certaines petites tumeurs 
vasculaires, comme les tumeurs érectiles si sujettes aux hémorragies, quand on y porte 
le bistouri. 
La pointe en platine (Voir Figs. 1 et 2) est portée au rouge sur une lampe à alcool, 
on presse la poire p, l'air qu'elle contient arrivant dans le récipient r en expulse par le 
Fig. 2. 
Extrémité du Thermo-injecteur portée au rouge à l'aide d'une lampe à alcool dont la flamme est action- 
née par la pression exercée sur la poire de caoutchouc qui sert de chalumeau. 
tube V les vapeurs de pétrole rectifié qui viennent se brûler à la pointe de platine et la 
maintient à l'état d'ignition. 
On comprend que cette carburation constante met à la disposition du chirurgien un 
cautère ne se refroidissant pas ; tel est le thermo-cautère du Docteur Paquelin pouvant 
rendre non seulement les plus grands services au chirurgien, mais même au dentiste là 
où il faut cautériser profondément et maintes fois en avons nous retiré d'excellents 
résultats, surtout depuis que la tige de platine a pu être faite aussi fine qu'une aiguille. 
Malheureusement la vue de cet appareil effraie souvent le patient, aussi préférons-nous 
l'emploi de l'électricité depuis que ses merveilleux perfectionnements nous l'ont rendue 
d'une manipulation simple et commode. 
Mais, pour produire de l'air surchauffé volatilisant les médicaments, desséchant les 
cavités, etc., il est nécessaire d'ajouter à l'appareil la douille d. La chaleur se com- 
munique à l'air que renferme cette douille et chassé alors au moyen d'une seconde 
tubulure. 
Ce thermo-injecteur, en apparance très-simple présente de nombreux inconvénients; 460 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
d'abord la préparation, c'est-à-dire l'allumage nécessite ou un aide ou les deux mains 
de l'opérateur, la flamme de la lampe à esprit devin venant chauffer l'extrémité du 
tube en platine (ainsi que le montre la Fig. 2) ; l'obligation d'avoir suspendu à sa bou- 
tonnière un flacon contenant de l'essence minérale, propre à entretenir l'ignition du 
platine ; le volume même de l'instrument constituant un ensemble aussi embarrassant 
pour l'opération qu'inquiétant pour le patient toujours anxieux dès qu'il s'asseoit dans 
nos fauteuils. 
La source de calorique est elle-même trop intense et inutile, car on risque de faire 
une véritable cautérisation parfois très-douloureuse, alors que le patient loin de ressen- 
tir un effet pénible doit, dans certains cas, obtenir un soulagement (excision de la den- 
tine). Le degré de température est peut facile à régler, par cela même que, pour le 
bon fonctionnement de l'appareil, la tige de platine doit être constamment maintenue 
Fig. 3. 
Appareil à eir chaud de M. Barbe, Dentiste. 
a. Canule mobile pouvant se remplacer par une canule droite, i. Cautère électrique, b. Tube en bois 
isolant et recouvrant le cautère, d. Poire, e. Entrée de l'air à l'intérieur de la poire, s. Entrée de 
l'air à l'extérieur. Pile : c. charbon ; z. zinc. Cassette de l'appareil, t. tige, soutenant la pile et l'en- 
levant ou la descendant dans le vase ; v. vase, contenant le liquide ; g. crochet; pp. corde poulie ser- 
vant à manœuvrer le contrepoids p. 
au rouge cerise, sous peine de voir l'appareil s'éteindre. La vue de cette tige qui par 
l'intensité de la coloration pourrait aider le praticien à connaître le degré approximatif 
de l'air employé, est cachée par la double enveloppe métallique, à l'intérieur de 
laquelle passe l'air ; c'est donc par tatonement que l'opérateur agit, aussi arrive-t-il 
qu'il n'est souvent avisé de l'excès de chaleur que par les plaintes du patient. 
Enfin, l'inventeur reconnaît lui-même qu'une odeur très-désagréable due à la vola- 
tilisation d'une certaine quantité d'essence, se fait désagréablement sentir, or ce qui est 
simplement désagréable en chirurgie ordinaire devient un inconvénient sérieux dans 
nos opérations dentaires, puisque nous opérons sans cesse à l'entrée des voies olfactives 
et respiratoires ce qui, chez certaines personnes occasionne des accès de toux pouvant 
nuire à la bonne réussite de l'opération que nous avons entreprise. Pour remédier à 
cet inconvénient, un second appareil a été construit différant du premier en ce que la 
douille d qui dans la Fig. 1 emprisonne la tige de platine c d'où s'échappe l'air chaud 
a été isolée ; il en résulte que le tube d reçoit de l'air pur par un second tube m où 
vient s'adapter un tuyan de caoutchouc sans aucune communication avec l'air qui vient SECTION XVIII DENTAL AND ORAL SURGERY. 
461 
de la soufflerie alimentant le foyer incandescent. Ce perfectionnement ajoute à l'appa- 
reil une grande complication en nécessitant la présence d'un aide, ou les deux mains 
de l'opérateur qui n'en a jamais assez pour tenir les lèvres écartées et l'instrument, à 
défaut des mains, il faut se servir du pied et une des mains, cet appareil constitue dès 
lors, un véritable impédimentum. 
D'ailleurs nous ne pensons pas que l'odeur soit beaucoup atténuée, car c'est en se 
volatilisant que les gaz s'échappent à travers les pores du métal rougi et que l'odeur se 
répand. Enfin, comme dans la poire primitive dont nous avons parlé, il faut à chaque 
opération chauffer l'appareil au dessus d'une lampe ce qui retarde beaucoup l'opération 
en elle-même et la rend difficile si l'on a besoin d'air chaud alors que l'opérateur ne 
peut quitter de ses mains la bouche du patient. 
On conçoit aisément que, lorsqu'il s'agit d'aller porter un courant d'air chaud au 
fond de la cavité buccale, on risque facilement de causer des brûlures sur la muqueuse 
des joues, accident toujours pénible et facile à éviter avec un appareil pins perfectionné 
et n'offrant pas une surface de calorique aussi intense que le thermo-cautère, converti 
en thermo-injecteur. 
Nous mentionnerons pour mémoire seulement, un appareil qui fut de suite aban- 
donné dès son apparition. Il consistait en une sorte de chaudière d'où sortait un petit 
jet de vapeur passant dans un premier tube, chauffant ainsi l'air qui s'échappait d'un 
second tube. 
M. Barbe dentiste, imagina à son tour un appareil d'une simplicité très-ingénieuse 
fonctionnant par la pile électrique (Voir la Fig. 3) cet appareil consistait en une poire 
de caoutchouc montée sur un tube n'atteignant pas 20 centimètres de longueur; à l'aide 
d'une soupape l'air était attiré de l'extérieur et refoulé au dehors par l'action même de 
la pression de la main sur la poire. Dans l'intérieur de ce petit appareil était un stylet 
en platine qui, mis en communication avec une pile, rougissait et chauffait l'air à son 
passage et très-prêt de sa sortie. La chaleur de la pile était réglée par des cordes sup- 
portant des contrepoids qui permettaient d'immerger partiellement ou complètement les 
zincs dans le liquide. 
A cette combinaison nous préférerions en tout cas la pile à pédale, les contrepoids 
nécessitant une manipulation plus longue et plus difficile ; il faut régler la température 
avant l'opération et:, si dans le cours de celle-ci, on veut obtenir plus ou moins de cha- 
leur, il faut abandonner un instant la poire que l'on tient entre les mains ou avoir 
recours à un aide. 
Enfin, nous connaissons tous les désagréments des piles à liquide dans nos cabinets, 
qui en outre des manipulations constantes répandent des émanations désagréables et 
détériorantes pour les différents métaux. Quand on pressait la poire entre ses doigts 
on imprimait à la canule une déviation qui faisait que le jet d'air chaud déviait du 
point précis qu'il devait atteindre. De plus ce petit thermo-injecteur ne peut pas ser- 
vir facilement dans l'emploi de l'air sons pression si utile dans nos mains. Aussi quoi- 
que très-ingénieux, l'appareil ne fut pas adopté dans la pratique. 
En vous présentant à notre tour un thermo-injecteur de notre invention nous croyons 
avoir obvié aux inconvénients que nous vous venons de signaler. 
A l'aide de notre instrument nous pouvons avoir de l'air froid ou chaud à volonté ; 
pour ce dernier nous utilisons le gaz qui, aujourd'hui se trouve dans tous nos cabinets 
d'opération. 
Dans cet appareil (Voir Figs. 4 et 5) la chambre de chauffe réduite à un très-petit 
volume est formée par un tube roulé en spirale qui déployé représente une surface de 
plus de 15 centimètres de longueur. Au centre de cette spirale se trouve un petit tube 
genre Busen, à l'extrémité duquel brûle un très-léger filet de gaz. 
Le tirage se fait par des ouvertures que laissent les différents tours de spirale entre Fig. 4. 
Fig. 5, 
Notre Thermo-Injecteur à gaz. 
a. Bec de gaz faisant suite au tuyau à gaz en communication avec le robinet p. B. Spirale creuse, repré- 
sentant la chambre de chauffe et communiquant par le tube s. avec la soufflerie, c. Tube en cuivre 
ouvert au milieu en forme de lanterne pour permettre au gaz de brûler. D. Chambre à air. ee'. 
Trous à air pour permettre au gaz de brûler bleu et de ne pas s'éteindre dans les différentes positions 
de l'instrument. F. Bouchon de métal fermant la chambre à air. g. Palette en ivoire pouvant se 
retirer à volonté et se plier û angle droit ou entièrement se renverser comme l'indiquent les traits 
pointillés, h. Canule mobile. J. Monture en métal creux faisant écran et tenant la palette d'ivoire, 
i. Isolateur d'ivoire, L. Armat ure servant à tenir la palette, m. Manche en ébène garni d'une sub- 
stance non-conductrice de la chaleur, o. Ecrou A vis tenant tout l'instrument et percé à jour pour 
laisser passer un courant d'air froid à travers toute la longueur du manche et en empêcher réchauf- 
fement. P. Robinet A gaz. q. Spirale servant à tenir le tube en caoutchouc pour l'empêcher de se 
casser en se pliant. R. Olive en métal sur laquelle vient se fixer un tube en caoutchouc qui établit 
la communication avec le bec de gaz. T. Prise d'air, communiquant soit avec la soufflerie formée de 
poires en caoutchouc obéissant à la pression du pied comme dans la !■ ig. 6, soit avec l'appareil à air 
sous pression, u. Prise de gaz sur un bec quelconque. 
462 SECTION XVIII-DENTAL AND ORAL SURGERY. 
463 
eux ; de plus, ces mêmes ouvertures permettent à l'air ambiant de circuler librement 
et évitent ainsi un trop haut degré de température. 
Un isolateur en ivoire empêche la chaleur de se communiquer trop facilement au 
manche de l'instrument qui est rempli d'ailleurs d'une substance non conductrice. 
Pour plus de précaution, un écran en ivoire et mobile, pour qu'on puisse l'éloigner de 
la chambre de chauffe, protège les lèvres contre la chaleur et les met à l'abri du contact 
de l'instrument qui, dans un mouvement brusque pourrait occasionner une brûlure. 
En même temps que notre thermo-injecteur fonctionnant au moyen du gaz, nous 
vous en présentons un second dont la source calorique est due à l'électricité. Dans ce 
second injecteur (Voir Fig. 7) il suffit de toucher un bouton qui se trouve sur l'instru- 
ment pour que les contacts s'établissent et fassent rougir un fil de platine en forme de 
spirale disposé dans la canule elle-même. 
Cette canule offre une disposition spéciale et forme en même temps chambre de 
chauffe ; elle est en verre et présente plusieurs avantages tels que :- 
1° De ne pas être aussi bon conducteur de la chaleur que le métal dont sont faites 
les canules ordinaires ou chalumeau, ce qui est à apprécier pour un instrument destiné 
à être introduit dans la bouche. 
Fig. 6. 
Vue de notre Thermo-Injecteur â. air chaud par le gaz, en position pour fonctionner. 
2° Il est facile de se rendre compte à peu près du degré de chaleur employée en 
voyant à travers le verre l'intensité calorique produite par l'ignition du fil de platine. 
3° C'est un instrument toujours très-propre ne répandant pas d'odeur, l'air chaud 
ne traversant pas de partie métallique, le métal légèrement chauffé répandant souvent 
une odeur désagréable due à des oxydations qui se produisent. 
Nous avons blâmé dans ce travail l'emploi de l'électricité, mais vous savez tous 
qu'en s'adressant à cet agent les idées forcément changent brusquement en raison de ses 
applications et modes de production toujours nouveaux, de sorte que ce qui était vrai 
hier ne l'est déjà plus le lendemain. Chaque jour, en effet, surgit une invention nou- 
velle dans la production de ce fluide. Peut-être ne sommes-nous pas éloignés du jour 
où l'idéal sera atteinte. 
Cet idéal serait d'avoir l'électricité à sa portée, chez soi, comme nous avons actuel- 
lement le gaz et l'eau. En attendant ce jour, nous avons actuellement des piles dites 
piles thermiques complètement dépourvues de tout liquide, et exemptes de toutes mani- 464 
NINTH INTERNATIONAL MEDICAL CONGRESS 
Fig. 7. 
Notre Thermo-Injecteur électrique. 
a. Bouton servant ft laisser passer le courant électrique pour faire rougir la spirale B. B. Spirale en pla- 
tine portée au rouge blanc, l'air arrivant sur ce fil par le tube g, s'échauffe et sort par la canule en 
verre e, assez chaud pour l'emploi que l'on veut en faire, c. Vis servant ft tenir la spirale de platine 
et ft la remplacer si elle vient ft être brûlée par le courant, n. Spirale en platine, e. Canule en 
verre permettant de voir l'intensité de calorique employée. F. Fils servant à établir la communica- 
tion avec les commutateurs, g. Tube amenant l'air; lés fils et le tube se trouvent réunis dans une 
seule enveloppe. SECTION XVIII-DENTAL AND ORAL SURGERY. 
465 
pulations chimiques toujours si désagréables dans nos cabinets. Cette pile fonctionne 
simplement par le gaz ; il suffit d'allumer un bec pour avoir toujours à sa disposition 
une source constante d'électricité d'autant plus précieuse qu'elle peut nous servir à 
faire fonctionner notre moteur dentaire, les galvano-cautères, les miroirs ou polyscope 
et enfin le thermo-injecteur que nous vous présentons. 
Fig. 8. 
Vue en perspective de la pile génératrice thermo-électrique, système chandron. 
Fig. 9. 
Coupe suivant l'axe vertical de l'appareil. Vue des armatures. 
T. Tubulure servant à l'arrivée du gaz. a. Tuyau en terre réfractaire percé de trous N, par lesquelles 
s'écoule le gaz mélangé à l'air, pour brûler dans l'espace annulaire, d. Prise d'air servant à la com- 
bustion. bb. Barreaux thermo-électriques, rk. Rondelles en amiante servant à isoler les éléments 
du générateur. 
Vol. V-30 Fig. 10. 
Disposition d'une installation de la pile thermo-électrique et d'accumulateurs en vue d'amener l'électri- 
cité dans le cabinet d'opérations. 
a. Pile génératrice thermo-électrique, b. Tablette sur laquelle se trouve un rhéostat et appliquée sur 
un meuble à la disposition de la main de l'opérateur, e. Bornes pour mettre les fils du cautère en 
communication avec la pile. c. Accumulateurs servant de réservoirs à l'électricité produite par la 
pile génératrice. 
466 SECTION XVIII-DENTAL AND ORAL SURGERY. 
467 
Les générateurs thermo-électriques du système Chaudron (Voir Figs. 8, et 9, 10,) 
transforment directement la chaleur en électricité. La qualité maîtresse des appareils 
de ce genre est de produire un courant absolument constant. Ils suppriment complète- 
ment les émanations malsaines et dangereuses qu'entraîne l'usage des piles à liquide, 
l'emploi est des plus faciles, l'entretien nul, la mise en train des plus simples puisque 
l'allumage s'y produit comme celui d'un bec de gaz ordinaire ; c'est-à-dire qu'on peut 
à tout instant, assurer le fonctionnement, en interrompre la dépense d'ailleurs peu con- 
sidérable. 
A défaut de gaz on peut employer le pétrole qui par une disposition spéciale se 
trouve réglé de façon à assurer le bon fonctionnement de la pile. 
Nous vous avons présenté le moyen pratique d'injecter de l'air chaud ou froid, 
grâce à différents modèles de thermo-injecteurs. Mais, comme nous l'avons souvent dit 
dans le cours de cette description, il importe dans notre pratique d'employer le plus 
souvent de Pair sous pression, pour cela nous vous signalerons différents appareils. Le 
plus usité de tous, celui que tout dentiste peut avoir sous la main, consiste en un tube 
de caoutchouc sur le trajet duquel se trouvent deux poires en caoutchouc. L'une sert 
d'aspirateur et envoie l'air aspiré dans la seconde où. il s'emmagasine et donne grâce à 
l'élasticité de la poire, une légère pression à la colonne d'air, pression insuffisante pour 
certains cas, comme par exemple la pénétration des médicaments au fond des racines, 
l'enlèvement des résidus de dentine provenant de l'emploi des fraises, mais suffisante 
pour dessécher l'ivoire et calmer l'hyperhestésie dentaire. La poire aspiratrice peut 
marcher soit à la main ce qui est gênant, soit au pied, soit enfin par l'action du tour 
dentaire dont nous nous servons continuellement. 
A côté de cet appareil presque primitif, le Docteur Bing avait imaginé de condenser 
par des appareils pneumatiques de l'air dans un grand récipient en tôle, mais cette dis- 
position était trop dispendieuse et convertissait nos cabinets- en véritables établissements 
de mécanique. 
Plus tard, M. Guillermin, de Genève, auquel l'art dentaire doit plusieurs applica- 
tions fort heureuses, employa une simple pompe à main. Il condense chaque matin 
une certaine quantité d'air dans un récipient. La pompe et le réservoir réunis par un 
court tube de cuivre forment un seul appareil facile à placer dans un meuble quel- 
conque, un bas de bibliothèque par exemple ; il n'occupe qu'une place de 0.70 m. de 
hauteur, 0.50 m.»de largeur et 0.25 m. de profondeur. Un jeune homme de 14 à 15 
ans, un apprenti, pompe chaque matin cinq minutes et emmagasine l'air en assez 
grande quantité pour toute la journée. C'est, je crois, l'appareil le plus pratique dont 
nous puissions disposer jusqu'à ce jour où, comme le gaz, nous aurons dans chaque mai- 
son l'air comprimé à notre disposition. 
Quant à nous, nous avons fait installer, à l'exemple de plusieurs de nos confrères, un 
appareil consistant, en une pompe semblable à celle qui sert aux limonadiers pour faire 
monter par la pression atmosphérique, la bière ou tout autre liquide des sous-sols aux 
différents étages. Cette pompe fonctionne facilement sans effort et envoie l'air dans un 
grand récipient de tôle placé dans un coin de l'appartement loin du cabinet d'opérations 
et de tout regard ; l'air ainsi condensé à deux atmosphères est suffisant pour nos opéra- 
tions, il se rend par une petite canalisation faite d'un tube d'un centimètre de diamètre 
dans chacun de nos cabinets, prêt à sortir dès qu'avec le doigt nous touchons la soupape 
placée dans le manche du thermo-injecteur, disposition préférable au robinet à pédale 
susceptible de se déranger, d'encombrer les abords du fauteuil d'opérations. 
Nous serons heureux si nous avons pu, grâce à cette communication, répandre 
l'usage de l'air en thérapeutique dentaire, et nous sommes certains que ceux de nos 
confrères qui voudront l'essayer ne sauront s'en passer dans la suite ; le plaisir de leur 
avoir été utile sera notre meilleure récompense. 468 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
After the recess, the discussion of Dr. Brasseur's paper was opened by Dr. C. A. 
Brackett, of Newport, B. I., who said:- 
Mr. President and Members.-The propositions made in a carefully-prepared 
paper, embodying the results of much thought and extended experimentation, as doçs 
the essay to which we have just listened, are not to be lightly regarded, even if they 
do not at first impress us as being fully in accord with our own sentiments. The 
chances are that the deliberate and elaborate study of the subject by the author has 
given him better light upon it than is possessed by those who have attended to it 
less carefully. When, as in this case, we find at first acquaintance so much that is 
fully in harmony with our own ideas, and so much of practice that is in the same 
line as our own, only being more extended, systematized and more nearly perfected, 
it should be with becoming modesty that we make any criticisms whatever, and the 
few which we do make are liable, from their mere mention, to seem magnified out of 
their true proportion to our general appreciation and admiration of the paper. 
Our author might have expressed in his title the scope of his subject a little more 
fully by making it include the force heat and the quality dryness, as well as the 
matter air ; as it is plain that in his practice he considers each of these things as not 
less important than the other, and it is to their combination that the happy effects 
obtained are due. 
It is manifestly unfair to criticise a paper for that which it does not contain and 
does not purport to contain ; but it seems my privilege and duty, in opening the 
discussion, having had the opportunity-of course not possible for all-of studying 
the paper in advance of its reading here, to endeavor to emphasize and supplement 
certain portions of it. If a theory is to be constructed to account for the substan- 
tiated fact of lessened sensitiveness of dentine brought about through the agency of 
anhydrous heated air, I apprehend that, as has been suggested by Dr. Jack, of 
Philadelphia, it is to be found in the circumstance that in the process of drying there 
is eliminated, in a greater or less degree, the normally-contained water of the tissue, 
and it is to just that extent so much less than its normal self and so much less 
capable of performing its normal, and we may say in case of hyperæsthesia, its 
pathological functions. This is the principle upon which is based the use of a 
variety of desiccating agents for obtunding the sensitiveness of dentine, and which, 
alone or in combination, have been suggested for the purpose from time to time by 
different investigators. To express this idea in a way to probably make it more 
tangible, let us consider for a moment an anatomical tissue in many particulars 
closely allied to dentine, viz., bone. Burn a bone in the fire ; it loses certain of the 
elements of bone ; it becomes less than bone, and if it were possible to replace it in 
its natural position in the living body with its environment in normal condition, it 
would be capable of performing less than the function of normal bone. Dissolve 
out from another bone, with acid, its calcareous salts ; the remaining portion differs 
very greatly from the intact tissue in a variety of characteristics, and is very mark- 
edly incapable of performing its functions. Take out from dentine by any process, 
mechanical or chemical, one or more of its normal constituents and it becomes less 
than dentine and imperfectly capable of performing the functions of entire dentine, 
among which function is the conveyance of sensation. That the contained water of 
a living tooth is very considerable is made plainly apparent through the changes in 
its weight and other physical characteristics which take place when it is extracted 
DISCUSSION. SECTION XVIII DENTAL AND ORAL SURGERY. 
469 
and left for a long time to dry. I apprehend that this water of the tooth is con- 
tained largely in its living portion rather than in its lime salts, and it is this living 
portion which conveys sensation. Eliminate from it a material percentage of its 
water, and we may roughly, and by way of apprehending through magnifying what 
takes place, compare it to a jelly fish, removed from its native element and exposed 
in the sun. 
It is this principle which I have tried thus to express, and which I believe to be 
sound, that is at the basis of our efforts to obtund the sensitiveness of dentine in the 
way which the paper advocates ; and it is well to have it clearly in mind that our 
efforts in this line may be as intelligent as possible. There are other desiccating 
agents than heated air ; there are other means and methods of obtunding dentine 
than through dryness ; but we are discussing them now only so far as the author 
suggests them to us. Suffice it to say, that they are reasonably well understood and 
practiced by our countrymen, and doubtless by Dr. Brasseur, his countrymen, ana 
others as well. In fact, there are given in the paper some excellent formulae for the 
purpose. 
The principal objection which it seems to your reviewer important to make to 
the position taken in any part of the paper is to that portion which is now quoted :- 
"We reject the use of crystallized carbolic acid or of any caustic agent, for it is 
not to be doubted that when it gets into the canaliculi, it provokes sooner or later 
certain trouble on the part of the pulp. ' ' 
On this point particularly I am gratified with my position in being permitted to 
review this paper, because I have not been in accord with many prominent and 
influential men in the profession in this country, who have taught, at least in times 
past-it is to be hoped that they have reformed-that such agents as deliquesced 
carbolic acid and creasote are proper and advisable to use almost indiscriminately in 
the treatment of exposed pulps, and that such pulps are most hopefully treated 
conservatively by capping them with a combination of such an escharotic agent as 
one of these with oxide of zinc. It has long been the earnest conviction of many 
men, including myself, that such agents as these escharotics should be kept from 
direct contact with such delicate tissues as those of the tooth pulp, if those tissues 
are to have their vitality preserved with their functions unimpaired. If the odon- 
toblasts are situated upon the surface of the pulp, if the office of the odontoblasts 
is, at least in part, the formation of dentine, and if we desire that the exposed por- 
tion of pulp should become covered over and protected by nature's material, we 
should not, with specious pretense of friendship, assassinate the workmen ere they 
have time to even begin the building of the bridge. 
I would pit against each other the author of the paper-who, through fear of 
"certain trouble on the part of the pulp," will not allow us to use deliquesced car- 
bolic acid for the lessening of sensitiveness, the disinfection and antisepsis of ordinary 
non-perforating cavities-and those other practitioners who advise direct applications 
of deliquesced carbolic acid, or of its combinations, to the fully-exposed pulp with a 
view to its protection and preservation. It seems to your reviewer that the absurdity 
of the position of each of these partisans is best seen in connection with that of the 
other, and that the safest and best course in this, as in most other discrepant 
suggested plans of procedure, lies in the happy medium. As a matter of personal 
practice, I have systematically, substantially and invariably, during the last fourteen 
years, wiped with deliquesced carbolic acid all non-perforating cavities which were to 
be filled with materials not in themselves germicidal. I have also sought to avoid 
the application of powerful escharotics directly to such pulps as could be preserved. 470 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It is verily believed that such practice is right. If the position of the author of the 
paper in regard to the use of deliquesced carbolic acid in ordinary cavities be right, 
it seems very remarkable that the most blind and prejudiced eyes have not detected 
the resultant harm in the practice of many men on this side of the water who have 
long made use of it. 
If the essayist, in condemning the use of carbolic acid, refers to the placing of 
crystals in the bottom of a cavity in close proximity to the pulp, sealing them there 
and leaving them an indefinite time, we shall find less occasion for disagreeing with 
him. It may be that in the translation of his paper his words are not given quite 
the meaning which he intended. In all discussion there is much danger of misun- 
derstanding, and allowance should be made for all of these things. 
For teeth merely pulpless, the expression "dead teeth," as it appears in the 
paper, is an inaccuracy of either the author or translator, which needs only to be 
named to have its inappropriateness become apparent. 
The condemnation which the paper expresses of arsenious acid as an agent for 
obtunding the sensitiveness of dentine we all cordially indorse. 
We are glad, too, that the author recognizes in exposed pulps pathological differ- 
ences, that he sees therein indications for differences in treatment, and that he would 
avoid destruction so long as salvation can be hopefully attempted. The better the 
familiarity with pathological principles, the more wise and successful will all practice 
in this field become. 
The combination of the oxide of zinc and oil of cloves for pulp capping has the 
practical approval of many careful men in this country. It possesses, perhaps, as 
many good qualities and as few objectionable ones as any of the numberless materials 
that have been suggested for the purpose. Its hygrometric property seems a marked 
advantage in that the capacity of the capping to absorb a slight exudation from the 
pulp may be sufficient to constitute the determining circumstance of whether the 
pulp shall do well or not. The imperviousness of gutta-percha is one of several 
objectionable qualities which that material has as a pulp capping. The use of plati- 
num or any other metal in direct contact with the pulp seems unwarrantable. 
Making clean and dry the canals of teeth which are affected with alveolar abscess 
is excellent ; but few of us would attempt to apply to the diseased surface medica- 
ments in the form of powder blown through the canals. Perhaps, if we should try it 
with the proper appliances, it would seem as practical to us as the author represents 
it is to him. In the use of medicines in the form of dry powder, of course the 
operator must depend upon the fluids of the parts to which the medicament is 
applied for that solution which is a necessary precedent of action. The question 
arises : Is the effect of drugs so used better than that of freely washing the diseased 
territory with prepared solutions? 
The use of antiseptic and germicidal agents which are not escharotic is a field in 
which probably most of us should go further than we have in the past. 
The temperature figures given in the paper are most probably those of the Centi- 
grade thermometer, and the fifty degrees named correspond with ninety degrees 
Fahrenheit. It thus seems that the author seeks to avoid the pain of suddenly 
drying the tooth and the risk of irritation and harm from too high a degree of heat. 
We can be only grateful to Dr. Brasseur for what he has told us of his experi- 
ments with different forms of apparatus, and for what he has described and figured 
of his invention as the best yet obtained. 
Air, heat and dryness are each and all valuable therapeutic agents. During the 
development of modern dentistry they have had more and more attention paid to SECTION XVIII-DENTAL AND ORAL SURGERY. 
471 
them as the years have passed. It is reasonable to believe that in the future they 
may be accounted as still more important, and that at least a portion of the increased 
valuation and appreciation of them may fairly be ascribed to the paper to which we 
have listened to-day. For the privilege and honor of reviewing it, and for the 
patience with which you have heard me, I thank you. 
Dr. James Truman, of Philadelphia, said it was an admirable paper. He 
regretted only that the author had not aimed more at condensation. It seemed to 
him (Dr. Truman) that there was a danger in the use of hot air, which, probably, 
many had not taken into consideration. When a gentleman with such evident 
ability as the author of the paper in question came before a Convention of this 
character, he was very apt to be accepted as authority, and he (Dr. Truman) had no 
doubt that many members of this Section would return to their homes determined 
to make use of the process recommended by Dr. Brasseur for the purpose of reducing 
the sensibility of dentine. Every dentist knew that what was called a dead tooth 
was not by any means a dead body, but had throughout its structure prolongations 
extending through the tubuli of the dentine. And these prolongations were as 
sensitive to any irritant as the pulp itself. Therefore, when the heat was carried 
beyond a certain point, the life in the minute ramifications throughout the dentine 
was possibly, and very probably, destroyed. The same irritation (set up under these 
conditions) would be continued into the pulp, and eventually that pulp would die. 
This statement was not based on mere theory. He had observed it in times past, 
and he was therefore very careful indeed in applying extreme heat to a sensitive 
tissue. 
As to the action of creasote, he was not one of those who believed in the use of 
creasote and carbolic acid to the extent to which they had been generally used in the 
profession. He disagreed with the reviewer (Dr. Brackett) in the opinion that the 
using of creasote or carbolic acid in the pulp in the way of capping was likely to 
destroy that capping. It seemed to him (Dr. Truman) that Dr. Brackett was incon- 
sistent, inasmuch as he refused to apply creasote or carbolic acid to the pulp, while 
he was willing to wash out a cavity with it, thus producing the same effect on the 
ramifications extending to the tissue of the tooth. He did not suppose that the 
Section desired to go any further into the paper. He repeated that it was an admi- 
rable paper. He was glad that it had come before the Section, and he had no 
doubt that it would be of great benefit. 
Dr. W. H. Morgan, of Nashville, Tenn., said that he had listened with great 
interest to the admirable and learned paper of Dr. Brasseur. While he subscribed 
most heartily to most of the propositions contained in it, there were some of them 
which he thought a little too broad. He did not think that its language was always 
sufficiently precise and exact. For instance, the proposition to dry a tooth with 
heated atmosphere was not exact. Heated atmosphere might be dry, or it might 
not be dry. That would depend upon its degree of humidity. He presumed that 
what was meant was dry, warm atmosphere. A hot atmosphere might be saturated 
with moisture. 
The paper, on another point, justified the treatment of pulpless teeth with the 
most energetic antiseptics known to surgery. He (Dr. Morgan) wanted to emphasize 
that view. He believed that it was true, and that, to a very large extent, success in 
the treatment of teeth depended upon antiseptic treatment. If dry, warm atmo- 
sphere were pumped into a pulpless tooth, and the contents of its tubuli were desic- 
cated and then filled antiseptically. the proper thing would be done. If that was 472 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
what Dr. Brasseur meant, he (Dr. Morgan) commended most thoroughly that view 
of the matter. 
There was another general statement in the paper with which he (Dr. Morgan) 
took issue. . It stated that absolute dryness was necessary for success in filling with 
gold. There were many gray-headed men present who had practiced thirty or forty 
years ago, who knew that that was not exactly true. They knew that fillings had 
been made in those days which had preserved the teeth perfectly, and which were 
done by the ' ' submarine operation. ' ' 
He regretted that he was so hoarse as to be scarcely able to make himself heard ; 
but there was another point in the paper which he wished to allude to. The paper 
went into a long discussion of alveolar abscesses, making no exceptions. It took 
broad ground and made a broad assertion. He was talking to gentlemen who knew 
that the old principle which had been regarded as fundamental in medicine-that, 
if the cause were removed, nature would take care of the balance-was true. So 
the proper treatment of alveolar abscesses would simply attempt to remove that 
which was the cause of their production. In a large majority of cases, if decompo- 
sition were arrested, nature would take care of the balance. 
Dr. Geo. W. Whitefield, of Evanston, Ill., said that he would like to speak 
on a point mentioned in Dr. Brasseur's paper, as to the way to dry the cavity so as 
to produce less pain. He said that every time that a sensitive spot was touched, it 
produced pain, but if a burr is properly adjusted, and if the engine has a certain 
amount of speed, the first touch of the burr will be the last one that produces pain. 
That could be done within an instant of time, if the engine was kept properly 
revolving and if the burrs were properly attached, so as not to produce friction. It 
is friction that produces pain. 
Dr. S. II. Guilford, of Philadelphia, said that Dr. Brasseur's paper spoke of 
the use of air in dental operations as therapeutical treatment, but he should rather 
regard it as mechanical. All dentists knew that when a cavity which is sensitive 
has had an opportunity of having the moisture evaporated from it, either by means 
of ordinary atmospheric air at a normal temperature, or by other artificial means, a 
good deal of the sensitiveness of the tooth was got rid of. He was now using in his 
office a contrivance which he thought of great benefit. It was like that on which 
the paper really treated. The first person whom he knew to use air in that way was 
Dr. Bing, of Paris. That was the first recorded instance, he thought, of using 
compressed air, properly warmed, for the purpose of rapidly drying the tooth cavity. 
Within the last few years certain gentlemen in Philadelphia, himself among the 
number, had adopted an apparatus which enabled them to accomplish the purpose 
pretty satisfactorily. In the first place, there was a reservoir to contain the air. 
He had one in his office made of boiler iron, properly riveted and galvanized by the 
regular process, both inside and out. The boiler was about five and a half feet long 
and sixteen inches in diameter, closed at both ends, and hung between joists in the 
ceiling immediately below his office. The boiler was perforated at each end, and was 
connected in the office with a double-acting air pump, so that at every motion of the 
lever a compression of the air was obtained. It was devised and made by a firm in 
Philadelphia, Shaw & Geary. The pump was connected with the reservoir under 
the floor. To it was attached a double stopcock, having two nozzles. Immediately 
above it was a pressure gauge capable of registering fifty pounds to the square inch. 
From that nozzle a little rubber tube ran out, with which he was now using a right- 
angle, nickel-plated brass tube, at the end of which was attached a chip syringe with SECTION XVIII-DENTAL AND ORAL SURGERY. 
473 
a bulb containing hot air. By this contrivance he got all the results spoken of in 
Dr. Brasseur's paper, with almost entire painlessness to the patient. There were no 
means of keeping the air at a fixed temperature, at blood heat or any other point, so 
as to apply it to the tooth. It would give a stream of cold air if the bulb was not 
heated with warm air, and if warm air was needed the hot bulb could be used. In 
a devitalized tooth it was of great assistance to have the cavity as dry as possible, so 
that when it was cut out with the burr it could be done with the best advantage. 
If the tooth were living, the operation could be gone on with very rapidly. It did 
not take more than five minutes to render an ordinary tooth nearly painless by the 
use of compressed warm air in the manner which he had described. He did not 
look on it as a therapeutic agent but as a mechanical agent, and as a very valuable 
one. It enabled him to dry the tooth cavity and to remove pain. Besides, it was 
of inestimable value in the setting of dowel teeth. When it was necessary to cut in 
very near to the gum line, the cavity should be as dry as possible before introducing 
the dowel teeth, and by applying the stream of cold air, they could get it so dry that 
the color of the dentine would turn to that of ordinary chalk. In regard to the 
application of this contrivance to a living tooth, the result obtained by using warm 
air was that it saved time and saved pain, and that it thus gave satisfaction to the 
patient and to the operator. In every way it was very desirable. Some dentists had 
carried it further than this and had used it as a therapeutic agent. He had never 
used it in that way, because he thought it would not succeed. He had used it simply 
in a mechanical way. But if it did nothing more than to relieve pain in ordinary 
excavations, he would feel sufficiently paid for the expense he had gone to. The 
entire contrivance had cost him only $55.00, so that while it was a little e'xpensive, 
it was not so expensive as many supposed. 
Dr. A. H. Brockway, of Brooklyn, said that his objection to all the elaborate 
appliances described was that they were frightfully cumbersome, and, in his judg- 
ment, absolutely needless. They reminded him of the expedition fitted out by John 
Phoenix to survey a route from San Francisco to the Dolores Mission, about a mile. 
Having formed the company (which included all his relations), they thought it neces- 
sary, in order to begin properly, to get the correct time. So the astronomer of the 
company set to work to ascertain the time, putting into operation all the proper 
instruments to get the data. After getting the data, it was discovered that it would 
take some hours to work out. the problem, and then the expedition concluded that 
it would be just as well to send round to the corner grocery to get the correct time, 
which was done. So with all these appliances described. They were just as need- 
less as this complicated contrivance for obtaining the time of day. With a simple 
chip syringe in the hands of an assistant, warm air and absolute dryness could be got 
in less than five minutes. He was amused by the statement of the writer of the 
paper to the effect that the use of his contrivances obviated the necessity of an 
assistant. Well, the successful and easy practice of dentistry involved the necessity 
of a good many things-excavators, and burrs, and faucets and the like, and he con- 
sidered an assistant just as essential as any of these appliances. He had used for 
some years the method of desiccating cavities in order to produce insensibility of the 
dentine, but he had gradually abandoned it, having been impressed with the idea (to 
which Dr. Truman had alluded) that it was probably dangerous to living teeth to 
produce excessive dryness. He now overcomes the sensibility of the dentine largely 
by this method : The burr used in his engine was sharply cut ; he never used a 
dull burr. In order to prevent clogging, which produced the friction and which 474 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
caused the pain in excavating, he had his assistant keep the burr wet with a stream 
of tepid water, and his experience had been that no other method which he had ever 
employed had been so satisfactory to himself and to his patients as that very simple 
one. 
MANAGEMENT OF PULPLESS TEETH 
SUR LE MANIEMENT DES DENTS DÉPOURVUES DE PULPE. 
ÜBER DIE BEHANDLUNG PULPALOSER ZÄHNE. 
BY JUNIUS E. CRAVENS, D.D.S., 
Indianapolis, Ind. 
This paper was prepared with the object of presenting the merits of a system of 
managing pulpless teeth successfully and quickly, without the use of medicinal appli- 
cations in or through pulp canals; a system by which the structure of dentine is not 
impaired by saturation with foreign substances; a system that recognizes the necessity 
of a normal pericementum, and that seeks to protect that membrane from contact with 
all foreign agents, to the end that a longer tenure of usefulness for pulpless teeth may be 
assured. 
This system is based on the proposition that a pulpless tooth is not necessarily dead. 
The primary function of the cementuni of roots of teeth is to maintain vital con- 
nection between the dentine and pericemental membrane, by which the roots are pro- 
vided with collateral sustenance. It is essential that this vital connection should be 
maintained, at least for the benefit of the cementum, after a tooth has become pulpless. 
By such connection pulpless teeth may be retained in apparent health, certainly with 
comfort and usefulness, for many years. 
Whenever, from any cause, the pericementum has been subjected to influences that 
have caused a suspension or perversion of the function of that membrane as a con- 
servator of cementum, a pulpless tooth is in that case practically dead, and soon becomes 
offensive to the economy; therefore the ground is here taken that any method of practice 
that so affects the pericementum as to interfere with the conservation of cementum 
after death of the pulp, is erroneous and pernicious. 
The apical space was originally filled with a denser than Egyptian darkness, and a 
great light was let in when it was first invaded by a bristle through a pulp canal; and 
the apical space has ever since been a battlefield for different dental opinions, a tilting 
ground for theories, a sort of "champs de Mars," where "new remedy" hobbies are 
persistently paraded with advocates astride. 
Long time ago a theory was promulgated that root canals in pulpless teeth should 
be utilized as avenues for the induction of medicines (usually into the apical 
space; that irritant medicine thus applied would or should induce acute inflammation 
of the apical pericementum ; that inflammation thus induced previous to filling pulp 
canals, prevented subsequent inflammation, alveolar abscess, etc. 
The very close application of the parts that form and fill the apical space would 
appear to suggest the impracticability of seeking accommodation there for quantities of 
medicine ; iu most cases the apical space is intact when presented, complication with 
alveolar abscess at that time being the exception. 
The pericementum is closely confined between the cementum and the wall of the 
alveolus, having accommodation for the membrane in a state of health only. In event SECTION XVIII-DENTAL AND ORAL SURGERY. 
475 
of inflammation of the pericementum, there is consequent thickening of that membrane, 
and an urgent demand for additional space, which is obtained by the lifting of the root 
in the socket slightly, but enough to render the elevation of the crown of the tooth 
painfully conspicuous when in occlusion. 
What then shall be said of a practice that forces irritant agents through a pulp canal 
into the apical space, with a full knowledge on the part of the practitioner that inflam- 
mation of the pericementum will ensue, with tolerable certainty, and possibly may be 
attended by alveolar abscess ? 
Recently there has been developed among a few observing practitioners a tendency 
to eschew escharotics and other irritant agents, and to adopt milder medicine per pulp 
canals-a change that is at once an improvement and a half confession. 
But why should medicinal applications be made at all in or through pulp canals ? 
If the objective point is a congested tract of pericementum, it must necessarily be con- 
fined to the apical space, and must immediately surround or approximate the apical 
foramen, in order to be reached by medicine thus applied. 
Those practitioners who cultivate a habit of careful observation of freshly extracted 
roots, doubtless are familiar with the fact that an inflammation of the pericementum rarely 
affects the entire membrane, even of a single root; that only occasionally it is confined 
to the apex; that it is often found upon one side of a root, sometimes extending to the 
apical foramen, and sometimes quite remote, having not entered the apical space at all; 
that upon molars it is frequently confined to the crotch at the bifurcation of the roots, 
the apices bearing no evidence of congestion. 
When a tooth, under percussion, exhibits tenderness about the roots, diagnosis of 
pericemental congestion or inflammation is to that extent definite; but diagnosis is not 
complete until it has indicated the particular root involved, and located the part of the 
membrane affected ; it may be suggested that as such diagnosis never locates the par- 
ticular tract of inflamed pericementum, therefore the diagnosis is never complete. 
In absence of complete diagnosis, topical medication within the apical space is random 
practice. 
Diagnosis of blind abscess of the alveolar process is largely guesswork, because the 
single item of a wet canal does not prove the presence of pus nor the existence of an 
abscess cavity. So-called blind abscess is often diagnosticated as a convenient excuse 
for flooding pulp canals with medicine, the practice often resulting in abscess; when 
blind abscess exists, the accumulation of pus is so very slight that it will cease alto- 
gether after the cause has been abated by closing the apical end of the pulp canal. In 
nearly all such cases prompt closure at the apex will be followed by no noticeable 
inflammation, if proper care be observed in the manipulation within the pulp canal. 
With a large number of dental practitioners the idea prevails that pulp canals must 
always be "treated " for some imaginary condition before filling. 
A pulp canal is merely an axial opening through a root, when mechanically con- 
sidered, and the countless tubules that open into it only serve to render canal medica- 
tion the more objectionable. 
The tubuli of dentine absorb fluids that by accident or design are present in pulp 
canals. An agent absorbed by the tubuli does not stop at their entrances, but by 
virtue of capillary attraction, slowly and surely passes toward the periphery of the 
root, until the cementum is invaded and the mischief begun-that will be completed 
when the agent finally shall have reached the pericementum at a remotely subsequent 
period ; the pericementum is affected by such agents along the sides of a root in the 
same manner, if not in the same degree, as within the apical space. 
When such subsequent exudation does occur within the alveolus, the exuded irri- 
tant will be voided through a quick fistula, or the pericementum having become per- 
manently thickened and the socket enlarged about the root, the irritating agent so 476 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
recently exuded will be permitted to escape at the gum margin. In such cases the 
individual may detect the taste of the medicine that had been inducted into the pulp 
canal years previously. 
The final history of a tooth the structure of which has been saturated with medi- 
cine via the pulp canal, is that the pericementum becomes permanently hypertrophied, 
and its function as a conservator of cementum perverted or suspended; that structural 
deterioration ensues, and that the tooth becomes discolored, after which fillings are 
maintained with difficulty. Such teeth are eventually cast off as foreign bodies, the 
system refusing longer to tolerate them. 
The method presented by this paper requires that the apical end of a pulp canal 
shall be permanently closed as soon as the canal is laudable-that is to say, as soon as 
free from pus or other fluid, and all obstructive matter. 
A clear, clean canal is always laudable. 
If the apical ends of pulp canals are properly and permanently closed, it matters 
little with what material the remainders of the canals may be filled. 
In clearing out pulp canals, simple manipulation will accomplish all and medicine 
will be of no assistance. Solid or semi-solid substances, such as broken-down pulp 
tissue, etc., may be easily removed from pulp canals by the use of slender steel broaches, 
the free ends of which are slightly hooked or barbed. Gaseous contents of a pulp 
canal may readily be removed by displacement by the use of a roughened or slightly 
barbed broach, about which a few fibres of absorbent cotton have been loosely wound 
so as to form a swab ; the swab should always be small enough to pass easily along the 
canal to the apical constriction ; the precaution to insure easy and free passage of the 
swab is absolutely essential to avoid disaster. 
The loose swab should be passed to the apex in such a manner as to afford oppor- 
tunity for the canal gas to pass by and out; which it will do to avoid compression. 
While the swab is being withdrawn, air will pass by and in to occupy the tract of canal 
being vacated by the swab and to satisfy a threatened vacuum ; a few repetitions of 
such manipulations will effectually clear a pulp canal of sulphureted hydrogen or other 
residual gas. 
Fluid contents of pulp canals may be easily and rapidly removed by absorption, by 
using the free swab of absorbent cotton already mentioned; but the swab should be 
very slowly inserted until the fluid has been reached, and should be frequently 
removed and dried, or fresh swabs substituted. 
No pressure should be exerted in cleansing a pulp canal and haste should be avoided, 
because if gas or fluid of any character should be forced from the canal into the apical 
space, pericemental inflammation will certainly ensue. 
Whenever a closely-fitting swab or other device is employed in a pulp canal, the 
contents-of whatever character-are subjected to compression, and liable to be, to 
some extent, forced through the apical foramen; whatever enters the apical space from 
the pulp canal is liable to remain, to produce serious pericemental inflammation and 
alveolar abscess, and this abscess will be temporary or permanent, according to the 
solubility or mobility of the substance forced through the apical foramen. 
An easy and safe method of closing the apical end of a pulp canal is to cut No. 10 
tin foil into very narrow strips about an inch long; these strips should be narrow enough 
not to clog the canal nor to compress the contained air while being passed toward the 
apex or into place. The strips of tin should be carried singly and slowly toward the 
end of the canal-to the point that is usually indicated by a slight constriction, and 
should there be rendered as compact as possible by very gentle manipulation, using a 
small, springy canal plugger. 
Mallet force in pulp canals is unnecessary and should be avoided, because it over- 
comes sense of touch and may force the filling material beyond the apex. SECTION XVIII DENTAL AND ORAL SURGERY. 
477 
The philosophy of this method of managing pulpless teeth recognizes an apparent 
sanctity that hedges the apical space; whatever enters there from the pulp canal is 
regarded as an impudent intruder, and the vigorous inflammation that ensues is but 
the expression of the righteous indignation of offended membranes. 
If a case is complicated by extensive alveolar abscess with a fistulous opening through 
the gum and a liberal discharge of pus through the pulp canal, the conditicns are 
favorable to final success; the fact that pus escapes through the pulp canal is merely 
incidental, because the canal chanced to be open, and, naturally, the free route is 
accepted by the pus seeking escape. The operator should at once clear the pus from the 
canal by absorbing swabs, as already described; the canal may rapidly refill for a time, 
but the absorbing process should be persisted in until the canal becomes laudable, after 
which the apex should be filled or closed promptly and permanently. 
A fistula may be depended upon to accomplish all necessary drainage of pus from 
the cavity of an abscess after closure of the apical end of the pulp canal. When no 
more pus shall be formed the fistula will disappear for want of exercise. 
It may require some time for the obliteration of extensive alveolar abscesses, particu- 
larly if of long standing, but under the method herein detailed they may usually be 
depended upon to disappear in a few days without the consequent irritation and alto- 
gether doubtful assistance of pulp canal medication. 
If, at time of presentation to the dentist's observation a tooth is too sore to admit of 
the necessary operation of opening the pulp cavity for initial relief, the policy of waiting 
for a favorable decline of soreness is preferable and better than attempting by a painful 
operation to force a conclusion by medication within or through the pulp canal, and in 
the end is more expeditious. 
A fistula is the dentist's friend and best ally; it accomplishes drainage of pus and 
thus relieves the pulp canal of a pernicious service, because the watery element of pus 
is absorbed to some extent by the tubules of dentine, according to opportunity. 
A fistula from an alveolar abscess should never be interfered with in any direct man- 
ner, but should be encouraged to perform its good offices, as it will certainly disappear 
when its task is done. 
Thus far the method detailed has reference to adult or permanent teeth only. 
DECIDUOUS TEETH. 
In managing pulpless deciduous teeth the method is much the same as for the adult 
teeth, except that the pulp canals should be filled entirely with phosphate of lime ; the 
phosphate of lime should be in the magma state, and may be thickened with the dry 
phosphate, or the water removed by the ordinary dental absorbents until a consistency 
to suit manipulative convenience is attained. 
No attempt should be made to close the end of a pulp canal in a deciduous tooth, 
and as much of the phosphate of lime should be worked into the canal as may be 
accomplished without force. 
No subsequent inflammation or fistula has occurred in connection with deciduous 
teeth managed in this manner during an observation that extends over five years. 
Often, deciduous teeth with old fistulous openings through the gum will surrender 
quite easily and satisfactorily under this method, a fistula usually disappearing in one 
or two days. 
No medicine should be used in pulp canals of deciduous teeth, because there is no 
apical space at the ages at which those teeth usually become pulpless; and no foreign 
nor insoluble substance should be used for filling in such pulp canals, because of certain 
detriment to the process of resorption of the roots. 
Force is absolutely inadmissible in the pulp canals of deciduous teeth, because of a 
loss of apical constriction in partially resorbed roots. 478 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
NOTES. 
In many adult teeth, when the pulps have been devitalized and removed, and the 
pulp canals have been filled at once without deluging them with medicine, the teeth 
have afterward manifested unmistakable sensibility to thermal change, and to the touch 
of metallic substances, even to the irritating effect of sweets. 
These manifestations of sensibility should be accepted as evidencing unimpaired 
pericementum and cementuni. 
There have been very strong indications in some cases under the observation of the 
writer, that the roots of deciduous teeth have continued to be resorbed after the pulp 
canals were filled with the phosphate of lime, as described; but the evidence of subse- 
quent resorption is necessarily incomplete, because so many deciduous crowns are cast 
at home and lost to observation, and because the previous stage of resorption could not 
well be determined. . 
This paper is presented with a full consciousness that the method advocated is at 
right angles to one so long established as to have become a tenet of the dental profession. 
A hope is entertained that so progressive a profession may be induced to try this 
method, fairly and faithfully. If the method proves successful and satisfactory, then, 
so far as pulpless teeth are concerned, we may indeed "throw physic to the dogs." 
DISCUSSION. 
After Dr. Cravens' paper, the discussion was opened by Dr. Thos. Fillebrown, 
of Boston, Mass., as follows :- 
Mr. President.-I feel honored to have the opportunity to address this meeting 
of representative dentists of the world, and I am pleased to respond to your invitation 
to open the discussion of the very able paper just read. 
By a pulpless tooth, I suppose, is understood one whose pulp has ceased to per- 
form its functions, whether simply devitalized, putrescent or hardened, or any other 
condition of permanent disability. The main proposition of the paper, ' ' that 
cleanliness and dryness are the essential points in treatment of pulp canals," I 
believe to be strictly true. That medicine in pulp canals never does any good, but 
always results in injury, is not to me so plain. That attempts to medicate the parts 
beyond the tooth through the pulp canal have, on the whole, done much harm, I 
firmly believe. Occasionally most excellent results follow the practice, but even in 
those cases equally good or better results would very likely follow non-interference. 
The difficulty in such cases is to tell "what might have been," and to tell, also, how 
much nature accomplished in spite of the treatment. 
I am pleased to notice that non-interference through the canal is gaining in the 
estimation of the profession and finds to-day such able advocates. 
The number who advocate immediate filling in all cases is increasing, and great 
and uniform success is claimed ; but the familiarity with the use of the trephine, 
shown by many such practitioners, leads me to question, whether there may not 
be different standards of success. I have never been able to find it safe to hermetic- 
ally seal the apex of a root when active inflammation of the pericementum exists ; 
serious results are almost sure to follow. If it is meant by "immediate filling," 
immediately after the tooth is well, I will fully accept the conclusion. Whenever 
active inflammation exists, beyond insuring an open pulp chamber, non-interference 
of every kind with the pulp canal until the inflammation subsides is, beyond ques- 
tion, the best practice. 
When a chronic abscess exists, discharging through the root canal of a tooth, and SECTION XVIII-DENTAL AND ORAL SURGERY. 
479 
no fistula exists, I cannot conceive it safe to immediately fill the canal and stop the 
discharge. In such cases, the formation of pus does not depend alone upon the 
condition of the canal. The inflammation outside the canal, within the jaw, primarily 
excited by the dead pulp, has become a persistent secondary cause, and simply 
cleansing the canal will not cause an instantaneous healing of the abscess. I under- 
stand it to be a fundamental principle of surgery not to stop the discharge of pus by 
closing a superficial opening through which it is discharged. The truth of this is 
too patent to need argument, and the dangers from pyæmia too imminent to need 
more than a warning given, to prevent the adoption of such a practice. 
Another important point made in the paper is the necessity of an impervious, 
indestructible filling which hermetically seals the apical end of the root canal. Any 
filling which is porous, which will absorb any moisture, will inevitably tend to make 
trouble, and if the tooth so filled remains quiet, it is because of nature's ability to 
tolerate a large amount of poison. 
The danger from malleting is over-estimated. If skillfully and lightly done, no 
harm will be inflicted, and it compacts the filling solidly and well, and often over- 
comes a little clogging that may resist hand pressure. 
If a tooth is very sore, I would not wait until better before opening for relief ; 
this is just the time mechanical means will prove the true remedy. Open the pulp 
chamber immediately and allow the products of the inflammation to pass off, and 
the resultant abscess is aborted and the patient saved days of agony, and a peri- 
cementum restored to perfect health, instead of being nearly destroyed by the process 
of suppuration. Sharp instruments, delicately handled, will accomplish this, and 
without excessive pain to the patient. 
The apical space, spoken of in the paper, and often mentioned by writers, is to 
me a myth, existing only in the imagination of the writer or the drawings of the 
figurative microscopist. In the normal, healthy specimen, the cortical substance of 
the alveolar wall closely invests the root all around, over the apex as well as the 
sides ; the pericementum is closely adherent to both the bone and cementum ; con- 
tinuous with the cortical substance is the cancellous tissue of the bone-no space 
whatever until the tissue is excavated by art or absorbed by diseased actions. It 
may be the writer uses the term in the sense of locality rather than open space, but 
I do not think this a legitimate use of the word. 
The remotely subsequent troubles of hypertrophied cementum, structural deterio- 
ration, discolored dentine, etc., are more frequently the results of retained pulp. If 
a pulp be thoroughly removed before disorganization takes place, and the tubuli free 
from coloring matter from the blood, discoloration is very slow to take place, whether 
the canal be medicated or not. If hæmatin has been taken into the tubuli and 
septic matter from the disorganized pulp taken up, discoloration will follow and 
continue in spite of medication or non-interference. The darkest teeth are those 
whose pulps have died and become disorganized without ever being exposed. In 
these cases medicine can have had no effect either way. It is hard to conceive of 
the dentine of teeth taking up enough of any medicine, during an application in the 
canal, to exert any permanent influence for good or evil. 
If pulp canals be filled with cotton or other porous substance saturated with 
irritant drugs, to which will be added the fluid absorbed through the foramen, it is 
very plain that the mixture will prove a source of an irritation which will require 
repeated attention and permanently injure the tooth, and very likely cause a loss of 
the organ. 
The treatment of pulpless deciduous teeth described is not consistent with pre- 480 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
vious statements of the paper nor with itself. It says : " No medicines should be 
used in the pulp canals of children's teeth," and then proposes to permanently fill 
the canals with phosphate of lime, and claims complete success as the result of the 
treatment. If medicine is good for the roots of deciduous teeth, it must follow that 
it may sometimes be good for others also. Probably most operators leave the root 
canals of deciduous teeth unfilled. Here we have a new method proposed, of filling 
them with a non-irritating substance, and its results confirmed by an experience 
extending over several years. It is worthy of trial, and ought not to be cast aside 
without consideration. 
A method which has proved very uniformly successful during more than twenty 
years of practice is as follows :- 
Cleanse the root canals as thoroughly as possible, avoiding passing an instrument 
through the foramen. If any tendency to inflammation exists, keep the canal patu- 
lous, or with only a light dressing, until it subsides. Then fill tight with cotton 
dressing that can be easily removed to test its condition. Use sedative antiseptics on 
the dressings in the root. Stop the cavity with cotton wet with gum sandarach or 
other means. When proved to be healthy, fill the canal with a solid filling, hermeti- 
cally sealing the apical foramen. Treat any complications that persist around the 
apex of the root through the alveolar wall, and not through the root canal. If 
patient waiting is exercised in doubtful cases the trephine will seldom be required. 
As the paper discusses the application of the method only to teeth in which the 
apex of the root can be reached, it will be out of place to consider the numerous 
conditions which make the results of any method uncertain, especially those which 
make it impossible to reach the end of the canal, and, consequently, impossible to 
remove all of the pulp tissue ; any system which does not take these into considera- 
tion cannot be called complete. 
Dr. W. C. Barrett, of Buffalo, N Y., said : I think the theory in the paper 
just read a singular one. I think that, pathologically, it is yet more singular ; that, 
etymologically, it is peculiar, and that, orthographically, it is quite sui generis. It 
seems to me that when a pathological, or a lack of pathological, knowledge is seri- 
ously considered, in a World's Congress of Doctors, from the low standpoint of the 
pathological knowledge of twenty-five or thirty years ago, we are taking steps back- 
ward. Within the past five years such advance in pathological knowledge has been 
made that when, in a meeting of this kind, it is utterly and entirely ignored, and 
when we are brought back to the old exploded ideas of a quarter of a century ago, 
we are not up to the intelligence which should be exhibited in a meeting of this 
kind. I simply want to enter my protest against the acceptance of such ideas as 
those expressed in the paper we have just heard, as a mark of the intelligence of 
American dentists aqd American dentistry. I say this because I feel that it is a 
duty which we owe to ourselves and to our profession to have it said. Of course, 
no one will so far misapprehend me as to think that in this there can be any personal 
allusion of any kind. I simply think that we should come down to a later period in 
the world and view these things in the light of the manifestations of the past five or 
ten years. When we consider the pathological condition or the antiseptical condi- 
tion of the root canal in a tooth, without considering antiseptical treatment exclu- 
sively from the commencement, we are, according to my ideas, away out in the 
woods.. It is impossible, within the limits of a discussion of this kind, to attempt 
to set forth the principles of antiseptical surgery in this day, and I hope, moreover, 
that it is utterly unnecessary in such an assemblage as this. The treatment of these 
root canals must, from the very commencement (according to my ideas-but I do SECTION XVIII-DENTAL AND ORAL SURGERY. 
481 
not speak ex cathedra), be entirely from a septic point of view. The first thing to 
be done in everything of this kind is to afibrd drainage egress to whatever septic 
matter is present, under stress of the inflammatory conditions which preceded this 
state. And when we are warned-as we are in this paper-against opening a pulp 
canal which is in a septic condition, which contains within its recesses all the septic 
organism and all the septic matter which is gathered there (and which is always 
gathered under such conditions)-when we are warned, I say, against opening that 
pulp canal and allowing an exit to the matter, I am astonished. It is the very first 
thing which must and should be done, under all circumstances. The first thing to be 
done is to give egress to the septic matter which maybe therein contained; the second 
thing is to introduce something which will entirely disinfect the diseased territory ; 
the third thing is to introduce an agent which is an antiseptic and germ destroyer, 
and which will not only cleanse that which has not been removed, but which will 
destroy the very germs which are producing this condition, which have originated it, 
which have sustained it, and which will continue to do so as long as they are allowed 
sway. From the standpoint of antiseptic surgery these are the three points in the 
treatment. The territory having been rendered entirely aseptic, then comes con- 
servative surgery, with which the paper that has been read, or its consideration, 
has, necessarily, nothing whatever to do. 
Dr. A. W. Harlan, of Chicago, said : The title of the paper says that it is on 
the "Management of Pulpless Teeth," and then we have read to us a mediaeval 
romance. We are dealing, gentlemen, with modern advance in antiseptic surgery 
and bacteriology. The author of the paper says that he banishes mephitic odors 
and swabs the canals of teeth from which pus is flowing, and renders the roots 
laudable in this manner-forgetting that the dentine of the tooth becomes satu- 
rated with mephitic gases, and polluted with the pus which flows from the root 
canals ; and then he proposes to fill the apical ends of such teeth without disinfec- 
tion or any medication whatever. That is too far behind the advance of American 
dental surgery to go forth in this Ninth International Medical Congress as the opin- 
ion of the American dentists of to-day. It is true that the filling of the roots of 
teeth and the treatment of abscesses do not go back many years ; but it was due to 
American dentistry, in the first instance, that the method of practice was first begun 
of filling roots of teeth. Now, to say that we must go back to the days of forty 
years ago, and discard all of the hardly-acquired knowledge which we have of anti- 
septics and disinfectants, and discard them for a mechanical method in the treatment 
of root canals, is, to say the least, absurd. 
The author of the paper seems to rate the intelligence of American dentists 
at this plane, which would include, as the whole treatment of pulpless teeth, the 
mere medication of the pulp canal. The pulp canal does not produce an abscess. 
The dead pulp which putrefies within the canal produces no irritation at all within 
the canal. He seems to think that the object of medicating the root canal is to cure 
a disease within it, while the disease is beyond. But if we mechanically displace an 
odor (the possibility of which I deny), if we cause the cessation of the flow of pus 
from the root of a tooth, it merely means the drainage of the sac beyond ; and if we 
then fill the root of this tooth, without any disinfection, disaster inevitably follows, 
unless there be a fistulous outlet. The gentleman says, in his remarkable paper, 
that we are not certain that a wet canal contains pus. What is the object of pos- 
sessing the microscope, or having a technical knowledge of its use, unless we can 
detect pus by the examination of a fluid taken from the root canal ? I will grant 
Vol. V-31 482 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
him that the unaided eye will not always detect pus corpuscles in the fluid that comes 
from a canal, but any surgeon with a respectable knowledge of microscopy can detect 
at once whether the fluid contains pus corpuscles or not. 
Now, gentlemen, this paper proposes to be a system on the management of pulp- 
less teeth. A "system" on the management of pulpless teeth includes a considera- 
tion of every grade of pulpless teeth, even when produced in the first instance by the 
dentist himself through a destruction of the pulp by mechanical means. It utterly 
ignores the destruction of the pulp and the filling of the teeth. The author of the 
paper assumes that the practice of the dentists of America of to-day is to force 
escharotics into and beyond the abscesses of roots where there is no fistulous egress. 
I ask you, gentlemen-and I beg you to corroborate me or not, according to your 
understanding of the situation-if it be true that the prevalent system of this day is 
to force escharotics into the blind abscesses which have no fistulous outlet? It would 
inevitably bring about a trouble which every one would seek to avoid. Therefore, 
without taking up any further time, I say that the ' ' system " as a system is unworthy 
of consideration, and that I am astonished that an American dentist of to-day should 
present a system which is obsolete, and which is not based on the present advance 
of our knowledge in pathology and the microbian theory of disease. 
Dr. W. H. Morgan, of Nashville, Tenn., said: I wish to notice two or three 
things which have been brought out in this discussion. That grand old man (pointing 
to Dr. Maynard, of Washington, D. C. ) practiced fifty years ago a treatment of pulpless 
teeth which involved every single principle adopted in the most successful practice of 
modern dental surgery. If you go back to the literature of the profession and examine 
papers that were published in 1854 and 1855, you will find every single therapeutical 
principle set forth that is now adopted and advocated by the most advanced in our 
profession. One of the gentlemen who sat under his teachings in my presence (Mr. 
Charles W. Ballard, of Edinburgh) published such papers at that time. We did not 
have all the remedies that we have now, but the principles were precisely those that are 
adopted at present. Something has been said in the paper of the mallet. I use the 
mallet as a remedial agent. I know that when there is chronic inflammation of the 
peridental membrane, I can drive it out with the mallet, on the same principle as a man 
who goes out and uses an axe in the chopping of wood. He comes in next morning and 
says that his elbow is stiff-that he had used it too much yesterday. And what will 
cure it? A little more of the same axe. There is a little stasis-a want of molecular 
movement in the arm. Movement will set the molecules in motion, and he will have 
relief. I know, both from observation and experience in my own person, that the 
use of the mallet on the tooth that has moderate inflammation of the peridental 
membrane will tend to its relief. We are gravely told in this paper that we must 
not fill the roots of the deciduous teeth with metallic filling, because, forsooth, the 
structure of the teeth will be reabsorbed and leave the metal in the way ; in other 
words, we are told that we are going to have a physiological action in a dead body. 
Now, I admit that in a pulpless tooth the entire structure is not devitalized, but the 
entire dentine is devitalized, except in rare instances, and whenever you destroy the 
pulp of a deciduous tooth, you stop the progress of absorption, at least so far as the 
dentine is concerned. No such physiological action ever occurs in pulpless teeth 
beyond the mere cementum. Sometimes the structure is broken down by chemical 
action, when an abscess is formed, and then you have the root destroyed. That is 
true. The proper treatment of pulpless, deciduous teeth is their extraction, gentle- 
men. It is their extraction, without a single exception, that I would make. SECTION XVIII-DENTAL AND ORAL SURGERY. 
483 
Dr. Chas. R. Butler, of Cleveland, Ohio, said : This case reminds me of 
some little discussion which was excited by a man connected with this profession 
many years ago. He took the opposite side of a question for the very purpose of 
drawing out facts, and sometimes principles. I can hardly conceive that any man 
practicing dentistry to-day, and who calls himself intelligently based on pathological 
principles, would project such a "system" (as the caption of this paper sets forth) 
without having some object in view besides just enunciating such a practice as we 
must infer he pursues. Certainly some very earnest and most intelligent enunciation 
of the system which governs practice in such cases has been brought out here, which 
I am glad to hear, so that our friends from the other side of the Atlantic may un- 
derstand that Americans are still alive, intelligent practitioners of dentistry. There 
is a great variety of notions as to the mode of treating canals in teeth, but the prin- 
ciple is all the same, with, perhaps, very few exceptions. In order to present this 
subject intelligently, it would have to be divided into classes, and that, of course, is 
not admissible with the limited space of time which we have for the discussion of 
the paper presented. Just the most intelligent points to be brought out I am not 
able to enunciate, but it would seem that this paper has had some beneficial effect. 
The result will be seen in the discussion. Perhaps we could not have got at a more 
definite enunciation of the true practice which is pursued by the great majority of. 
American dentists if the subject had not been presented to us as it has been. There- 
fore I am disposed to be a little charitable, even if Dr. Barrett did criticise the paper 
pretty sharply, and I am disposed to think that it will probably result in some good. 
The President (Dr. Taft).-I do not desire the discussion to close without hear- 
ing something on the subject from our friends from abroad. We should not have all 
the talk on our side, and therefore I should be glad to have some expression of 
opinion from our friends of the other side. The author of the paper has been so 
severely criticised that it is due to him that he should have a few minutes for reply, 
and then the discussion will close. We will be glad to hear now from any of our 
friends from abroad. 
Dr. W. E. Harding, of Shrewsbury, England, said : Since I came to America I 
have seen many things which have excited my admiration and my wonder, but I 
think that nothing which I have seen or heard here has excited in me so much 
astonishment as the paper that I have heard read this afternoon. In England, we 
are thoroughly imbued with the ideas which were first promulgated by Prof. Lister, 
of England, following the researches of Prof. Tyndall, particularly the theory that 
pus and septic matter were the results of microorganisms, and that the proper way 
to cure the production of pus and to prevent its formation in a wounded condition of 
the structure was by antiseptics, or, as we now generally term them on the other side 
of the Atlantic, germicides. To be told, as we are to-day, that we can get rid 
of a septic condition of the root canals by mechanical treatment, excites in me the 
utmost atonishment. I think that on the other side of the Atlantic the proposition 
will be treated (as has been suggested by one gentleman here) as the result, probably, 
of a desire on the part of the writer to elicit a discussion. I am glad to say that some 
of the speakers who followed have not the general opinion that a septic condition of 
the root canals can be secured by mechanical treatment. When you have pus formed 
beyond the dead pulp, that pus is certain to infiltrate the matter around and to be 
absorbed in the dentine, and as long as these germs remain in a vital condition, as 
long as they have the pabulum to live on, you will find them reproduced. That is 
as far as my light goes, and that is the generally received opinion in England. The 484 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
idea that the application of germicides to the canal (provided you do not force them 
through to the tissue beyond the apex) will produce inflammation of the periosteum, 
is, I think, absolutely unfounded. But if you force it through the canal by a piston- 
like action, you will then certainly get inflammation of the membrane, if you have it 
not in the first instance. I think that the opinion of most men who are up to the 
times in regard to physiological or pathological research on this subject is, that 
where you have germs present in a cavity, you must find an exit for them, and must 
not block them up, and you must apply germicides to destroy the vitality of those 
that remain. When you have the last germ devitalized, then you may fill your 
canal with a certainty of success. 
The President informed Dr. Cravens that if he desired to state anything in 
reply, he might now do so. 
Dr. Geo. Cunningham, of England, expressed the hope that the discussion 
would not be brought to a close until he should have had an opportunity of present- 
ing some statistics which he expected to have in a day or two, and which, he thought, 
might show that the position taken by Dr. Cravens was not so untenable as had been 
suggested in the discussion. 
Dr. Cravens said that, inasmuch as the presentation of the statistics mentioned 
was to be made, he desired to defer his remarks until these papers were presented. 
The suggestion was agreed to, and the discussion was closed for the present. 
MATRICES AS ADJUNCTS IN FILLING TEETH. 
MATRICES COMME ACCESSOIRES AU PLOMBAGE DES DENTS. 
MATRIZEN ALS BEIHÜLFE BEIM PLOMBIREN DER ZÄHNE. 
BY DR. T. E. WEEKS, 
Minneapolis Minn, 
Mr. President and Gentlemen :-I do not come before you to exhibit my own 
offspring, but my neighbor's. 
Being fully aware of the interest that of late has been manifested by the profession 
in this subject, that many have exercised their inventive ability in perfecting the mat- 
rix, and that much has been written and said better than I can say it, I only hope, 
by what I have written, and the aid of drawings, to place all under the strong light of 
discussion, feeling that the result must be the revealing of the weak points as well as 
bringing into greater prominence the strong ones. I grew into the use of matrices very 
slowly, not adopting them until after a thorough trial, as I feel that one can hardly 
afford to envelop himself in conservatism, allowing his more progressive brothers to 
establish the merit of every good thing ; neither is it wise to embrace fondly and adopt 
blindly every creation of the inventive brain, but rather strive to study critically and 
experiment carefully with each new device. 
Matrices, of more or less varying forms, are becoming as numerous as the children 
of the old woman " who lived in the shoe," many of them resembling each other so 
closely that their parentage might be identical. I have no objection to multiplying SECTION XVIII-DENTAL AND ORAL SURGERY. 
485 
forms in matrices or other appliances, providing they are called by their proper name, 
"improvements," instead of "inventions." 
The principal office of the matrix is to convert compound or complicated cavities 
into simple ones, i. e., to supply so much wall as may be necessary to form a cavity 
having four walls; consequently it findsits greatest usefulness upon molars or bicuspids 
having mesial or distal cavities, although it may be used to advantage (in the Herbst 
method it must be) in the filling of all cavities which have not four walls. 
No one form will be found to answer in all cases. Complete success cannot be 
insured by using any one to the exclusion of all others ; especially is this true of those 
of rigid forms; for, like any appliance presenting arbitrary lines, designed to restore or 
imitate, wholly or in part, the form of teeth, which present so many, and at times such 
strange variations, they are absolutely useless in all cases which do not present the out- 
lines of those types which have been used in the forming of such appliances. 
In their manufacture we may use portions of steel pens, bits of the handles of 
separating files, ribbon saws, clock springs, or any thin steel, gold, platinum, silver, 
copper, brass, German silver, phosphor-bronze, tin, etc. 
All forms may be divided into two classes, the first embracing all those which 
require for their adjustment the presence of any adjoining tooth ; the second, those 
which either partially or completely encircle the tooth. The simplest form of the first 
class is a thin slip of metal passed between the tooth in which is the cavity and the 
one adjoining, being keyed against the walls of the cavity by some form of wedge. 
Then comes the depressed matrix, shown in Fig. 1.* For these, as well as some very 
useful forms of pluggers designed for use with the matrix, we are indebted to Dr. 
Louis Jack, one of the pioneers in this line of work. Dr. J. A. Woodward suggests 
patterns for what he calls a clasp matrix, Fig. 2. These are made of steel, 25, 27 or 
28 standard wire gauge. Their efficiency is due to the lug, which, resting upon the 
adjoining tooth, prevents undue pressure of the cervical edge, and the grooves upon 
the reverse side prevent impingement of the wedge upon the soft tissues. Where 
space is limited, I have found useful a matrix fashioned after Dr. Woodward's patterns, 
made of thin brass or phosphor-bronze. This I fix in position with resin wax, or 
modeling compound, after the method of Dr. Herbst (the compound should be warmed 
over a flame to render it sticky ; the rubber dam and all surfaces, where adhesion is 
not desired, should be coated with glycerine). When it is desirable to depress a 
matrix in order to give the necessary swell or contour to the filling, it may be done 
cither with the " contouring pliers," Fig. 3, the dappling punches and die block used by 
jewelers, or the end of a hard-wood stick properly fashioned and struck into a lead 
block. 
Dr. Jennings, of Cleveland, suggested to us a simple matrix formed by flattening a 
bit of copper wire over the horn of a small anvil, using larger or smaller wire, and 
placing it closer to or further from the body of the anvil, as the tooth was large or 
small. The result is shown in Fig. 4. 
Those of Dr. Wm. B. Miller, shown in Fig. 5, as will be seen, require no wedging, 
being held in position by the spring of the metal. In Fig. 6, we have a matrix by Dr. 
H. A. Whitney, which does not require wedges, being secured by a combination of 
springs and set-screws. 
In Fig. 21 is shown an arrangement of two semi-circular pieces of thin brass, fastened 
together at the top with soft solder in such a way as to admit of separating the cervical 
edges. This is especially useful in cavities between second bicuspids and second molars, 
* In consequence of inability to obtain many of the cuts illustrating this paper, and as they 
have all of them been published in the various Dental Journals, it was deemed advisable to omit 
the illustrations. 486 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
where the first molar is missing and the second molar has tipped forward. This was 
sent me by Dr. D. Freeman, of Chicago. 
Before leaving this class, I wish to call attention to the little device invented by 
Dr. E. T. Darby, for retaining matrices in position, doing away entirely with wedges, 
and, if desired, can be made to act as a separator. It is shown in Fig. 7, and will need 
no further comment. 
Passing to the second class, we find those which seem to-day the most popular, and 
the field wherein most matrix inventors are laboring. Here, as in the first class, in my 
remarks and illustrations, I shall purposely slight no one. If I chance to omit any, I 
trust its author will attribute the omission to my ignorance of its existence. 
Here it seems to me that the same principle is present in all, but differing in shape, 
material used in construction, and means of securing in position. We see them tied on, 
soldered and driven on, screwed on, held on by springs, and by the combination of 
screw and spring. While really belonging to the second class, I choose to regard as a 
sort of connecting link, possessing many of the valuable features of both classes, the 
partial loop forms, which occupy but one interdental space. Where the teeth are 
crowded, this is undoubtedly an advantage. Those devised by Dr. S. H. Guilford (Fig. 
8) are held in place by the little screw clamp or holder; while those of Dr. A. C. Hewitt 
(Fig. 9) are secured by a spring clamp, which is adjusted with the rubber-dam clamp 
forceps. 
I have made what I consider an improvement on Dr. Hewitt's clamp, as it permits 
the insertion of the band in the jaws of the clamp prior to its adjustment upon the 
tooth, thus enabling the operator to apply it as one piece, which in most cases is an 
advantage. The jaws are so shaped, too, as to insure the greatest tension at the cervical 
border. This is illustrated in Fig. 10. 
Of those which encircle the tooth completely, occupying two interdental spaces, 
which is an advantage where we desire to employ the matrix in filling both a mesial 
and distal cavity in the same tooth at one sitting, we will consider, first, Dr. Guilford's 
bands, with the second clamp, shown in Fig. 8. Then the set known as the ' ' Ladmore- 
Brunton matrices," made by Ash & Son, shown in Fig. 11. Those employed by Dr. 
Herbst are made of a thin strip of tin or brass, strained around the tooth with a pair 
of pliers made for the purpose (Fig. 12), removed and united with soft solder and forced 
into position. In connection with this form, I cannot refrain from digressing sufficiently 
to describe an operation which has afforded me much satisfaction. 
When a crown is much broken down, and circumstances render it advisable to build 
it up with amalgam, I make a Herbst matrix of platinum, or platinum on one side and 
gold on the other, fit it perfectly to the neck of the tooth, bevel and shape the cervical 
edge so it will pass beneath the free margin of the gum all around, give it the desired 
contour, and, after carefully drying the tooth, fix it in position with cholora-percha or 
zinc-phosphate, leaving it on the tooth after the filling is completed. This insures the 
tooth against fracture or the recurrence of caries, making an operation in usefulness not 
inferior to a gold crown. 
Dr. Huey was the pioneer in band matrices. His original pattern, made of platinum 
and fastened by a bolt and nut, passing through holes in the end, was almost identical 
with many that have appeared since. 
Dr. E. B. Call's bears the closest resemblance to the Huey, but is made of thin brass, 
a strip cut the desired length, a hole punched in each end, and strained around the 
tooth by pliers, differing from the Herbst pattern in that the beaks engage in the holes 
in the band. It is then fastened on with a small steel bolt and nut (see Fig. 13). 
Modifications of this are seen in the loop matrix of Dr. W. Finney (Fig. 14), that 
of Dr. Frank Creager (Fig. 15), also those of Dr. Woodward (Fig. 16), which are designed 
to do away with the space which appears between the ends in other similar forms. SECTION XVIII-DENTAL AND ORAL SURGERY. 
487 
The second form, shown in Fig. 21, I also obtained from Dr. Freeman. After 
straining the strip of metal around the tooth with pliers, it is secured by slipping the 
little steel key astride the ends, close to the tooth, and separating them over the key. 
Another valuable suggestion of Dr. Freeman's is the semi-circular form of the metal 
strips, which insures a more perfect adaptation on those teeth having bell-shaped 
crowns. 
Another loop matrix, which is tightened by the pressure of a screw through the 
band against the tooth, is that of Dr. Truman W. Brophy. Fig. 17 will show its 
merits. What is evidently intended as an improvement upon the Brophy is that of 
Dr. John H. Reed (Fig. 18). The evident intention is to cheapen the cost without 
detracting from its usefulness. This, I understand, is not manufactured ; but it 
seems to me that if we could have the "Brophy screw" constructed in some such 
way as to allow the operator to supply bands adapted to individual cases, we should 
have a matrix cheap, convenient and better adapted to many cases than any other 
of its class. 
There are several points which a matrix should possess, most important of which 
is adaptability to the largest number of cases. Then it should be simple in its con- 
struction , of some material not liable to corrode or amalgamate when brought in contact 
with those agents capable of producing such results. Whichever pattern is used, should, 
when in position, form a cavity which will give to the completed operation some such 
form as shown in Fig. 19, rather than that shown in Fig. 30. Its adaptation should 
not be so close as to prevent the filling material from perfectly covering the margin, i.e., 
we should have enough surplus to enable us to finish and still leave the with 
the margins. In this respect matrices which are thin and yielding are better than those 
which are thick and stiff. I think, too, that the means of securing the matrix in place 
which will yield a trifle, are on this account superior to the more rigid methods. For 
this reason, in the partial loop forms, I frequently find the Hewitt more satisfactory 
than the Guilford, and in the loops, the Brophy better than any of the other forms. In 
those of the first class, which are wedged against an adjoining tooth, the natural yielding 
of the tooth to the wedging pressure of the material as it is inserted, will produce the 
desired result. Here, as in other operations, I think we should choose those appliances 
which encumber the mouth the least and cause the patient the least discomfort, for it 
certainly is our duty to regard their comfort as much as possible, without endangering 
the perfection of the operation. 
Valuable as is this little appliance where its use is indicated, it certainly should not 
be used in filling every cavity not having four walls. Just here is where mistakes may 
be made. Ours is undoubtedly a profession which has demonstrated its right to stand 
among progressive scientific bodies. Yet we are all prone to mount the back of hobbies 
and ride madly until we find ourselves in the ditch, and our steed vanished. We are 
apt to fall into habits of operating which in our hands produce, it may be, operations 
as near perfect as can be attained in any other way, forgetting that our neighbor has 
habits and methods of his own for producing the same results, and whenever we hear 
him describe them, denounce them as wrong, because they differ from ours, when often 
the difference is more in detail or means employed than in principle involved. 
Life is too short to waste in bickering over these minor points. Better is it to 
endeavor to learn the successful methods of our colleagues and adopt into our practice 
so much of them as we can handle advantageously, being careful the while to avoid 
being copyists, for no copy can equal the original, unless some original features are 
introduced which may be said to improve it; then it ceases to be a copy in the strict 
application of the term. 
It is not necessary to fill our cabinets with all the various patterns which I have 
noticed, but, keeping principles in mind, with ft careful survey of the collection, one 488 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
can easily avail himself of all the advantages offered by the use of matrices. Suitable 
ones for each case may be easily and quickly provided, from materials at hand, by the 
exercise of a little ingenuity. All are possessed of some talent in this direction, be it 
ever so little. The less one has, the more should he strive to cultivate it, especially in 
the manipulative part of our profession, for the cases presented are so varied that our 
inventive genius is constantly taxed. 
DISCUSSION. 
The discussion of Dr. Weeks' paper was then opened by Dr. S. II. Guilford, 
of Philadelphia, who said that a matrix was an appliance intended to supply the lost 
wall of a tooth during the operation of filling. Its object was to enable dentists to 
perform a difficult operation with less difficulty than they otherwise could. Matrices 
were made of various materials, and had been used for a* good many years, and had 
come to be used in a great variety of forms, as was well illustrated in the diagrams 
exhibited to-day. He only proposed to speak about the value of the matrix as an 
aid in filling teeth, and would not discuss the matrices themselves. It seemed almost 
unnecessary at this late day to come before an assembly of dentists and argue in favor 
of an appliance that so many had found to be of incalculable benefit to them, and 
yet it was true that there were to-day men who would argue against the use of that 
appliance, who could see no good whatever in it, and who totally condemned it, 
because they recognized certain disadvantages and failed to see certain advantages 
associated with its use. Persons who had been in the habit of reducing compound 
equations to simple ones during school life, could see the importance of reducing 
a compound cavity to a simple one by the aid of a matrix. How did we manage 
difficult cases before the invention of the matrix? When there was a large com- 
pound cavity to be filled, we were obliged, when the tooth was filled with gold, to 
begin at the neck and come down to the cutting edge. As one wall was entirely 
missing, we had to be careful not to overstep the limits of the cavity. We had to be 
careful to fill the tooth absolutely, and to more than fill it, for fear that there would 
not be enough left after it was finished. Thus we either had an excess of gold, which 
had afterward to be dressed off, or else were required to have the skill and fine 
artistic taste of men like Marshall Webb. Few possessed that skill. He (Dr. Guil- 
ford) never pretended to it. Now, with the aid of a matrix forming a wall, we can 
fill the tooth easily and satisfactorily with the minimum amount of gold. In addition 
to that, we save our own and the patient's time, and in saving the patient's timê, we 
naturally save him suffering. All these were reasons why a matrix should be used. 
A matrix properly constructed should grasp the tooth firmly and be relatively immov- 
able, but not absolutely so, for a slight yielding under the pressure of the gold would 
be found to be of advantage. In the next place, it should describe the outline of the 
lost part of the tooth. When a matrix of this kind was properly adjusted, and the 
tooth filled in connection with it, all that was necessary, after the matrix was removed, 
was to dress off the slight surplus of the gold with delicate plug trimmers and strips 
of emery cloth. 
These were the advantages of the matrix. What were its disadvantages? There 
were very few urged against it. It was said that if an artificial wall were put around 
the cavity, the margins could not be reached and filled properly. Another objection 
was that the matrix often got out of place or became dislodged. Of course that 
depended on how the matrix was used. If it was properly constructed so that it 
would yield slightly, then the cavity not only describe the proper contour of SECTION XVIII-DENTAL AND ORAL SURGERY. 
489 
the tooth, but it would have a little excess. For that reason he thought that the 
stiff, solid matrix of Dr. J ack had partially gone out of use and the more flexible 
one had taken its place. A matrix should describe a circle or part of a circle around 
the tooth, just as a hoop surrounds a barrel. If a barrel was taken with the hoops 
on, and then a few staves removed, it would present a parallel case. The thin 
band of the matrix would, in the course of the impaction of the gold, yield slightly, 
because it possessed a certain amount of elasticity, not enough to affect the filling, 
but just enough to give a little surplus. 
At the close of the discussion on matrices, the Section adjourned for the day. 490 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THIRD DAY. 
The Section met at eleven o'clock A.M. A paper on "Phthisis Cured by the 
Continuous Application of Medicine to the Palate,'' by Dr. Pradére, of Lyons, 
France, was taken up, partially read and then by vote referred to the Section on the 
Practice of Medicine. 
The following paper on the subject of " Osteo-Myelitis ' ' was read by its author, 
Dr. J> von Metnitz, of Vienna, Austria. 
OSTEO-MYELITIS. 
OSTEO-MYELITIS. 
OSTÉO-MYÉLITE. 
DR. J. VON METNITZ, 
Wien, Oesterreich. 
Die Entzündungen des Knochenmarkes im Unterkiefer, welche für die intacte 
Erhaltung des Knochens, wie f ür das Leben des Patienten meist eine so grosse Gefahr 
in sich schliessen, kommen in unserer zahnärztlichen Praxis zum Glück recht selten 
vor. Häufiger jedoch hat man in den grossen Spitälern Gelegenheit, hin und wieder 
einen derartigen Process zu beobachten, der in vielen Fällen zur partiellen oder aus- 
gedehnten Necrose, in seltenen aber auch sogar zum Tode führt. 
Sei es, dass der Patient durch Ausserachtlassung der gewöhnlichsten Reinigungs- 
vorschriften die durch eine Extraction gesetzte Wunde vernachlässigt ; sei es, dass die 
Instrumente und die ungefüge Hand des Operateurs die Schuld tragen ; oder auch, 
dass, wie in einem zu beschreibenden Falle, die Entzündung des Knochenmarkes unbe- 
kannten oder schwer zu deutenden Ursprunges ist : niemals können wir uns bei Beob- 
achtung eines solchen Krankheitsverlaufes eines gewissen Eindruckes erwehren. 
I. Der eine Fall, den ich Ihnen, meine Herren, im Bilde zeige, 'ist ein ausgesprochener 
Casus von Osteo-Myelitis acuta suppurativa. Der Krankheitsverlauf gestaltete sich in 
Kürze folgendermaassen : Im October des Jahres 1886 wurden einer 43 Jahre alten 
Frau mehrere Zähne extrahirt. Einige Tage darauf erkrankte sie unter fortdauernden 
Schmerzen an Schüttelfrösten. Am fünften Tage traten Delirien, psychische Störungen 
und am siebenten Tage Bewusstlosigkeit ein. In diesem Zustande wurde sie in das 
Krankenhaus überbracht. Die Farbe der Haut zeigt einen leichten Stich in's Gelbe, 
ebenso die sichtbaren Schleimhäute, insbesondere aber die Sclera, die intensiv gelblich 
gefärbt ist. Die Kopfhaut ist bedeutend geschwellt, ebenso die linke Wangen-, Joch- 
bein- und Schläfengegend. Die Haut in diesen Partieen ist blass und glänzend gespannt. 
Beide Bulbi stark prominirend, die Conjunctiva deutlich gelb und stark chemotisch. 
Die Pupillen mittelweit, reactionslos. Aus dem Munde dringt ein entsetzlicher Fötor. 
Kieferklemme im höchsten Grade vorhanden. Die Drüsen der Submaxillargegend SECTION XVIII-DENTAL AND ORAL SURGERY. 
491 
geschwellt, die Nachbargebilde starr infiltrirt. Nackenstarre. Das Sensorium tief 
benommen. Delirien, Unruhe. Urinentleerungen und Defäcation unwillkührlich. 
Am folgenden Tage furibunde Delirien, Puls sehr beschleunigt. In einem comatösen 
Zustande tritt Nachts darauf Exitus letalis ein. 
Dazu braucht es aber immer sehr lange Zeit. Dass der Process an diesem Knochen 
lange gedauert, ersieht man aus der Dickenzunahme, der characteristischen Form der 
Spina ventosa. Der Sequester ist 50 mm. lang und besteht ausschliesslich aus spongiöser 
Knochensubstanz. Der Sectionsbefund weist auf, äusser der Osteo-Myelitis maxillæ 
inferioris cum necrose centrali, eine Osteo-Myelitis diaphyseos humeri cum necrose cen- 
tral! et ostitide incipiente epiphyseos ulnæ. 
Die directeste Todesursache war neben der allgemeinen Entkräftung und der hoch- 
gradigen septischen Infection in diesem wie in dem früheren Falle eine ausgedehnte 
eiterige Meningitis. 
Therapie.-In Fällen einer leichten Entzündung wird eine energische antiseptische 
Behandlung genügen. In den schweren Fällen wird man nach Billroth den Jauche- 
heerd in der Markhöhle des kranken Knochens möglichst rasch eröffnen. Der hierzu 
nöthige Eingriff ist jedenfalls ein schwerer. Die weitere Aufgabe besteht in der Ent- 
leerung des Eiters, in der Desinfection der Höhle, Drainage derselben und Application 
eines antiseptischen Verbandes. 
Bei der Section erscheinen nach Eröffnung des Schädeldaches die Meningen ver- 
dickt, getrübt und von zahlreichen dicht gefüllten Gefässen durchzogen, an der linken 
Hemisphäre von einer bedeutenden Eiterschichte bedeckt. Die rechte Hemisphäre 
zeigt gleichfalls deutliche Eiterdepöts längs der starrgefüllten Gefässe. Die Gehirn- 
substanz weich, stark durchfeuchtet, zahlreiche Ekchymosen darbietend. Die linke 
mittlere Temporalwindung ist in ihrer ganzen Ausdehnung gelblich sülzig erweicht. 
Die Gehirnbasis von einer besonders an der Sella turcica dicht angesammelten Eiter- 
schichte bedeckt, die sich an die Fissura orbitalis superior und an das Foramen opticum 
linkerseits verfolgen lässt. 
Die Untersuchung der Mundhöhle ergiebt links im Ober- und Unterkiefer je eine 
leere Alveole. Die erstere, dem Molaris I. entsprechende, ist von mässigen, hellrosa- 
farbigen Granulationen zum Theil ausgefüllt, und zeigt ihre Umgebung keine Spur 
einer entzündlichen Reaction. Anders im Unterkiefer. Die Schleimhaut in der 
Umgebung der mit fötidem Eiter erfüllten Alveole des III. Molaris ist missfarbig und 
lässt sich in Fetzen abziehen. Die Sonde stösst allenthalben auf rauhen Knochen. 
In vielen Fällen ist es möglich, den Abscess zu eröffnen, oder derselbe sucht sich 
selbst einen Ausweg. Es kommt zu mehr oder minder ausgebreiteten Necrosen. 
In anderen Fällen, wie im vorher beschriebenen, tödtet die Krankheit durch allge- 
meine septische Infection. 
II. In seltenen Fällen, wie in diesem zweiten, den ich in Natura wie im Bilde mir 
zu demonstriren gestatte, tritt dieselbe an mehreren Knochen zugleich als mWftjpZe 
Osteo-Myelitis auf. Der 17 Jahre alte Patient litt zur selben Zeit an einer Osteo-Myelitis 
des Oberarmes, einer beginnenden der Ulna, und hatte durch ein Jahr eine chronische 
Entzündung des Markes im linken Unterkiefer. Nach Billroth ist es nicht entschieden, 
ob die Krankheit auftritt in Folge einer an vielen Stellen zu gleicher Zeit einwirkenden 
Infection, oder durch Verschleppung des Giftes von einem primären Knochenheerde 
aus. Die Krankheit befällt fast ausschliesslich die Röhrenknochen jugendlicher Indi- 
viduen. Das Periost vereitert und wird der Knochen dadurch seiner ernährenden 
Gefässe beraubt. Derselbe stirbt ganz ab, oder es kommt zur Sequesterbildung. 
Gelenksaponeurose eiterig infiltrirt, stellenweise zerstört, jauchig, missfarbig. Das 
Kiefergelenk vereitert. Die Submaxillardrüsen sind stark vergrössert, in ihren cen- 
tralen Theilen gleichfalls eiterig infiltrirt. 492 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Der Unterkieferknochen ist links in seiner ganzen Ausdehnung, mit Ausnahme des 
Processus coronoïdes, bis gegen die Mittellinie vom Perioste entblösst. Bicuspidaten 
und Molares fehlen. Die Pars alveolaris ist demgemäss sehr geschwunden. Die leere 
Alveole des extrahirten III. Molaris ist ungefähr 6 mm. tief und communicirt direct durch 
weite Lücken mit dem Knochenmarkraume. Das Knochenmark selbst ist verfärbt, fettig 
degenerirt und zum Theil eiterig geschmolzen. 
Ohne Zweifel ist als Ursache dieser so heftigen Entzündung im Knochen die Ver- 
unreinigung und Vernachlässigung der durch die Extraction erzeugten Wunde anzu- 
sehen. 
Quer- und Längsschnitte durch macerirte Unterkiefer, von denen ich einen, der von 
Köpfchen zu Köpfchen durch den ganzen Knochen geht, vorlege, zeigen deutlich genug 
die Ausdehnung und Mächtigkeit des Knochenmarkraumes. Sei es, dass bei der 
Extraction es geschieht, dass die dünne Wand der Alveole fracturirt wird, wie es bei 
festsitzenden Zähnen im vorgerückten Alter so häufig vorkommt, sei es, dass die in 
einfacher Lage die Wurzel und Alveole überziehende Wurzelhaut entfernt wird: immer 
wird eine Communication der schwammigen Knochensubstanz mit der Aussenwelt 
geschaffen. Für die Gefährlichkeit der Entblössung der Alveole vom Perioste spricht 
die am gut macerirten Knochen sichtbare siebförmige Durchlöcherung des knöchernen 
Trichters. Die der Extraction folgende Blutung wirkt im mechanischen Sinne reinigend ; 
wir wissen aber, wie spärlich meist die Blutung bei solchen festsitzenden Zähnen 
eintritt. 
Es haben durch Versuche Kocher, Rosenbach, Busch und Andere nachgewiesen, dass 
man bei Thieren eine acute eiterige Osteo-Myelitis durch gar kein Trauma erzeugen 
kann, ob man auch den Knochen oder das blossgelegte Mark wie immer insultirt, 
chemisch oder mechanisch reizt,-dass aber dieselbe sofort entsteht, wenn man eine 
Infection der frischen Knochen wunde durch jauchige oder faulende Substanzen bewirkt. 
Nachdem durch die im Munde in reichlichster Menge vorkommenden Fäulniss- 
producte die Infection erfolgt ist, entwickelt sich zunächst ein acuter Eiterungsprocess, 
der in den schlimmsten Fällen zur Verjauchung des Markes führt. Besteht kein 
eigentlicher Abscess im Knochen, sondern eine eiterige Infiltration des Knochenmarkes, 
dann ist es zweifelhaft, ob selbst die Eröffnung der Markhöhle einen besonderen Vor- 
theil schaffen kann. Billroth räth von der Désarticulation oder Resection des eiterig 
infiltrirten Knochens ab, weil man nie genau die Ausdehnung des Processes zu beur- 
theilen vermag, und, zweitens, weil die Gefahr einer neuen eingreifenden Verletzung 
bei an acuter Osteo-Myelitis Leidenden immer sehr bedeutend ist. Es kann nach Bill- 
roth nur dann von einer Resection die Rede sein, wenn die Weichtheileiterung eine 
sehr grosse Ausdehnung erlangt hat und dabei das Gelenk vereitert ist. 
Was aber eine Kiefergelenkvereiterung durch die unmittelbare Nähe der Gehirnbasis 
für eine Gefahr für das Leben in sich schliesst, kann man aus den beschriebenen Fällen, 
in denen jedesmal eine fortgeleitete eiterige Meningitis den Tod bedingt hat, zur Genüge 
ersehen. SECTION XVIII-DENTAL AND ORAL SURGERY. 
493 
Fig. 1. 
Osteo-Myëlitis Acuta. 
Fig. 2. 
Osteo-Myëlitis Multiplex Chronica. 494 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Fig. 3. 
Ein durchschnittener Unterkiefer, die schwammige Substanz zeigend. 
DISCUSSION. 
Dr. M. L. Rhein, of New York, said that the paper just read was certainly a 
very interesting one. There was only one feature of it concerning which he wished 
to speak, that was in reference to the treatment mentioned. The paper mentioned 
the treatment of two classes of cases, one where there was a distinct abscess, the 
other where there was an infiltration, in the form generally known as caries, where 
the bone was infiltrated through a considerable course. The paper mentioned the 
advisability of not interfering with such cases, and the risk of interferences. He 
(Dr. Rhein) thought that these were the very cases where the free use of the bur 
directly on the infiltrated portion of bone would be productive of the most beneficial 
results. It was merely in reference to this one point that he wished to draw the 
attention of members. 
Dr. G. J. Friedrichs, of New Orleans, La., said that, so far as he could under- 
stand the paper just read, the treatment did not amount to anything, because the 
result was that at a certain time the patient died. He had no personal experience 
in such cases, but he had read about them, and he was sure that in these aggra- 
vated cases the only way of obtaining any result whatever in regard to cure was the 
excision of the lower maxilla. 
ART IN DENTISTRY. 
ART DANS LA CHIRURGIE DENTAIRE. 
DIE KUNST IN DER ZAHNHEILKUNDE. 
BY DR. M. G. JENNISON, 
Minneapolis, Minn. 
Art is a term that can hardly be restricted to any one branch or department of sci- 
ence, although it may be used in all. Taken in its broader sense, I should define it as 
perfected talent and a correct conception of principles in the case involved. Thus we 
might include almost any pursuit or vocation in life. In what would be classed as the 
fine arts, we have the more restricted list. In the former, a clear mechanical knowledge SECTION XVIII-DENTAL AND ORAL SURGERY. 
495 
and training is often all that is required ; in the latter, it must be this careful perfect 
training in connection with an active and acting brain, full of thought and originality. 
The Greeks gave us statuary that has remained as the ideal through the ages of the 
past. 
In painting, some of the Old Masters have never been excelled, especially in the 
portrayal of form. 
When looking at a beautiful canvas or statue, we are apt to consider only the pleasing 
effect, and not think of the years of study and labor requisite to produce the result. 
One of the greatest advances in fine art which has come during recent years is in 
operations on the human form itself, restoring injuries and deformities, partially or 
wholly to usefulness and beauty. In surgery we see it illustrated in the removal of 
diseased and the restoration of lost parts. Noses built up, ugly scars and sores obliter- 
ated, the blind made to see, and the lame to walk. 
In dentistry we have a wide and prolific field for the display of artistic talent, but, 
sorry to say, it is a field filled with dead attempts and lamentable failures. In the 
mouth we have that wonderful range and variety of expression that exist nowhere else. 
To preserve this in its natural and useful state comes within the scope of dentistry 
alone. 
Why do we see such a lack of a correct conception of what is requisite ? Probably 
one cause is that which underlies the but partial perfection in many lines of business, 
the wish to get something for nothing, to see the mighty dollar quick, the attempt to 
put up a structure with no suitable foundation. As some men in our ranks have hon- 
estly said of themselves, ' ' The money is what we are after, ' ' and, casting all con- 
scientious feelings aside, they make this their prime object in life. 
Again, there are many who have the wish to do what is right, but who have no sense 
of the correct or beautiful in their composition ; men who have drifted into the profes- 
sion because they thought it a respectable and easy way to make a living. A man must 
have some love for his work, as well as talent for it, or he will never rise to any height. 
Dental colleges and preceptors are probably responsible for part of this condition as 
it now exists. To them must we look for the greatest future improvement. In edu- 
cating the public lies another great work for those who are striving for improvement 
and progress. There are many who appreciate the best in dentistry, and there are many 
yet who think that all operations are of equal value, and that all high-priced men are 
impostors. 
Dentistry is usually considered in the two departments of operative and prosthetic, 
but in both, the opportunity for art or perfect conception of operations appears at every 
step. 
Stopping a cavity of decay should not always consist in that alone. The teeth should 
be restored, as far as possible, to usefulness and beauty. I should advocate contour in 
nearly every instance, although some of our brightest lights have opposed it. 
The tooth was constructed as it was for a definite purpose; if we cut away one or 
both sides, we destroy that purpose, losing cutting or masticating surfaces, and allow 
food to crowd in, making sore teeth and causing inflammation or recession of gums. A 
full restoration, leaving a free space near the gum margin, and the surfaces in contact 
near the cutting or grinding edge, will avoid this, and, jn my opinion, render the teeth 
less liable to decay than with separations (Figs. 1 and 2). 
We should also consider the serious results which may come from the loss of support 
furnished by contiguous surfaces of the teeth, which, if cut away, or entirely removed 
by injudicious extraction, may produce a change or injury to the articulation, and pos- 
sibly an entire change in the appearance or expression of the mouth. Dr. Davenport's 
paper, published in the Cosmos, covers this thought in a thorough and admirable 
manner. 496 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In the prosthetic branch probably comes the greatest opportunity for fine artistic 
operations, as in that the useful and ornamental are both so essential. In either we are 
not dealing with the teeth alone; the health and happiness of the patient are at stake; 
for who, with a mouthful of diseased teeth, and the usual vitiated secretions, or a 
crippled mouth with but few teeth remaining, can properly prepare the food to be taken 
into the system? What they can do is, to prepare the way for dyspepsia and the chain 
of troubles coming in connection with it. It has been truly said, that good teeth are 
the foundation of good health, but many persons are and probably always will be 
obliged to wear artificial substitutes, and with them we have to consider external beauty 
and internal utility. This branch of our profession should not be looked down upon, 
as it so often is, nor relegated to Cheap John offices or incompetent assistants. Let us 
give our patrons the best that can be made. One writer claims that prosthetic dentistry 
has made little or no advance for many years. If this is true, it is certainly time that 
we have concerted action to place this branch in the high position it deserves. The 
Figs. 1 and 2 
Showing Contour and Lack of it. 
introduction of cheap bases did much to throw us into a rut that I think we will get 
out of only by having more competent specialists in this work. 
Dentistry must come to specialties to grow and perfect itself. 
The first requisite in restoring an edentulous mouth is to make a careful study of the 
face, so as to restore as fully as possible, and in some cases, possibly, improve on, the 
original. To do this we should bear in mind an ideal head, the standard of which has 
been handed down through many ages, the head of the Apollo Belvidere. (Fig. 3.) 
I will quote from an essay of Dr. Kingsley's a description of a perfect face, or what 
we know as such :- 
' ' I presume that the general impression is that the eye is located in the upper part 
of the head. To one who has not carefully considered it the eye would very naturally 
be placed with about one-third of the head above it and two-thirds of the head and face 
below it; but I shall place it below the middle line, i.e., in the lower half of the head. 
The placing of the eye will serve to impress more thoroughly upon your minds the 
relative proportions of the features than any other method that can be adopted. Then 
we have added a nose, which you will observe occupies one entire space, or one-fifth of SECTION XVIII DENTAL AND ORAL SURGERY. 
497 
the head. By giving to the mouth and chin one-fourth, to the forehead one-fifth, and 
to the head, including the hair above the forehead, one-fourth, we have the outline of 
a physically well balanced head. 
"By a still closer analysis we perceive that the upper lip is short and slightly promi- 
Fig. 3. 
Showing Change of Expression, From Loss of Teeth. 
Showing Improvement by Artificial Substitutes. 
nent, in length from one-fourth to one-third that of the nose, the lower lip round and 
full, but distinctly separated from the chin by a marked depression. This depression 
must not be overlooked by us. It develops the chin. Fill out this depression, as is 
often done by artificial dentures, and one of the finest features of the face is destroyed ; 
Vol. V-32 498 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
but retain it when it is natural, or otherwise endeavor to produce it, and the beauty of 
the outline is correspondingly enhanced. 
" In the head of the Apollo Belvidere-the statue (as you well know) is that master- 
piece of Greek art which has been accepted as a standard of male beauty for hundreds 
of years-the object of the artist in the representation was to portray the highest type 
of physical rather than intellectual beauty, and the character of this god gave him 
abundant opportunity. The general line of forehead and nose, you will observe, is the 
same. In many of the Greek statues it is a single straight or nearly a straight line, 
from the tip of the nose to the tip of the forehead, and it is this line which forms the 
distinctive characteristic of the Grecian profile. 
"But the parts to which I call your special attention are the nose, mouth and chin. 
None of these features will admit of any material modification without detracting from 
their beauty. A variation ever so slight causes changes that are astonishing. A 
writer, by the name of Fuseli, said : 'Shorten the nose of Apollo by one-sixteenth of 
an inch and you destroy the god.' The necessity for a close study of each patient is 
so apparent that none should fail to see it, and study them in such a manner that their 
thoughts will be taken from what you are doing, and in this way observe the changes 
of expression. ' ' 
If we shorten the bite, fail to fill out the canine prominence, let the cheeks fall in 
and the corners of the mouth drop, we can produce a melancholy, dyspeptic expression, 
from one that could be almost ideal. 
Fig. 4. Fig. 5. 
Incorrect Outline. 
Correct Outline. 
A close scrutiny of the countenance reveals many peculiarities-variations in curve 
and height of eyebrows, eyes different in form and position, nose more or less curved, 
unequal distance between mouth and eyes, and a marked digression in the median 
line. In the play of the muscles around the mouth the changes are almost without 
limit. A point to be emphasized is to watch the mouth in repose and full action. A 
very pleasing result in the one might be almost a deformity in the other. As an 
illustration of the great lack of study and appreciation of requisite conditions, we need 
only to watch the hundreds of deformed faces that are to be seen almost every day. 
Very seldom do we see the depression by the wing of the nose restored to normal 
fullness : so frequent is this that I believe Dr. Haskell claims it is becoming almost 
characteristic in this country. Plates or dentures are much too frequently cut to a 
nearly straight line at the upper border, paying no regard to position or attachments 
of muscles further than to clear them all so it will not hurt, and paying much less 
attention to any external appearances. 
In the arrangement of teeth comes a great opportunity for disfiguring or beautifying 
the mouth. Many times the outline which is followed is a full curve, as seen in Fig. 
4. The result is, that in most cases the patients show all the porcelain in their pos- 
session every time they open their mouth. Change this more to the line of Fig. 5, 
raise the posterior teeth a trifle, vary the positions to a slight extent, and we have a 
closer copy of nature's intended pattern (Fig. 6). SECTION XVIII-DENTAL AND ORAL SURGERY. 
499 
A close observation of temperament, age and personal peculiarities is essential, not 
giving old age the rounded, cutting edge and white or light color of youth ; and, vice 
versa, not furnishing the fleshy, full-faced blonde with the narrow, bluish or translucent 
tooth of the nervous temperament. Avoid spacing or making perfectly regular the 
Fig. 6. 
Showing Outline and Arrangement of Dentures. 
substitutes in a narrow, contracted arch, where everything shows them to have been 
crowded and overlapped. In partial cases, not to insist on putting as many teeth into a 
space as came out of it, though the space may have lessened ; and so we might continue. 
In Fig. 7 we have shown a condition which, in all its variations, is annoying to a 
Fig. 7. 
Short Upper Lip and Prominent Process. 
great degree-a full or prominent process, and a short, tightly-drawn upper lip. Some 
operators advocate cutting away of this over-fullness of the process at the time of 
extraction of the teeth, and I think it might sometimes be justifiable. 
I would like to ask : Where would gum sections leave us with such patients ? 500 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
One great difficulty in carrying out any artistic conception is in the teeth supplied 
us by manufacturers. Those in sections, even when reasonably good in shape and color, 
are so restricted in adaptation that their nature is usually manifest at first sight. They 
will answer where the patient wants a " pretty set " and the dentist is willing to work 
somewhat according to rule. But there is little scope for freedom in construction, or 
originality in thought or arrangement ; the chief objection to the use of single teeth 
being the rather unsightly gums, in anything but that acme of prosthetic dentistry- 
continuous gum work. Where the gums are much displayed, this is an objection ; 
where they are not, it amounts to but little. 
Of the thousands of artificial teeth furnished us to select from, a large percentage 
are totally lacking in desirable color, expression and adaptability. 
With the elevation and advancement of this branch of dentistry will come a demand 
for- a closer imitation of nature in porcelain teeth, and that demand, we hope and 
believe, will be supplied. 
In the complete restoration of the natural organs to their full usefulness-and beauty, 
too-with present possibilities, and the restoration, by artificial substitutes, of the full 
power of expression, are some of the crowning glories of dentistry as an art. 
The following paper was read, after which the usual recess was taken. 
FORM AND EXPRESSION OF THE FACE. 
FORME ET EXPRESSION DU VISAGE. 
ÜBER FORM UND AUSDRUCK DES GESICHTES. 
BY DR. JOHN ALLEN, 
Of New York, N. Y. 
Although we can trace historical sketches of our profession to a period of more than 
two thousand years, which is shown by gold fillings which have been found in the teeth 
of mummies in the tombs of the ancient Egyptians, and also artificial teeth made of 
ivory or wood, some of which were fastened upon gold plates; and although artificial 
teeth are alluded to by some of the Greek and Latin poets, yet the works of Galen, 
which were written in the second century, contain the earliest treatise upon this subject, 
after which other works were published by Eustachius, Fallopius and Ambrose Pare. 
Those works appeared in the fourteenth, fifteenth and sixteenth centuries. During the 
present century the attention of medical men in France and England has been directed 
to the subject, and a number of elaborate works were published devoted exclusively to 
this specialty, and by far the greatest advances made in dental science have been devel- 
oped within the present century. It is within this period that dental colleges, dental 
journals and dental associations have been established, and also a degree of harmony 
and unanimity among our members which has tended to promote a greater interest in 
our profession. Hence, with these facilities combined, dental science now stands higher 
than at any former period ; and yet there is still a greater degree of perfection that 
should be attained, especially in the artificial department; and here we would suggest 
that the words " Mechanical Dentistry " should be substituted by those of " Artificial 
Dentistry." For we have no rule or scribe by which to be governed, as the mechanic SECTION XVIII-DENTAL AND ORAL SURGERY. 
501 
has. We have no two cases alike, consequently, we must supply the wants of mechan- 
ical rules with practical perception-to see what each case requires, and then employ 
cultivated, artistic skill to meet the requirements of each individual case. 
The special point to which I would call your attention at this time is the more 
perfect restoration of the natural form and expression of the mouth and face than that 
which we often see as the result of mechanical dentistry. There are very important 
points yet to be perfected in the construction of artificial dentures. You are aware 
that the loss of the natural teeth, and consequent absorption of the alveolar processes, 
cause a great change in the physiognomy of a person ; and in order to restore the 
original contour and expression of the face the highest degree of artistic skill is very 
essential-far more so in the living features than in the lifeless form upon canvass; for 
it is the countenance which is expressive of the quality of thought; whether joy, love, 
sorrow or gratitude, we can see it in the expression. The heart of a man changeth his 
countenance, whether for good or evil. " I do believe thee," said Shakespeare; " I saw 
his heart in his face." 
Now, as the face combines both physical and mental functions, we can see the great 
importance of restoring its natural form and expression. And in order to do this the 
dentist must note with care the change that may have taken place in the face of his 
patient, and then, by means of his own powers of conception, devise ways and means 
to meet the requirements of each individual case; for it is expression which raises 
affection which dwells pleasantly or painfully in the memory. When we look forward 
to the meeting with those we love, it is the illuminated face we hurry to meet. 
Now, in order to advance beyond our present standpoint in this respect, we should 
first acquire a thorough knowledge of that which is now known and rendered avail- 
able through the medium of books, colleges, associations, etc. And when these exter- 
nal resources shall have become exhausted, then direct the thoughts inwardly among 
the hidden recesses of the mind, with a view to discover still higher practical points than 
those acquired from other sources, as others have done, depending upon their own 
power of conception to accomplish their purpose. 
It was his individual efforts that enabled Herschel to extend his astronomical 
observations far beyond those of his predecessors, and bring to view other planets 
previously unknown to man. It was through the medium of his own mind that 
Rittenhouse first calculated eclipses. 
It was the individual efforts of Morse (aided, perhaps, by other suggestions com- 
paratively insignificant) that enabled him to develop the. principle in electricity by 
means of which ideas can now be transmitted with lightning speed from one distant 
point to another. 
It was by the strength of his own reasoning powers that Columbus discovered 
the American continent. 
These, and many other examples that may be given, show the wonderful power and 
capacity of the human mind to work out things which would appear to casual obser- 
vers as impossibilities. But the human mind is so constituted that it can work upon 
and within itself, and, by this means, important principles can be brought to light. 
This is the central thought that w'e wish to present with reference to individual efforts 
as a means of advancing dental science. 
"Man, know thyself," is an injunction applicable to each one of us. Our Creator 
has endowed us with mental faculties which we ought to understand, and we should 
study them assiduously, we should cultivate and strengthen them, that they may be 
relied upon when brought into requisition. 
It is said that "Every person has two educations, one which he receives from others, 
and one more important, which he gives to himself. " It is this self culture which 
should be relied upon more than any other, for advancement in our profession, for if 502 
NINTH INTERNATIONAL MEDICAL CONGRESS 
none go beyond where others have gone there will be no advance. It is the neck 
ahead that wins the race. 
This brings us to the consideration of original ideas, or those which may have been 
suggested to the mind by some external object or circumstance. In either case they 
should be fostered with care. 
Good ideas often perish for want of nourishment. In such cases, there has not been 
a sufficient amount of reflection bestowed upon them to mature the conception. In 
order to develop an idea it should be cultivated with patience ; it should be cared for, 
turned and re-turned in every direction, looked at in all its aspects, placed in its various 
relations, scrutinized in all its dimensions and proportions, then clothed with a body. 
After this is done, then test its merits, note the results, strengthen the weak points, 
devise means to overcome unforeseen difficulties. "Labor and wait" until sufficient 
time shall have elapsed to fully develop the principle involved. 
When an idea is first conceived it is usually vague and chaotic, a mere germ ; but 
by revolving it over and over again in the mind, it gradually unfolds like a thing of 
life, and we can then begin to see whether it possesses merits or practicability. If we 
can discover that it does, we should not let it flit away again, void as it came to us, but 
carefully nurture and cherish it, for it may develop a principle of great importance. 
You recollect when Franklin discovered the identity of lightning and electricity, it 
was sneered at, and people asked: " Of what use is it? " To which he replied: " What 
is the use of a child? It may grow to be a man." 
Give heed to these little silent messengers, called ideas, that come gently gliding 
into the mind, for they may prove to be of incalculable value. They may reveal 
important principles not to be found elsewhere. It was the silent whispering of ideas 
that revealed to Newton the principles of astronomy, to Archimedes the means of 
determining the distances between the different planets, and to Fulton how to propel 
the steamboat. 
It was an idea that enabled Whitney to make the cotton gin, and Jenner to prevent 
smallpox by vaccination. 
Thousands of instances may be given in every branch of science and art where indi- 
viduals, by their own efforts, have made valuable discoveries or improvements by simply 
carrying out their own practical ideas; true, in many instances they have been attended 
with great labor and expense ; for it is only the bare idea that first comes into the mind ; 
the minute details all have to be wrought out by those who conceive them, but the ends, 
when accomplished, have fully justified the means employed. 
The man who becomes the humble instrument for developing an important principle 
will often meet with difficulties and trials almost insurmountable; but by keeping his 
mind's eye steadily fixed upon the idea as his pole star, and gradually working his way 
onward by the light it reflects, he may have the pleasing satisfaction of seeing his efforts 
ultimately crowned with success. 
Newton, on being asked by what means he had worked out his extraordinary dis- 
coveries, replied: " By always thinking unto them." At another time he said: "I 
keep the subject continually before me, and wait until the first dawning opens slowly, 
little by little, into a full and clear light." In these few words he gives the key with 
which to unlock the citadel of the mind, and bring out hidden treasure that might 
otherwise have remained concealed. 
There are those who conceive good ideas, but their restless spirits will not permit 
them to wait patiently, and labor on perseveringly, until practical results are obtained, 
and they abandon them because of the slow progress of their development. Such men 
have not the patience and perseverance which is necessary to convert the mulberry leaf 
into satin. 
' ' There are those who have good ideas, but have not the gift of continuance. ' ' This SECTION XVIII-DENTAL AND ORAL SURGERY. 
503 
may be said of many who have strong powers of conception, but their working qualities 
are not well trained, and their ideas perish in darkness. " See, first, that the design is 
wise and just; that ascertained, pursue it resolutely. Do not, for one repulse, forego 
the purpose that you resolved to effect. ' ' 
Let each member of our profession apply these principles to himself, and put forth 
his own personal efforts, with a view of doing something that will tend to advance our 
cause. 
"It is not enough," said John Locke, "to cram ourselves with a great load of col- 
lections ; for unless we chew them over again, they will not give us strength and 
nourishment. ' ' 
That which is put into us by others is always far less ours than that which we 
acquire by our own diligent and persevering efforts. 
Knowledge conquered by labor becomes a property entirely our own and of great 
practical importance to those who possess it. 
In conclusion, let us ever cherish the fond recollection that our profession is sus- 
ceptible to advancement, and sure of flourishing when moistened with the dew of 
wisdom and warmed with the sun of science. 
The afternoon session of the Section was held in the National Theatre, on 
account of the facilities there offered for the use of the stereopticon. The follow- 
ing paper was read and illustrated by use of the stereopticon :- z 
THE ORIGIN OF THE DENTAL FIBRIL. 
ORIGINE DE LA FIBRILLE DENTAIRE. 
DER URSPRUNG DER ZAHNFIBRILLE. 
BY R. R. ANDREWS, D. D. S., 
Cambridge, Mass. 
Mr. President and Gentlemen :-The various processes of the development of 
the teeth, up to the formation of the dental follicle, are now known, and cannot be 
questioned. After the commencement of calcification and after the tissues have been 
decalcified, hardened, stained and clarified, there comes in a diversity of opinion among 
investigators. This is not strange when we consider the character of the reagents used, 
and how much the delicate tissues may have been changed by them, making it well 
nigh impossible to get at the exact structure of the minute details involved in the 
development of the dental fibril. 
My interpretations, arrived at after careful personal investigation, compel me to 
differ from the views expressed by late writers, and are offered as a contribution to 
what has already been written concerning this subject. When it shall be possible to 
work nearer the life of the tissue than we can at present, we may hope to arrive at 
more exact conclusions. 
The methods of the laboratories, although better than ever before, are still imper- 
fect. Tissues are decalcified in a solution of chromic acid, varying in strength from 
one-half of one per cent, to one per cent., and allowed to remain there from two to six 504 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
weeks, generally stained in mass, washed, placed in absolute alcohol, then in oil of 
cloves, and from that in very hot paraffine, where it remains until the tissue is thor- 
oughly permeated, so that when it is cooled in this enclosure, sections may be cut with- 
out a possible chance of moving. The instrument used for cutting these sections, is 
usually the Thoma microtome, and the sections are so cut that one pushes the next up 
to the blade of the knife and joins it, many sections forming a ribbon. These ribbons 
are cut and placed on the slide in serial order, the slide being prepared so that they 
will adhere to it. The paraffine is then dissolved, balsam added, and the cover glass 
placed over them. When dry they are ready for study. 
The method of clarifying with oil of clove, soaking in hot paraffine, or in absolute 
alcohol, is always a dangerous one, even for the coarser tissues, while for the delicate 
tissues involved in the development of the dental fibrils, it is fatal. They are so 
shrunken, shriveled and changed, that it is impossible to draw exact conclusions from 
them. 
Fig. 1, Specimen 17. 
A section of forming dentine showing the odontoblasts abrupt and square against it, and the pear-shaped 
fibril cells in this layer and just beyond it. Objective toiles 
The method of preparation of the tissue from which my photographs are made 
differs very considerably from the foregoing. I take the forming teeth from the jaws 
of embryos, at or nearly at the time of birth, while the tissue is still warm. These are 
placed in a quarter of one per cent, to one-half of one per cent, solution of chromic acid,, 
which is changed daily for three or four days. At the end of this time, the edges of 
the dentine that were calcified are found to be sufficiently softened to make a number 
of sections. The teeth are taken from the acid solution, washed in distilled water, and 
then placed in a solution of gum-arabic for several hours. They are then put in a 
solution of alcohol, to take out the water. Paraffine and lard are melted together and 
poured into a convenient mould. When the former is clouded in the process of cooling, 
the tissue, which has had its outer surface dried as much as possible 'with bibulous 
paper, is placed in it and allowed to cool. Sections are now cut from it. The micro- 
tome which I use has an advantage over others, the tissue and knife both being under 
fluid when the sections are cut, these sections float off in the fluid and remain there 
until used. I cut until the calcified tissue is reached. The method has cost me a SECTION XVIII-DENTAL AND ORAL SURGERY. 
505 
number of fine knives, for each cutting ruins an edge. But I have the satisfaction of 
working as near life as we can with our present knowledge. 
•After cutting the sections, they are placed in distilled water for a few minutes, to 
dissolve out the gum, and are then mounted in Markoe's glycerine jelly. The difference 
Fig. 2, Specimen 20. 
Section of forming dentine, odontoblasts and fibril cells. Objective toiles A- 
Fig. 3, Specimen 22. 
Section of forming dentine with odontoblasts square and abrupt against it ; a fibril cell and fibrils from 
the forming dentine. Objective toiles 7s • 
in the appearance of the tissue prepared by this method is marked. I seldom stain 
those tissues which are to be studied under the higher powers of the microscope. 
In the formation of the bones of the jaw, and of the cementum of the root, and in 
the formation of the dentine itself, there are two kinds of cells called into action. 506 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
This opinion, I am aware, differs from that of the recent authorities. The odonto- 
blasts and osteoblasts have a common duty to perform, which is the formation of the 
matrix, or basis substance only. In the forming cementum the osteoblast, sometimes 
called cementoblast, can be seen forming the cementum, and there is an absence of 
other kinds of cells than the osteoblasts until we reach the deeper portions. These 
osteoblasts, by losing their identity in the process of calcification, form the thinner 
layers of cementum found just below the neck of the tooth, and before becoming 
thoroughly identified with the already-formed cementum, show a part of their former 
contour. Other osteoblasts are supplied by the adjacent embryonic elements, and the 
process is continued until the thicker portion of the cementum is reached. Here we 
find a cell having a higher vital function called into action. It is the bone corpuscle, 
and is surrounded and enclosed by formed matrix, or by the matrix formers, the osteo- 
blasts. This corpuscle only partially calcifies, and remains as the contents of the lacunæ 
space, and its anastomosing canals. 
Fig. 4, Specimen 24. 
A. section of forming dentine showing the layer of odontoblasts; in the central portion of the picture 
they have been pulled away, leaving the fibrils clinging to the dentine. Objective 
Tomes, speaking of the formation of the bones of the jaw, says, " Dental Anatomy," 
p. 156, " as the osteoblasts calcify, they lose their individuality, and all traces of the 
great majority of them disappear. Some of them, however, retain their individuality 
as encapsuled lacunæ. " It will be seen he makes no distinction between these two 
kinds of cells, but there is a marked distinction. One has a higher vital function than 
the other-that is, the nourishment of the basis substance. While admitting that 
there are two forms of cells active in the formation of the jaw bone, he does not 
admit the same in the formation of the dentine, but says ' ' no one can speak of a 
young, active odontoblast as drawn out into the dental fibril. These cells are square 
and abrupt toward the dentine. They do not taper into the dentinal processes in the 
smallest degree." 
While these masses of protoplasm, the odontoblasts, are square and abrupt toward 
the dentine, it is a very easy matter to find among them, and just adjacent, large 
numbers of pear-shaped cells, drawn and tapering into the dental fibril. (Figs. 1, 2, 7, SECTION XVIII-DENTAL AND ORAL SURGERY. 
507 
and 8. ) These are the true fibril cells. The odontoblasts, having no membrane, which 
are square and abrupt against the dentine, are hardly more than granular masses of 
protoplasm when calcification is active. At this time there is hardly a trace of a 
Fig. 5, Specimen 30. 
A section of the pulp of a forming tooth with its layer of odontoblasts; above the centre of this layer 
is seen a fibril having its origin from the deeper layers of the pulp tissue; others can also be seen, 
but not so distinctly. Objective toiles A- 
Fig. 6, Specimen 31. 
A section of the pulp of a forming tooth with its layer of odontoblasts ; from the ends of these, which 
are square and abrupt, will be seen fibrils and the line of demarkation between the fibril and the 
odontoblast. Objective -fr. Hartnach water immersion. 
nucleus-the fibrils which appear to come from them, described by Tomes as pulp, 
lateral and dentine processes, originate really from the fibril-forming cell. They are 
forced into the edges of odontoblasts sometimes, by pressure, and seem to be a part of 508 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
them, but in fresh, thin sections, I have seen the so-called processes move in the sub- 
stance of the edge of the odontoblast by pressure on the cover glass, tracing them to 
a fibril cell beyond. These fibres cling to them after the process of granulation and 
calcification commences, and in the action of separating the cells these fibrils break, 
clinging to the odontoblast ; hence the lateral pulp and dentine processes of Tomes. 
It is a difficult thing to demonstrate these processes in cross-sections of the odontoblasts, 
but I am very certain I have seen them with a fine glass of high power. They appear 
as very delicate light spots in the substance between the odontoblasts, just within the 
edges of them. 
When the layer of odontoblasts is teazed away from the forming dentine, processes are 
seen pulled away from the tubes of the formed dentine, being apparently offshoots from 
the odontoblasts, but on careful examination there will always be found a line of de- 
markation between the process itself and the square end of the cell. (Fig. 6.) This line 
seems to be a slight layer of calcoglobin, and I have specimens which show these cells, 
Fig. 7, Specimen 37 
Section of forming dentine, fibril cells and odontoblasts. Objective toiles 
whose side masses of protoplasm have been pulled away, leaving a slight cross line of 
calcoglobin that was up against the forming dentine, and also a ragged continuation of 
the process running into the pulp tissue adjacent, with every appearance of having its 
origin there. In the early stages of calcification of the dentine it is not uncommon to 
see the fibrils dragging a portion of the soft, membraneless, protoplasmic mass of the 
odontoblast into the structure of the forming dentine. 
The fibril cell, having a higher functional purpose than the odontoblast, is found to 
be almost always pear-shaped, having a process-or processes-next toward the dentine, 
and sometimes having a smaller process running into the tissue of the pulp. These 
cells are found in the layer with the odontoblast, as well as in the pulp tissue adjacent 
-the fibril being either long or short, as the case may be. The fibril cell is never found 
to be abrupt and square against the forming dentine, although sometimes it has an 
appearance of that kind when there are two processes running into the dentine from a 
single cell, as are found in newly-forming dentine. These afterward join in one, and 
are branches of the parent fibril. They are frequently figured as odontoblasts by many SECTION XVIII-DENTAL AND ORAL SURGERY. 
509 
of the writers. They are the origin of the dental fibril, having the same functions as 
do the bone corpuscles in the formation of bone, namely, the nourishment of the basis 
substance or matrix. Lent, who was a pupil of Kölliker, figured the fibril cells, with 
their long processes, many years ago. These are mistaken by Tomes for aged and spent 
odontoblasts. Klein is the only author whom I can recall who admits there are two 
different kinds of cells called into play by the formation of dentine. He says: " From 
my observations I am led to assume that the superficial layer of cells yield only the 
dentinal matrix, while the dentinal fibres are derived from the processes of the cell of 
the deeper layer." Dr. C. H. Stowell, in The Microscope for September, 1886, pictures 
these two layers from specimens which he had himself made. His views in regard to 
these layers are the same as those described above by Klein. 
In the March number of The Microscope, 1887, Dr. Stowell retracts his former state- 
ment, and says he is convinced that the dental fibrils are the true processes from the 
odontoblasts. The whole article, refuting his former views, is hardly more than a 
paragraph. 
Fig. 8, Specimen 38. 
Section of forming dentine, fibrils, fibril cells and odontoblasts. Objective toiles T's 
When a tooth is fully formed, most of the writers picture the pear-shaped fibril cells 
as odontoblasts. We find them on the periphery of the mature pulp, surrounded by 
embryonic elements, and it is from these elements, and not from the pear-shaped fibril 
cells, that any addition to the walls of the pulp cavity is formed. Called into activity, 
these elements become the odontoblasts, or osteoblasts, in the same manner as do the 
embryonic elements in the substance of the pericementum, or periosteum, become 
osteoblasts, or cementoblasts, when exostosis, or hypertrophy of the parts, occurs. In 
all new growths against the déntine within the pulp cavity there are fewer fibrils than 
in normal dentine. They take a changed direction, and the new substance formed is 
more like bone. This is called osteodentine. 
Between the dental fibril and the formed dentine surrounding it there exists a thin 
layer of partially calcified tissue. This is a layer of calcoglobin, and is always found 
between the organic and inorganic tissue in the substance of bone, dentine or cementum. 
It is the earliest stage in the process of calcification, and is a part of the calcified tissue, 510 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
only differentiated after the action of acids, forming the so-called sheath of Neumann, 
in dentine, and the lining of the lacunae spaces in bone and cementum. 
The points I wish to specially note are these:- 
1. That the osteoblasts, the odontoblasts and the cementoblasts are analogous, their 
functions being simply the formation of the matrix or basis substance of their respective 
tissues. 
2. That the bone corpuscle, the dentine corpuscle, or fibril cell, and the cement 
corpuscle, with their anastomosing branches, have a higher vital function, that being 
the nourishment of the matrix or basis substance of their respective tissues. 
The photo-micrographs which are to be shown in my demonstration are actual repro- 
ductions of the tissue; no line has been added to carry out a theory. I can speak 
positively on this point; for I have done all of the work myself, including the selection 
and preparation of the tissue, the cutting and mounting of the specimens, the micro- 
photographing and re-photographing for making the lantern slides. 
Those of the specimens illustrating the origin of the dental fibril have been made 
with the higher powers of the microscope; they are very delicate, and have been very 
difficult to prepare and photograph, many of them necessitating numbers of negatives 
and positives before a perfect reproduction of the tissue was shown. In their prepara- 
tion I have devoted all the time I could spare from a busy winter and spring-and even 
the vacation season-that I might, in a manner, do justice to the honor conferred on me 
by our honorable President. They have been prepared especially for this Congress, to 
illustrate this paper. 
Let us now, if you please, consider the demonstration. 
[Forty-one photo-micrographs were shown, by means of the oxyhydrogen lantern. 
From these forty-one specimens eight have been selected by Dr. Andrews to illustrate 
the paper. The sections are all from the forming teeth of a calf at, or nearly at, the 
time of birth.] 
DISCUSSION. 
Dr. Frank Abbott, of New York, said :-Mr. President and Gentlemen 
-It is with no little degree of pleasure that I open the discussion upon this most 
admirable paper, to which we have had so much pleasure in listening. 
While I cannot, from my present knowledge of the growths and development of 
the teeth, coincide with the views advanced, I wish to take this occasion to publicly 
acknowledge the great debt the specialty of dental surgery owes Dr. Andrews for 
the immense work he has done and the time he has devoted to the interests of our 
education. 
In order to present the process by which the dental fibril is produced, as I under- 
stand it, it is necessary for us to consider the matter from the third to the fifth month 
of intra-uterine life, at which period of the existence of the fœtus the papilla of teeth 
are so far developed that a material change is observed to be taking place. The papilla 
is a mass of myxomatous connective tissue, liberally supplied with medullary elements. 
In some instances at three months, at others as late as the fifth month, of intra- 
uterine life a coalescing or uniting of several of the medullary corpuscles into one, 
may be observed upon the periphery of the papilla, adjacent to the enamel organ, 
which at this period may be observed forming a cap upon the papilla. The united 
medullary corpuscles are known as odontoblasts. The impression has generally 
prevailed among histologists and embryologists that the odontoblasts were directly 
formed into dentine ; in other words, that lime salts were deposited directly into the 
odontoblasts as such. This theory, through recent researches, has been proven to be 
incorrect. The odontoblast, when viewed with a low power, presents a granular SECTION XVIII-DENTAL AND ORAL SURGERY. 
511 
appearance; but if a power of from 1000 to 1200 diameters be used, a delicate 
reticulum is seen uniting the nuclei with the wall of each body, and the corpuscles 
with each other. This reticulum, as well as the walls of the odontoblasts, is living 
matter, which remains as the living portion of the dentine. Before the beginning 
of the deposition of lime salts, the odontoblasts are reconverted into medullary bodies. 
As such they receive the calcareous basis substance, and thus a certain territory of 
the papilla becomes dentine. While this process of calcification is going on, another 
row of odontoblasts makes its appearance, from the sides and ends of which prolon- 
gations of the living matter may be seen running into the canaliculi of the dentine 
already formed or in process of formation, a spindle or wedge-shaped odontoblast, 
giving off one, while in those with broad ends two, three, four and in some, even, as 
many as five prolongations may be seen. It will be observed from the above that 
the deposition of lime salts takes place around the lining matter or dental fibril and 
its branches. If the views advanced in the paper were correct, it would necessarily 
follow that territories of considerable size would be left in the dentine with no cana- 
liculi whatever, nor would there be any provision for furnishing these territories with 
living tissue. Lifeless territories, or those devoid of canaliculi, are not known to 
exist in dentine, that I am aware of. 
PROTECTIVE DENTINE, OR DENTINE OF REPAIR. 
DENTITION PROTECTRICE, OU DENTITION RÉPARATRICE. 
DAS PROTEKTIV-DENTIN, ODER DENTIN DER REPARATION. 
M. H. FLETCHER, D. D. S., M. D., 
Of Cincinnati, Ohio. 
Terminology.-In the terminology of the pathological growth of the teeth known as 
Secondary Dentine, or Dentine of Repair, the two terms are used synonymously. But 
since the term secondary dentine may be, and is, applied to a new growth of dentine, 
whether in or out of the pulp chamber, and whether conservative or otherwise, this 
usage has become conventional. But this seems hardly the most specific name to give 
to the particular new growth which we wish to present. The term dentine of repair 
is applied to that growth of dentine which the pulp throws out, or builds up, in order 
to protect itself from an external enemy. But since, in these cases, nothing is restored 
or repaired to a sound or good condition, as is done in restoring the contour of a decayed 
tooth, the word "repair" does not seem the most appropriate. The writer proposes 
for this form of growth the name Protective Dentine, as being best suited to the condi- 
tions attending this formation. This term should be used in the place of " Dentine 
of Repair," and should be confined strictly to that growth which is intended to, and 
does, protect the pulp from exposure produced by external agents, and the term Second- 
ary Dentine should include all varieties of new growths of dentine, whether in or out of 
the pulp chamber. This being, as it were, the specific name, and the other forms being 
varieties, the writer suggests, therefore, the following division, in order to simplify the 
classification:- 512 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Secondary dentine to include :- 
1. Protective dentine. 
2. General deposit of dentine within the pulp chamber. 
3. Dentinal tumors either within or without the pulp chamber. 
4. Pulp nodules of dentine. 
The unorganized calciferous deposits form another specific class. 
This growth of protective dentine is clearly for protection and is to be found in most 
of the herbivorous animals as well as in man, when their teeth are sufficiently worn to 
need it. 
This term may have been used formerly as above, but I have not yet met with it. 
Definition.-Protective dentine then is that form of new growth of the hard tissues 
of the teeth characterized by its appearance within the pulp chamber at a point where 
Fi«. 1. 
Vertical section of deciduous canine.-D, dentine; E, enamel ; P, pulp chamber; C, cavity of decay ; Pd, 
protective dentine. X 15. 
the pulp would have been exposed if the destructive process which excited the growth 
had been continued. (See Fig. 1.) 
Another characteristic which is common to this as well as other new growths of 
dentine, is its comparatively few and somewhat irregular dentinal tubes and a larger 
per cent, of globular masses or calciferous material than is normal. We also find 
between the irritated surface of the tooth and the surface of the pulp, a zone in which 
the dentinal tubes are greatly reduced in size by a deposit of lime salts in their walls, 
in consequence of which the matrix of the dentine is much greater in proportion than is 
normal. This gives it a dense, horny appearance and makes it quite translucent. The 
portion of dentine thus affected is called by Magitot the " Zone of Resistance." (See 
Fig. 2.) SECTION XVIII-DENTAL AND ORAL SURGERY. 
513 
Classification.-New growths of the pulp and pulp chamber are primarily of two 
classes: those which fasten themselves to the inner wall of the chamber, called adherent, 
and those which are found in the pulp itself, called unattached. Dr. Black classifies 
and defines them as follows :- 
1. Secondary dentine. A new growth of dentine more or less regular in forma- 
tion. 
2. Dentinal tumor within the pulp chamber. 
3. Nodular calcifications among, but not of, the tissues of the pulp. 
4. Interstitial calcification of the tissues of the pulp. 
5. Cylindrical calcifications of the pulp. 
6. Osteo-dentine. 
Fig. 2. 
Transverse section of lower first molar, just above neck of tooth, having had large amalgam filling on 
approximal and crown surfaces.-I), dentine ; Zr, zone of resistance ; St, small tumor ; T, peduncu- 
lated tumor almost filling pulp chamber; P, pulp chamber; B, where the tumor was broken from its 
seat of growth. X 15. 
This is the most comprehensive classification the writer has met with, and yet it 
does not give any definite character to that particular growth which is so prevalent as 
to be almost physiological and without which many teeth would become useless. 
Ætiology.-In the aetiology the chief cause seems to be the disturbance of the pulp 
through the dentinal fibrils, the irritant being at the peripheral ends. This irritation 
may be caused by anything which persistently disturbs the ends of the fibrils, such 
as caries, fillings, abrasions, clasps, etc. Garretson says: " Teeth subject to sources of 
local irritation are frequently-indeed, it is to be said-are commonly found responsive 
in the way of self-attempting deposits." He also says, "No substance introduced into 
a tooth seems to exert greater influence in the excitation of that action which produces 
secondary dentine than does oxychloride of zinc." And it is a practice highly thought 
of, and followed by many practitioners, to stimulate in every known way a deposit of 
Vol. V-33 NINTH INTERNATIONAL MEDICAL CONGRESS. 
514 
new dentine when a pulp is exposed or approximates an exposure. Some English 
amalgams are supposed to possess this stimulating property to a marked degree, and 
are used by many with that object in view. But from observation of final results this 
seems to be a pernicious practice. We have some specimens to present which illustrate 
this point. They show that not only protective dentine has been induced, but a gene- 
ral deposit of secondary dentine sufficient to reduce the chamber very greatly in size, 
with pulp nodules in addition, and that to the degree of the loss of the teeth. (See 
Figs. 2 and 3. ) 
Enough of such specimens can be presented to prove almost conclusively that any- 
thing which constantly irritates the distal ends of the dentinal fibrils-providing it is 
not too rapid and destructive in its progress-is likely to stimulate not only one but ail 
Fig. 3. 
Vertical section of lower first molar.-D, dentine ; P, pulp chamber ; F, amalgam filling In situ ; Pd, pro- 
tective dentine caused by irritation of filling; E, enamel. X 35. 
of those new growths and calcareous deposits mentioned. My own observations show 
that large amalgam fillings exert a greater influence in stimulating new growths than 
gold. Nevertheless, this stimulation seems to come largely from thermal changes con- 
veyed to the pulp through the metal. 
The influence, however, does not always stop with the particular tooth irritated, 
but may extend to any or all of the others. Dr. Black speaks of this effect and likens 
it to a certain disease of the eye, presumably sympathetic ophthalmia, in which case 
the offending organ is frequently enucleated in order to save the sight of the good one. 
If it were possible to arrest this new growth just when one would like, its intentional 
stimulation would be a most excellent procedure. But investigation seems to prove SECTION XVIII-DENTAL AND ORAL SURGERY. 
515 
that the final result is generally evil rather than good. However, it should be remem- 
bered that a growth of protective dentine in many cases (abrasion especially) extends 
the period of usefulness of the teeth to a marked degree. While this conservative 
process is most desirable up to a certain point in the human teeth, there is a point at 
which it should be arrested in order to still prolong their usefulness. 
Pathology.-In the pathology of this growth, we find on the surface of the tooth 
some lesion. As above mentioned, this may be anything which constantly irritates the 
distal ends of the dentinal fibrils. At an early stage of the lesion the zone of resist- 
ance can usually be found forming in that portion of the dentine lying between the 
lesion and the pulp adjacent. (See Fig. 2.) Within the chamber we find in apposi- 
tion to that portion of the pulp which comes in contact with those dentinal fibrils 
Fig. 4. 
'-'4 
Vertical section of a deciduous canine.-Pd 1 shows protective dentine from abrasion of crown marked 
A; C, cavities of decay; Pd, protective dentine caused by decay on approximai surface; P, pulp 
chamber ; D, dentine. X 15. 
whose ends are exposed to the irritant, a deposit of protective dentine. (See Figs. 1, 
2, 3 and 4. ) 
If the exciting cause is abrasion, that cornua of the pulp chamber nearest exposed 
is the first place of deposit. (See Fig. 4, Pd 1.) If the irritation is caused by filling, 
decay or erosion, the point at which the pulp is nearest the irritant is the first to show 
the new growth. 
In the beginning the growth is confined to those fibrils thus affected, but progresses 
in proportion to the lesion, up to a certain degree. If the irritation continues, the 
deposit becomes more and more general until the whole membrana eboris is excited to 
an abnormal amount of work, and the result is a narrowing down of the size of the pulp 
chamber from a general deposit of secondary dentine within the walls (see Figs. 5 and 6), 516 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
or as nodules, or as deposits of calcareous material, or, it maybe, all of these forms. In 
numbers of these cases the pulp dies, but whether as a consequence of simple com- 
pression or, as seems to me more probable, by reason of the occlusion of a large portion 
of the blood vessels owing to atheromatous and calcareous deposits in their walls, is 
not yet determined, but probably will be on further investigation. We have some 
examples of these narrowed pulp chambers to show. (See Fig. 5.) 
This substance, which is deposited for protection, is built much more rapidly than 
the normal tissue, and is inferior in quality. It has a much smaller percentage of tubes 
and a proportionally larger percentage of the matrix, which would make one expect to 
find it even harder than normal dentine. But it proves to be otherwise and wears 
away much more easily. The line between the normal tissue and the new growth is 
Fig. 5. 
Vertical section of same tooth as No. 6.-E, enamel ; D, dentine; Sd, secondary dentine ; P, remains of 
pulp chamber even with neck of the tooth, at which stage the pulp became exhausted and died. 
X 15. 
distinctly marked, as a result of the difference in their structure, which will be easily 
seen in most of the sections. 
The character of the tubes in the new growth is distinct. They are not so regular 
or so numerous, and, in fact, at times are quite irregular, and their courses are not so 
apt to be parallel to each other as in normal dentine. (See Fig. 7.) Many times they 
run at right angles with the normal tubes (see Fig. 5), and the new growth seen by 
transmitted light is quite translucent, as a result of the paucity of tubes. But as a 
section will show these points more plainly than they could be told, they, as well as 
other features of the pathology, will be left to be shown in the specimens. 
Diagnosis.-The diagnosis of this growth in cases of abrasion is usually very easy, 
for the new growth is distinctly seen as a bright yellow or clear spot (see Fig. 6), or in 
circles of brown, when the wearing away is sufficient to have encroached upon the SECTION XVIII-DENTAL AND ORAL SURGERY. 
517 
pulp chamber. However, the growth must have begun some time previous to its show- 
ing on the surface ; otherwise the pulp would have been exposed. It is not uncommon 
to find abraded teeth quite sensitive to the touch of steel or other hard substances. 
This sensitiveness probably arises from the dentinal tubes not having been sufficiently 
filled by the process which produces the zone of resistance, or it may come from the 
rapid work of the destructive agent, it being such that the pulp cannot build the pro- 
tection fast enough to shield itself entirely from the disturbing influence. Hence, when 
we find a tooth worn down into close proximity to the pulp, we maybe reasonably sure 
that there is a deposit of protective dentine going on in that tooth. The amount of 
wear may be determined by comparing the present length of the crown with what it 
originally was. Erosion may be judged in much the same manner as abrasion. If 
shallow, there is probably very little or no growth at all ; if deep, the deposit is apt to 
be in proportion to the extent of the erosion. 
Fig. 6. 
Transverse section of lower central incisor; one-half of crown worn away by abrasion.-D, dentine ; E, 
enamel ; Sd, secondary dentine entirely filling the pulp chamber with the exception of the small 
space at P. X 15- 
To diagnose in caries is much more difficult, since there is usually no pain attendant 
■with these growths so long as the pulp retains its full vitality; nor can the deposit be 
easily seen, as it can in abrasion. Besides, the decay is in many cases so rapid that 
the pulp has not sufficient time to make a deposit of any considerable amount before 
its surface is reached. Much can be determined, however, from the general appearance 
of the tooth in connection with other points. For instance, if the decay is dark and 
hard and almost stationary instead of rapid in its progress, and the patient is forty or 
over, new growths are most likely to be present, at least the protective growth, since 
at the age of forty they are most commonly found. Dr. Black says that he "occasion- 
ally finds them in those not yet past their teens." And Salter says, " dentine of repair 
sometimes occurs in temporary teeth." 518 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The writer has found it in a majority of deciduous teeth, when they have been 
retained up to or past their normal time and are much decayed or abraded. (See Figs. 
1 and 4.) But I have found no nodules or other new growths in connection with the 
protective dentine. It seems evident they would follow, however, if the life of the 
tooth was not destroyed by natural processes. An approach to the spontaneous arrest 
of decay is most frequently found in what are recognized as a good quality of teeth. 
Abrasion is also found in teeth of this kind, and it is in just such teeth that we may 
expect to find not only protective dentine, but many of the other forms of new 
growths. 
Prognosis.-In the prognosis of these cases we come to the practical part of our sub- 
ject. For if we can tell what will be the result of these growths, we are the better 
able to decide what to do in order to prevent evil results. From the foregoing (as has 
Fig. 7. 
Character of tubes in new growths of dentine ; field taken from specimen No. 5. X 175. 
been stated) it is evident that this building of protective dentine is a provision of nature 
for the express purpose of protecting the pulp from a recognized enemy; hence the 
names which have been given it: "Secondary Dentine," "Dentine of Repair," and 
" Protective Dentine. " In cases where musket balls have been shot into the pulp 
chamber of an elephant's tusk, they have become perfectly encapsuled with ivory-a 
specimen of which will be shown. From this, and the other specimens of protective 
growths, we may get some idea of what a tooth pulp will attempt to do if called upon 
for such work. The elephant's tusk is a tooth of persistent growth, and the formation 
of dentine goes on about the bullet until it is completely encased, and is carried out of 
the skull with the tusk as it proceeds in its growth. The formation of dentine is car- 
ried on by the same process in man as in other mammals. But the human tooth is of SECTION XVIII-DENTAL AND ORAL SURGERY. 
519 
limited growth, and if the process of forming more dentine within its chamber is con- 
tinued abnormally, it can only be done at the expense of the pulp, and this to its own 
peril. For it must be understood that this process of repair once established in a human 
tooth, appears in many cases to be attended by, or to result in, the death of the pulp. 
Whether this is a result of a purely local condition of the pulp chamber, or of a disease 
of the blood vessels, remains to be determined, as stated in a preceding portion of this 
paper. In many cases the pulp begins to be exhausted and show symptoms of death 
while there is yet considerable pulp chamber left (see Fig. 5), and it seems that there 
is, in all these cases, more or less of the chamber remaining unoccupied by the new 
growth, whether adherent or unattached. It has never been my experience to see a 
' ' complete dentification of the cavity of the pulp, " as is mentioned by Magi tot, Owens, 
and others. The writer is convinced that such a condition cannot exist, since the pulp 
must have room for its necessarily constituent parts in order to form any of its pro- 
ducts. The utmost limit of space to which pulp can be contracted and yet live, is 
large enough, when the pulp dies, to form a reservoir for putrid matter sufficient to 
cause an alveolar abscess, which is usual, providing the apical foramen of the tooth 
does not become occluded by the debris of the dead pulp. The amount of space thus 
remaining varies in different teeth and different persons. With this morbid condition 
of affairs at hand, we may have all the symptoms usually present with a dying or dead 
pulp. The writer is convinced that when pain accompanies new growths of the pulp 
chamber, it is not caused by their presence there, or by their pressure on the pulp from 
their size or quantity, but from the inflammation excited by the presence of a necrosed 
pulp. Hence, it seems safe to conclude that if means are not taken to stop the progress 
of these growths in their incipiency, evil will result in many cases, sooner or later. 
Treatment.-It is the mission of the profession not only to repair and replace broken- 
down tissues, but to institute prophylactic treatment when it is indicated. The treat- 
ment, then, in these cases, to prevent evil results, would be the removal of the exciting 
cause. If the cause be caries, plug the cavity in such a way that the filling is non- 
irritating. If it is abrasion or erosion, stop its progress with a gold capping. If a pulp 
has been exposed, it would seem a bad practice to lift more of the dentine and make 
the exposure larger in order that a substance may be applied, supposed to excite a new 
growth of dentine. If the pulp lived under these circumstances to deposit new material, 
it would do so only to protect itself from the work thus done. The rational treatment, 
then, in such a case would be the sterilizing of the softened dentine with a suitable 
germicide and the careful adjustment of a non-irritating cap to both pulp and dentine 
before filling. By adopting the above methods we would hope to avert destructive 
processes and not to excite dangerous new growths. 
DISCUSSION. 
Dr. W. Xavier Sudduth, of Philadelphia, said he had been much pleased by 
the exhibits of photo-micrographs, and especially with the last, because it appealed 
to the profession at large, most of whom had the materials for constructing specimens 
like those Dr. Fletcher had shown. The dentine, as all knew, was developed by the 
odontoblasts. They remained quiescent upon the surface of the pulp after the den- 
tine was developed, but they could be again stimulated into activity. Their office 
was to produce dentine, either physiological, as in the case of the first or normal 
dentine of the tooth, or pathological, such as was found in secondary dentine or 
dentine of repair. The most common causes of the production of secondary dentine 
were thermal changes, conveyed to the pulp by large metal fillings, or irritation pro- 
duced by abrasion. Whatever interfered with the normal condition of the tooth 520 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
would give, as a result, secondary dentine. If there was any point in the micro- 
scopical pathology of the teeth more unsettled than another in the mind of observers, 
it was the "zone of resistance." It had been made the subject of much investiga- 
tion, and no satisfactory conclusion had been reached. Dr. Miller had gone through 
a laborious line of experiments on the layer of dentine lying between the forming 
cavity and the pulp, and had found that there was no diminution, neither any 
increase, in the quantity of the lime salts in this much-discussed zone. Dr. Black 
claimed that he could clear it up with ether and more or less reproduce the normal 
color. There was evidently something in those tubuli which could be dissolved out 
by the action of ether. Dr. Black held that it was fatty material produced from the 
decayed dentinal fibres. Whether this was the true solution or not, the speaker did 
not know. In his own experiments, by soaking the specimens in essential oils, he could 
trace the permeation of the oils into the tubes. He had showed this work to Dr. 
Miller, who also considered the observation correct. If this was true, one thing was 
settled by it-the tubes were not filled up with lime salts, were not calcified. What 
had been said by the essayist regarding the capability of the pulp to deposit dentine 
might be objected to on fine technical grounds. The pulp did not deposit dentine. 
The formation of dentine was the work of the odontoblastic layer, which, while it 
might be said to be a part of the pulp, was not the pulp, but a specially endowed 
functionizing layer, and did not depend upon the pulp for its action other than the 
supply of salts of calcium conveyed to it by the vessels of the pulp. As long as the 
foramen was open and the vascular supply kept up, it might go on and entirely fill 
the chamber, except that portion occupied by itself. This was shown very nicely in 
the tusks of ivory, where only a trace was left to mark what had once been the pulp 
chamber. The speaker was much pleased to see the specimens of pathological ivory. 
It showed that others were becoming interested in the subject, and he was satisfied 
that something would come out of the research. He understood that Prof. Busch, 
of Berlin, had a paper to be read before the Section, on pathological ivory, and, 
furthermore, that he coincided with the speaker's views of inflammation in dentine 
and enamel. It was to Dr. Busch's collection that he had referred in his paper read 
before the First District Dental Society, on February 1st, 1887, and published in the 
Dental Cosmos for May of the same year. 
What Dr. Fletcher had said to-day, when exhibiting his beautiful preparations, 
fully coincided with the views then expressed ; and so far as he (Dr. Sudduth) was 
acquainted with the literature of the subject, the writers of the article on eburnitis, 
published in the Independent Practitioner, and to which his article above referred 
to was an answer, stood alone and uncorroborated in their views of inflammation in 
non-vascular tissues. He had given the subject a great deal of attention, and he did 
not find in the whole domain of pathology the least analogy to the process they 
described. Dentine was strictly non-vascular tissue, and derived its nourishment by 
osmosis. Other examples of non-vascular tissues were found in the cornua and in 
articular cartilage. It was well known that inflammation in these two tissues occurred 
by the formation of capillary vessels, which in the cornua occupied the lymph spaces. 
These spaces became dilated, and a vascular connection was made with the circula- 
tory system at large. Then, and not till then, did true inflammation set in. Now, 
the dentine being a calcified structure, dilatation of the tubuli was not possible ; 
consequently, the formation of a circulatory system previous to decalcification was an 
utter impossibility, and, as he had so many times set forth before the dental profession, 
and which had not been controverted, decalcification in the centre of formed dentine 
was not possible. He had hoped that the authors of the article above referred to SECTION XVIII-DENTAL AND ORAL SURGERY. 
521 
would have been here, and that there might have been an opportunity to further 
discuss the question. So far, they had not made the least attempt, in a scientific 
manner, to answer the arraignment of their theories by Drs. Black, Allen and the 
speaker, but had contented themselves with casting slurring remarks at those who 
had the temerity to oppose their views. Sarcasm was a Damascus blade that cut 
both ways, and it was barely possible that those who had taken it up might yet be 
mortally wounded. 
NOTES ON PHOTO-MICROGRAPHS OF THE DENTAL TISSUES AND 
OF THE DEVELOPMENT OF THE TEETH. 
REMARQUES SUR LES PHOTO-MICROGRAPHES DES TISSUS DENTAIRES ET 
DU DÉVELOPPEMENT DES DENTS. 
BEMERKUNGEN ÜBER PHOTOMIKROGRAPHIEEN DER ZAHNGEWEBE UND DER ENT- 
WICKELUNG DER ZÄHNE. 
BY J. HOWARD MUMMERY, M.R.C.S., L.D.S., 
London, England. 
The photographic fruits which I have the honor to submit to you to-day do net 
claim to rank among the highest branches of the interesting art of photo-micrography, 
but they are an attempt to illustrate a part of the anatomy of the mammalian tooth 
germ by means of photographs, which perhaps are not open to the same suspicion of 
misinterpretation of appearances to which drawings, however careful, are subject. 
The first shows the earliest condition of the human enamel organ, the involution of 
the stratum malpighi of the oral epithelium. 
The next in succession shows early germs, about the tenth and fifteenth week respect- 
ively, exhibiting the bell-glass or crescentic shape of the enamel organ at this stage, 
and the first appearance of the dentine germ rising from the submucous tissue of 
the jaw. 
No. 5, which is from a specimen lent to me by Mr. S. J. Hutchinson, of London, 
shows almost diagramatically the different parts of the tooth germ before the com- 
mencement of calcification. It exhibits the heaped-up cells of the oral epithelium 
forming the dental papilla, the involution of its deeper or malpighian layer to form the 
enamel organ, which is well seen, its ' ' stellate reticulum ' ' filling up the space between 
the outer and inner epithelium. The dentine germ is also seen with its blood vessels 
injected, and the involution for the permanent tooth springing from the neck of the 
enamel organ. 
No. 6 shows, under a high magnifying power, the cells of the stellate reticulum of 
the human enamel organ. 
No. 7, the "inner or columnar epithelium " of the enamel organ with its nucleated 
cells, and the rounded cells of the " stratum intermedium," communicating on one side 
with the cells of the "internal epithelium," and on the other with those of the " stel- 
late recticulum." 
Nos. 8 and 9 show tooth germs also from the human embryo. 
Nos. 10 and 11 show the several layers of the enamel or jaw on one side, and the 
odontoblasts on the other side of the forming enamel and dentine in the cat. 
No. 12 is a tooth germ from the cat under a low magnifying power, to show the 522 
NINTH INTERNATIONAL MEDICAL CONGRESS 
relations of the different portions of the dentine and enamel germs to the forming 
dental tissues. 
A few words as to the use of the iso-chromatic plate in these photographs may be 
desirable. 
It is well known that, owing to the difference in the chemical or actinic power of 
the rays in the different parts of the solar spectrum, some colors do not produce so 
much effect upon the photographic plate as others. 
Colors in the more chemically active portion of the spectrum, such as violet and 
blue, produce a very powerful effect upon the photographic film, while during the same 
exposure the reds and yellows may have shown little perceptible result. An ordinary 
photograph does not, in fact, give the true tone values of the different colors : while 
yellow and green come out in a photograph dark, in fact, nearly black, blue and violet, 
instead of appearing dark in tone, as they do to the eye, show as nearly white. It was 
found by Vogel, as long ago as 1873, that by treating collodion plates with certain dyes, 
they could be made much more sensitive to the yellow and green, and the same treat- 
ment has been, during the last few years, applied to gelatine plates; Ives, in America, 
and Dr. Elder, in Europe, having very fully developed the process; the dyes principally 
used now being eosine and erythrosine, which render a gelatine plate much more sensi- 
tive to yellow and green, and to a considerable extent diminishing the sensibility to 
blue and violet, although they are still over-sensitive to these latter colors, and require 
the interposition of a yellow screen when daylight is used. But when a yellow light 
is used, such as a lamp-light, photographing with the microscope, the blues and greens 
will come out dark without the intervention of a yellow screen, as is well shown in the 
photograph of the dental germ No. 5, which was stained and injected bright blue. 
For a yellow specimen, iso-chromatic plates are not necessaiy or desirable, as the 
yellow in a thin section, with proper exposure, will give the details with great dis- 
tinctness ; but when the preparations have a green, or blue, or violet stain, they are of 
great value, photographing details that would otherwise be lost. Specimens stained red 
are not helped much, in my experience, by the iso-chromatic plates I have used. 
I have employed in these photographs the plates prepared by Messrs. Edwards & 
Son, of London, in accordance with Tailfer & Clayton's patents. Great use has been 
made in Germany of this iso- or ortho-chromatic process, in the photographing of bac- 
teria, the most difficult branch of photo micrography. In 1886 Van Ammengen 
executed photographs of "comma bacilli" which had been stained with fuchsine 
and methyl violet, it having been necessary before to stain all preparations of bacteria 
brown for photographic purposes-a matter often of great difficulty. 
The apparatus employed was made for me by Messrs. Swift & Son, of London. 
It is a slight modification of a form of apparatus made by them and used by several 
microscopists, and serves its purpose excellently well. 
It consists of a firm base board, mounted on four legs. The microscope is clamped 
on to a turn-table attached to a mahogany sliding board, which traverses the base board 
by means of a slot. This turn-table also carries the lamp, and can be turned to one 
side, so that a full examination of the object can be made in the ordinary manner, with 
the same lighting that will be used in photographing it. 
When the lamp has been accurately centred, and the object brought into the field 
of the microscope, the eye-piece is removed and the turn-table swung back to a stop, 
which accurately centres it with the camera. 
The focusing is done by means of a milled wheel at the end of a brass rod, passing 
the length of the base board and acting, by pulleys, on the fine adjustment. The micro- 
scope, which was made for me by Messrs. Swift & Son, is on the pattern of the Ameri- 
can "Wale Microscope," which is eminently adapted for photographic work. It allows 
of complete concentric rotation of the stage, and can be clamped by means of a screw SECTION XVIII-DENTAL AND ORAL SURGERY. 
523 
in the stand, which fixes it firmly in the horizontal position. It is fitted with Swift's 
achromatic condenser. The camera, which will take any plate up to 12 x 10, is of 
mahogany, with an extending bellows front, to give greater range. 
The illumination used was that from a powerful flat-wick kerosene lamp, employing 
the edge of the flame for any objective higher than one inch. 
The ordinary ground glass screen of a camera is too coarse to enable one to focus a 
delicate object satisfactorily, and, in place of it, it is well to adopt the suggestion of 
Mr. W. H. Walmsley, who, in the United States, has done such excellent photographs 
with the microscope. He advises that a plate be exposed to a flash of daylight, and 
developed sufficiently to produce a general darkening of the film. It is then placed in 
a saturated solution of bichloride of mercury until the film is whitened, and thoroughly 
washed with water. The result is a very fine surface, which shows the image of the 
object with great distinctness. 
It should be placed in the camera in the position to be occupied by the sensitive 
plate, and both back and front of the plate carrier should be removed while focusing. 
This completed, the sensitive plate is substituted for the focusing glass, and the exposure 
given. 
In photographing such subjects as these of development, which are especially diffi- 
cult, from the thickness of many of the sections, it is necessary to pay great attention 
to the accurate centring of both condenser and lamp. The condenser should, in fact, 
be centred afresh for each objective used. 
Two methods of printing have been employed, both in the photographs of develop- 
ment and in those of the dental tissues also exhibited. One is the platinotype process, 
the essential feature of which is that the image is produced by a deposit of metallic 
platinum, which is so indestructible that it is probably the most permanent of all the 
direct photographic printing processes. 
The other prints are upon a silver paper having a gelatine surface, the Obernetter 
gelatino-citro-chloride paper. This is very well suited for fruits of microscopic objects, 
as it gives a very clear print, in which every detail in the negative is brought out. The 
polished surface is obtained by squeezing the gelatine surface on to glass when wet, and 
stripping it off when dry. 
The specimens from which most of the photographs were made are chiefly from 
preparations kindly lent me by Mr. Charles Tomes and Mr. S. J. Hutchinson, the diffi- 
culty of finding suitable sections for photography necessitating the examination of a 
number of specimens.* 
PHOTO-MICROGRAPHS ILLUSTRATING THE DEVELOPMENT OF THE DENTAL. TISSUES. 
(I) First condition of the dental germ in the human embryo. The involution of epithelium 
to form the enamel organ. Section stained violet. Embryo about seventh week. 
Photographed on an isochromatic plate. Printed on Obernetter gelatino-chloride paper. 
Magnified 450 diameters. 
(II) Early germ (about tenth week) from human foetus. Shows crescentic shape of enamel 
organ and first appearance of the dentine germ. Section stained red. Photographed on 
an isochromatic plate. Printed on Obernetter gelatino-citro-chloride paper. Magnified 
40 diameters. 
(Ill) Dental germ from human embryo (about fifteenth week). Showing involution of epithe- 
lium, dentine and enamel germs and involution for permanent tooth. Section stained red. 
Photographed on isochromatic plate. Printed on Obernetter paper. Magnified 35 diameters. 
* During the reading of Dr. Mummery's paper a large number of photo-micrographs were 
passed around in the audience for exhibition, five illustrations of which we insert. 524 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(IV) Vertical section of fœtal jaw and tongue, etc. Shows two temporary molar tooth germs. 
Section not stained. Photographed on ordinary gelatine plate. Printed on Obernetter 
paper. Magnified 30 diameters. 
(V) Germ of human milk molar. Showing- 
(1) Involution of the deeper layer (stratum malpighi) of the oral epithelium to 
form the enamel organ. 
(2) Enamel organ. 
(a) Outer layer of cells. 
( 5) Stellate reticulum. 
( c ) Inner layer of columnar cells. 
(3) Dentine germ with its vessels injected. 
(4) Involution from neck of enamel organ to form enamel organ of permanent 
tooth. 
Section stained and injected Prussian blue. Photographed on 10x8 isochromatic 
plate. Printed on Obernetter gelatino-chloride paper. Magnified 40 diameters. 
(Va) Print from the same negative in platinotype. 
(VI) Stellate reticulum of the human enamel organ. Stained violet. Photographed on iso- 
chromatic 10x8 plate. One-quarter inch objective and Abbé projection eye-piece. 
Magnified 800 diameters. 
(Via) Print from the same negative in platinotype. 
(VII) Human enamel organ. Showing- 
(1) Internal epithelium of enamel organ with columnar nucleated cells. 
(2) Stratum intermedium of rounded cells. 
(3) Stellate reticulum. 
Stained violet. Photographed on 10 x 8 isochromatic plate. One-quarter inch objective. 
Abbé projection eye-piece. Magnified 800 diameters. 
(VIII) Vertical section of jaw of human fœtus. Showing involution of epithelium and portions 
of two tooth germs. Stained red. Photographed on isochromatic plate. Magnified 
30 diameters. 
(IX) Vertical section, human embryo, milk molar. Showing dentine germ (injected) and the 
involution for the permanent tooth. Injected blue. Photographed on isochromatic 
plate. Magnified 40 diameters. 
(X) Dental germ in kitten. Showing forming dentine and enamel. All the components of 
the enamel organ are seen, viz. :- 
(a) External epithelium. 
(5) Stellate reticulum. 
(c) Stratum intermedium. 
(d) Internal epithelium, and a portion of the dentine pulp with the odontoblasts in 
situ. Stained violet. (Section rather thick.) Photographed on isochro- 
matic 10x8 plate. Magnified 270 diameters. 
(XI) Forming dentine and enamel in kitten. Showing same tissues as the last. Violet stain. 
Photographed on isochromatic plate. Magnified 175 diameters. 
(XII) Dental germ in kitten under a low magnifying power, to show relations of enamel organ 
and dentine germ to forming enamel and dentine. Stained violet. Photographed on 
isochromatic 10 x 8 plate. Printed in platinotype. Magnified 40 diameters. 
PHOTO-MICROGRAPHS OF DENTAL TISSUES. 
(1) Interglobular spaces in dentine, x 550. Photographed with one-quarter inch objective 
and Abbé projection eye-piece. Printed on Obernetter gelatino-citro-chloride papeh 
(2) Interglobular spaces in dentine, x 500. Photographed with one-quarter inch objective 
and Abbé projection eye-piece. Printed in platinotype. 
(3) Interglobular spaces in dentine. One-quarter inch objective, no eye-piece, x 250. Ober- 
netter paper print. 
(4) Section of dentine and enamel showing defective enamel and interglobular spaces. One- 
half inch objective, no eye-piece, x 8$. Obernetter paper print. Fig. I. 
'"Dental Germ in Human Embryo. X 450. 
Fig. V. 
Germ of Human Milk Molar. X 40. 
Fig. VI. 
Stellate Reticulum of Human Enamel Organ. X 800. 
525 526 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Fia. XII. 
Dental Germ in Kitten. X 40. 
Fia. (6). 
Lacunæ and Canaliculi from Section of a Molar. X 750. SECTION XVIII-DENTAL AND ORAL SURGERY. 
527 
(5) Lacunæ and canaliculi, from section of a molar exhibiting very vascular cementum. One- 
quarter inch objective. Abbé projection eye-piece, x 450. Printed on Obernetter paper. 
(6) Another portion of same specimen, x 750. 
(7) Teeth and jaw bone of eel. Showing enamel tips, x 40. Printed on Obernetter paper. 
(8) Hinged teeth of the pike, x 40. Printed on Obernetter paper. 
(9) Transverse section of the poison fang of a rattlesnake (Crotalus). Stained violet. Isochro- 
matic plate, x 80. 
(10) Transverse section of teeth of rattlesnake. Showing teeth in various stages before and 
after the formation of the poison canal by the meeting of the cornua of the dentine. 
Printed in platinotype. x 30. 
DISCUSSION. 
After the reading of the papers and their description, discussion upon them was 
opened, the President (Dr. Taft) stating that he regarded the presentations which 
the members of the Section had just witnessed as one of the richest treats that has 
ever been given. 
Dr. W. H. Atkinson, of New York, said, I fully accord with the sentiment 
just expressed by our President, as far as the excellencies of the presentations are 
concerned, but if we are to utilize the laborious work which preceded these presenta- 
tions, we must go a little deeper than any of the presentments themselves indicated 
to superficial observation. The thing which is to be regretted above all others, 
respecting histological research and microscopical investigation, is the lack of liber- 
ality of sentiment in one worker toward another. If we could forget that the indi- 
vidual who first pronounces any doctrine is no more entitled to credit for penetration 
of observation than many others, we would have swept a deal of mischief away from 
the field of our labor. It takes a vast amount of research to entitle any one to an 
opinion respecting generalization. But generalizations must be had, to enable us to 
understand any of the special presentments of organization that come within the 
purview of our science. I speak feelingly on this point. I am but just fledged in 
one sense, and in another sense I am "in the down," not fledged at all. But I 
remember with such keenness of wounded feelings the manner in which I was treated 
when I was a student, that I want to make it clear to you all that you had better 
have respect for the "day of small things," and listen to the suggestions of your 
youngest pupil and of your most obscure investigator, rather than to sneer him away 
and hurt his feelings, and, may be, quench a life that was sent from above to illumi- 
nate us and lead us in the way of appreciating the truth. I studied for divinity, and 
therefore you will excuse me if I touch a little on those moral principles which are 
the measure of the man always. Give me the measure of a man's moral character, 
and I will give you the measure of his intellectual ability and his size every time. 
If we do not understand how tissues are built up in the first place, under the 
demand of whatever it is that builds the type, we will be very poor judges of how 
they are taken down. 
Now I am delighted with the exhibits which we have had, and I would be glad 
if I could bring every one, mentally and affectionately, to the same point of view 
that I stand on myself with regard to the excellence of these presentments, about 
which there has been such a difference of interpretation. We have had the alterna- 
tions in the generations of microscopic life-the fungi, the moss forms, and all the 
facts in the field of algæ and the lower forms of life. I wish I could obliterate that 
word ' ' life ' ' from our discussions, because it is the great stumbling block before us. 528 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
We see how the organism is first built. Take the incubation of a common hen's egg, 
and what is the first important phase you see? They are called blood islands. They 
go through all the metamorphoses that you have heard of here to-day, of square- 
shaped cells and pear-shaped cells, and are ultimately ripened into the differential 
characters of the tissue which is to perform the various functions of the human body. 
The first that you see is, as I have said, the blood islands. You will then find 
these blood islands from one to many of them. If it is to be a unicavital heart, only 
one of them will persist ; for bicavital, two ; tricavital, three ; and in a quadro- 
cavital heart four will persist, which is the mammalian heart. They are there in all 
their preformative stages, without defined walls. They are simply blood tracts, with- 
out provable limit of vessel. Just so we have it in micrology ; just so we have it in 
the early stages of the differentiations of the various tissues of the human tooth, and 
we had better not try to deal so much with causes and ask ' ' why, ' ' but ask ' ' how, 
and then simply tell how it appears to us, without pronouncing it as a finality. Then 
we will work together and see eye to eye, and be a help to each other, instead of 
trying to see who shall be transcendent and who shall put the other to shame. I 
have known many excellent men very deficient in this regard. When they supposed 
they had got hold of a truth in histology, they pronounced it warmly, and when 
somebody else supposed that he had hold of a truth antagonistic to the other, he 
pronounced it so. And why were these two truths antagonistic? Simply because 
those who discovered them compared things as equal which were, in fact, unequal. 
They compared things as being in the same line of alternations of generations which 
were not in the same line, but were in succession one to the other. This is what we 
want to get at. Then we can see how we have these pear-shaped heads to tubes 
that are said to be organized into dentinal fibrils. Then we can see the line through 
which nutriment goes. Whatever it is that does nourish, it is a power which we 
have not quite agreed about sufficiently for us to accept it as the same thing. Is it 
the line of resistance? the clear space? the dentine? We have tried to get that 
affirmatively, and yet we have not had humility enough to go slow and hold satis- 
factorily each successive step. Melting the lime salts is that which produces the 
disappearance of the zone of resistance, and "don't you forget it.'' When it comes 
to be recalcified, it is brought back to the embryonic condition. It becomes one 
continuous lump, and there are no tubuli in it. You see that that is looking toward 
the "why" and the "how." But as to cause, let us go very carefully when we talk 
about aetiology and all those things that have been like an incubus on men in all 
branches of science. Would to God we could get rid of fallacies and know that when 
we are in the recipient condition, the very air is full of righteousness, and that the 
truth will be revealed to us step by step until we shall become masters in Israel in our 
teaching men how to avoid the evil of bad teeth. 
Dr. W. X. Sudduth had a few words to say regarding Dr. Andrews' paper. 
Protoplasm left alone had a tendency to assume the spheroidal form. The form of 
cells in tissue was largely due to the lateral pressure of fellow cells-variation in form 
in the same class of cells was due to this influence-as seen in the case in hand ; the 
embryonic cells were compressed, and hence the variation in shape. In this instance 
form had nothing to do with function. The ameloblasts were also a good example. 
By compression they became hexagonal instead of spheroidal. Dr. Andrews laid 
stress on the form of the cell as determining its function, with which idea he (Dr. 
Sudduth) disagreed. He wished to bear his tribute to the illustrations which Dr. 
Andrews had presented. They were, without qualification, the finest line of photo- 
micrographs he had ever seen. The fibrils of the odontoblasts were shown most SECTION XVIII-DENTAL AND ORAL SURGERY. 
529 
elegantly ; that was his idea of demonstrating tissues, and, as he had just remarked 
to Dr. Abbott, if Dr. Heitzmann could demonstrate his reticulum, why did he not 
allow Dr. Andrews to photograph some of his slides instead of drawing them ? No 
one doubted his ability as a draughtsman, but many doubted his capability to inter- 
pret what he saw under the microscope. By photographing he could do away with 
the personal equation and vindicate his position. If all observers could look through 
the same tube at the same specimens, with eyes of equal quality, the probabilities 
were that this variation would not exist. The camera did this and gave the results 
shown. As to the interpretation of the specimens shown by Dr. Andrews, every 
one who saw them to-day had as much right to draw his conclusions from them as 
had Dr. Andrews. They had seen them as well as he, and had really seen them 
better than he did in his laboratory, for the photo-micrographs showed many fine 
lines not seen under the microscope. The speaker thought it a mistake to make a 
differential diagnosis as to function on account of differences in shape, as it did not 
make any material difference what the shape was, the function remained the same. 
The nearer the specimens to the living tissue, the better the work of the micro- 
scopist. He believed he had gone one step further than Dr. Andrews in studying 
the odontoblasts. Osmic acid, one-half per cent, solution, preserved the cells the 
best of any reagent used by the speaker. If a freshly-extracted tooth was put in 
equal parts of a one per cent, solution of osmic acid and alcohol for half an hour, then 
placed in alcohol for twenty-four hours, and then broken and the pulp extracted, it 
would be found that the odontoblasts had not altered greatly in form or size. Some 
of them would be found spindle-shaped, some square, while still others would be 
dumb-bell shaped, and all with fibrils projecting from the side next to the dentine. 
By this method of preparation it could be seen that the fibrils varied in number 
from one to as many as five or six, and that they extended from the body of the cell 
itself. Some of Dr. Andrews' specimens showed this very prettily, and one of them 
showed the form which had been pictured by Tomes, in which there were the double 
layers of the odontoblasts and the fibrils lying side by side and projecting into the 
dentine. The variation in the size and form of the odontoblasts in the developing 
tooth and the mature tooth was due to the fact that the odontoblasts in the devel- 
oping tooth were functionizing while those in the mature tooth were quiescent, and 
odontoblasts decreased in size when their function was completed. 
At the close of the discussion, the Section adjourned until the following day. 
Vol. V-34 530 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FOURTH DAY. 
The Section met at 11 A.M., in the Universalist Church, corner of Thirteenth and 
L streets. 
THE INFLAMMATORY PROCESSES IN THE ORAL TISSUES. 
PROCÉDÉ INFLAMMATOIRES DANS LES TISSUS ORAUX. 
DIE ENTZÜNDLICHEN VORGÄNGE IN DEN MUNDGEWEBEN. 
BY L. C. INGERSOLL, D. D. S., 
Of Iowa. 
Pathology is one of the culminating points of progressive science in the nineteenth 
century. This is responsive to the just claim of humanity, for pathology touches the 
sources of human suffering and the possibilities of relief. 
Physiology binds the human organism into a complete and harmonious whole under 
the operation of what we term physiological laws, which tend progressively toward the 
development of a higher and more perfect organism. 
Each individual organism has an environment not a part of itself, and not wholly 
in harmonious relations to itself, which tends constantly to disturb its harmony, to 
hinder, obstruct and cause deviations from the course of physiological law. These devia- 
tions accomplished, present physiology under abnormal conditions, and in negative 
aspects. 
Deviations from physiological law cause a reversion of the progressive tendencies 
and an introduction of retrogressive tendencies. Thus we find the vital organism drawn 
by dual forces in opposite directions. 
We find a like exhibition of opposing forces in non-vitalized matter-cohesion and 
disintegration-attraction and repulsion. Electricity is both an attractive and a repel- 
lant force ; called in the one case positive electricity, and in the other negative 
electricity. 
Viewed abstractly, we have also a positive and a negative physiology. When 
removed from its purely scientific aspects, and viewed in its relations to human experi- 
ence, we call the devious and abnormal ways of negative physiology, pathology. Hence, 
pathology has been defined to be " the science of deviations." 
As a science it has certain primal and germinal ideas. These are not derived from 
books and from the technicalities of scientific research, but from the expressive lan- 
guage of human experience when the individual cries out I have pain, soreness, aching, 
heat, burning, inflammation, swelling, hardened flesh, suppuration, and finally, to include 
all, he says, I suffer. Hence, the origin of our word pathology-derived from two Greek 
words, pathos and logos, the science of suffering. This literal signification, however, 
does not cover all the meaning included in modern days, in the science of pathology . 
for it takes cognizance of all abnormal conditions, whether attended with pain or not. SECTION XVIII-DENTAL AND ORAL SURGERY. 
531 
Of the many words, both common and technical, used to express pathological con- 
ditions, there is one which in its fully developed meaning is so comprehensive, and 
defines at once a pronounced feature of so large a number of diseased conditions and 
processes, that I have chosen it in preference to all others in naming the general sub- 
ject of this paper-Inflammation. But to make it more pertinent to the Dental and 
Oral Section of this Congress, I shall confine my discussion of the subject to the oral 
tissues, with special application to dental practice. 
I probably could not have introduced a subject concerning which there is a greater 
variety of opinions and a greater confusion of ideas. This arises in great part from the 
want of an accepted definition of terms. What one calls inflammation, another, with 
equal confidence, calls congestion. One fastens his attention upon the first well-marked 
feature and calls it inflammation, while another would call it hyperæmia and deny that 
it is inflammation. One will fix his attention upon a more advanced stage of disease 
and name that inflammation. Another will project his thought forward to final results, 
and so fix his attention there that, to his mind, results shall seem to furnish almost the 
only features worthy to be named inflammation. 
The subject expands into a great sea, and around the different views have been gath- 
ered the materials which form so many islands of thought that I can scarce expect to find 
clear sailing, nor to harmonize all views with my own. If I am able to make clear to 
your minds my own thought on the subject, with a fair correspondence to observed 
facts, I shall be quite content. 
There is no one word that can name the subject. Agnew says "Inflammation is a 
concrete term, designed to express the totality of several distinct processes, and, there' 
fore, incapable of being defined by a single word." The subject is not one that can be 
treated in any abstract or synthetical way as a simple condition. A part is said to be 
little or much inflamed, implying a difference simply in degree, as we might say of 
heat, there is little or much heat. But to know anything of the nature of heat we 
must know something of the changes produced in a heated body. We must know 
something of the precincts of combustion, the transformation of substances by heat, the 
expansion and liquefaction of metals, the reduction of wood to gas, carbon and alkaline 
earth. Hence, we are called upon to observe a series of changes which are the direct 
results of heat. 
I shall treat of inflammation not as a simple condition, but as a series of changes of 
function and substance-a series of progressive changes in diseased tissue, each of which 
is the direct result of the conditions preceding; and shall trace the course of inflamma- 
tion from its starting-point-irritation-to the total destruction of tissue observed in 
death and decomposition. 
One writer speaks of inflammation as a "retrograde process; " by which is meant a 
reversion of the wheels of nature, a turning back of nature by some perverted function 
to tear down what she had before built up, a disorganizing process by which tissue 
returns, to the elementary state. But this does not define inflammation. The writer 
simply substitutes other words to indicate the unexplained process. What we desire to 
know is the process by which the retrogression is produced. 
Stricker defines inflammation to be a manifestation of two features : (1) "an active 
hyperæmia, and (2) an active tissue metamorphosis." 
Under the first he includes all the commonly observed features of inflammation as 
enumerated by pathologists since the days of Celsus, such as redness, heat, swelling, 
pain, hardness and impaired function. Under the second he includes all other mani- 
festations not included under the first. 
The term metamorphosis is a technical word. All change of tissue is not a metamor- 
phosis, and it may well be questioned whether that process of inflammation by which 
there is a complete destruction and disorganization of tissue can, in any proper sense, 532 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
be called a "metamorphosis of tissue ; " for metamorphosis of tissue means a change 
of one kind of tissue into another and different kind of tissue. 
Again, Stricker characterizes inflammation as "areturn of tissue to its embryonic 
state." I cannot conceive how that portion of tissue which is in a disorganizing and 
decomposing state can be considered in an "embryonic state." True, embryonic pro- 
cesses are instituted for the work of repair in the very midst of the wasting elements 
of the tissue undergoing change. If this be the meaning of Prof. Stricker, I have no 
objection to his characterization. 
What is now known of the once hidden processes, and the exact nature of the 
changes which result from progressive inflammation, has been ascertained within the 
last thirty years, and chiefly through the researches and experimental methods of inves- 
tigation introduced by Stricker, Cohnheim, Norris and Sanderson. 
The definition of inflammation which may serve best to harmonize all theories, and 
will serve best my purpose in this discussion, is that given by Dr. Burdon Sanderson. 
He says: " It is simply the aggregate of those results which manifest themselves in an 
injured part;" or, as Agnew has it: "The totality of several distinct processes." 
Inflammation is known as such wherever its characteristics are found. Congestion 
is congestion wherever its attendant conditions are manifest. 
Dental pathology, therefore, does not differ from general pathology, except in those 
modifications of disease which result from peculiarities of structure. 
I shall make no special reference to wounds and acts of violence as producing causes 
of diseased action. 
The progress of inflammation, from whatever cause, depends upon the susceptibility 
of the tissues involved to the impression of an irritant or injury. If there come upon 
the body, into the body, or into any tissue of the body, any foreign element or influ- 
ence, however slight, to disturb the perfect harmony with which the functions are 
performed, that foreign touch, element or influence is an irritant, and the effect pro- 
duced is- 
IRRITATION. 
This is the first of the series of changes to be noticed in this paper as constituting 
the inflammatory processes. 
Au irritant may be of such a nature as to affect an area of no definable dimensions, 
even a single point-that minutest point or particle of protoplasmic matter called a 
cell-or it may affect simultaneously the entire cell life of a tissue. 
Fig. 1. 
DIAGRAMATIC VIEW OF THE PROGRESS OF INFLAMMATION. 
Distinction should be made between irritation and excitation. All the organs and 
functions of the body are brought into normal action by excitants or stimuli. Light 
is the normal stimulus to the organ of vision; food to the salivary glands and to the 
stomach. Any abnormal stimulus becomes an irritant-abnormal either in kind or 
quantity. Light too intense irritates the eye. Food in excess brings the stomach into 
a state of irritation. 
Gentle friction promotes healthful action of the skin, but if too rapid and continu- SECTION XVIII-DENTAL AND ORAL SURGERY. 
533 
ous it irritates. The irritated portion is redder than before. The capillary vessels are 
thrown into excitement, and, by a series of contractions and elongations of the cell 
elements composing the capillary tubes, a vascular action is excited similar to the peri- 
staltic action of the intestines, and the blood is forced forward with greater rapidity. The 
elongation of the capillary cells causes a corresponding lengthening of the vessels them- 
selves, which is exhibited by their more tortuous course. This exposes to view a large 
amount of blood in the same area and accounts for the increased redness. In quick 
succession an increased rapidity of blood-flow may be noticed in the arteries and veins. 
The accelerated current and rapidity of the vascular changes induces increased warmth 
in the part. A brief continuance of this disturbed condition of the vessels terminates 
in their permanent dilatation. If, however, the irritation be removed prior to this 
permanent dilatation, the vascular excitation ceases; the increased redness gradually 
fades into the normal color, the normal warmth is restored, and the quickened flow of 
blood subsides ; thus nothing results from the irritation more than a momentary vascu- 
lar excitement. 
Should the irritation be continued and the dilatation of the vessels become perma- 
nent, there is a noticeable change of condition. This change marks the introduction 
of the second stage of the inflammatory processes. Now come forward the doctors to 
name it. One says it is the stage of hyperæmia; another, the stage of fluxion; another 
calls it congestion; another, determination; another says that congestion and hyper- 
æmia are the same; another calls it inflammation; the patient and all the common 
people call it inflammation. 
INFLAMMATION. 
To avoid confusion, it must be borne in mind that this word is used in both a popu- 
lar and a technical sense. In the technical sense it includes the preceding stage and 
all the succeeding stages ; for there is no stage of the inflammatory processes that does 
not manifest some of the characteristics of the second stage. 
Again, for the purpose of diagnosis and study, inflammation is divided into two 
separate stages, acute and chronic. When disease arises suddenly and passes rapidly 
through the several changes from irritation to suppuration ; or, if it terminates suddenly 
by resolution in the midst of the changes, it is called acute. If inflammation lingers, 
subsides, and again becomes active, but gives the disappointment of frequent subsi- 
dences, it is called chronic. 
I have chosen the word inflammation to designate the second stage of the inflam- 
matory processes, for two reasons:- 
1. In spite of the good authority for using some other word, it is most commonly 
called by the word which I have chosen, and is the first distinctively marked exhibi- 
tion of the inflammatory processes. 
2. For the reason that growing out of the manifestations of this second stage there 
are so many peculiar and distinct manifestations of inflammatory action in the devel- 
opment of new kinds of tissue or in the breaking down of old tissue. (See diagram.) 
Acute inflammation begins with the permanent dilatation of the blood vessels. 
Pathologists are accustomed to characterize acute inflammation as a condition of intense 
pain. But how often do dentists find that a tooth pulp has passed through all the inflam- 
matory processes to suppuration and death of the organ without severe pain being expe- 
rienced. The presence of the symptom pain depends upon a variety of idiosyncrasies 
and constitutional diatheses, and is controlled much by the tendencies either toward 
congestion or toward a chronic condition. The same may be true of inflammation of 
the peridental membrane. We may say, therefore, that acute inflammation is char- 
acterized by slight pain, increasing in severity, slight swelling, a sense of fullness, 
pressure and weight. If it tends toward congestion, the pain will be greatly increased 
and often be attended with great nervous excitement. If the tendency is toward 534 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
chronic inflammation, the acute sensations will lessen in intensity, with frequent decep- 
tive intermissions of pain. 
There is more uncertainty concerning this second stage of the inflammatory pro- 
cesses than concerning any other in the series. 
What particular modification of diseased action will result from continued irritation 
and the introduction of the inflammatory processes, will depend not only upon consti- 
tutional diatheses, but upon the nature of the impairment of the tissue, the severity of 
the injury, and upon a variety of accidental circumstances, the relations of which we 
may not be able to trace. An injury may be so severe that congestion will immediately 
supervene. If the irritation or the injury be slight without increasing severity, and there 
be no controlling constitutional diatheses, the tendency is simply toward the chronic 
and to the hypertrophied condition, which involves no metamorphosis of tissue. If 
the irritation be more severe and constant, changing from sharp thrusts to intermissions 
of pain, the tendency is toward induration, with gnawing and worrying pain, and 
involves a metamorphosis of tissue. 
The condition of the blood may also determine the line of progress of inflammatory 
action. In many cases we cannot tell the cause or causes that have operated to direct 
the course of inflammation. Reference can only be made to that nice adjustment and 
equilibrium of function which may be disturbed by causes so slight as not to be mani- 
fest by any known diagnostic signs. They are like the grains of sand on the top of the 
Rocky Mountains which determine the course of the falling rain drop, whether it shall 
mingle with the waters of the Columbia river or with those of the Missouri. A mere 
breath of air, a change in the thickness of the soles of shoes, may be cause sufficient to 
give direction to inflammation of a tooth pulp or of the tissue of the gums toward 
chronicity, hypertrophy, induration, or congestion and suppuration. Motion and rest, 
the erect and recumbent posture of the body, heat and cold, each and every varying 
outward condition brings with it the possibility of some pathological change. 
This is not so noticeably true of chronic inflammation. This condition is more 
fixed. The constant recognition of pain is one of the most cognizable symptoms of 
acute inflammation. On the other hand, one of the chief characteristics of chronic 
inflammation is its freedom from pain. Hence, we may carry about in our bodies for 
months, or even years, dangerous forms of disease, with only an occasional appearance 
of marked symptoms. Acute disease usually compels attention, excites alarm and 
makes demand for doctor or dentist. With the chronic form of disease comes a relaxa- 
tion of physical pain and mental disquietude, and doctor and dentist are put far off as 
readily as an evil day. 
Take, for example, the exposure of a tooth pulp which taxes the power of human 
endurance to suffer pain. A breath of air, contact with water or a particle of food, is 
sufficient to excite the most excruciating pain. But by continuance and the use of 
palliating remedies the functions of the pulp gradually undergo adjustment to the expo- 
sure and necessary surroundings. Neither the contact of air nor food disturb it as 
before. The functions of the pulp have been trained into a new habitude. They will 
now tolerate what was intolerable in the acute form of the disease. Under these cir- 
cumstances the patient is induced to believe that the pulp is dead. The same manifes- 
tations of suffering and of tolerance appear in the acute and chronic disease of the peri- 
dental membrane. 
Chronic disease is, therefore, a condition brought about by time, nature's gentle 
palliative. By simple continuance the functions are enabled to adjust themselves to the 
abnormal surroundings, to take on a new habitude, and they no longer report the true 
condition. Chronicity of disease brings about the pleasing hallucination of fancying 
yourself well when you are sick. 
We naturally expect and look for congestion to follow acute inflammation, and it SECTION XVIII-DENTAL AND ORAL SURGERY. 
535 
very often does. The worst evil lies in that direction, for it is the short, quick route to 
local or to general death-to the death of the tissue involved, and possibly to the 
destruction of the life of the body. Hence, for the disease to take the chronic form is 
to lengthen the road to death, and afford a partial relief, although far from cure. The 
chronic condition may be considered to be an off-the-main-line track along which there 
are several stop-over stations. 
The first of these stop-over stations which I will mention is- 
HYPERTROPHY. 
Hypertrophy is the result of chronic inflammation. Irritation brings on capillary 
hyperæmia. Through the capillaries the tissues are fed. In the hyperæmic condition 
more blood is supplied than is needed for the normal support and development of the 
tissue. Here now is presented a functional problem to be solved-What shall be done 
with this over-supply of blood ? Instead of expelling it from the tissues by some forcible 
eviction, it is utilized in the production of more than the ordinary and needed amount 
of tissue. It is a case of over-production, such as sometimes happens in the commercial 
world. Hypertrophy is, therefore, an excessive growth of normal tissue by normal func- 
tions in a state of chronic irritation. 
The growth and enlargement of tissue is of the same sort as the surrounding normal 
tissue. The enlargement of tissue in case of an hypertrophied gum is not an ordinary 
Fig. 2. 
A, Hypertrophy ; b, b, Tumefaction. 
swelling of the gum from over-fullness of the blood vessels, but it is a new growth by a 
multiplication of the cell elements composing the tissue. Not the gum alone, but also 
the peridentium and cementum are subject to hypertrophy. Distinction should, how- 
ever, be made between pathological and physiological hypertrophies. The former is 
the result of irritation ; the latter the result of normal excitation, and is an increase of 
tissue by healthful functional use. In the same sense we have exhibited pathological 
hyperæmia and physiological hyperæmia. 
In my reference to hypertrophy of the cementum I do not include that development 
of cementum properly called excementosis, but only the physiological development. 
TUMEFACTION. 
All kinds of bodily tissues, both hard and soft (the enamel only excepted), are sub- 
ject to tumefactions ; and the oral cavity is a fruitful field for their development. 
It is not my purpose to " write up " and name the different orders of tumors, but to 
show the characteristics of tumorous tissue in general, and the inflammatory process 
involved in its development. 
Like most abnormal growths and enlargements it is one of the products of inflamma- 
tion. All have some features in common. From this fact has arisen some confusion 
in their classification. A tumefaction differs from hypertrophy of tissue, both physi- 
cally and functionally, while in some features they agree. Both are enlargements of 536 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tissue, and both are dependent upon an active hyperæmia for their development, but 
their physical differences are very marked. In case of hypertrophy it is impossible to 
observe where the new growth begins, because the hypertrophied tissue is of the same 
kind as the surrounding tissue. In case of tumefaction there is a distinct elevation of 
the tumefied tissue above the surrounding tissue. It is different in color from the sur- 
rounding tissue, and different also in texture, having in some cases an excessive rough- 
ness or an excessive smoothness ; and again an excessive hardness or an excessive 
softness. 
Besides the physical differences which I have mentioned as at once perceptible to the 
senses, there are functional differences not so readily discernible. The different defini- 
tions which have been given of a tumefaction, by writers on this subject, are at once 
confusing and instructive. 
Dunglison defines a tumor to be "A rising of greater or less size developed by a 
morbific cause. ' ' 
Boyer says, a tumor is ' 'Any preternatural eminence developed on any part of the 
body. ' ' 
Paget : "Tumors are formed of new materials infiltrated and growing in the inter- 
stices of natural parts." 
Virchow : "A tumor, however parasitic it may appear to be, is always a part of the 
body from which it springs. ' ' 
Green says, ' ' Tumors are new formations which in their development and growth 
are characterized by their independence of the rest of the body; they increase in size by 
virtue of their own inherent activity, which differs from, and is to a great extent inde- 
pendent of, the surrounding tissue. ' ' 
From the foregoing definitions we may arrive at the following conclusions : that 
tumors are not of a parasitic character-something coming from without and attaching 
themselves to the body to gain sustenance by thieving ; that, however foreign to the 
human body they may appear to be, they are not wholly foreign, they have something 
in common with the part to -which they are attached ; that they are nourished by the 
same nutritive system as the surrounding tissue, but have an organism differing from 
the surrounding tissue, an organism in which all the life functions are perverted, and 
new functions developed which are foreign to other parts of the body. 
In view of the characteristics just stated, I have formulated the following definition: 
A tumor is an excrescence rising out of normal tissue as a result of chronic inflamma- 
tion and the development and exercise of abnormal functions, and is characterized in 
its development and growth by its independence of surrounding tissue. 
Its pathology becomes now apparent. The excessive amount of blood brought to 
the inflamed part is utilized in the production of new tissues, not, however, as in 
hypertrophy, of the same kind as the surrounding tissue, but, by a perversion of func- 
tion, a new kind of tissue is produced, wholly unlike the surrounding tissue. The 
former is the product of normal functions abnormally excited; the latter is the product 
of abnormal functions working according to their inherent tendencies, to the develop- 
ment of abnormal tissue. This is one of the metamorphoses of tissue covered by 
Stricker's definition of inflammation-a metamorphosis of both function and structure. 
The favorite sites of tumors in the mouth, which are brought specially to the notice 
of dentists, are the apical portions of the gum in the interspaces of the dental arch ; the 
gum surrounding the rough and sharp edges of decayed and broken teeth; the gum 
between bicuspids and molars, where there is in the proximal walls large extent of 
decay; around such teeth as are made to support artificial teeth by clasps or bands; in 
the integument of the lips and cheeks at the line of union with the gum, when irri- 
tated by badly-adjusted artificial teeth, and on the exposed pulps of teeth. In each of 
these cases the tumefaction presents a seeded or cauliflower appearance. They bleed SECTION XVIII-DENTAL AND ORAL SURGERY. 
537 
freely on the slightest touch, although not peculiarly sensitive to touch. Their waste 
products have a very disagreeable odor. 
The most common of the tumors of the mouth are the epuZis tumor, originating in 
the periosteum of the alveolar ridge; cystic tumors, originating in the mucous mem- 
brane; also the epithelioma proper, and vascular tumors, springing from some bloodvessel 
supplying the tissues, and tumors of the dental pulp. 
Each has some peculiarities characteristic of the tissue from which it springs. A 
tumefaction of the dental pulp presents several interesting features: first, its painless 
character, as compared with the organ in its early exposure and when in acute inflam- 
mation. In changing to the chronic condition, and developing an abnormal growth, it 
Fig. 3. 
Tumefied Pulp. 
changes its habitude as regards sensation; again, the enormous size of the tumor, as 
compared with the organ upon which it is developed-the tumor being, in some cases, 
three or four times the size of the normal pulp, and not only filling a crown cavity of 
the largest extent, but projecting over the borders in cauliflower-like lobes. 
INDURATION. 
This is another of the stop-over stations which chronicity establishes along the line 
of progressive inflammation; it is known as a circumscribed swelling and hardening of 
a soft tissue, sometimes presenting to the touch a hardness almost equal to bone under- 
lying the gum. 
It is a condition of chronic inflammation, in which all the functions of the diseased 
part are morbid and inactive. The circulation becomes impeded, exuded lymph 
becomes coagulated in the interstices of the tissue, the excessive amount of blood is 
utilized in producing a kind of cell plethora by their morbid feeding, the individual 
cells become enlarged and fibrillated; all these conditions contribute to produce the 
hardness of the tissue. 
Observe, now, that this is a case of tissue enlargement wholly unlike either of the 
two enlargements before mentioned. Hypertrophy is an enlargement by cell prolifera- 
tion, thus multiplying the number of normal tissue elements and producing an excess 
of normal tissue. Tumefaction is the production of abnormal cells with perverted 
functions and excited activity, which utilize the superabundance of blood in an abnor- 
mal growth. Induration is an enlargement of tissue, not by a multiplication of cells, 
but by an enlargement of individual cells and the accumulation of exudates. 
There is no limit to the continuance of either one of the three abnormal formations 
if the producing cause continues unchanged. But the possibility of change is one of 
the laws of the organism. Should the irritation greatly increase, the chronic form of 
the inflammatory action might change to the acute, and with the change the morbific 
functions become normal and resolution supervene. Or the acute disease may again 
become chronic and the abnormal formations be repeated. Or from acute inflamma- 538 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tion-to which, hy retrograde processes, the tissue returns-it may pass into conges- 
tion, and hasten, by a quick process, into suppuration. This is one of Nature's methods 
of ridding the organism of tumefactions: the tissue breaks down by the suppurative 
process. In the same manner, hypertrophy may be changed to congestion, and ulcerar- 
tion cause a wasting of the gums or a wasting of an indurated tissue. To produce this 
condition artificially is one of the most successful means of curing induration. 
CONGESTION. 
I have chosen to make this one of the distinct and distinguishing features of the 
inflammatory processes, because it presents so many features not before manifest, and 
presents, in an exaggerated form, so many of the inflammatory features before men- 
tioned. It is the alarming feature of inflammation. It is alarming because it is next 
door to destruction. The chances of resolution are well-nigh lost. Congestion is hyper- 
æmia, and more too. Hyperæmia means a dilatation of the blood vessels, a quickened, 
active current. But congestion means a lessened vascular activity and an accumulation 
of blood in a part. The differences will be seen more plainly as I proceed to show the 
pathology of congestion. 
The permanent dilatation of the blood vessels which is found in the second stage 
is a result of weakening of vascular action, and is evidence of the impaired function 
of the vessels themselves. The unusual blood-flow continuing, the capillary vessels are, 
at length, unable to pass the full amount of blood supplied through the arteries over 
into the veins; hence the retardation of the current and the accumulation of blood. In 
the effort to pass, large numbers of corpuscles are massed together in the vessels, and 
to such an extent in some of the capillaries as to arrest the flow of blood. 
Blood stasis is, therefore, the first of the histological characteristics which mark 
congestion; not that the stasis is complete, for were this true, gangrene would appear 
at once. Rebound of the current of blood because of the stasis, causes a back-flow to 
the nearest anastomosing vessels and the establishment of circumferential currents. 
Because of the stasis and the rebound of the current of blood, the pain becomes throb- 
bing in its character. This kind of pain is not experienced in the second stage of the 
inflammatory series. 
The following may, therefore, be named as the pathological characteristics of con- 
gestion: inflammatory stasis, increased swelling and hardness of the tissue, a severe 
throbbing pain, a reduction of nutrition and weakened vascular tissue. Intense throb- 
bing pain is a peculiarity manifest chiefly in congestion of the dental pulp, and of the 
peridental membrane. 
SUPPURATION. 
The subject of pus formation has elicited more discussion than any other of the 
inflammatory series. It embraces an inquiry into the nature and the sources of pus. 
The area of its exhibition has been made the battle ground of the giants in pathological 
histology. 
The importance of the subject is estimated by its relations to life and death. In pus 
formation is centred the "last chance " of the life forces to gain the victory over the 
destructive forces of inflammatory disease. Suppuration is one of the processes of 
death. It is dying particle by particle. It is molecular death. 
As commonly observed pus seems to be simply dead, waste matter thrown off from 
a diseased part. It is not a definite compound. It is not uniformly composed of the 
same elements. 
Whatever its apparent character, it should never be considered to be wholly dead, 
waste matter, incapable of being reorganized into the tissues. It is in some sense 
living matter still. SECTION XVIII-DENTAL AND ORAL SURGERY. 
539 
All the tissues of the body, hard and soft, in their elementary state, are in a fluid 
or a semi-fluid condition, with some of their elements living, active and migratory. 
This is the embryonic state of the tissues. Pus partakes of some of the same charac- 
teristics, that is, it has embryonic characteristics. 
It is found to be composed of embryonic cells, blood corpuscles, the of 
blood cells, blood serum, microorganisms, and the débris of the tissue involved in the 
inflammation. Whence and by what process came these elements to be thus inter- 
mingled is a pathological problem. 
Attention was first called specially to this subject in 1855, by Virchow. 
He maintained that the active inflammatory process which immediately preceded 
the formation of pus induced a rapid prolification of cells in the connective tissue, 
which, becoming detached from the parent cells, wandered into surrounding parts and 
became what are known as pus cells or pus corpuscles. 
Thereafter Virchow's theory came to be known as "the suppurative theory of 
inflammation. ' ' 
In 1867, both Cohnheim and Norris discovered that the pus corpuscles resembled 
the white blood corpuscles-the leucocytes. 
They therefore concluded that pus corpuscles were emigrants from the blood. To 
demonstrate this new theory, Prof. Cohnheim introduced coloring matter into the blood 
in the immediate neighborhood of a suppurating wound, and found that the color pig- 
ment attached itself to the protoplasmic matter of the leucocytes, and thus was carried 
out through the walls of the blood vessels into the surrounding tissue to mingle with 
the other elements of the forming pus ; thus identifying them as the pus corpuscles, 
the very same, too, that received pigmentation in the blood vessels. 
Prof. Stricker, of Vienna, denied the validity of the demonstration. While he did 
not deny the permeability of the vascular tissue, and the possibility of the ' ' emigra- 
tion " of the leucocytes and the "diapedesis" of the red corpuscles, he maintained 
that the color pigment introduced into the blood vessels by Prof. Cohnheim may have 
passed out through the walls of the vessels with the liquor sanguinis, and afterward 
have stained whatever corpusclar elements were wandering as pus cells. 
Hence, he finds nothing in Prof. Cohnheim's demonstration to invalidate his own 
theory, known as the "modern theory of inflammation, " which he states thus: 
" Metamorphosis of tissue, return to the embryonic condition: division into amoeboid 
cells of the masses which have become movable; hence the destruction and the sup- 
puration ; this is briefly the outline of my new doctrine. ( ' ' International Surgery, ' ' 
Vol. I, p. 28.) 
It is quite possible that both Cohnheim and Stricker are right. I do not see any 
necessary antagonism between them. I do not understand that Cohnheim denies the 
possibility of embryonic cells appearing in pus as the result of " active metamorphosis;" 
or that Stricker denies the possibility of the appearance in pus of emigrant blood cor- 
puscles, which are conceded to be identical in appearance with the embryonic prolifica- 
tions of the surrounding connective tissue. 
Hence, without doing violence to either theory, we may assume that the corpus- 
cular elements of pus may be derived both from the blood immigration, and from the 
surrounding connective tissue by prolification. It should be said, however, that Green 
and other pathologists believe that the larger number of pus corpuscles are immigrants. 
I will now proceed with the pathology of pus formation on the basis of accepted 
facts. 
We have before seen how continued irritation quickens the circulation and results 
in an active hyperæmia, an expansion of the blood vessels, a retardation of the current, 
an enlargement of the capillaries and veins, and, finally, in that blood stasis which is 
the earliest manifestation of congestion ; that, in consequence of the blood stasis, nutri- 540 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tion is diminished, the vascular tissue weakened and its function impaired. As a result 
of the retarded though incomplete statical condition of the blood, its vital quality 
degenerates for lack of the frequent oxygenation which it normally receives. 
It will now be seen that unless resolution supervenes, disastrous results must follow; 
for progress is the law of retrogression, paradoxical as it may seem. 
In the stage of congestion the leucocytes float languidly along the peripheral portion 
of the vessels, while the red corpuscles mass themselves in the axial portion. 
Under this strain the weakened vascular coatings soon become permeable and permit 
liquor sanguinis to percolate into the surrounding tissue. The white blood corpuscles 
adhering to the walls of the vessels imbed themselves in the tissue, changing somewhat 
their form, preparatory to making their exit. Their passage through the walls of the 
vessels may be microscopically observed at various stages of progress. Green, in his 
"Pathology and Morbid Anatomy," gives the following description of it : "At first 
small button-shaped elevations are seen springing from the outer walls of the vessels. 
These gradually increase until they assume the form of pear-shaped bodies which still 
adhere by their small ends to the vascular walls. Ultimately the small pedicles of pro- 
toplasm by which they are attached give way, and the passage is complete, the cor- 
puscles remaining free outside the vessels. ' ' 
Fig. 4. 
Capillary vessel passing through connective tissue, showing emigration of corpuscles.-a, Connective- 
tissue cells ; b, Broods of connective-tissue embryonic cells. 
PUS FORMATION. 
Red corpuscles follow the white, but not in so large numbers. Stagnant blood, in 
which the corpuscles are dead, also passes out. From the damage done to the vascular 
tissue and to the contiguous intercellular tissue, there is a débris left to mingle in the 
flood of disorganized matter which constitutes pus. In addition to the matter which is the 
result of disorganization of tissue, there is, according to modern discoveries, a large 
emigration from without, in form of microorganisms of various types, considered to be 
" exopathic " causes in the formative processes of developing pus. 
Conditions so abnormal must have an influence upon the living tissue surrounding 
the seat of destructive inflammation. Its vitality is endangered by mere contiguity, 
and the life energy is stimulated by an emergency which arouses an antagonism to 
whatever tends to weaken, impair or destroy any portion of the living organism. 
Agnew, in his work on Surgery, says : "It will be conceded that there is a force ever 
present in all pathological mutations of structure, which resists destruction and tends 
to consume and to restore." It will plainly appear, therefore, that the inflammatory 
processes are not only destructive but also reconstructive; for the tissue surrounding the 
inflamed and disorganizing part is stimulated and excited to a rapid prolification of SECTION XVIII DENTAL AND ORAL SURGERY. 
541 
cells which are the living elements of new tissue. These are the embryonic cells which 
enter into reparative work. 
Now, it will be seen that when the corpuscular elements of the blood break through 
the walls of the vessels and appear outside in the surrounding tissue, they must there 
meet broods of embryonic connective tissue cells engaged in the active work of tissue 
construction ; and in their embryonic condition they so nearly resemble the emigrant 
leucocytes from the blood as not to be distinguished from them, and, hence, both alike 
are known as pus cells. I think it can now more plainly be seen that both Cohnheim 
and Stricker are right regarding the origin of pus corpuscles. 
Were it not for the presence of the reorganizing elements and the reconstructive 
energy of vitality in the very midst of the destruction of tissue, suppuration, at first 
scarcely perceptible, would rapidly increase unchecked. Septic poison would infiltrate 
into the surrounding tissues and speedily death would supervene. An alveolar abscess 
would not be dreaded simply because of the swelling and attending pain; it would be 
dreaded as a death stroke. 
The waste of tissue is so great in pus formation, that were it not for the constant 
renewal of tissue, in the midst of the waste, a daily loss of small amount would soon 
destroy any organ of the body. On the other hand, with the daily renewals, a wasting 
abscess may go on with its destructive work for years, and when resolution takes place 
the tissue will be found so nearly intact as to seem to have lost but very little of its 
substance. 
Were it not for the life which is manifest in its renewing energies in all the tissues 
of the body, except in the enamel of the teeth, there could be no antagonism within 
the body, during pas formation, to the same hasty decomposition that occurs after 
somatic death. 
GANGRENE. 
Gangrene is the direct result of blood stasis. The weakened condition of the blood 
vessels of any part in a congestive stage of inflammation, the impairment of function 
and the capillary engorgement, are all concerned in producing the statical condition 
of the blood and the consequent arrest of nutrition. Nutrition being cut off, gangrene 
is inevitable. 
Gangrene is death of a soft tissue in a body. It is death without waste of substance. 
Dentists seldom have occasion to observe a case of gangrene in their practice. In a 
careless handling of arsenic for the devitalization of a tooth pulp, they are sometimes 
called to witness gangrene of the gum surrounding the open cavity in which the arsenic 
is placed. 
A gangrenous death of tissue is ordinarily death by an inflammatory process. When 
a tooth pulp dies by the inflammatory process it suppurates on the exposed surface and 
wastes its substance gradually. When it dies from the application of arsenious acid, it 
gangrenes without waste of tissue. 
The ordinary account that is given of the death of the pulp by arsenic is, that the 
inflammatory swelling induced by the arsenic causes a strangulation of the blood ves- 
sels at their entrance through the apical foramen, and that by this means, nutrition 
being cut off, the pulp dies. 
On this theory the pulp should die throughout its entire body at once. But this 
we know is not the fact. In many cases the application of the arsenic causes gangrene 
of only the bulbous portion of the organ, while the portions occupying the root canals 
are still alive, and will remain so for an indefinite length of time. And, although 
devitalization of the organ is complete, it is gradual ; beginning with the portion in 
contact with the arsenic, it progresses gradually toward the extremities of the roots. 
From the character of the pain experienced almost immediately on the application 
of the arsenic, we may safely judge that the drug, acting as a vital irritant, has para- 542 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lyzed the capillaries, and that a clot or thrombus has been formed which arrests circu- 
lation. A thrombus in a vessel gradually extends in the direction toward the heart 
until it reaches an anastomosis of a blood vessel whose current is strong enough to 
break the thrombus and take its fragments along in its own current. Such anastomos- 
ing vessels may not be found in a tooth pulp, and not until the thrombus has reached 
the apex of the tooth and the apical space where are numerous vessels supplying the 
surrounding tissue. Here the thrombus is broken and devitalization ceases. Death by 
thrombosis is the only rational account that I can give of arsenical devitalization of 
the tooth pulp. 
NECROSIS AND CARIES. 
Thus far I have treated of inflammation as manifested only in soft tissues. The 
inflammatory processes pertain also to all the hard tissues, excepting only the enamel 
of the teeth. Inflammation of enamel are terms that have as yet scarcely found their 
way into our literature. Inflammation of enamel is certainly not a clinical discovery. 
The evidence of such a condition will be found, I opine, chiefly in the reticulum of 
fancy. It is quite impossible to conceive of vital functions and nutritive support of 
tissue carried on by means of from one to three per cent, of its substance. Where 
there are no vital functions there can be no inflammation. 
I am not speaking of the embryonic condition, or of developmental processes, during 
which period the relative proportions of animal and mineral substance are far different 
from the same found in adult structures. 
Nor am I quite willing to accept the evidence derived primarily from fœtal teeth of 
the ovine, bovine, feline and porcine species of animals, or of any other of the short-lived 
animals whose organism is adapted to an existence for so brief a period as compared 
with that of man. 
When we speak of living matter in enamel, distinction should be made between 
living matter and animal matter once living, but afterward atrophied and remaining 
in the tissue as. a component element. 
In all allusion to the inflammatory processes in the hard tissues, I have excepted the 
enamel of the teeth. I regard its place in the economy of the living organism as a 
protector of the living structure which it covers. It corresponds to cuticle covering the 
soft tissue of the skin. The outer layer of cells once vital, being no longer so, remain 
on the surface a protection to the cutis ver a beneath. A like protection appears in 
the outer bark of trees, the shells of nuts and in the skin of an apple. In each case 
we find a non-vital outer covering to protect the vital tissues underneath. I find no 
evidence that the enamel is an exception to this rule, its extreme hardness and strength 
being in complete adaptation to the protection required in the hard service which the 
teeth must perform. 
Whatever may have been the vital organism of enamel during the process of amelifi- 
cation, and whatever may have been its active functions in the fœtal state, there is no 
evidence that it performs the same functions after the emergence of the teeth. On the 
other hand, it seems quite evident that both the external and internal epithelia cease 
their vital functions with the completion of the enamel, and in an atrophied or corne- 
fied condition afford a temporary protection to the formed enamel, under the name of 
' ' cuticle of the enamel " or " Nasmyth's membrane. ' ' Without the performance of vital 
processes the enamel cannot be subject to inflammation. 
With the exception before named, all the hard tissues are subject to inflammation, 
modified only by the peculiarities of their structures. 
As inflammation can only pertain to vital animal substance, the processes of inflam- 
mation can be found only in that organic vital substance so mysteriously united with 
mineral substance in forming the hard tissues of the body. 
In corticular compact bone it is found in the periosteum, the bone cells and their SECTION XVIII DENTAL AND ORAL SURGERY. 
543 
numerous processes which inosculate with each other through canaliculi and with the 
circulatory system of the Haversian canals. In cancellated bone the vital and organic 
portion is found chiefly in the medullary tissue lining the walls of the cancelli. 
No one will doubt that so highly vascular a tissue as periosteum is subject to inflam- 
mation, and that its conditions may be communicated through all its vital connections 
into the substance of the bone. When, therefore, in the last stages of congestion, 
inflammatory stasis supervenes so that nutrition of the bone is suddenly cut off, necrosis 
is the inevitable result. 
The suppurative process of inflammation may be communicated from the soft tissue 
of the gum to the periosteum of the alveolar processes and this hard tissue be wasted 
by ulceration. This is true caries of bone, but on account of the thinness of the struc- 
ture and its compact nature, it does not afford a favorable illustration of the process. 
But when by the progress of disease the maxillary bone proper is reached, we find a 
clearer manifestation of the true nature of caries by observing it in the cancellated 
structure. 
The alveolar processes ought not to be considered as part of the maxillary bone. 
Although built upon it, they have a distinct development as to time and purpose. 
They have a contemporaneous development with the teeth, and have only a contempo- 
raneous existence. The jaw bone exists prior to the alveolar ridge, and remains after 
the teeth are extracted and the alveolar ridge has been absorbed. The external and 
internal oblique lines of the lower maxilla are the dividing lines between the dental 
processes and the maxillary bone proper. 
About the apices of the tooth roots the corticular shell of bone forming the parietes 
of the alveoli ends in the midst of the cancellated bone of the maxilla. Here the pro- 
portions of animal and mineral matter are such as to afford a manifestation of the 
redness and swelling of inflammation, in a limited degree. Not that the whole body 
of the bone swells, but the lacunal cells and the medullary tissue lining the cancelli 
expand at the expense of the mineral walls; hence the proportions of animal and mineral 
matter not remaining the same, the bone becomes softened. 
The walls of the cancelli being thus broken down, there appears an irregular rami- 
fication of medullary matter. Here appear, also, in limited numbers, the same immi- 
grant leucocytes and embryonic cells as in the more vascular tissues, for reparative work. 
The prolificated cells become sufficiently numerous to cover the wasting surface of 
the bone and constitute a granular tissue, which is the tissue of reconstruction. If the 
granular tissue fails in the battle against destruction, some of the cells die and mingle 
with the pus as irritating matter, while others undergo fatty degeneration and are 
absorbed. 
Bearing in mind, now, the character of caries in bone, its suppurating and pus- 
discharging tendencies, and its reconstructive granulation tissue spread out over the 
carious surface, for the work of repair, it will be seen how far-fetched and inappro- 
priate is the word caries to express the wasting process in the crowns of teeth, com- 
monly called decay. 
INFLAMMATION OF CEMENTUM. 
The tissue of the cementum is a modified bone. It has more delicate lacunae, and, 
on account of its extreme thinness, it is, for the most part, void of Haversian canals. 
The peridental membrane which covers it corresponds, in a general sense, to the peri- 
osteum of true bone. Wherein it is like bone its pathological conditions correspond to 
those of compact bone. But sustaining, as it does, vital relations to the tooth pulp, 
through the dentinal fibrilli (pulp fibrils), it is endowed with higher sensibility than 
bone, and when inflamed it becomes acutely sensitive to the touch of a tooth pick or 
tooth brush, so much so that patients are often led to believe that there must be deep- 
seated decay and an exposure of the pulp. 544 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The essential point to be noticed here is, that, normally, this tissue is not peculiarly 
sensitive, but that this peculiar sensibility to touch is developed by inflammatory 
action. It manifests itself at the necks of teeth, and is usually caused by want of 
cleanliness or by too severe effort with the brush to promote cleanliness. 
INFLAMMATION OF DENTINE. 
Some may consider this phraseology a misnomer. Twenty-five years ago it was con- 
sidered appropriate ; but probably from misapprehension of tissue relations, and the 
nature of the inflammatory processes, what was called inflamed dentine came to be 
called sensiïwe dentine. As all dentine is not sensitive in any high degree, nor all the 
dentine of a single tooth, how is the condition of exalted sensibility induced ? A decayed 
tooth may be peculiarly sensitive to the touch of an instrument on one side and not so 
on the opposite side, although a similar condition of decay may be found there. All 
sensation in the dentine is attributable to the living animal tissue, which, in form of 
minute fibrils, multitudinous in number-which proceed out from the pulp through all 
the substance of the dentine-and by loops and inosculations, form a plexus of vital 
tissue on the periphery. But neither this plexus, the dentine fibrils (pulp fibrils) nor 
the pulp itself are peculiarly sensitive to touch when in a normal condition. Let a 
tooth pulp be exposed by fracture, instead of irritating decay, and it may be touched 
with the finger, or touched lightly with an instrument, without Causing pain. But as 
soon as inflammation begins it manifests its high degree of sensibility and pain. What- 
ever is true in this respect of the dental pulp is also true of the fibrils proceeding out 
from the pulp and ramifying the dentine. Whenever these fibrils of the pulp are 
keenly sensitive it is evidence of inflammation. 
A further evidence of the inflammation of dentine is found in the fact that through 
the pulp fibrils inflammation may be communicated to the dental pulp. A metal filling 
put into a small cavity in the tooth-every part of which is two lines distant from the 
chamber of the pulp-will, in numerous cases, cause inflammation in the pulp. The 
moment you establish the fact of continuity of animal tissue, and vital 
relations between the periphery and the central organ of the tooth struc- 
ture, you establish also the fact of the possibility of like pathological con- 
ditions in the pulp and throughout all its dentinal ramifications. Science 
is unfortunate, and our dental nomenclature at fault, in calling this vital 
organ of tooth tissue a pulp, which signifies no more than an inert, struc- 
tureless, homogeneous mass of matter. On the contrary, it is of a gang- 
lionic nature. It is a nerve centre. It should be called the dental gang- 
lion ; for from it as a centre radiate innumerable nerve fibrils, promoting 
life and nutrition in all the surrounding hard tissues of the dentine, and 
irritation of its peripheral nerve tissue finds ready communication with 
the centre. We might, with about as much propriety, call the brain the 
cranial pulp, as to call the ganglionic centre of all the vital processes of 
the dental organism a tooth pulp. 
I have met with this objection, that inflammation pertains only to the 
vascular and circulatory system. I answer, that in the human organism we have differ- 
ent kinds of circulating fluid, light red, dark red, and colorless blood. All blood is not 
corpuscular and pigmented. The term blood is a common term to denote the nutritive 
fluid of the body. Nor is it necessary that a tissue to be called vascular should have mem- 
branous vessels. The tubules of the dentine are the vessels for the circulation of tooth 
pabulum. Neither is it necessary that white and red corpuscles should pass into the tubuli. 
The colorless fluid in which they float in the arteries and veins contains in solution all 
the elements that make up the hard structure of dentine. Cartilage is not considered 
a vascular tissue. There are no vessels ramifying it and carrying corpuscular blood, yet 
Fig. 5. SECTION XVIII-DENTAL AND ORAL SURGERY. 
545 
it has blood nutrition by absorption from surrounding tissue, and is subject to inflam- 
mation. Hence, both in its physiology and in its pathology it exhibits conditions com- 
mon to all living animal tissues, nutrition and inflammation. 
The processes of inflammation in dentine can best be understood by reference to analo- 
gous processes in bone. I have already called attention to the expansion of the medullary 
tissue by inflammation in cancellated bone at the expense of the mineral walls of the 
cancelli, thus changing the relative proportions of animal and mineral substance, and 
softening the bone. In some of the processes of dental decay we find a similar break- 
ing down of the walls of the tubuli of the dentine by expansion, leaving a hypertrophied 
condition of the animal portion of the tissue, leaving a softened condition of dentine 
known as demineralized dentine. This is of a leathery or corky consistency, and by 
hypertrophy induced by inflammation, this animal portion comes to be a much larger 
percentage of the whole tissue than in normal dentine. In fact, when demineralized 
dentine is removed from the cavity of decay, as it may sometimes be, in a large mass, 
it seems to constitute the chief part of the whole substance of the dentine. 
When dentine presents a brown or black decay it is necrosed dentine ; but de- 
mineralized dentine is, in many cases, far from it. On the other hand, it is extremely 
sensitive, and to touch it causes severe pain. It may, however, become necrosed and 
wasted by microorganisms or chemical decomposition. 
With all the facts before us concerning the loss of hard tissue by inflammatory pro- 
cesses, in our efforts to solve the problem of dental decay, while giving full credit to 
chemical decomposition and microorganisms, we should not omit to give credit to 
inflammation as an active factor. 
DISCUSSION. 
Dr. A. 0. Rawls, Lexington, Ky., in opening the discussion, said he was not 
aware that he could add to or gainsay the statements contained in the paper. It is 
a well known fact, that all this which has been recited of the Inflammatory Process 
has been stated by Cohnheim and others, whose opinions on pus formation are gen- 
erally accepted, that it is by transference of the leucocytes through the walls of the 
vessels. The only difference between Cohnheim and Dr. Ingersoll is that the latter 
believes that in inflammation not only are the leucocytes passed through walls of 
blood vessels and increased in numbers, but that new tissue is formed, which takes 
part in this process* 
He does not believe that Cohnheim intended such an interpretation, or that Dr. 
Ingersoll can substantiate his position. His own idea is that pus is composed of 
leucocytes and the broken down débris of tissue. No embryonic elements enter into 
it unless they are first broken down. It is true that, according to Stricker and 
Cohnheim, there seems to be a return to embryonic life, because in the early forma- 
tion more leucocytes are found than in the complete tissue. The paper will be 
valuable to dentists, for the reason that he did not believe that, as a rule, they 
sufficiently understood the processes of inflammation. With a better understanding 
of these they would be better able to treat inflamed pulps. Dr. Ingersoll claims that 
hypertrophy of the pulp is in the nature of a tumor, with which idea he disagreed. 
He apprehended that it was more in the nature of a strangulation of the tissue of the 
nerves. 
It was more properly a fungous growth. A tumor was more regular in its forma- 
tion, while the hypertrophy was conglomerate. He thought Dr. Ingersoll was 
wrong as to inflammation in the dentine. He must mean that there is inflammation 
in the pulp to produce it, and that sensitive dentine arises from inflammation of 
Vol. V-35 546 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the pulp. The speaker's idea of this was, that strangulation takes place only where 
the closing of the canals permitted it. Contact of the instrument with dead nerve 
tissue will lead many to believe that the pulp was still alive. Dr. Ingersoll says that 
pus may be considered a living tissue. The speaker could not see how this could be 
true, in any sense. It was alive as to chemical action; it was alive as to its affinities, 
but it had no connection with any living organization. The leucocytes may be con- 
sidered as living, wandering cells, but when they pass out of the vessels, they are no 
longer living. They have lost their place in the part that once owned them. Again, 
Dr. Ingersoll speaks of the granulation of living tissue over carious surfaces. The 
speaker could not conceive of such action. Granulations must form over living tissue. 
Sensitive dentine, he apprehended, arose from a hyperæmic condition of the fluids 
contained in the dentine. It was true that it was similar to inflammation, and it 
might be caused by inflammation, not in the substance itself, but which produced 
pressure on the pulp, whence the hyperæmia was communicated to the fluids in the 
canaliculi; when a healthy tooth was freshly broken, and the pulp exposed there was 
no sensitiveness to the touch. Demineralized dentine was caused by one of the forms 
of inflammation in the pulp, as from compression, which melted away the lime salts, 
the same as a soft tissue under similar circumstances. 
Dr. M. II. Fletcher, of Cincinnati, Ohio, described what he had observed under 
the microscope in isolating by electricity the mesentery of a frog. He found that 
after a few moments of isolation the leucocytes would gather along the edges of the 
capillaries, finally forming a complete row on both sides all around the blood vessels. 
Then the migration began. lie saw them coming through. He had arranged the 
mesentery so that he could connect the battery with each edge by tin foil. After 
the vessels had become entirely occluded in some cases he had turned on the current 
and immediately the movements of the leucocytes could be seen. Where the vessels 
had not been perfectly occluded, the leucocytes would start off, and go out through the 
circulation. By continuing the current the blood vessels were perfectly cleared and 
the circulation established again in its normal condition. Of course, the experiment 
did not prove anything; but he thought it might be interesting to report it in con- 
nection with Dr. Ingersoll's paper. It seemed to show that the life of corpuscles was 
such that they were directly affected not only by electricity, but by other topical 
applications, and by anything which might be an irritant to them. It seemed to 
show that the life was in the corpuscles. He merely reported the experiment for 
what it was worth. 
Dr. J. C. Storey said that if Dr. Ingersoll's statement-that in inflammation 
there was a flow of blood to the parts-was correct, then all his (Dr. Storey's) teach- 
ing had been completely upset. He had been taught that where there was an irrita- 
tion there was a stasis-that the blood could not get away from it; that it was 
dammed up; and that hence the increased swelling, redness and heat. Another 
thing he had heard to-day which completely upset another theory of his. He had 
been taught that pus never entered the blood circulation as pus; that poisonous mat- 
ter (bacteria, microbes, or whatever else it might be called) might generate life and 
poison the circulation, but that, as pus, it never did. He had been so taught and 
had always reasoned from that standpoint. If he was wrong, he asked that some 
person present might set him right. 
Dr. Ingersoll gave some further explanations of the drawings which he exhib- 
ited in illustration of his paper. 547 
SECTION XVIII-DENTAL AND ORAL SURGERY. 
Dr. M. L. Rhein, of New York, antagonized one of the points made in Dr. 
Ingersoll's paper, as to the impossibility of healthy granulation covering a carious por- 
tion; and said that that was the very means which nature took to form new tissue. 
In a healthy organization there was a proliferation of healthy granulations, forming 
new bone or tissue. Of course that did not come directly from the portion where there 
was caries; and he did not understand the paper to intimate that. But the healthy 
granulations came from all around the surface of the carious portion. He believed 
they all understood a tumor to be a new formation entirely. In that respect Dr. 
Ingersoll was entirely right in the representation of a hypertrophied condition of the 
pulp. 
PAIN IN THE TEMPORO-MAXILLARY JOINT, CAUSED BY IRREGU- 
LARITY OF THE TEETH. 
DOULEUR DANS L'ARTICULATION TEMPORO-MAXILLAIRE CAUSER PAR L'IR- 
RÉGULARITÉ DES DENTS. 
SCHMERZ IM KIEFERGELENK, DURCH UNREGELMÄSSIGKEIT DER ZÄHNE VERURSACHT. 
BY C. L. GODDARD, A.M., D.D.S., 
Of San Francisco, Cal. 
In the spring of 1883, a patient, Mr. A. B. C., thirty years of age, presented him- 
self, complaining of pain in the region of the temporo-maxillary joint. The pain was 
not constant, but appeared only during mastication. My first thought was that it was 
caused by an impacted dens sapientiæ. Upon examination, however, all four of these 
teeth were found fully erupted, with plenty of room behind them. 
The patient was tall, with large bones, the inferior maxilla being longer than usual. 
The mucous membrane about the dentes sapientiæ was in normal condition, there being 
no signs of inflammation. There was no tenderness to pressure around the joint. 
The cause of the pain was not apparent, especially as the patient said it was of 
several years' standing, and not only prevented his masticating hard food, like crusts of 
bread, but even was present when he was singing. 
Upon examining the articulation of the teeth, I found that when the jaws closed 
normally, the only articulation was with the cutting edges of the superior and inferior 
incisors, as shown in photograph of cast, Fig. 1. 
The bicuspids and molars did not antagonize by at least a sixteenth of an inch. In 
order to masticate his food, it was necessary to protrude the inferior maxilla so that the 
inferior incisors could lap over outside the superior, then the bicuspids and molars 
articulated somewhat in a normal condition, as shown by photograph of cast, Fig. 2. 
Upon questioning the patient I found that pain ensued only when he used his teeth in 
that position. The question then arose in my mind whether the cause might not be a 
long-continued strain of the muscles of mastication and the ligaments of the joint 
when used out of their normal line of action. 
Upon trial with my own jaws, I found that it was impossible to bite as hard when 
the inferior maxilla was protruded as when it was in its natural position. The more I 
thought about it the more I was convinced that I had discovered the cause of the pain ; 
that it was produced by straining the parts, by masticating while the inferior maxilla 
was protruded. 548 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The only remedy that suggested itself was a change in the articulation of the teeth 
by correcting the irregularity. Either the superior incisors must be moved forward or 
the inferior incisors backward. The former seemed the most feasible. 
I expected to use an appliance having a gold wire extending around in front of the 
incisors, so that they could be drawn out toward it by means of rubber ligatures. The 
occupation of the patient, however, prevented its use. He was a teacher of vocal 
music, giving part of his time to a young ladies' school, hence he would not consent to 
the use of any appliance that could be seen in conversation or in singing. It was also 
Fig. 1. 
necessary that it should not interfere with his tongue. He was very anxious to have 
the experiment tried, and desired me to devise some appliance that would act under 
these peculiar conditions. I chose the Coffin split plate, modified to suit the case. The 
plate was split transversely on a line extending across in front of the bicuspids, and 
two springs were inserted, one on each side. One end of each spring was inserted pos- 
terior to the canine, and the other near the neck of the first molar, thus exerting pres- 
sure as nearly as possible at right angles to the lingual surface of the incisors. If the 
spring had been placed in the median line of the plate, the posterior end would have 
Fig. 2. 
been so high up in the arch of the palate that the line of pressure would have been 
almost parallel to the lingual surfaces of the incisors. Piano wire No. 15 was used, 
and when the two parts of the plate were drawn slightly apart and inserted in the 
mouth, powerful pressure was brought to bear to move the teeth outward. It was 
necessary to tie the plate to the first bicuspids, which fixed it very firmly. The springs 
were so conformed to the surface of the plate that they offered no special impediment 
to speech, and the instruction in singing went on as usual. 
(In using such an appliance in another case, an improvement was made by inserting SECTION XVIII-DENTAL AND ORAL SURGERY. 
549 
a staple of piano wire in the plate near the anterior edge o# the larger part, so that the 
straight part of the spring could play through it. It prevented the tendency of the 
spring to lift itself up from the surface of the plate when in action by sliding on the 
inclined surfaces of the incisors.) 
The patient wore this appliance, comfortably, and the teeth moved as fast as could 
be expected at the age of thirty years. In a few weeks the superior incisors closed over 
the inferior, and a normal articulation was secured, as shown in photograph of cast, 
Fig. 3. The molars and bicuspids antagonized well in their new position, with the 
exception of one inferior molar, which was too short, and which was elongated with 
gold. 
It was necessary to move out the right superior cuspid more than the others, to 
carry it over the inferior teeth. Another modification of the Coffin split plate was 
used. The spring wds inserted about as usual, but instead of splitting the plate in the 
middle, a piece, the shape of a new moon or crutch, was cut out, holding one end of 
the wire and pressing against the cuspid. A platinum band was cemented on the 
cuspid to prevent the crutch-piece from sliding off. By this means the tooth was moved 
in due time to the desired position. One of the incisors was rotated while being pushed 
Fig. 3. 
forward, by inserting a piece of soft rubber between the edge of the plate and the 
side of the tooth that needed to be moved most. An atmospheric-pressure retaining 
plate was inserted and developments awaited. 
The pain during mastication or singing gradually disappeared, and in a few weeks 
the patient declared himself cured. 
The case presents unusual interest, inasmuch as a long-standing pain or disease was 
eured entirely by mechanical means and by an apparatus that did not extend outside 
the teeth. 
The Section then adjourned. 550 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ÆTIOLOGY OF IRREGULARITIES OF THE JAWS AND TEETH. 
ETIOLOGIE DES IRRÉGULARITÉS DES MÂCHOIRES ET DES DENTS. 
ÆTIOLOGIE DER UNREGELMÄSSIGKEITEN DER KIEFER UND ZÄHNE. 
E. S. TALBOT, M.D., D.D.S., 
Chicago, Ill. 
By comparing the condition of the teeth of the ancients, as shown by existing 
skulls, with the teeth of the lower grades of humanity now living, and also with those 
of the more civilized races of the present day, it will be observed that irregularities are 
not only more frequently seen in the latter, but that their frequency increases, pari 
passu, with advancing civilization. As these deformities are associated with that por- 
tion of the human anatomy which we, as dental and oral specialists, are called upon to 
treat, they demand our most careful consideration, and an amount of attention which 
necessitates most thorough observation and research. The maxillary bones develop and 
grow independently of each other, and, therefore, one cannot influence the other as 
regards development or growth. It is quite common to find that the superior maxilla 
is proportionately much smaller than the inferior, but it is rare that the inferior max- 
illa is not fully developed. The inferior maxilla, being entirely free from the other 
bones in the body, develops independently, and because of its mobility, constantly 
receives a large blood supply which amply nourishes it. 
The superior maxilla, on the other hand, is developed in conjunction with the other 
bones of the head, consequently becoming one of the fixed bones of the face, and, as 
Mr. Coles suggests, it may be that arrested development of the bone is due to prema- 
ture ossification of the suture, or, according to Cartwright, "to the intermarriage of 
races and high and select breeding;" but personally I entertain the opinion that the 
arrested development of the superior maxillary bone is caused by inefficient supply of 
blood to the part to develop it, because of the inaction of the jaw; this is illustrated in 
other members of the body, exercise or action developing the other part. 
Narrow and contracted jaws are more numerous among the present people than was 
seen in former races. Then they subsisted chiefly upon roots, nuts, grains and coarse 
foods of all sorts, which required mastication to prepare them for digestion; the jaws 
were thoroughly exercised and developed accordingly. Now, the food is about ready 
for digestion -when taken into the mouth, and mastication is becoming one of the lost 
arts; the jaws being but little exercised, which frequently results in narrow and con- 
tracted arches. Anatomists, in describing the maxillary bones, speak of them as the 
superior and inferior maxillæ. But we, as orthodontologists, should divid« each bone 
into two parts. The parts below the mental foramen on the lower jaw and above the 
palate on the upper jaw are hard and dense and are designed for the attachment of 
muscles. The alveolar processes, situated above the mental foramen on the lower jaw 
and below the palate on the upper, are expressly for the formation of the teeth while 
in their crypts, and for their retention after they have erupted. When the teeth are 
removed the processes are absorbed away and nothing remains but the dense bone. In 
intra-uterine life, while the teeth are forming, the alveolar processes cover and protect 
the crypts in which the teeth are located, and as they grow and force their way through 
the process, absorption takes place and much of the bone vanishes. After the teeth 
have erupted, deposition of bone again takes place, which holds the teeth firmly in 
place. Again, these teeth are shed and bone is absorbed to admit the second set, after 
which new material is deposited for their retent on. 
It will be observed that from the time the first teeth make their appearance until SECTION XVIII-DENTAL AND ORAL SURGERY. 
551 
the second set are firmly fixed in position the alveolar process has changed twice. 
These changes, however, do not affect the shape of the maxillary bones proper; the 
teeth grow and develop independent of the alveolar process, but the processes are 
dependent upon the teeth for their development, position and shape. If the crypts 
containing the crowns of the teeth be situated on the inner border of the alveolar 
process, or if the teeth should erupt through the inner border of the alveolar process, 
when dentition is completed, the diameter of the circle would be much smaller than 
that of the jaw bone. If, on the contrary, the teeth are situated upon the outer border 
of the alveolar process, and the teeth, in their transit, are directed outward, the diam- 
eter of the circle will be as great, or greater, than the jaw bone. It may be observed 
that when several teeth are missing upon one jaw, the teeth of the opposite jaw having 
no resistance, the alveolar process elongates, showing that the physiological process of 
growth, furnishing support to the teeth, is properly performed, though many times 
under difficulties. 
The teeth of the present generation decay more rapidly than those of former times, 
and are extracted earlier in life. Thus, as generations pass, the teeth gradually decrease 
in the time they remain in the jaw, and the diameter of the alveolar process is reduced, 
like other parts of the body when deprived of support. The eruptive fevers common 
among children, or constitutional disturbances of any nature, may cause arrested devel- 
opment of the maxillary bones. 
Arrested development of the maxillary bones is characteristic of idiots, imbeciles 
and feeble-minded children. This fact was emphasized by Dr. Langdon Down, in a 
paper read before the Odontological Society of London, in 1871. He said that in 
examination of a great many congenital idiots he found that, with very few exceptions, 
the arches were contracted in width between the bicuspids, and that irregularity in 
arrangement of the teeth was the rule rather than the exception. Dr. W. W. Ireland 
found, out of 81 idiots examined, 37 had either vaulted or V-shaped arches. 
These opinions awakened the interest of many scientific men of our country; among 
them were Dr. Kingsley, of New York, and Drs. J. W. White and Stell wagen, of Phila- 
delphia. Dr. Kingsley observed that in the two hundred idiots, of different nationali- 
ties, at the asylum on Randall's Island, "he did not find a single pronounced case of 
V-shaped dental arch, but very few cases of narrow palatine arch, and but three or 
four saddle-shaped palates. ' ' Drs. J. W. White and Stellwagen examined the inmates 
of a large school for feeble-minded children in Pennsylvania, and found large, well- 
shaped jaws the rule. In these reports no definite statistics of the proportion of regular 
and irregular jaws and teeth are given. It is rather curious that these gentlemen, 
equally eminent on their respective sides of the ocean, should differ so widely on this 
question. In the different institutions for feeble-minded, the inmates of which I have 
examined, and from blank reports filled out by resident dentists of institutions which 
I could not visit, I deduce the following statistics:- 552 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CLASSIFICATION OF IRREGULARITIES OF THE JAWS AND TEETH OF INMATES 
OF EIGHT INSTITUTIONS FOR FEEBLE-MINDED, IMBECILE AND 
IDIOTIC CHILDREN IN THE UNITED STATES. 
TABLE NO. 1.-ASYLUM FOR IDIOTS OF THE STATE OF NEW YORK, SYRACUSE, DR. 
CARSON, SUPERINTENDENT. EXAMINATION BY DBS. S. B. PALMER AND J. C. HOUSE. 
DEFORMITIES IN THE JAWS. 
LOW GRADE. 
3 
Q 
Male. 
Female. 
Sex. 
B 
Normal. 
Large 
Jaw. 
Protrusion 
Lower Jaw. 
Protrusion 
Upper Jaw. 
*- 
V-Shaped 
Arch. 
Partial 
V-Shaped 
Arch. 
Thumb 
Sucking. 
Saddle- 
Shaped 
Arch. 
Small 
Teeth. 
TABLE NO. 2.-MASSACHUSETTS SCHOOL FOR FEEBLE-MINDED, SOUTH BOSTON, ASBURY 
G. SMITH, SUPERINTENDENT. EXAMINATION BY DR. C. E. ESTABROOK. 
DEFORMITIES IN THE JAWS. 
HIGH GRADE. 
GH 
£ tU tO 
Co M Cd 
CO GH o 
er - 
p 
Male. 
Female. 
1 
Male. 
Female. 
Male. 
Female. 
Sex. 
-J 
03 tO 
: to S 
CO O 
Normal. 
00 
Ci tO CO 
*■ ■*- M 
to tn 
Large 
Jaw. 
tO 
tO ; H* 
*•! w 
14 
Protrusion 
Lower Jaw. 
r 
CO 03 2 03 
o 
g 
8 
09 : ü W 
N 
h-* to 
Protrusion 
Upper Jaw. 
to 
1 15 
RADE. 
11 
11 
O 
w 
>-* {► to 
CIO CO 
F 
53 
High 
Arch. 
H* 
: *-* 
J H* GH 
to 03 
V-Shaped 
Arch. 
bO 
C4* CO 
Partial 
V-Shaped. 
Arch. 
** : : 
Thumb 
Sucking. 
tO 
CD 03 
to to LO 
-4 on 
Saddle- 
Shaped 
. Arch. 
- . 
09 tO tO 
CO rft. 
Small 
Teeth. 
TABLE NO. 3.-ILLINOIS ASYLUM FOR FEEBLE-MINDED CHILDREN, LINCOLN, DR. WM. B. 
FISH, SUPERINTENDENT. EXAMINATION BY DR. E. S. TALBOT. 
DEFORMITIES IN THE JAWS, 
MIDDLE GRADE. 
£ 
►u to 
to co 
3 
o 
Male. 
Female. 
Sex. 
Ot 
148 
107 
Normal. 
*■ 
*•• 
Large 
Jaw. 
H* O> 
Protrusion 
Lower Jaw. 
c© 
to *4 
Protrusion 
Upper Jaw. 
© : 
High 
Arch. 
Ci - 
V-Shaped 
Arch. 
t 
to to 
w □» 
Partial 
V-Shaped 
Arch. 
to 
- 
to • 
Thumb 
Sucking. 
••* 
Saddle- 
Shaped 
Arch. 
Oi 
to 
Small 
Teeth. SECTION XVIII-DENTAL AND ORAL SURGERY. 
553 
TABLE NO.4.-ASYLUM FOR IDIOTS, RANDALL'S ISLAND, DR. HEALEY, SUPERINTENDENT. 
EXAMINATION BY DR. E. J. RANHOFER. 
DEFORMITIES IN THE JAWS. 
HIGH GRADE. 
No. 
Sex. 
j Normal. 
Large 
Jaw. 
Protrusion 
LowerJaw. 
Protrusion 
Upper Jaw. 
High 
Arch. 
15 • 
O-J5 
ei o 
> 
Partial 
V-Shaped 
Arch 
Thumb 
Sacking. 
Saddle- 
Shaped 
Arch. 
Small 
Teeth. 
40 
52 
Male. 
Female. 
11 
23 
12 . 
7 
3 
5 
15 
7 
24 
19 
4 
5 
7 
12 
6 
2 
92 
34 
19 
8 
22 
43 
9 
7 
18 
2 
MIDDLE 
GRADE. 
9 
Male. 
Female. 
3 
1 
2 
3 
5 
1 
9 
3 
1 
2 
3 
5 
1 
... 
LOW GRADE. 
33 
23 
Male. 
Female. 
7 
7 
10 
3 
8 
1 
18 
11 
20 
17 
7 
2 
12 
8 
56 
14 
13 
9 
29 
37 
9 
20 
TABLE NO. 5.-MINNESOTA TRAINING SCHOOL FOR IDIOTS AND IMBECILES, FARIBAULT, 
DR. A. E. ROGERS, SUPERINTENDENT. EXAMINATION BY DR. S. T. CLEMENTS. 
DEFORMITIES IN THE JAWS. 
HIGH GRADE. 
- te ci 
Ci O o 
te 
No. 
Male. 
Female 
Male. 
Female. 
Male. 
Female. 
Sex. 
Ci 
co co 
ce 
te o 
te oo 
Normal. 
CO 
h- te • 
: : « 
»SW 
Large 
Jaw. 
: r-> to 
Protrusion 
Lower Jaw. 
K. 
.= | * 
Q 
3 
MIDDLE 
1 
Protrusion 
Upper Jaw. 
h- 
W 
► 
ü 
*-• M ce 
0 
S 
► -J 
H-IO 0 -J 
M 
: m 
High 
Aich. 
: * *"L 
H* • CO 
te 
V-Shaped 
Arch. 
te 
to • co 
te i-1 te 
Partial 
V-Shaped 
Arch. 
co to 
to ; te 
te ; 
Thumb 
Sucking. 
te 
to 
4-00 h-* 
te 
i-O CO 
Cl CO 
Saddle 
Shaped 
Arch. 
Small 
Teeth. 554 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
TABLE NO. 6.-KANSAS STATE ASYLUM FOR IDIOTIC AND IMBECILE YOUTH, WINFIELD, 
DR. II. M. GREENE, SUPERINTENDENT. EXAMINED BY THE SUPERINTENDENT. 
DEFORMITIES IN THE JAWS. 
HIGH GRADE. 
to 
to 
to O 
00 
MM 
O» 
co to 
No. 
Male. 
Female. 
Male. 
Female. 
Male. 
Female. 
Sex. 
to to 
to 
to ; 
Normal. 
MW 
to 
I-' ' 
• F-» 
Large 
Jaw. 
Ot 
to 00 
Protrusion. 
Lower Jaw. 
to 
to • 
5 
Si 
o 
to 
: 10 
g 
5 
ö 
E 
»-* 
H* • 
Protrusion. 
Upper Jaw. 
•- co 
50 
► 
0 
W 
* 
-* co 
o 
N 
► 
Ö 
K 
CO 
tO 
High 
Arch. 
-> 
to ÜI 
to 
: 10 
V-Shaped 
Arch. 
co co 
o> o 
Partial 
V-Shaped 
Arch. 
Thumb 
Sucking. 
to 
Saddle 
Shaped 
Arch. 
00 
■* 
CO rft 
Small 
Teeth. 
TABLE NO. 7.-PENNSYLVANIA INSTITUTION FOR FEEBLE-MINDED CHILDREN, ELWYN, 
PENNSYLVANIA, DR. I. N. KERLIN, SUPERINTENDENT. 
EXAMINATION BY DR. A. W. WILMARTH. 
DEFORMITIES IN THE JAWS. 
HIGH GRADE. 
152 
to 
-J co - 
tOQ CM 
CO to GO 
4- >-■ CH 
tO 03 
No. 
Male. 
Female. 
Male. 
Female. 
Male. 
Female. 
Sex. 
CO 
s 
4- 4*. CH 
03 CO CT» 
S2 § 
80 
55 
Normal. 
BO 
- M 
/ 
: : to 
• to 
Large 
Jaw. 
tO IO 4* 
to 
►- »-» 
Protrusion 
Lower Jaw 
03 
- 1 . 
Q 
1 1 
MIDDLE 
î H* 
Protrusion 
Upper Jaw. 
CH 
■ 
Ö 
-JOO PS 4- 
ffl 
w 
k>5 Q o 
« 
CT> 4*. 
High 
Arch. 
« 
On co to 
On -j to 
IO 09 
V-Shaped 
Arch. 
co 
Ä OS £ 
CO 03 to 
00 
Partial 
V-Shaped 
Arch. 
• 
** 
w 
03 tO 
Thumb 
Sucking. 
4* 03 CO 
03 CO CM 
to 03 
Saddle- 
Shaped 
Arch. 
co 
•-* tO CH 
tO OB 
: 
Small 
Teeth. SECTION XVIII-DENTAL AND ORAL SURGERY. 
555 
TABLE NO. 8.-COOK COUNTY INSANE ASYLUM. DUNNING, ILLINOIS, DR. S. MAY, SUPER- 
INTENDENT. EXAMINATION BY DR. EUGENE S. TALBOT ASSISTED 
BY DRS. BRYAN AND HUNT. 
DEFOBMITIES IN THE JAWS. 
HIGH GBADE. 
ê 
h- 03 
-U to 
!z! 
O 
Male. 
Female. 
Sex. 
00 
00 O 
Normal. 
Cn 
03 tO 
Large 
Jaw. 
Ci 
te 4- 
Protrusion 
Lower Jaw. 
H* 
î »-* 
Protrusion 
Upper Jaw. 
M 
CO 4- 
High 
Arch. 
s 
bU o> 
V Shaped 
Arch. 
03 
CH 00 
Partial 
V-Shaped 
Arch. 
Thumb 
Sucking. 
» 
•-* te 
Saddle- 
Shaped 
Arch. 
*- 
te to 
Small 
Teeth. 
TABLE NO. 9.-TOTAL NUMBER OF DEFORMITIES OF THE JAWS OF BOTH SEXES IN 
EACH GRADE. 
HIGH GBADE. 
557 
•- tO Ci 
CO - >U 
03 00 
to 03 . g 
»-» to 
-1 to 
CM CM 
No. 
Male. 
Female. 
Male. 
Female. 
Male. 
Female. 
Sex. 
279 
Cl fe 
CM tO C© 
|S 
03 O Cl 
115 
101 
Normal. 
03 
CH 
»-» tO IO 
CIO o 
O O to 
»-» to 
h- r- 
Large 
Jaw. 
tO 
« 
k-» to 
CH *-*■ 
ci cn co 
00 CM 
Protrusion 
Lower Jaw. 
& 
to to g »-» 
** 5 « 
Q 
30 
MIDDLE 
13 
6 
to 
CO H* 
Protrusion 
Upper Jaw. 
00 
Ci 
W 
► 
A. Ü Qt 
O Ci M H- 
o 
» 
»-»03 > 
CD to y 2 
M 
4- Ci 
C> r- 
High 
Arch. 
o 
to 03 
03 "4 03 
ES2 E 
5 K 
V-Shaped 
Arch. 
CD 
03 03 00 
4- tO 
03 Q3 
03 CO CO 
CO O 
Partial 
V-Shaped 
Arch. 
s 
Ot h-» 
CH tO 
Thumb 
Sucking. 
CH 
Cl 
to to 
«4 CD CM 
to CM 
CO c> CO 
to 03 
O CO 
Saddle- 
Shaped 
Arch. 
co 
to 
CO CD 03 
to ►-» Cm 
CO *4 
Small 
Teeth. 
TABLE NO. 10.-TOTAL NUMBER OF DEFORMITIES OF THE JAWS OF BOTH SEXES 
IN ALL GRADES. 
No. 
Sex. 
1 
Normal. 1 
Large 
Jaw. 
Protrusion 
Lower Jaw. 
Protrusion 
Upper Jaw. 
High 
Arch. 
V-Shaped 
Arch. 
Partial 
V-Shaped 
Arch. 
Thumb 
Sucking. 
Saddle- 
Shaped 
Arch. 
Small 
Teeth. 
1605 
924 
87 
63 
97 
238 
101 
200 
31 
159 
56 556 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It must be conceded that in an equal number of strong and feeble-minded persons 
the larger percentage of irregularities is found in the latter class. These irregularities 
do not confine themselves to the V- and saddle-shaped arches, but statistics show a large 
percentage of partial V-shaped arches and arrested development of the maxillary bone. 
Excessive growth of the superior maxilla and protruding superior and inferior jaws 
also share in the generally irregular character of the jaws and teeth of the feeble 
minded. 
In the examination of the mouths of idiots, the class distinction shows itself very 
conspicuously. The three grades of high, medium and low-bred idiots carry the stamps 
of their respective social positions in the shape of the jaws quite as prominently as other 
dominating characteristics. Institutions containing either class exclusively will record 
the characteristic jaws of that special grade; consequently, examinations by different 
men in different institutions may not show the same proportion of cases of a given 
deformity. Irregularities of individual teeth and those caused by extraction of, or 
want of attention to, the deciduous teeth were not recorded, although they were 
numerous. 
The high, the V- and the saddle-shaped arches, mentioned so frequently by Drs. 
Down, Ireland and Ballard, as being common among foreign idiots, are seen as often 
among the idiots of our own country. But the percentage of thumb-sucking cases is so 
small that it does much to disprove the reductio ad absurdum that thumb-sucking pre- 
cedes and causes idiocy-if, indeed, any disapproval be necessary. 
IRREGULARITIES THE RESULT OF ARRESTED DEVELOPMENT. 
As a result of arrested development of the jaws, two forms of irregularities will be 
observed in this paper-the V-shaped and the saddle-shaped arches. A similar result 
follows the too early extraction of the temporary molars, the modus operandi of which 
will be given further on. The normal size of the teeth vary but slightly from those 
of former ages, when deformities of the jaws or irregularities of the teeth did not 
exist. We must, therefore, look for the cause of these deformities in the jaw, and its 
relation to the development of the teeth. 
The V-shaped arch (Fig. 1) is always associated with the superior maxilla, never 
with the inferior. It is not associated with the first set of teeth, as the jaws always 
change after the eruption of the first permanent molars and incisors. The central 
incisors are turned in their sockets so that their mesial surfaces are directed toward the 
lip, the crowns inclining forward and carrying the alveolar process with them. The 
lateral incisors have changed their positions posteriorly toward the median line, not 
to the extent, however, of the centrals. The cuspids may be situated on a line with 
the laterals and bicuspids, but are frequently partially or wholly outside. The bicus- 
pids and first molars have usually dropped forward and become directed inward, until 
all, or nearly all, of the space usually occupied by the cuspid is filled. The roof of the 
mouth may or may not be vaulted, but the teeth are always crowded in this deformity. 
According to Dr. Tonies, this malformation is associated with greatly enlarged tonsils, 
which necessitate breathing through the open mouth. 
Dr. Kingsley thinks that it is nearly always of congenital origin, that it is an inher- 
ited tendency, favored, in all probability, by like circumstances with those which initi- 
ated it in the ancestry. Mr. Oakley Coles is of the opinion that premature ossification 
of the sutures produces this deformity. 
Mr. Cartwright attributes the deformity to high breeding and luxurious habits of 
life in the ancestry of the subject. 
Dentists commonly class it as one of the results of thumb-sucking, one author 
speaking of it as a thumb-sucking variety of deformity. Dr. Ballard, of England, 
after his investigations of the subject, discovered the V-shaped arch to prevail with SECTION XVIII-DENTAL AND ORAL SURGERY. 
557 
idiots, and held the theory that thumb-sucking was a forerunner of idiocy, thus apply- 
ing the argument of post hoc, ergo propter hoc with a vengeance. 
Peculiarities in the size and shape of the jaw bone may be inherited, but the manner 
of the eruption of the teeth cannot be transmitted. The jaw is always small in the 
V-shaped arch, and the first permanent molars appear and have large, long roots, which 
establish them as fixed points of resistance. At the anterior part of the mouth, the 
next teeth to erupt are the central incisors, which, with their round, conical roots and 
broad crowns, make a perfect wedge. The laterals are next to follow, and are smaller 
than the centrals, but with much the same appearance. These teeth are situated in a 
long, thin alveolar process; this, with the broad cutting edges and long conical roots 
of the central incisors, offers but slight resistance to the pressure between the laterals 
and the bicuspids and first permanent molars. Next come the first and second bicus- 
pids into place. The last to erupt are the cuspids, which, with their long roots and 
their situation outside the arch, possess great leverage. They are propelled downward 
by the pressure of the lips, and guided by the roots of the lateral and first bicuspid 
teeth. If the space is small they will encroach upon the lateral incisors, inasmuch as 
Fig. 1. 
they are smaller than the first bicuspids, and will force them (the incisors) forward and 
inward. 
The point of contact would naturally be upon the crowns, and, as a result, the cutting 
edges of the incisors are carried forward, and, being conical, are rotated in their sockets. 
While this is going on externally, the tongue, owing to the narrow space between the 
first molars, is contracted laterally, and necessarily elongated, the tongue being largely 
instrumental in shaping the contour of the alveolar process and in fixing the position 
of the teeth. When the temporary cuspids and molars are prematurely removed from 
well-developed jaws, the bicuspids and permanent molars work forward and fill the 
space, and the V-shaped arch will be formed in the manner just described. In this 
deformity the hard palate may be either low or vaulted. 
The saddle-shaped jaw (Fig. 2) is usually found in connection with the superior 
maxilla, although it is occasionally found in the inferior maxilla. It will be observed 
that in this deformity the central incisors, unlike those in the V-shaped deformity, 
never protrude, but always stand vertical with the alveolar process. The teeth are 558 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
always close together, the alveolar process is much smaller in diameter than the body 
of the jaw, and the alveolar process is situated on the inner border of the bone, being 
directed inward at the bicuspid and first molar region, and outward at the second and 
third molars. The cuspids may either be in their normal positions or pushed forward 
and outward, and, in common with the incisors and alveolar process on the lower jaw, 
they present a straight line. 
Fio. 2. 
This deformity has its primary cause in the location of the crowns of the permanent 
teeth in a dwarfed alveolar process. The bicuspids and molars, instead of being in the 
jaws in their normal position, as illustrated by curve A-B in Fig. 3, stand in a line rep- 
resented byc-D. This abnormal position in the jaws may represent a natural position 
of the follicles, or the bicuspids may be deflected by roots of the temporary teeth, and 
the crowns directed toward the roof of the mouth. When the permanent teeth erupt 
Fig. 3. 
the order is changed, the centrals and laterals take the natural position, but the cuspids 
follow instead of the bicuspids. These teeth make a fixed point of resistance in the 
anterior part of the mouth, thus protecting the incisors and preventing their protrusion. 
The first permanent molars work forward and become a fixed point in the posterior part 
of the mouth. The space between the first molar and cuspid is smaller than the long 
diameter of the crowns of the bicuspids, and both are crowded in toward the roof of SECTION XVIII-DENTAL AND ORAL SURGERY. 
559 
the mouth. The lateral and forward pressure is so great that with the aid of the 
tongue the cuspids on the lower jaw are carried forward and outward until they and 
the alveolar process appear flattened. It sometimes happens that the first bicuspid 
erupts and secures its position before the second bicuspid appears. In this case the 
crown of the first permanent molar will come in contact with the crown of the second 
bicuspid and will form an inclined plane, thus carrying the second bicuspid inside the 
arch, which will frequently be found turned in its socket, the cusps facing the anterior and 
posterior part of the mouth. In all cases the alveolar process is built about the teeth, 
giving them strength and firmness in whatever position they assume. 
This deformity is always associated with a high-vaulted arch. It is less frequently 
seen than the V-shaped arch, because the natural order of eruption is interfered with in 
the saddle-shaped deformity; the cuspids appearing before the bicuspids. We find in 
the saddle-shaped arch that the second and third molars are forced laterally. The alve- 
olar process is carried with it and rounded out. The same condition is also noticed in 
jaws having very flat arches. These abnormal conditions are caused by the pressure of 
the tongue against the posterior part of the hard palate, in the process of swallowing, 
the constricted arch preventing the normal position of the tongue. 
HEREDITY IN ITS RELATIONS TO IRREGULARITIES. 
It is a fact, universally recognized, that various morbid conditions and peculiarities 
of structure are often transmitted from parent to child, through many generations. 
This law of heredity is almost universal in its application, and its influence may be 
either enhanced or depreciated through successive or alternate generations, until we 
have, upon the one hand, a total disappearance of the heredity impression, or, upon 
the other, an increase so great that the condition becomes incompatible with the life of 
the individual. This variation is a fortunate circumstance, as by it the human race is 
protected from certain destruction. 
This plan of variation is powerful for good or evil, according to the environment of 
the individual, or of the family to which he belongs. This fundamental, evolutionary 
law of heredity is nowhere more manifest than in the case of perversions of develop- 
ment of both internal and external organs, either embryonal or post-natal, and it is a 
most powerful factor in the production of deformities of the jaw and irregularities of 
the teeth. Not only does this hold true in the case of general irregularities due to max- 
illary deformities, but it also applies to malformations of individual teeth. Thus, I 
have observed, in a family consisting of mother, daughter and grand-daughter, a pecu- 
liar fissured condition of the enamel upon the labial surface of a left superior lateral 
incisor. 
It is not uncommon for a child to possess peculiarities of the teeth of one jaw 
resembling those present in the father, while the other presents irregularities of develop- 
ment precisely identical with those present in the mother. Again, one parent may 
transmit peculiarities of maxillary development, while the other transmits certain char- 
acteristic appearances of the teeth. Much has been said of late regarding the influence 
of ante-natal impressions upon the development of deformities, and if the claims 
advanced be but half true, it is probable that the teeth and jaws may occasionally suffer 
their share of the resulting detriment. Evidence of dental from this cause 
is of necessity difficult to obtain. A case is recalled, however, in which a peculiar con- 
dition of irregularity of teeth was attributed by the mother to her constant worry, 
during gestation, lest the coming child should have teeth as irregular as her own. When 
dentition was finally completed in the child, the arrangement of the teeth was identical 
with those of the mother. This case is not advanced as an evidence of ante-natal 
impressions, but because of its suggestiveness. 
Very often we are absolutely unable to determine the precise degree of influence 560 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
exerted by heredity, even when we are convinced that it is a powerful factor. It is evi- 
dent to any one upon reflection that the same causes which will produce deformities 
independent of hereditary influences, will also prevent the latter from acting as they 
otherwise would. 
The teeth are creatures of circumstances, i. c., they develop independently of the 
alveolar process, hence their order of development, and the resistance imparted by 
other teeth and roots, all combine to produce irregularities; in short, local causes pro- 
duce a majority of irregularities and modify formations which might be otherwise the 
exact counterpart of those presented by the teeth of the parent. 
The following cases in practice illustrate this theory. In one family under my 
observation, the father's jaws are well developed and contain large, strong teeth. The 
mother's jaws are small, the teeth being regular in the lower maxilla. In the upper 
maxilla the central incisors are regular and in normal position, but the cuspids, bicus- 
pids and molars have come forward and filled the spaces occupied by the laterals, which 
were extracted at the age of thirteen. Two sons (their only children) have lower jaws 
and teeth closely resembling the mother's. The upper jaws and teeth of both resemble 
the father's in size and strength, but, unlike the father's, they are very irregular in 
Fig. 4. 
position. This tendency to irregularity of position is a marked inheritance from the 
mother. 
Fig. 4 is a model of the jaws of the eldest son, who is fourteen years of age. As 
may be observed, the central incisors of the upper jaws are regular, the laterals are 
forced by the cuspids some distance inside the natural line, the cuspids, bicuspids and 
molars are anterior to their normal position. 
Fig. 5 illustrates the jaws of the younger son, aged eleven. The centrals and laterals 
erupted at the proper time. The cuspids are encroaching upon them to such an extent 
as will eventually form a V-shaped arch. Both boys have been under my càre from the 
beginning, the temporary teeth being removed at the proper time. 
It will be observed that the tendency toward irregularity in arrangement is decidedly 
inherited from the mother. The conditions are so modified by local influences that, 
although the hereditarily irregular arrangement comes from the mother, they are not 
exact counterparts of the mother's irregularity, nor are they alike. It is questionable 
whether exact counterparts of irregularities are ever inherited from parents. Various 
local interferences and conditions will, as we have seen, influence this one way or the 
other. Transmissions of small jaws and of peculiarities of individual teeth are, how- 
ever, quite common. SECTION XVIII-DENTAL AND ORAL SURGERY. 
561 
* In 1864, Messrs. Cartwright & Coleman, of London, examined some 200 skulls in 
the crypt of Kythe church, Kent, which had been deposited there for centuries. They 
found the alveolar processes and teeth perfectly developed and formed. 
In 1869, Mr. John R. Mummery, London, read a paper before the Odontological 
Society of Great Britain, in which he gave a report of his extended researches, includ- 
ing over 3000 skulls of ancient and modern uncivilized races, and concluded that the 
early and half-savage people were freer from dental irregularities than moderns. Dr. 
Nichols, of New York, has examined the mouths of thousands of Indians and Chinese, 
and says, with but one exception, he never found an instance of irregularities in either 
of these races. 
I can confirm the statement of Dr. Nichols as regards the Chinese, having examined 
the teeth of many of them on the Pacific coast. The above reports, together with the 
testimony of other investigators, show that ancient uncivilized and nomadic barbarians 
have perfectly-shaped dental arches. 
The interesting circumstance that irregularities occur more frequently now than 
formerly, and among people living in new countries, would suggest the idea that irregu- 
larities caused by heredity may result from the intermarriage of different national!- 
Fig. 5. 
ties, the offspring of such unions partaking irregularly and in different degrees, of the 
racial peculiarities of maxillary development of either or both parents. It is probable 
that the varying character of food, and the abuse of the teeth incident to the depraved 
hygiene of modern civilization, have much to do with dental malformations. Again, 
the higher the evolutionary type of individuals, the more imperfect the teeth and jaws 
become. 
The nearer the monkey, and the further removed from refined and civilized man, the 
better the teeth. As the animal becomes less and less dependent upon his jaws and 
teeth for a livelihood, the less perfect these structures become, and after the lapse of 
many generations, marked variations and imperfections of development are logically to 
be expected. 
THUMB-SUCKING. 
As compared with other causes, thumb-sucking but rarely produces irregularities of 
the teeth and jaws. Those irregularities which are produced by this vicious habit are 
not uniform or extensive. They may occur in the centre of the jaw or upon either side, 
this depending upon the position of the thumb or finger. The teeth of either jaw may 
Vol. V-36 
*■ Kingsley's " Oral Deformities." 562 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
be prevented from erupting or the alveolar process may not develop, on account of the 
pressure, as illustrated in Fig. 6. The superior teeth and jaw may be brought forward 
by absorption and deposition of bone, and the lower teeth and alveolar process carried 
backward in the same manner, by the pressure of the thumb. (Fig. 7.) 
The inferior maxilla may be carried backward, in which event the angle will be a 
right angle instead of an obtuse one. In thumb-sucking the arch changes to an oval 
Fig. 6. 
Fig. 7. 
shape rather than to a sharp V-shaped angle. The habit of thumb-sucking is acquired 
in infancy and continued while the first teeth are in the jaw, when the roots are small 
and very impressible. It will be found that this form of irregularity does not occur in 
the second set of teeth unless the habit of thumb-sucking was acquired and made mani- 
fest in the first set of teeth, while the alveolar process was in a constructive and forma- 
Fig. 8. 
tive stage and easily influenced by pressure in any direction. During this time the 
teeth also are readily moved by constant pressure of the thumb, finger or lip. Such 
irregularities of the first set of teeth are easily diagnosed. The rapid growth of the 
jaws and the comparatively small teeth at this period would admit of no other general 
deformity. The habit is usually outgrown or corrected by the time the permanent 
teeth appear. If the habit is continued after the second teeth erupt, they will assume SECTION XVIII-DENTAL AND ORAL SURGERY. 
563 
the shape and position of their predecessors. The teeth protrude in a fan shape, which 
is quite marked, on account of the anterior teeth being large and long ; the alveolar 
process meantime will take the shape of the object sucked, making it round instead of 
at an angle. There are always spaces between the teeth of the superior maxilla, a char- 
acteristic not seen in other irregularities. The teeth of the inferior maxilla are always 
crowded inward. Occasionally the finger or substance sucked is carried far enough into 
the mouth to change the shape of the alveolar process or the palatine surfaces of the 
incisors, but the hard palate is seldom changed by such pressure. The arch or hard 
palate in such cases is as likely to be perfectly flat as it is to be vaulted. The illus- 
tration (Fig. 8) is taken from a model in the collection of Dr. E. D. Swain, of Chicago. 
The deformity is exactly in the centre of the superior maxilla, involving the incisors 
and canines. The hard palate is flat in the extreme, consequently the thumb might 
have produced absorption of the bones, or a change in the shape of the arch, were the 
prevailing theory correct, but in this case no change took place. 
INTRODUCTION OF PROF. N. S. DAVIS, PRESIDENT OF THE NINTH INTERNA- 
TIONAL MEDICAL CONGRESS. 
The President of the Section (Dr. Taft) said : You are all aware, gentle- 
men, that the dental profession (if I may use that expression) is in a very different 
position from that which it occupied four months ago. It stands to-day, in some 
respects, much above the plane on which then, and previous to that time, it stood. 
A movement has been made which has much changed its position and given it one 
far better in many respects than it has ever occupied before. The success with 
which we are meeting to-day is owing, in a goodly measure, to the action which took 
place at that time, and with which you are all acquainted. By that action many 
embarrassments were removed which, prior to it, seemed to be almost insurmountable. 
The influence of that action is not only operative on the representatives here assem- 
bled, but on the whole profession in our country, and although it may not reach so 
definitely the profession in other countries, its influence will be reflected around the 
world, wherever dentistry is practiced. He to whom you are indebted for that 
movement is present with us to-day, the President of the Ninth International 
Medical Congress, a friend of the dentist, as he has manifested himself to be for a. 
quarter of a century past. He has done as much as (yes ; may I not say more 
than ?) any medical man in the land for the elevation and promotion of the interests, 
of dentistry. I now have the pleasure of introducing to you Prof. N. S. Davis, the 
author and mover of the resolution which has had so great an influence on the pro- 
fession, an influence which will extend to the future, growing and becoming more 
and more manifest as the course of time moves on. (Applause. ) 
Dr. Davis said :- 
Mr. President and G-entlemen:-I had no thought, in coming in, of inter- 
rupting your proceedings a moment. I have had the curiosity, or rather I have 
thought it my duty, as time offered in the afternoon of each day, to look through 
the Sections, all of them, simply to see what was the attendance and how they were 
progressing ; and so far I have found nothing but progress and cheering tidings, both 
in regard to attendance and the quality of the work. In regard to my action in 
relation to the department of dentistry, I have not been actuated by any temporary 564 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
influence or special regard fur the dentistry branch of medicine more than for any 
other branch. It has seemed to me that the goal at which we should all aim (as the 
different departments of medicine develop and arrive at a reliable, scientific plane) 
should be to bring them into harmonious action. The day has gone by when there 
can be any successful founding of sects and schools and dogmas. Medicine to-day is 
not an aggregation of some man's theoretical dogmas, but all medicine worthy of 
the name is founded on scientific investigations, accumulated facts and true inductive 
reasoning. 
When, in 1865, in the early history of the national organization of your branch 
of medicine, a session was held in Chicago, I Had the pleasure of inviting its mem- 
bers to a simple entertainment at my own house, simply as a matter of courtesy. 
But I was unexpectedly called upon to say something to the assembled guests, and 
I then made the suggestion that our teeth and jaws, from childhood up, were as 
important a part of the human organization as the eyes, the ear or any other part of 
it, and that a knowledge of how to treat their diseases, their accidents, their injuries, 
depended on the same application of scientific principles as in all other departments 
of medicine ; and I predicted then that the time would come when the dental pro- 
fession would be recognized, and would stand on the same plane with pathology, 
laryngology, ophthalmology, gynecology, or any othèr ' ology ' that may be named, 
as a part of the great, broad field of medicine. 
In the progress of events since that day I have seen schools develop for the 
education of dentists ; I have seen dental departments added to universities, gener- 
ally alongside of medical schools ; and I have seen their students being educated in 
the same classes, by the same professors, and taking their degrees from the same 
authorities. And this in some of the best institutions that we have. And it 
seemed to me, in the last meeting of the American Medical Association, the time 
had come when the American Dental department of Medicine should no longer stand 
as a profession by itself. For why should the doctors of the mouth and teeth have 
a separate profession any more than doctors in any other department? They 
demanded, in their best dental schools, almost identically the same education as in 
all the other departments. If they deviated in anything it was in requiring dental 
students to confine their clinical studies to the branch which they were to practice. 
And so, I say, the time had come when an official declaration (so far as the National 
Association was concerned) should bring them on the same plane as other recognized 
medical specialties, that whoever practiced dentistry by authority should be recog- 
nized as a member of the medical profession in the United States. ( Applause. ) 
I am most happy to say that I did not misjudge the signs of the times, for my 
proposition was received most cordially, and was adopted as the official declaration 
of that body. I did not hear a dissenting voice. This action put the educated part 
of the dental profession up to the proper standard. Its members are now a part of 
the general medical profession ; co-laborers in the broad field of medicine, one with 
all other departments, and I hail you, gentlemen, in that capacity. Moreover, if I 
can live a few more years (for the allotted time for me is drawing near), I hope to see 
the last vestige of pretended "schools'' of medicine swept away. There is no 
"school'' of medicine, in the proper sense. (App7«wse.) There is neither a 
homoeopathy, an eclecticism, nor an allopathy. (Applause.) Now no man should 
be recognized who is not willing to come on the broad platform of a simple doctor of 
medicine, without a ' ' pathy ' ' or " ism ' ' or a qualifying adjective. I trust that you, 
gentlemen, in your department of medicine, will labor to that end. If any man with 
a " pathy'' or "ism, " or special school approaches you, tell him that you know no SECTION XVIII-DENTAL AND ORAL SURGERY. 
565 
" school," no " pathy," and that you will not have anything to do with him unless 
he comes on the broad field of medical science, and that alone. ( Applause. ) 
The President then said :-I am sure there is not one of us here who will ever 
forget the kind and cheering words to which we have just listened. I am sure that 
every one will feel encouraged and strengthened by them, and that feeling will grow 
and mature with the future. We have present with us to-day one for whom we 
have been looking these three or four days, and wondering why he did not come 
among us ; I mean Prof. Busch, of the Dental Department of the University of 
Berlin. I now take great pleasure in introducing him as one of the representative 
men of our profession in Germany, Professor Busch. 
Prof. Busch acknowledged the compliment. His remarks were in German, and 
were interpreted by Dr. Rehwinkel, of Chillicothe, Ohio, one of the Secretaries, 
who said :- 
Prof. Busch expresses his regrets, gentlemen, that he was detained, on account of a 
very rough passage, longer than he anticipated. He was fourteen days on board the 
ship, and at one time he feared that it would be utterly impossible to reach America 
in time to participate with the Section. He arrived in Washington only this morn- 
ing. For the short time that he has been here he is delighted with the country and 
with everything that he has seen, more especially delighted with the kind and 
encouraging address just made to us by the President of the Congress. He is par- 
ticularly struck and gratified with the fact set forth by the President, that the dental 
branch of the profession now stands on the same plane with that of other branches 
of medicine. That object he has constantly pursued himself, and is constantly pur- 
suing, endeavoring to lead the profession in Germany up to the same plane. Although 
at the present time there is not that equality, in one sense, between dentists and 
physicians, the inequality is merely in title. So far as everything else is concerned 
the dentists and physicians are very nearly alike. The studies in Germany are very 
much like our own, perhaps a little more stringent. A preliminary education, for 
instance, is more requisite there than here; but when it comes to the university 
studies, they are very much alike in this department. Prof. Busch says he comes 
over especially to see and examine, and to inform himself on educational methods as 
practiced in this country. ( Applause. ) 
NOTES ON ORTHODONTIA. 
REMARQUES SUR L'ORTHODONTIE. 
ANMERKUNGEN ÜBER ORTHODONTIE. 
BY EDWARD H. ANGLE, D.D.S., 
Of Minneapolis, Minn. 
Gentlemen In reviewing the literature of the past fifteen or twenty years on 
the subject of Orthodontia, it is gratifying to note the progress made, and yet, when we 
consider the large number of patients possessing malposed teeth which need our atten- 
tion, and the frequent failures, or worse than failures, made by the limited number of 
our profession who give the subject any attention whatever, we are reminded that there 566 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is still much to be accomplished before this great subject is unfolded to us in a manner 
in which we may comprehend it in all its requirements. In this brief paper I shall 
confine myself to the consideration of movements of the teeth during treatment and, 
later on, shall offer for your consideration some appliances for accomplishing these move- 
ments and the retention of the teeth when in proper position. In studying the condi- 
tions by which we may best accomplish the movements of the teeth, we may simplify 
matters if we remember the movements are but five, viz., forward and backward in the 
line of the arch, inward or outward in the line of the arch and partial rotation. These 
and their slight modifications (with the exception of elongation and depression, which 
are so rarely necessary that I will not here speak of them) are all we are called upon 
to perform. The principles governing all of these movements are the same, so that by 
understanding the principles governing one we may comprehend them all. Only one 
of these movements by means of a mechanical appliance should be undertaken at the* 
same time, otherwise the liability to inflammation is greatly increased. After having 
moved a tooth the desired distance in one direction, it should bé firmly stayed from 
retrogression, when other movements, if desired, may be accomplished. In accomplish- 
ing the movement of a tooth by force, it matters little whether the pressure be con- 
tinuous or intermittent, since the results are the same. The movements of a tooth 
should be completely under the control of the operator, and should be fast or slow, as 
his judgment may dictate, system and accuracy being observed at every step. And 
perhaps no one of the mechanical powers so nearly fills the requirements in aiding the 
operator in this respect as the screw. It is powerful and compact and the many dif- 
ferent ways in which an ingenious operator may make use of it renders its application 
almost universal, and it may nearly always be used inside of the arch, thus avoiding 
the appearance of unsightly appliances. Next in value I should place the spring com- 
posed of piano wire. 
In applying force to a tooth, it should be sufficient to accomplish the movements as 
rapidly as is consistent with the laws of physiology. 
The unnecessary length of time often occupied is a very common cause of failure 
(both operator and patient oftentimes becoming exhausted before the operation is com- 
pleted). 
When pressure is once applied, it should continue without relinquishment, for there 
should be no retrogression of the tooth. Indeed, I attach so much importance to this 
fact that I believe it may belaid down as a law in orthodontia, for I believe the frequent 
removal of pressure is contrary to the laws of physiology, and when occurring, as by 
slipping, breaking appliances, frequent adjustment of ill-designed appliances, or for pur- 
poses of cleansing or changing of appliances, is the cause of nearly all the soreness and 
pain; and, I may add, a very common cause of failure in regulating. And to this cause 
directly, I believe, may be traced strangulation and death of the pulp, which is so often 
attributed to the too rapid movement of a tooth. 
An appliance for accomplishing the movement of a tooth should be so perfect in 
design, construction, application and operation that there should be no occasion for its 
removal until the object for which it was designed is accomplished. 
In the movement of a tooth, it is necessary that the resistance, at the point from 
which pressure is exerted, should be sufficient to completely overcome the resistance 
of the tooth being moved, but the regulating appliance should never be allowed to 
rest in contact with the gum, as no substantial resistance can be gained by so doing, 
and more or less inflammation will be the result. 
The practice of covering the crowns of the molars or bicuspids with metallic caps 
or vulcanite, thereby preventing the proper closure of the jaws, is unnecessary, and 
should be deprecated. SECTION XVIII-DENTAL AND ORAL SURGERY. 
567 
On this subject little has been given us, and to this question far too little importance 
is attached. After the malposed tooth has been moved into the desired position and 
proper occlusion secured, it should be firmly supported and retained in such position 
until it has become firm in its socket. 
A retaining appliance should hold the tooth so firmly that there will be no move- 
ment to disturb or in any way interfere with the new bone formation. Absolute 
rest is essential to the most speedy and satisfactoiy results. The importance of a firm 
support and rest while the tooth is becoming firm, is well illustrated, says Guilford, in 
the necessity of placing a fractured limb in immovable splints. 
I greatly doubt if alveolar tissue, formed under unfavorable circumstances (such, for 
instance, as would obtain in mal-occlusion, or in the use of appliances necessitating fre- 
quent springing in and out of place for the purpose of cleansing) would, on close 
examination, be shown to be normal. 
A retaining appliance should remain stationary until the object for which it was 
designed is accomplished; at the same time it should be clean, and in no way irritating 
to adjoining tissues, as it must of necessity be worn for a long time. 
A number of devices for retaining the teeth have been constructed, such as lacing 
the teeth with silk and wire ligatures, rubber plates, plates with clasps, etc., all more 
or less uncertain in their action, and defeating, to a greater or less extent, the object 
for which they were designed. 
I will now call your attention to a few simple appliances for accomplishing the 
different movements of the teeth, and retaining them when in the desired position. 
Their great strength, simplicity, cleanliness and the firmness with which they are held 
in position while accomplishing their work, render it possible for any dentist of average 
ability to easily construct and apply them, and to continue the movements, without 
interruption, to the most speedy and satisfactory termination ; and I may add, if the 
work is carried forward with care and judgment, the operation will, in the majority 
of cases, be comparatively painless. 
Before passing to the consideration of my own appliances, I wish to speak of the 
valuable practice of cementing delicate bands of gold or platinum around the teeth to 
be moved. This is not a new idea. I believe the honor of bringing this invention before 
the profession is due to Dr. W. E. McGill, of Erie, Pa. It plays so important a part in 
connection with the appliances I am about to show you, that I wish to speak especially 
of the method which I have found to be the easiest and quickest in making and applying 
these bands. A strip of 32 to 36 gauge platinum, about one-eighth of an inch in width, 
is made into a loop and slipped over the tooth to be banded. The ends are now grasped 
close to the tooth by a pair of flat-nosed pliers, and the band drawn tightly about the 
tooth, a strong burnisher being applied atAhe same time, to still further assist in making 
it conform to the shape of the tooth. The band is now removed and presents the 
appearance as shown in Fig. 1 ; a small bit of solder is now placed in the band at the j unc- 
tion, and all carried in contact with the flame of a soldering lamp; after it is soldered 
the ends are clipped off, and the band is now complete and ready for any attachments 
which may be made, after which it is cemented in position upon the tooth, as shown in 
Fig. 2. 
For accomplishing the five movements of the teeth, I use the following simple 
appliances. A small jack-screw, as shown in Fig. 5. A traction screw, shown in 
Fig. 4. Rotating appliance, shown in Fig. 3. For making and using these appliances, 
all that is needed is Stubb's steel wire, of three or four sizes, some jeweler's gold-plated 
wire and some hollow wire, or, as it is known among jeweler's, joint wire, which may 
be of either gold or silver. 
The jack-screw is made by cutting a thread on a piece of Stubb's steel wire the 
RETAINING APPLIANCES. 568 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
desired size and length; one end of this screw is then beaten flat. On to the other end 
is screwed a small nut made of platinized gold. The whole, complete, is shown in Fig. 
8. A piece of the joint wire is now sawed off the desired length and the end left square, 
FIG 8 
FIG 7 
F I G 6 
FIG 5 
F I G 4 
FIG 3 
FIG I. 
FIG 2 
as in Fig. 7, or plugged, and filed or turned to around point, as shown in Fig. 6. The 
screw is then slipped into this pipe, and the whole jack-screw is now complete and 
ready for use, as shown in Fig. 5. This style of jack-screw may be made of any size SECTION XVIII-DENTAL AND ORAL SURGERY 
569 
or length; the largest I have yet made being two and a half inches in length, the 
shortest one-fourth of an inch. 
The traction-screw is made of Stubb's steel wire gauged, as in Fig. 4, in a very 
similar manner to the jack-screw, with the exception that one end of the screw is bent 
sharply at right angles. The screw complete is shown in Fig. 4. The entire length of 
the screw is about three-eighths of an inch. The angle or bent portion of an 
inch. 
The rotating appliance, a piece of piano wire about two and a half inches in length, 
is bent at one end into the form of an eye. Complete, it is shown in Fig. 9. Rotation 
by means of this instrument is accomplished by banding the tooth to be rotated in the 
usual manner. Before cementing the band in position on the tooth, a piece of joint 
wire (the bore of which is exactly the size of the piano wire just described), one-fourth 
of an inch in length, is soldered to the band on the buccal portion, at right angles to 
the axis of the tooth. Complete, it is shown in Fig. 2. The band is now cemented in 
PIG 
FIG 9 
position on the tooth. The straight end of the piano wire is inserted into the little 
tube, the other end sprung around and made fast by means of wire ligatures to the 
tooth nearest the eye. Fig. 9 shows an incisor tooth being rotated by this method. 
After the tooth has been moved into the desired position, it is retained in such position 
by removing the spring and inserting a piece of gold-plated wire into the tube from the 
opposite side, long enough for the end to rest on the labial surface of the tooth adjoin- 
ing, as shown in Fig. 9|. For accomplishing the movement of a tooth from within 
outward into line of arch, the jack-screw is used in the following manner: The tooth 
to be moved is banded and piped, in the manner just described in rotating. Into the 
palatal side of the band is formed a slot, into which is inserted the flat end of the jack- 
screw. Resistance for the base of the jack-screw is gained by selecting a sufficient 
number of teeth to completely resist the pressure of the moving tooth. These teeth 
are banded in the usual manner and piped, close to and on a line with the gum, and a 570 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
piece of the gold-plated wire is threaded through these little pipes, either before or 
after cementing the bands in position. Against this wire is placed the base of the 
jack-screw. Fig. 10 shows the screw in position in moving an inlocked canine. 
Force is applied by tightening the nut with a small wrench. 
After the tooth is moved into the desired position, it is secured and firmly held in 
such position by passing a short piece of the gold-plated wire through the little tube 
previously soldered to the labial or buccal portion of the band, the wire being long 
enough for the ends to rest upon the labial or buccal surface of the tooth on each side. 
Thus the tooth is effectually keyed into its new position, as shown in Fig. 10i. 
The movement of a tooth from without inward into the line of the arch is accom- 
plished by banding and piping the tooth to be moved, the pipe resting close to and on 
a line with the gum on the palatal side. The angle of the traction-screw is hooked into 
the pipe. Resistance is gained by banding, piping and wiring together (either gold or 
piano wire may be used) a sufficient number of teeth in the arch to overcome the resist- 
Fig. 10%. 
Fig 10. 
ance of the tooth being moved, the traction-screw and nut drawing through and 
against a short piece of the joint wire soldered to the wire of resistance on a line with 
the screw. Fig. 11 shows the screw in position in moving a central incisor. After the 
tooth is moved into the desired position, it is retained by removing the angle of the screw 
from the pipe and slipping into its place a short piece of the plated wire, the ends rest- 
ing against the palatal surface of the tooth on each side, as shown in Fig. llj. The 
movement of a tooth backward in line of the arch is accomplished by banding and 
piping the tooth to be moved (for example, a canine) same as for rotation; a suitable 
tooth of resistance is selected (for example, second molar), banded and piped, the pipe 
being soldered to the band on a line with the axis of the tooth. Into this pipe is hooked 
the angle of the traction-screw. (A longer screw than the one first described is used, 
but of the same gauge.) The screw is passed through the pipe in the tooth to be moved 
and the nut applied. Fig. 12 shows appliance in position. The nut is tightened as often 
as necessary, and the screw, as it passes through the nut and becomes irritating to the SECTION XVIII-DENTAL AND ORAL SURGERY. 
571 
Fig. liy2. 
Fig.11 
Fig. 12. 572 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lips, is snipped off. After the tooth has been moved back the desired distance, it is 
retained in such position by the screw already in position, or the screw may be removed 
and the plated wire inserted in its stead. The movement of a tooth forward in line of 
the arch is accomplished in the same way, only selecting a tooth of resistance from the 
opposite side. Such are the general ways of using these appliances, but the different 
Fig. 13. 
ways in which they may be applied are almost limitless, each case requiring some slight 
modification. Fig. 13 shows the manner in which the traction-screw may be used in 
moving into line an inlocked incisor, at the same time expanding the arch. 
The ligature represented by a dark line in the drawing is composed of fine steel 
Fig. 14. 
wire annealed. Fig. 14 shows the method in which the arch may be expanded by 
using two short jack-screws soldered to heavy pieces of brass wire bent to conform to 
the shape of the palatine arch. The screws in this case are about one-quarter of an 
inch in length; after the nut has been tightened until the screw is nearly passed over it, 
it is removed and the bent portion of the heavy brass straightened or drawn out, in SECTION XVIII-DENTAL AND ORAL SURGERY. 
573 
order to gain more purchase for the screw. Only one of these appliances is removed 
and straightened at a time, the other one remaining in position in order to prevent 
retrogression of the teeth being moved. 
In conclusion, let me add, the greatest care and accuracy should he observed in the 
construction, application and use of these appliances. The little tubes should be of 
gold and fit snugly the different parts of the appliances passing through them, and if 
you will derive as much satisfaction in using them as I have, I shall feel abundantly 
repaid. 
DISCUSSION. 
J. N. Farrar, m.d., d.d.s., New York City, N. Y., after discussing informally, 
at considerable length, the papers on Ætiology of the Teeth, spoke concerning the 
reason for correcting irregularities of the teeth by intermittent force, as follows:- 
Mechanical appliances for regulating teeth are constructed upon different princi- 
ples of mechanics, now known as the probable and the positive; so called because 
one is certain and definite in action, while the other is not. These two plans not 
only act upon different mechanical principles, but are thought to exercise peculiar 
characteristic influences upon the functions of the tissues involved. The plan of 
construction by probable mechanics implies the use of elastic materials, such as 
springs and rubber, in such a way that a continued force is maintained upon the teeth 
to be moved, the management of which force is not only generally beyond all control 
of the patient, but is, I think (especially in operations on adults), difficult to be made 
to harmonize sufficiently with physiological functions to attain the highest success 
with the least pain, in the majority of cases. 
The positive plan consists in constructing the apparatus in such a way that the 
force acts intermittently, at will., to any desired degree, and is not only manageable 
by the dentist, but also by the patient, who really is the best judge of the greatest 
degree of force that can be applied short of causing pain. 
This intermittent principle of action may be approximately attained by the use of 
the old and well known wooden wedge pegs set in a plate, metallic fingers projecting 
from the plate, so that they may reach out to bear upon the teeth by being occasion- 
ally bent, or by inclined planes, but generally can be better and more accurately 
applied by the use of the screw. 
Although various appliances have for a long time been in use for moving teeth, 
there was no classification attempted, so far as I know, until it grew out of an inquiry 
into the action of tissue changes, involving a long series of original experiments dur- 
ing the process of regulating the teeth. The result of these experiments appeared 
to me to prove the possibility of moving teeth sufficiently within the domain of 
physiological action (both progressive and retrogressive) to attain the highest possi- 
bilities, with little or no pain, a theory which years of subsequent experimental prac- 
tice, carefully recorded, has satisfied me to be the most scientific for the class of cases 
referred to.* 
Tissue changes in the sockets, requisite to the movement of the teeth, are not 
" necessarily pathological," as has been supposed. While the pain and exhaustion 
caused <by movements made artificially are clearly indicative of perverted physiologi- 
cal action, the unconscious straggling of a tooth from its proper position, or even the 
drifting of a tooth by improper antagonism with its mate, or from over-crowding by 
* The report of these experiments was placed in the Archives of Jefferson Medical College. 
Philadelphia, Pa., U. S. A., in 1873-4. 574 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
adjacent teeth, both of which, when occurring naturally, are accompanied with no 
pain or inflammation, are equally clear evidences that the tissue changes have been 
carried on within the domain of physiological or normal changes. 
If the double process of retrogressive metamorphosis and absorption and forma- 
tion of new tissue (in many cases the necessary tissue acts before and behind a tooth 
which is being artificially moved), when kept within certain limits, is painless, and 
if pain is the result of overstepping the domain of healthy action, it is self-evident 
that the painless method is more scientific, because more humane. Again, if pain is 
the result of perverted physiological action, whether caused by continued force or by 
too great a degree of intermittent force, it logically follows that, notwithstanding 
that the circumstances of cases may justify it at certain periods in some very difficult 
operation, or even where economy of time or expense is a matter of consideration, it 
cannot be denied that to the extent that pain is avoidable it is a violation of the law 
of harmony. This statement, however, is not intended and should not be considered 
to mean that pain or inflammation alone is evidence of malpractice. 
If intermittent force of a definite degree, alternated with proper intervals of rest, 
will more generally attain the highest possibilities with the least pain and least 
annoyance to the patient, then the interests of humanity naturally suggest that, as 
a general rule in adult cases, teeth should be regulated by this system whenever 
circumstances will permit. I said "whenever circumstances will permit," for every 
dentist knows that the conditions are sometimes such, owing to the shape and loca- 
tion of the crowns of the teeth, as to render it impossible to use such devices. 
It is a well-understood maxim that the most scientific way of doing a thing is the 
way which is best under the circumstances. This, of course, may be carried so far as 
to include the capacity of the operator, but I do not wish to be considered as imply- 
ing this; nor are these remarks intended to mean that such devices as act upon the 
positive mechanical principle of action should be generally used for patients at an 
early age, say under ten years, when the roots of the teeth are only partially devel- 
oped, and when the gums and alveolar tissues are so soft that the least assistance 
will move them into place with little or no pain. 
To differentiate more clearly, I will reiterate in brief that, while the old plans of 
constructing regulating apparatus only recognized one thing as essential, force, a 
view based upon the belief that " force is force," no matter of what character, or as 
one essayist puts it, ' ' it matters little whether the pressure be continuous or inter- 
mittent, since the results are the same,"-implying that the results are the same, 
and not even taking into account the almost necessary concomitant of such devices, 
filthiness,-I claim that the character of force can govern the question of pain, that 
the tissues will always painlessly tolerate a proper degree of intermittent force if not 
too frequently repeated, and that any cleanly mechanical apparatus which can be 
controlled at will so as to attain these ends, when based upon and operated with 
these functions in view, embodies the main principles of a system that I consider 
the most scientific. 
This being my opinion, it goes without saying that regulating apparatus con- 
structed substantially as here shown by the essayist preceding me, must be, in the 
main, in accordance with my views ; but when the essayist attempts to assert that 
this is a new system of regulation and retention, I think he is assuming that which 
cannot be accepted by readers of the dental journals. So far as the mechanical 
devices are concerned, it would be easy to mention the journals which contain descrip- 
tions and illustrations, substantially, of every one of them. But this is not the time 
or place to do so; indeed, it is unnecessary, as they must already be familiar to all. SECTION XVIII DENTAL AND ORAL SURGERY. 
575 
Mechanisms for regulating teeth are now numbered by the hundred; some are 
simple, others complicated; both kinds are equally valuable in their place. Of the 
many fixtures that I have devised and published from time to time, probably the 
simplest is a metallic clamp-band made of a ribbon of rolled gold wire, on each end 
of which is soldered a nut, which in turn are connected by a screw. These devices, 
which are of various sizes* (Fig. 1), are used either as regulating devices, per se, 
Fig. 1. 
Different sizes of Clamp-bands and Anchor-bands. 
for drawing teeth toward each other, as illustrated in Fig. 2, or as anchorage for the 
attachment of other regulating devices ; as, for instance, a splice-band connected by 
means of hooks and staples, as illustrated in Figs. 1 and 3, or for connecting a long 
band, extending partially or entirely around the dental arch (Fig. 4). This long 
band may be connected by detachable screws, as shown in Fig. 4, or locked, as shown 
in Fig. 5. 
This locking mechanism, which I devised many years ago, and published in 1886,f 
Fig. 2. 
Fig. 3. 
Clamp-band in use. 
Splice-band. 
has not proved as valuable as I expected, yet for adjusting a forward or a backward 
force it*is occasionally useful. To connect these extras to the anchor clamp-bands, 
the posterior nut of the band should be made double or triple, as shown in detail in 
Fig. 6. 
* Described by the author in The Dental Cosmos, January, 1876. 
f Dental Cosmos, March, 1886. 576 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The clamp-bands as well as the splice-bands may be prevented from working 
down upon the gum by having ears made upon them to rest in the sulci of the teeth, 
or by gum guard-rings having lugs for the bands to rest on (Fig. 7). These guards 
are placed over the teeth before the other devices are put on. 
Clamp-bands are excellent anchorages for jack-screws, which may be made to 
Fig. 4. 
Fig. 5. 
Long Bands with Connecting Screws. 
Fig. 6. 
Band locked. 
Clamp-band Nuts. 
Fig. 7. 
Fig. 8. 
Fig. 9. 
Push-jack. 
Push and draw yoke-jacks. 
Gum Guard-rings. 
push or to draw teeth in nearly every direction. This combination may be simple 
or complex, depending upon the number of parts and pieces used. Figs. 8 and 9 
will illustrate some of the simpler combinations and Fig. 10 one of the most complex. 
The spindle-points of the jack-screws may rest in holes in ferrules cemented to the SECTION XVIII-DENTAL AND ORAL SURGERY. 
577 
teeth to be moved, as illustrated in Fig. 11, or they may rest in sockets tied to the 
teeth with strings, as shown in Fig. 16. The more complicated fixtures in connec- 
tion with the clamp-bands I generally improvise from various elementary devices 
selected from what I denominate the "universal set." This consists of different 
Fig. 10. 
Machine for enlarging the upper dental arch. 
Fig. 11. 
Fig. 12. 
Ferrules for lodgment of spindle-jacks. 
C, screws; K, rings; T's, N, for draw-jacks 
sizes of anchor-bands, push-jacks, E; draw-jacks, anchor-jacks, J; rings, R; T's, 
N; ferrules, T, etc., samples of the most of which are represented in Fig. 10. Fig. 
13 illustrates three modifications of ferrules for turning teeth in their sockets. To 
turn a tooth, a ferrule is first cemented to the tooth with phosphate of zinc and then 
Vol. V-37 578 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by a lever soldered to or caught into a staple, single or double, or a short tube. The 
tooth is turned by springing the lever and tying it to some tooth near by. Levers 
are of various forms, some of which are shown in Fig. 13. 
To illustrate the benefit of correcting irregularly arranged teeth from a medical 
point of view, the following instance has been selected : Several years before the 
time of the operation which I am about to relate, a young lady of robust health was 
placed under my care for preservation of her teeth. Examination showed that the 
dental arches were so shaped that they did not properly antagonize, and the teeth 
were practically of little or no use for the purpose of mastication. The upper arch 
was much smaller than the lower, and, but for the partial antagonism of the poste- 
rior molars, it would have shut completely inside the lower. Besides this defect, the 
two dental arches were hindered from closing upon the proper plane by the too early 
antagonism of these posterior teeth, which prevented the front ones closing suffi- 
ciently ; it also necessitated considerable effort in closing the lips. Articulation of 
certain sounds was impeded, and a distortion of the face was caused by the appear- 
ance of undue prominence of the chin, owing to the recession of the upper lip (see 
Fig. 14). 
Measurement of the dental arches showed that the difference between their 
transverse diameters on a line drawn through the bicuspids was about four- to five- 
eighths of an inch. The lower incisors were in advance of the upper ones somewhat 
Fig. 13. 
Ferrules and Levers for turning teeth. 
more than one-eighth of an inch, and owing to the peculiar conformation of the 
posterior portion of the alveolar ridges, which, as before said, caused the posterior 
molars to antagonize before they should, the cutting edges of the front teeth could 
not close sufficiently by about one-eighth of an inch. Owing to her robust health at 
this time, the family were satisfied with filing of the teeth only. 
But in her twenty-second year her health began to fail, from indigestion, and she 
was troubled with gastric pains, increasing in severity. In the autumn of her twenty- 
second year she experienced an attack of so severe a nature as to convulse and pros- 
trate the entire system. This was followed by others, recurring with more frequency 
until they were of daily occurrence. She finally became so much prostrated that she 
was confined to her couch for long periods. Medical treatment at her home availed 
only temporary relief. 
Being unable to digest solid food she subsisted upon liquids in the form of beef 
tea and broths, and upon boiled rice and cream. She became reduced in flesh and 
strength until her friends began to think her health was permanently ruined. She 
was finally removed to the residence of her medical adviser, in order that the case 
might be more closely watched by him. Under such vigilance she began after a 
time to improve slowly, and the convulsive attacks became less frequent. When 
able to travel she visited the city, a distance of fifty miles, to consult me in regard 
to having her teeth made more efficient for mastication. 
As she had beautiful teeth, the substitution of an artificial denture was not to be SECTION XVIII DENTAL AND ORAL SURGERY. 
579 
thought of ; but we concluded that by proceeding carefully, with the apparatus oper- 
ated upon the intermittent principle of action, which, properly managed, would 
cause little or no pain, her teeth might be successfully regulated ; certainly so, if 
alternated by periods of rest at stages of the process when it might be practicable to 
suspend action. In accordance with this plan an operation for enlarging the upper 
arch was commenced in the following January. As the patient was still weak and 
occasionally subject to prostrating attacks of indigestion and vomiting, the apparatus 
was constructed in such a manner that she could operate it herself, thus enabling 
her to remain at her home. 
The first step in the operation was to correct this last-mentioned defect as much 
as possible by grinding down the molars. Examination showed, however, that if the 
left third molars were ground even to the gum it would not be sufficient ; therefore, 
it seemed necessary to cause absorption of this portion of the alveolar ridge. In 
order to accomplish this shrinkage, these teeth were extracted ; after a few weeks 
Fig. 14. 
Appearance before the Operation. 
this proved to be successful. The gums at this point, however, were nearly in con- 
tact for a long time afterward. 
The cusps of the remaining molars were then ground down as much as was pru- 
dent for the time being. At this stage of the case the cutting edges of the incisors 
were enabled to close upon the same plane, but not enough to enable the upper teeth 
to shut sufficiently over the lower ones, when the completion of the spreading of the 
arch should make that a necessity to hold them in place. When the mechanical 
portion of the operation was completed the molars were again ground, without caus- 
ing pain. This grinding of the teeth not only gave increased capacity for masticating 
food, but improved the expression of the face by shortening it, and by enabling the 
patient to close her lips without effort. 
A remark may be made here in reference to grinding teeth, as some dentists are 
averse to such a measure. I advocate judicious grinding only ; that which confers 580 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
great benefit, with no disadvantage, as in some cases like this. Although grinding 
the antagonizing surfaces may, when it is improperly done, cause, in rare cases, con- 
tinued sensitiveness, there is no danger of causing decay. In this operation all the 
necessary grinding on any particular tooth should be done at one sitting, if it be 
possible to do it without causing pain. If it cannot be sufficiently ground, the oper- 
ation should be suspended for several months, until time enough shall have elapsed 
for the consolidation of the peripheral extremities of the dentinal tissues (tubuli) 
exposed. This solidification not only prevents sensitiveness, but hardens the surface. 
To return to our case, the upper jaw received the principal share of the attention, 
the lower teeth being reduced only sufficient to better fit the needs of the upper arch 
when it should be properly enlarged. While the upper jaw was too small to be in 
proportion with the other parts of the face, the lower jaw was not, and only required 
slight alteration. The lower arch was somewhat crowded in the region of the cuspid 
teeth, which were inclined forward, lapping and partially hiding the front of the 
lateral incisors. The bicuspids also had not sufficiently erupted to be on a plane with 
the antagonizing surface of the others. To regulate the lower arch one of the bicus- 
Fig. 15. 
pids on each side was extracted, and the cuspids drawn back by means of gold clamp 
bands extending around the molar teeth for anchorage ; the bands being operated by 
screws and a key. 
The third and main step, the spreading of the upper arch, the most interesting 
portion of the operation in the case of this patient, was successfully accomplished in 
stages, intermitted by periods of rest. The first step of the operation upon the 
upper jaw was the partial outward movement of the bicuspids and the first molars. 
The apparatus consisted of a system of jack-screws capable, when used entire, of 
acting at the same time, as shown in Fig. 16. 
Only a part of the device, however, was applied at first ; this consisted of a 
double-yoke jacks-crew with a bar extending against the first molars, which was 
firmly bound to the bicuspids by means of screws and nuts, as shown. 
The use of this portion of the apparatus was to force outward these six side 
teeth. At this stage a cylindrical spindle screw-jack was placed across the arch for 
the purpose of forcing the cuspids directly outward before being carried forward. 
Figure 15 represents the appearance of the upper jaw at this time, with the six SECTION XVIII-DENTAL AND ORAL SURGERY. 
581 
side teeth nearly in position. These instruments had, in eleven weeks, carried the 
side teeth sufficiently outward to be directly over the lower arch. At this point the 
masticating functions of the teeth being perfect, these appliances were exchanged 
for a simple hard-rubber retaining plate, and the treatment suspended for several 
Fig. 16. 
months, for rest. The cuspids and four incisors required to be forced radially for- 
ward, over, and in advance of the under teeth. 
The retaining plate was finally removed and the jack-screw reinserted to hold the 
four bicuspids and two first molars in position, and to serve as a foundation to support 
the other portion of the compound system of jack-screws, for the purpose of forcing 
Fig. 17. 
outward the six front teeth. Figs. 16 and 17 show the appearance of the case at the 
completion of the operation and before the apparatus was removed. 
The question may arise, "could not all of these upper teeth have been acted 
upon at the same time ?" In reply I would say that while this machine is intended 582 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to be so used, the patient in the case was so feeble that it was thought all important 
that her grinding teeth should be made useful with as little inconvenience from the 
apparatus as possible, for it should be borne in mind that she continued to be sub- 
ject to severe attacks of vomiting. These points having been gained and her health 
regained, the other portion of the machine was applied and worn without much 
annoyance. 
This operation was performed nearly eight years ago ; her health thus restored 
has remained so to this day. 
Dr. L. P. Haskell, of Chicago, said, in reference to Dr. Angle's paper and 
appliances, that, at a meeting of the Minnesota State Medical Society, at Minne- 
apolis, last July, which he (Dr. Haskell) attended, Dr. Angle had read the same 
paper and exhibited the same appliances. The appliances had struck him as exceed- 
ingly simple. The jack-screw used by him was so entirely different from the jack- 
screw with which he (Dr. Haskell) was acquainted, that they were no more like each 
other than daylight and darkness. There was nothing in the apparatus to injure or 
irritate the gums. It was exceedingly simply, easily made and easily applied. 
In his own specialty of prosthetic dentistry he had noticed, for many years, that 
in ninety-five cases out of a hundred, there was more depression on the left side of 
the upper jaw than on the right. In restoring the contour of the lip, he found that he 
had to apply more material on the left side than on the right. The left side required 
longer teeth than the right, showing that the depression affected not only the gums, 
but the length of the teeth. In the lower jaw also, instead of both sides being sym- 
metrical, the left side of the jaw was often thrown out of the arch, and the teeth on 
that side had to be set further in. He wanted to know the cause of this, and 
inquired whether any of the gentlemen present could explain it. It antedated the 
extraction of the teeth. He could only conceive one reason for it, and it was this : 
A majority of people were right-handed, and most of their food (a crust of bread, 
an apple, or anything else) was bitten off out of the right hand, on the right side of 
the mouth, so that, if the teeth were equally good for mastication on both sides, 
they would probably masticate more on the right side of the mouth than on the left, 
the food being put in on that side. Consequently there was constant development 
there, and not on the left side. Was that the cause of it? [Applause.] 
Dr. John L. Gish, of Jackson, Mich., gave the particulars of two cases in his 
practice in which the apparatus for the regulation and retention of the teeth did not 
work satisfactorily, the incisors changing place after the plate had been worn for 
weeks and months. 
Dr. W. A. Spaulding, of Minneapolis, Minn., suggested a doubt whether, in 
the cases referred to, any arrangement had been applied to hold the teeth in place. 
Dr. Angle had explained the appliance by which the teeth might be held in their 
place permanently, and gentlemen could see, by the appliances themselves, how easy 
it was to hold the teeth permanently. 
Dr. W. N. Morrison, of St. Louis, Mo., said that he had published a paper 
several years ago, in the Cosmos, laying claim to the plan of using thin annular 
bands, to which was attached all manner of regulating apparatus (just as in Dr. 
Angle's appliances), and had there explained how the teeth were pushed from the 
inside only, and regulated into the arch, and that when the screw had been extended 
to the proper length, it should be allowed to remain quiet until the teeth were settled 
in their position. He would take great pleasure in showing this apparatus at a SECTION XVIII-DENTAL AND ORAL SURGERY. 
583 
clinic on Saturday. By it a set of teeth could be regulated in twenty-one days, 
which would ordinarily take, by any other apparatus, as many months to regulate. 
Dr. W. C. Barrett, of Buffalo, said that all this discussion was foreign to the 
object of the Section, and belonged purely to the clinical department. To his appre- 
hension, there was no force in the particulars alluded to in the first paper read this 
afternoon in regard to the malformation of the teeth and jaws. Sometimes, after the 
effusion of teeth, and after the eruption of permanent teeth, a malformation of the 
jaw could be traced to the want of proper occlusion. He understood that it was not 
expected of those who discussed papers that they should occupy much time. He 
desired to make the point that the mal-occlusion of the teeth was often the cause of 
malformation of the jaw. The influence of heredity in inducing malformation, how- 
ever, he believed to be a very potent cause indeed. He had seen a set of teeth, 
without crowns and almost without enamel (except a little at the edge of the teeth), 
and with the teeth themselves never coming below the margin of the gum. That 
condition of teeth was hereditary through a number of generations. He had traced 
it back for four generations, and found it cropping out here and there and being 
reproduced constantly, through the influence of heredity. That was a case of peculiar 
malformation of the teeth which induced a malformation of the jaw ; and the whole 
of it was due to heredity. Another point which he desired to make was this : The 
essayist (Dr. Talbot, of Chicago) made the assertion that the nearer we got to the 
primeval type of man, the more perfect were found to be the teeth and the jaws. 
He (Dr. Barrett) had pursued a series of observations and studied that special sub- 
ject, and had become thoroughly convinced in his own mind upon the question. He 
had presented to the profession, through a paper read to the American Dental Asso- 
ciation, as thorough statistics as were obtainable on the study of four thousand pre- 
historic skulls ; and he had shown by these statistics that, as near as he could judge, 
the type of teeth had not materially altered ; that the type of jaw had not materially 
altered ; that the eruption of the teeth had not materially altered ; and that the rudi- 
mentary condition of some of the teeth had not changed for probably four thousand 
years. Back of that he could not go. When he spoke of pre-historic skulls he did 
not refer to the same data as when he spoke of pre-historic American skulls ; because 
American history only went back to the contact of the aborigines with the whites. 
When he went back of that he found no material difference in the condition of the 
jaw and of the oral tissue, aside from the diseases which contact with the whites 
brought. Previous to that contact he had found no trace of syphilitic affection in 
the teeth or oral tissue of Indian skulls. He had not these statistics by him at pres- 
ent, but his recollection of them was very distinct, and he had endeavored to tabulate 
them as thoroughly as he could. He had shown that the prevalence of caries of the 
teeth had not materially changed for some thousands of years ; that the same dis- 
eases which existed to-day had existed three thousand years ago in nearly the same 
proportion and in nearly the same amount of virulence. He could not find any 
material changes in this respect. He had found evidence of the ravages of dental 
disease as prevalent at that time as now. So that he could not conceive that so far 
back as the history of the teeth went, and so far back as historical records existed, 
there was any material change in the type of the jaw, in the type of the teeth, in the 
precedence of the teeth, in the development of the teeth, or in the diseases of the 
oral cavity in connection with caries of the teeth. Different races of men, of 
course, presented different types and national characteristics. There were national 
types of the jaw, national irregularities and changes, and differences in the develop- 
ment of the teeth connected with national peculiarities. But he imagined that 584 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
heredity was a potent influence in this ; and the effusion of teeth was a potent influ- 
ence. So that he had to take exception to the position of the essayist, and to give 
it as his opinion that it was not a matter of record that the further back wé go the 
more perfect we find the development of the teeth and the less we find the amount 
of irregularities, aside from those which are incidental to the changes of type con- 
nected with the intermingling of races. 
Dr. I. A. Salmon, of Boston, said that, in the paper read by Dr. Angle, he had 
failed to discover one thing which he had found in his practice to be necessary, and 
that was the bringing of a tooth beyond the position which it was requisite that the 
tooth should eventually take. He said that even if a retaining belt had been worn 
for a year, a tooth which had been brought outward toward the lip would be very 
likely to fall back a little, and that, especially, in bringing a tooth from the inside out- 
ward it was necessary to make a little allowance for that. A tooth which had been 
brought inward would be retained more perfectly in its position, by the force and pres- 
sure of the lip, than one that had been brought outward. He did not know but that 
it would be well to bring the attention of those who had done very much of this 
kind of regulating to this particular point. 
Dr. C. M. Bailey, of Minneapolis, spoke in commendation of Dr. Angle's appli- 
ances. It was very true, he said, that many of the things which Dr. Angle had 
described were found described in past journals of the profession, but the jack-screw 
which Dr. Angle had presented here was at least fifty per cent, smaller (his larger 
screw) than the smallest screw to be found on the market. Not only was it so much 
smaller, but one of his screws was sufficient, for it could be made any length by 
simply making the tube longer. It was admitted in Dr. Angle's paper that this 
was simply the application of the screw, and attention was called to the fact of its 
being smaller, and therefore much easier for the patient and for the operator. 
Dr. E. P. Brown, of Flushing, N. Y., denied emphatically that there was any- 
thing new in the system described by Dr. Angle. With the assistance of Dr. Evans, 
of Washington, he had got from the files of the Cosmos several illustrations cover- 
ing the entire ground gone over in Dr. Angle's paper, and he would present these 
illustrations in rebuttal of Dr. Angle's claim. He had seen, ten or eleven years ago, 
in Dr. Farrar's office, all the contrivances described by Dr. Angle, and hundreds of 
others. A few of them he had tried himself, and they were nearly all successful in 
his hands. The drawings with which he was furnished by Dr. Evans were taken 
from the nineteenth volume of the Cosmos, and covered three or four of the princi- 
pal illustrations in the drawings exhibited by Dr. Angle. 
Dr. Angle asked what the appliances were, and where a description of them was 
to be found in the Cosmos. He had reviewed nearly all the later literature on the 
subject and he found no trace of any such thing. 
The President reminded gentlemen that questions as to priority of discovery were 
not proper subjects of discussion here. If there was anything in the proceedings 
to the publication of which gentlemen were opposed, they could bring it to the 
attention of the Secretary, who had charge of the preparation of the report. 
Dr. V. H. Jackson, of New York, said that the exact principle of the band in 
question was to be found fully described in the " American System of Dentistry." 
Dr. Angle claimed that that was an entirely different principle to the one which 
he had presented. He said that Dr. Guilford, of Philadelphia, bound the teeth in a 
somewhat similar way, except that he (Dr. Guilford) did not use a pipe, but soldered SECTION XVIII DENTAL AND ORAL SURGERY. 
585 
to the band a platina finger by which the pressure was produced. That was the 
nearest approach that he knew, in practice, to his own appliance. 
The President stated that when the papers and the drawings were published, the 
members of the profession would be able to judge for themselves as to their original- 
ity ; and he suggested to members that they had better confine their remarks to the 
principle of the papers read, rather than to mere mechanical details. 
Dr. A. E. Baldwin, of Chicago, said that Dr. Angle had presented certain 
things to the Association ; that the claim which Dr. Angle made had been questioned 
by different members ; and that proper courtesy required that Dr. Angle should be 
allowed to explain the apparent differences between his appliances and others. 
Dr. A. M. Dudley, of Salem, one of the Secretaries, said : I 
want to make a statement here, because, from what has been said, I foresee trouble 
to the editor of the Transactions. I do not wish it to be understood that I am at 
the beck and call of everybody who may fancy that I should take the responsibility 
of ruling out any of these proceedings. Whatever has been accepted by the com- 
mittee and has been presented here becomes the property of this Congress and goes 
into its Transactions ; and whatever is said in refutation of these papers is part of 
the proceedings and appears in the Transactions of the Section. It will be no part 
of my duty, as Secretary of the Section, to rule out anything which this body itself 
does not rule out. 
Dr. E. S. Talbot, of Chicago, said that the discussion of this subject was as 
important for gentlemen connected with the profession as the history of an inven- 
tion would be in an application at the Patent Office. It was a matter of honor and 
principle to put the credit where it belonged. He had great respect for Dr. Angle, 
and he was in somewhat the same position as Dr. Farrar-that is, he was publishing 
a work, and he was afraid that when that work came out it might be said (if Dr. 
Angle's claims were allowed to go unchallenged) that he had stolen some of his 
ideas from Dr. Angle. Now, he wished to say that he had used the device of a 
clamp with a pin for a number of years, and that the jack-screw used by Dr. Angle 
could be found in any machine shop, and could be found in Dr. Farrar's office to-day. 
He wanted it to go on record that he had seen the same appliances described by Dr. 
Angle in Dr. Farrar's office last winter. 
Dr. Angle said that he had just examined the drawings in the Cosmos, and that 
they were entirely different from his. He described what the difference consisted 
of ; and said that he remembered very well when the publication in the Cosmos was 
made ; but that the jack-screw there described was entirely different from his. If 
members would be good enough to look over his models and appliances and compare 
them with those described, they would be convinced that they were entirely dissimi- 
lar. He did not claim any originality in adopting the screw. It had been used for 
years and years, but he simply made another application of it, in the form of attach- 
ing it to bands by means of a pipe. 
Dr. Storey, of Texas, inquired whether the object of the Section was to estab- 
lish principles for guidance in the practice of the profession, or to establish the pre- 
cedence of certain little inventions. Instead of wrangling over the question of pri- 
ority, each of the claimants should have said, "Gentlemen, here is my discovery. 
You are welcome to it. ' ' {Applause. ) 
Adjourned till to-morrow, at 11 A.M. 586 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIFTH DAY. 
The first business of the Section was the reading, by title, of the following 
paper :- 
ZUR VERGLEICHENDEN PATHOLOGIE DER ZÄHNE, MIT BESON- 
DERER BERÜCKSICHTIGUNG DES STOSSZAHNES 
DES ELEPHANTEN. 
THE COMPARATIVE PATHOLOGY OF THE TEETH, WITH SPECIAL REFERENCE 
TO THE TUSK OF THE ELEPHANT. 
PATHOLOGIE COMPARATIVE DES DENTS AVEC UN RAPPORT SPÉCIAL SUR LES DÉFENSES 
D'ÉLÉPHANT. 
VON PROF. DR. BUSCH, 
Berlin, Deutschland. 
Das eingehende Studium der Erkrankungen der Zähne in der ganzen Säugethier- 
reihe ist für das Verständniss der an den Zähneu des Menschen vorkommenden 
Erkrankungen von hohem Werth, denn wenn auch der feinere Bau der drei harten 
Zahnsubstanzen, Schmelz, Dentin und Cement, bei den Zähnen der Säugethierreihe 
manche Abweichungen zeigt, so sind diese Gewebe in ihrer Grundform doch so ähnlich 
zusammengesetzt, dass auch ihre Erkrankungen keine grossen Abweichungen zeigen. 
Die Grösse, welche die Zähne in einzelnen Klassen der Hufthiere erreichen, zeigt uns 
viele Erkrankungen an denselben für das unbewaffnete Auge mit einer solchen Deut- 
lichkeit, wie man sie an den kleinen menschlichen Zähnen nur durch beträchtliche 
Vergrösserung erlangen kann. Und der Umstand, dass man das grosse Zahnpräparat 
frei in der Hand hält und nach allen Richtungen hin betrachten und wenden kann, 
giebt ihm einen unzweifelhaften Vortheil gegenüber dem feinen microscopischen Schliff 
des menschlichen Zahnes, der zwischen zwei Glasplatten in Canadabalsam eingebettet 
liegt und nur von einer Seite aus betrachtet werden kann. Die Zufälligkeiten des 
Schnittes und Schliffes verdecken viele Momente, welche von grosser Bedeutung sind. 
Findet man zum Beispiel eine interstitielle Höhle im Dentin menschlicher Zähne, so 
kann man nach dem microscopischen Präparate nicht entscheiden, ob dieselbe durch 
einen feinen Verbindungsgang mit der äusseren oder inneren Oberfläche des Zahnes 
zusammenhing. Hat man dagegen das aufgeschnittene Stück des Stosszahnes eines 
Elephanten in der Hand, in welchem sich eine derartige Höhle befindet, so ist man 
sehr wohl im Stande, zu entscheiden, ob dieselbe allseitig abgeschlossen war, oder ob 
sie mit der Aussenfläche oder Innenfläche des Zahnes in Verbindung stand. Das all- 
gemeine Gesetz, welches die Erkrankungen der Zähne in der Säugethierreihe beherrscht, 
lautet nun meiner Ansicht nach folgendermaassen : Diese Erkrankungen sind zwar 
nicht identisch, aber sie sind sehr ähnlich. Findet mau eine bestimmte Erkrankung 
au dem Zahne einer Säugethierspecies, so kann man zwar nicht den Rückschluss 
machen, dass genau dieselbe Erkrankung auch an den Zähnen aller übrigen Säugethier- 
species Vorkommen müsste ; aber man hat einen starken Hinweis darauf, auf diesen 
Punkt hin seine besondere Aufmerksamkeit zu lenken, und man wird meistens im 
Stande sein, den Nachweis zu führen, dass auch an den Zähnen der anderen Säuge- 
thierspecies eine ähnliche Erkrankung vorkommt, wenngleich dieselbe nicht unbedeu- 
tend modificirt sein kann durch die Grösse des Zahnes, die Feinheit in der Structur SECTION XVIII-DENTAL AND ORAL SURGERY. 
587 
seiner harten Gewebe, die Anwesenheit oder Abwesenheit von Schmelz, die verschiedene 
Art des Kauens, den Unterschied zwischen Zähnen mit abgeschlossenem und immer 
fortwährendem Wachsthum und derartigen Momenten mehr. 
Die häufigste Erkrankung der menschlichen Zähne, die Caries, ist bei den Zähnen 
der übrigen Säugethiere, wie von allen Forschern übereinstimmend anerkannt wird, 
auffallend selten. Am häufigsten findet man sie wohl noch bei den Zähnen der 
anthropomorphen Affen, besonders des Chimpanse (Troglodytes niger), und die natür- 
lichste Erklärung, welche sich hier bieten dürfte, besteht wohl darin, dass der frugivore 
Character des Gebisses dieser Thiere und der reichliche Zuckergenuss, den dieselben 
in den verschiedenen Früchten ihrer Nahrung und besonders dem Zuckerrohr, dessen 
Felder sie mit Vorliebe aufsuchen, begründet ist. Von denjenigen Thieren, welche 
seit Jahrtausenden von dem Menschen gezähmt sind und an den äusseren Verhältnissen 
seines Eigenlebens theilnehmen, den domesticirten Thieren, zeigt keine Species die 
Caries der Zähne als eine häufig vorkommende typische Erkrankung. Es sind wohl 
Fälle beschrieben, in denen sich an den Zähnen einzelner Hausthiere, wie z. B. des 
No. 155. 
Pferdes und anderer Pflanzenfresser, Höhlen vorfanden, welche der Caries der mensch- 
lichen Zähne mehr oder weniger glichen. Indessen sind das immer grosse Seltenheiten, 
denn es will in der That nicht viel sagen, wenn in den Sammlungen alter Veterinär- 
schulen, die theilweise seit Jahrhunderten bestehen, einzelne solcher Fälle vorgefunden 
werden. Der allgemeine Satz wird dadurch nicht erschüttert, dass auch bei den 
domesticirten Thieren die Caries der Zähne in ihrer typischen Form eine sehr seltene 
Erkrankung ist. 
Bei den in der Wildheit lebenden Thieren ist die Caries der Zähne nun entschieden 
noch seltener. Die reinen Fleischfresser und Insectenfresser sind von derselben so gut 
wie vollkommen verschont, und auch die Pflanzenfresser unterliegen ihr nur sehr 
selten. Um so auffallender ist es, dass bei einem Thiere, bei dem man am allerwenig- 
sten an die Möglichkeit der Caries denken sollte, dieselbe, wie es scheint, nicht ganz 
selten vorkommt. Es ist das der grosse Potwal (Cachalot, Physeter makrocephalus). 
Ich bin in der Lage, hiermit ein Präparat (No. 155) vorzuzeigen, an welchem sich in 588 
. NINTH INTERNATIONAL MEDICAL CONGRESS. 
der Substanz des Zahnes dieses Thieres, welcher keine Schmelzbedeckung trägt, sondern 
nur aus Dentin und Cement besteht (und zwar ist an diesem Zahne, welcher unzweifel- 
haft einem älteren Thiere augehört, die ganze Pulpenhöhle durch secundäre Dentin- 
bildung bereits verschlossen), eine Höhle befindet, welche mit hoher Wahrscheinlichkeit 
auf Caries zurückzuführen ist. Die Höhle ist 4 cm. lang, 1.5 cm. breit und ebenso 
tief. Ihre Wände sind buchtig ausgefressen, und sie steht mit der äusseren Oberfläche 
des Zahnes durch eine ovale Oeffnung in freier Verbindung von 1-cm. Längsöffnung 
und dicht über dem Zahnfleischrande gelegen. Die einzige andere Deutung, welche, 
soviel ich sehe, für die Entstehung dieser Höhle gegeben werden könnte, wäre die, dass 
ein der Klasse der Arthropoden angehöriges, mit bohrenden Mundwerkzeugen aus- 
gestattetes Thier sich in diesem Falle vom Zahnfleischrande aus in das Dentin ein- 
gebohrt und die dadurch geschaffene Höhle zur Brutstätte benutzt hätte ; indessen 
lässt sich für diese Deutung, soviel ich sehe, kein entscheidendes Moment angeben. 
In der Sammlung der Odontological Society of Great Britain finden sich in der Abthei- 
lung "Alveolar abscess ", No. 139, 140 und 141, drei Fälle angeführt, in welchen gleich- 
falls Höhlen in einem Zahne des Potwales gefunden wurden, und welche theils als 
Abscess, theils als Caries gedeutet sind. Sonst habe ich bisher an keinem anderen 
Thierzahne eine Erkrankung gefunden, welche als Caries gedeutet werden könnte. 
Viel häufiger als die Caries, ja man kann wohl sagen, von allgemeinem Vorkommen 
in der Säugethierreihe, ist die Entzündung der Wurzelhaut, und in deren weiterer Folge 
der Alveolarabscess. Diese Erkrankung tritt entweder ein, wenn an den Zähnen durch 
Abkauung die Pulpenkammer eröffnet ist, oder wenn nach Abschluss der Pulpen- 
kammer durch secundäre Dentinbildung der Zahn bis zum Zahnfleischrande herunter- 
gekaut ist, so dass nun die Wurzelhaut den schädlichen Einflüssen der Mundhöhle 
ausgesetzt wird. Auch Verletzungen durch Schlag oder Stoss mit Eröffnung der 
Pulpenhöhle oder Splitterung des Zahnes bis in seinen Alveolartheil führen fast aus- 
nahmslos zur Wurzelhautentzündung, zum Alveolarabscess und zur Fistelbildung. 
No. 150. 
Eine reiche Fundstätte f ür die Veränderungen, welche die Wurzelhautentzündung 
an den Zähnen der Thiere herbeiführt, bietet der Stosszahn des Elephanten dar. Ich 
bin in der Lage, aus der Sammlung des zahnärztlichen Instituts der Königlichen 
Universität Berlin sechs Präparate vorzulegen, an denen sich diese Veränderungen in 
deutlicher Weise zeigen (No. 146, 150, 153, 157, 162, 256). Diese Präparate zeigen, 
dass unter dem Einflüsse der Wurzelhautentzündung der alveolare Theil des Zahnes 
einer schweren Bildungsstörung unterliegt. Sowohl die äussere wie die innere Ober- 
fläche desselben verliert ihre normale glatte Beschaffenheit, und ist von stacheligen 
Auswüchsen und buchtigen Höhlen besetzt, welche ihr ein höchst unregelmässiges 
Aussehen verleihen. Die buchtigen Höhlungen finden sich meistens an der äusseren, 
dem Alveolarperioste zugewandten Oberfläche ; die stacheligen Auswüchse, welche SECTION XVIII-DENTAL AND ORAL SURGERY. 
589 
vielfach in Form langer Nadeln und baumförmiger Verzweigungen auftreten, liegen 
dagegen au der eigentlichen Bildungsstätte des Dentins, der Pulpenhöhle zugewandt, 
und verdanken ihre Bildung dem Reize, welcher sich von dem Alveolarperioste auf die 
Pulpa fortpflanzte und diese in ihrer Thätigkeit störend beeinflusste. Die Eiterung 
in der Alveole kann sich nun auch tief in das harte Zahngewebe herabsenken und bei 
dem fortdauernden Wachsthume des Zahnes eine zweite Höhle schaffen, welche mehr 
oder weniger tief neben der Pulpenhöhle herabsteigt und sich weniger an der äusseren 
Oberfläche des Zahnes bemerkbar macht, als dadurch, dass die der Pulpenhöhle zuge- 
wandte Dentinschicht nach innen zu vorgewölbt wird und dadurch den Raum für 
die Pulpa mehr oder weniger verengt. Ob in den gegebenen Fällen die Entzündung 
der Wurzelhaut ausschliesslich durch Verletzungen herbeigeführt wurde, oder ob hier 
auch Erkrankungen des Thieres mit in Betracht kommen, lässt sich bei dem Mangel 
jeder Anamnese schwer entscheiden. 
Solche neben der Pulpenhöhle tief in den Bereich des Zahnes herabsteigende 
Abscesshöhlen finden sich auch noch an vier anderen Präparaten (No. 145,160,167,169), 
No. 167. 
an denen sich jedoch, da sie den Alveolartheil nicht mehr in sich schliessen, nicht der 
Beweis führen lasst, dass sie Von einer Wurzelhaut ihren Ausgang genommen haben. 
Das Bild ist im Wesentlichen immer dasselbe, d.h. es findet sich neben der Pulpen- 
höhle eine zweite Höhle, von welcher aus die Dentinwand gegen die Pulpenhöhle vor- 
gedrängt ist. Die Wände der Abscesshöhle sind bisweilen glatt, meist aber besetzt 
mit baumförmig verästelten Dentinauswüchsen, zwischen denen sich die Reste des 
eingetrockneten Eiters durch ihren fauligen Geruch bisweilen sehr deutlich bemerkbar 
machen. 
Ein besonderes Verhalten zeigt das Präparat 167. In diesem Falle ist bei geringer 
Grösse der Abscesshöhle ein auffallend starker, solider Dentinauswuchs gegen die 
Pulpenhöhle vorgewuchert, so dass diese auf eine schmale halbmondförmige Gestalt, 
zusammengedrängt ist. Dieser mächtige Dentinauswuchs gleicht dadurch vollkommen 
den inneren Exostosen des Schädels, bei welchen ähnliche knollige, aus härtester 
Knochensubstanz bestehende Auswüchse gegen die Schädelhöhle vorwachsen und 
dadurch das Gehirn auf's Stärkste zusammendrücken. Unzweifelhaft hat dieser 
Dentinauswuchs durch sein Zusammenpressen der Pulpa während des Lebens des 
Thieres sehr schwere Störungen hervorgebracht. Ein besonders schönes Beispiel von 
abgeschlossener Abscessbildung mitten im soliden Elfenbein, ohne jede Verbindung mit 
der Aussenfläche des Zahnes oder mit der Pulpenhöhle, liefert das Präparat 211. Hier 
liegt, ohne dass die Aussenfläche des Zahnes die geringste Abweichung der Bildung 590 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
erkennen lässt, eine von buchtigen Aushöhlungen und dendritischen Auswüchsen 
begrenzte Höhle, an deren Wand der eingetrocknete Eiter noch deutlich sichtbar ist, 
von 8 cm. Länge, 4 cm. Breite und gleicher Tiefe, mitten im Elfenbein eingebettet. 
Es erscheint selbstverständlich, dass diese Eiterhöhle sich nicht mitten im Dentin hat 
bilden können, denn die Eiterkörperchen, welche nach allgemeiner Auffassung, gestützt 
auf die stärksten Beweismomente, als ausgewanderte Blutkörperchen zu betrachten 
sind, konnten unmöglich von der Pulpa aus durch die feinen Röhrchen des Dentins 
ihre Wanderung nach dieser Stelle vollziehen und sich hier eine so grosse Höhle graben. 
No. 170. 
No. 211. 
Die Deutung dieses Falles muss vielmehr, wenngleich sich am Präparate selbst nicht 
mehr der Nachweis führen lässt, dahin gegeben werden, dass auch diese Abscesshöhle 
ursprünglich in freier Verbindung mit der Pulpa oder dem Alveolarperioste gestanden 
hat, dass dann später durch neu abgelagertes Dentin ein Abschluss stattfand, und dass 
nun bei dem fortschreitenden Wachsthume des Zahnes der Abscess schliesslich an eine 
Stelle kam, an welcher er mitten im soliden Dentin eingebettet war und mit blut- 
führenden Gefässen keine Berührung mehr hatte. Das Auffallende des Präparats ist 
eben nur, dass diese schwere Störung in dem Zahne vorhanden war, ohne dass dadurch 
die weitere Bildung des Zahnes selbst erheblich gestört wurde. 
Präparat 170 bildet einen schönen Fall von geheilter Zahnfraktur. An diesem 
Präparat ist ersichtlich, dass ein Längsbruch durch den Alveolartheil des Stosszahnes 
eines Elephanten hindurchging. Die beiden Fragmente wurden durch die umschlies- SECTION XVIII-DENTAL AND ORAL SURGERY. 
591 
sende Alveole in annähernd richtiger Stellung zusammengehalten, so dass keine starke 
Dislokation derselben eintreten konnte. Die Fragmente sind nun zum Theil wieder 
mit einander zusammengeheilt, das heisst, das Dentin der beiden Bruchflächen ist zum 
Theil verwachsen, während dazwischen Stellen übrig geblieben sind, an denen der 
Spalt die Fragmente noch trennt, und an der einen Stelle hat sich eine mächtige, aus 
Dentin bestehende Calluswucherung erhoben, welche die Fragmente fest verlöthet und 
einen bedeutenden Vorsprung nach der Pulpenhöhle bildet. 
Die Schussverletzungen des Stosszahnes des Elephanten sind, besonders seitdem 
Goodsir dieselben auf Grund eines erheblichen Beobachtungsmaterials zum Gegen- 
stände einer ausführlichen Abhandlung machte, auch von anderen Forschem vielfach 
untersucht und beschrieben. (Goodsir: ' ' On the mode on which musket bullets and 
No. 173. 
other foreign bodies become inclosed in the ivory of the tusks of elephants. ' ' Edin- 
burgh. Philosophical Transactions, 1841. Vol. XV, Pl. 1, p. 93.) Ich selbst bin in der 
Lage, zwei einschlägige Präparate vorzuführen. In dem ersten Falle (No. 173) han- 
delt es sich um den Alvéblartheil des Stosszahnes eines Elephanten, welcher leider 
nicht mehr ganz erhalten ist. In diesem Falle ist eine runde eiserne Kugel in die 
Wand der Alveole eingeschlagen, hat die eine Alveolarwand des Zahnes durchbrochen, 
die Pulpa in ihrer ganzen Dicke in der Ausdehnung von 7 cm. durchsetzt und ist dann 
in der entgegengesetzten Alveolarwand des Zahnes stecken geblieben, in welcher sie 
einen langen Spalt hervorrief. Das Thier hat unzweifelhaft noch jahrelang nach der 
Verletzung gelebt. Die Kugel selbst ist nicht durch neu gebildetes Dentin umhüllt, 
sondern grenzt mit ihrer Innenfläche frei sichtbar an die Pulpenhöhle, und ist auch in 592 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dem Dentin, in welchem sie sich eingebettet hat, so wenig befestigt, dass sie mit dem 
Finger frei hin und her bewegt werden kann. Der Spalt in dem Alveolartheile des 
Zahnes ist grösstentheils noch offen. Unterhalb der Kugel befindet sich ein kleiner, 
nach der Pulpenhöhle zu vorspringender Dentinauswuchs ; die hauptsächlichste Ver- 
änderung jedoch zeigt die entgegengesetzte Alveolarwand, welche die Kugel zuerst 
durchbohrte. Hier liegt ein mächtiger, mit rauher Oberfläche versehener Dentin- 
auswuchs, welcher als eine starke Calluswucherung den Spalt überbrückt hat, den die 
Kugel an dieser Stelle des Alveolartheiles hervorgerufen hat, aber der Auswuchs besteht 
nur zum Theile aus solidem Dentin; der grössere Theil desselben birgt in sich eine 
Höhle, welche zur Zeit des Lebens unzweifelhaft mit Eiter erfüllt war. 
Das zweite Präparat (No. 210) bietet noch viel interessantere Verhältnisse. Hier 
ist eine 2.7 cm. lange und 1.2 cm. breite Bleikugel, welche unzweifelhaft aus einem 
Gewehr vollkommenster Construction herstammte, nicht in den Alveolartheil, son- 
dern mitten in das solide Dentin des Stosszahnes eingedrungen. Die grosse Schnellig- 
keit, mit welcher die Kugel geschossen wurde, hat es dahin gebracht, dass das Geschoss 
sich nicht an der harten Dentinwand abplattete, sondern ohne nennenswerthe Gestalt- 
veränderung mit seiner Spitze in schräger Richtung 4.5 cm. tief in das Dentin eindrang 
No. 210 
und dort stecken blieb. Das Blei liegt überall den Rändern des Dentins so genau an, 
wie bei der vollendetsten Füllung. Die Schichten des umgebenden Dentins sind durch 
den Einschlag der Kugel durchworfen, aber in ihrer neuen Lage wieder vollkommen 
zusammengewachsen. Dasjenige, was dieses Präparat aber am auffallendsten macht, 
ist, dass der Schusscanal hinter der Kugel sich wieder geschlossen hat durch ein neu- 
gebildetes Gewebe, welches aus Osteodentin zu bestehen scheint, und zwar dies, 
obgleich sich an dem Präparate der Nachweis führen lässt, dass die Einschlagstelle der 
Kugel einen Theil des Zahnes betroffen hat, welcher nicht mehr von Alveolarperiost 
bedeckt war. Für die Neubildung dieses Gewebes kann somit kein mit Blutgef ässen 
durchsetztes weiches Gewebe herangezogen werden, und es bleibt somit nichts Anderes 
übrig, als anzunehmen, dass die feinen in den Dentinröhrchen enthaltenen Ausläufer 
der Elfenbeinzellen die Fähigkeit gehabt haben, neues Dentin, wenngleich von unregel- 
mässiger Bildung, abzulagern und damit den Schusscanal hinter der Kugel wieder zum 
Verschluss zu bringen. So auffallend diese Fähigkeit wäre, so sehe ich doch keine 
Möglichkeit, eine andere Erklärung zu geben, und beschränke mich darauf, hervor- 
zuheben, dass auch Blumenbach am Ende des vorigen Jahrhunderts durch die Betrach- 
tung seiner Präparate sich zu derselben Auffassung gedrängt sah. Ein Herabwandern SECTION XVIII DENTAL AND ORAL SURGERY. 
593 
der Kugel aus dem ALveolartheile durch das fortsch eitende Wachsthum des Zahnes, 
wie dasselbe in vielen Fällen unzweifelhaft mit Recht herangezogen werden muss, um 
die Anwesenheit von Fremdkörpern und Abscesshöhlen mitten im soliden Elfenbein 
zu erklären, kann in diesem Falle nicht herangezogen werden, da sich der Schusscanal 
der ganzen Länge nach übersehen und sich dadurch der Beweis führen lässt, dass die 
Kugel, mag im Uebrigen der Zahn in der Zwischenzeit gewachsen sein, so viel er 
wollte, in ihrem Verhältnisse zu dem umgebenden Elfenbein noch genau an derselben 
Stelle liegt, an welcher sie durch den Schuss hineingeschleudert wurde. 
Bevor ich in der Betrachtung der Pathologie des Stosszahnes des Elephanten fort- 
schreite, sehe ich mich genöthigt, auf einen Punkt in dem normalen Bau desselben 
einzugehen. Es handelt sich nämlich um die Frage, ob der bleibende Stosszahn des 
Elephanten an seiner Spitze einen Schmelzbelag besitzt. Trotzdem ich die einschlägige 
Literatur nach dieser Richtung hin ziemlich genau durchgesehen habe, ist es mir nicht 
gelungen, eine bestimmte Angabe hierüber anzutreffen. Nun ist es unzweifelhaft, dass 
der Milchstosszahn des afrikanischen und auch wohl des indischen Elephanten an 
seiner Spitze von Schmelz umgeben ist. Dieser Schmelzbelag ist in Längsriefen 
angeordnet, hat die Dicke von etwa 1 mm. und eine Länge bis zu 5 cm. Nach oben 
hin läuft er mit verschmälerter Kante aus, so dass sein Uebergang in's Dentin keine 
scharfe Leiste bildet. Man findet jedoch an den Milchstosszähnen des Elephanten 
sehr vielfach, dass ein Theil dieses Schmelzbelages an der inneren Fläche des Zahnes 
abgerieben ist, so dass an dieser Stelle das durch die Reibung spiegelblank polirte 
Dentin frei zu Tage liegt. Ob nun auch die Spitze des bleibenden Stosszahnes des 
Elephanten, unmittelbar nachdem sie hervorgetreten ist und noch keiner Abnutzung 
unterlegen hat, mit Schmelz bedeckt ist, bildet die zur Entscheidung vorliegende Frage. 
Thatsache ist, dass an dem bleibenden Stosszahne des Elephanten, wenn derselbe eine 
erhebliche Länge erlangt hat, ein solcher Schmelzbelag nicht mehr gefunden wird. 
Indessen wäre es sehr wohl möglich, dass derselbe vorhanden war, aber durch die 
Abnutzung verhältnissmässig früh verloren gegangen ist. Jedenfalls wäre es eine sehr 
auffallende Thatsache, wenn der Milchstosszahn den Schmelzbelag an der Spitze hätte, 
der bleibende Stosszahn dagegen nicht. Da der Elephant in Indien seit Jahrtausenden 
gezähmt ist und dementsprechend der genauesten Untersuchung des Menschen unter- 
liegt, so erscheint es im hohen Grade auffallend, dass dieser Punkt in der zoologischen 
und auch in der speciell odontologischen Literatur, so z. B. in der ausserordentlich 
genauen Arbeit von John Mummery : " On the structure and adaptation of the teeth 
in the lower animals and their relation to the human dentition," Transactions of the 
Odontological Society of London, Vol. II, 1857-60, p. 223-253 und 311-359, keine Erle- 
digung gefunden hat. 
Eine sehr interessante pathologische Veränderung, welche sich verhältnissmässig 
häufig an dem Stosszahne des Elephanten vorfindet, ist die Dentikelbildung. Als 
Dentikel bezeichnet man eine aus Dentin bestehende Neubildung, welche sich von dem 
übrigen Dentin des Zahnes vollkommen losgelöst hat und ohne jeden directen 
Zusammenhang in den Geweben des Zahnes eingebettet liegt. Diese Dentikel benennt 
man auch als freie Dentikel gegenüber den wandständigen Dentikeln, welche letztere 
jedoch meiner Ansicht nach den Namen Dentikel überhaupt nicht verdienen, sondern 
besser als wandständige Dentinauswüchse bezeichnet werden. Die wandständigen 
Dentinauswüchse sitzen mit mehr oder weniger breiter Basis der Innenwand des Zahnes 
an und ragen frei in das Gewebe der Pulpa vor. Die freien Dentikel unterscheidet 
man wieder in pulpäre Dentikel und interstitielle Dentikel. Erstere liegen als abge- 
schlossene Dentinbildungen frei in dem Gewebe der Pulpa, letztere mitten im soliden 
Elfenbein. 
Wandständige, nach der Pulpenhöhle zu gerichtete Dentinauswüchse bilden sich 
nicht nur im Stosszahne des Elephanten, sondern wohl mehr oder weniger in dem Zahne 
Vol. V-38 594 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
jedes Säugethieres, wenn ein entzündlicher Reiz die äussere Oberfläche des Zahnes 
trifft, der sich jedoch in so engen Grenzen hält, dass er die Pulpa nicht in acute Ent- 
zündung und deren Folgen, Eiterung oder Brand, versetzt. Es bewährt sich hier das 
alte Gesetz der Pathologie, welches lautet : Acute Entzündung führt zu Eiterung oder 
Brand, chronische Entzündung zur Neubildung durch Gewebswucherung. Diese wand- 
ständigen Dentinneubildungen können nun mit einer schmalen Basis der Innenwand 
des Zahnes ansitzen und sich in der Form langer, zackiger Spitzen, sogenannter Stalak- 
titen, weit in das weiche Gewebe der Pulpa hinein erstrecken. Die schmale, der Dentin- 
wand anhaftende Basis kann nun im Laufe der Zeit der Resorption unterliegen, und 
die wandständige Dentinneubildung wird dann zum freien pulpären Dentikel. Ich 
lege hiemit zwei Präparate vor, an welchen sich dieser Process, wie ich glaube, mit 
voller Sicherheit verfolgen lässt. In dem einen Präparate (No. 166) sitzt der stalaktiten- 
förmige, tief in die Pulpa hineinragende Dentinauswuchs noch fest an der inneren 
Dentinwand. In dem zweiten Falle (No. 174), an welchem die Dentinneubildung in 
der Form der ersteren ganz ausserordentlich gleicht, ist die Trennung bereits ein- 
getreten und der seitliche Dentinauswuchs damit zum freien pulpären Dentikel 
geworden. Derselbe hat eine Länge von 10.5 cm., eine Breite von 2 cm. und eine Dicke 
von 1 cm., und gleicht auffallend den Stalaktiten, wie sie sich an den Wänden von 
Tropfsteinhöhlen finden. Die nachträgliche Abtrennung solcher seitlichen Auswüchse 
hat an sich nichts Ueberraschendes und kommt auch in der Knochenpathologie vor. 
Hier handelt es sich um die sogenannten todten Osteome, die bisweilen in den Stirn- 
beinhöhlen oder in der Nasenhöhle angetroffen werden. Es sind das knollige Massen 
bis zu Kartoffelgrosse härtester, sogenannter eburneierter Knochensubstanz, welche ohne 
jede Verbindung mit der umgrenzenden Knochenwand, allseitig umgeben von einer 
dünnen, festen Bindegewebslage, in diesen Höhlen frei vorgefunden werden. Ich halte 
es somit f ür unzweifelhaft, dass ein Theil der freien pulpären Dentikel durch Abschnü- 
rung aus wandständigen Dentinneubildungen hervorgeht. 
Ich will damit jedoch nicht behaupten, dass alle freien pulpären Dentikel diesen 
Ursprung haben, gebe vielmehr bereitwilligst zu, dass auch mitten im Gewebe der 
Pulpa Dentikelbildungen zu Stande kommen können. Hier muss man aber zuerst 
scharf unterscheiden zwischen Dentikeln und einfachen Verkalkungen. Die einfache 
Verkalkung ist, wie in vielen thierischen und specie! 1 menschlichen Geweben, so auch 
in der Pulpa der Zähne ein gewöhnlicher Altersprocess, und es gehört in der That zu 
den Ausnahmen, wenn man in der Pulpa eines Zahnes, der einem f ünfzig Jahre alten 
Menschen angehört hat, nicht eine Anzahl derartiger Verkalkungen, welche bis zu 
mehreren Hunderten vorhanden sein können, vorfindet. Die eigentlichen freien Den- 
tikel sind dagegen erheblich seltener. Die Unterscheidung eines Dentikels von einem 
Verkalkungskorne beruht darauf, dass der Dentikel bei der microscopischen Unter- 
suchung auf dem Schliffe, oder nach der Entkalkung auf dem Schnitte, deutliche 
Dentinstructur erkennen lässt. Es wird nicht verlangt, dass dieses Dentin dieselbe 
Regelmässigkeit in der Anordnung seiner Röhrchen zeigt, wie normales Dentin. Es 
genügt vielmehr, wenn überhaupt nur deutliche Dentinröhrchen vorhanden sind, mögen 
dieselben so unregelmässig angeordnet sein, wie sie wollen, und mögen sie auch mit 
Knochenkörperchen ähnlichen Lakunen durchsetzt sein in der Form des von Richard 
Owen zuerst beschriebenen Osteodentin. Dagegen muss mau sich hüten, einzelne Risse 
und Sprünge, wie sie in jedem Verkalkungskorne auf dem microscopischen Schliffe 
hervortreten, für Dentinröhrchen zu halten, und wenn man diesen Unterschied scharf 
fasst, wird man erkennen, dass eine nicht unbedeutende Anzahl der bisher beschrie- 
benen freien pulpären Dentikel zu den Verkalkungskörnern gerechnet werden muss. 
Es bleiben jedoch noch genug Fälle übrig, um die freien Dentikel in der Pulpa der 
menschlichen Zähne nicht als Seltenheit erscheinen zu lassen, und in Bezug auf die 
Bildung dieser Dentikel ist nun die Frage entstanden, ob dieselben auf die Thätigkeit SECTION XVIII-DENTAL AND ORAL SURGERY. 
595 
der Odontoblastenzellen zurückzuführen sind, oder ob sie im einfachen Bindegewebe 
der Pulpa entstehen. Um dieser Frage näher zu treten, ist es nothwendig, den Begriff 
zu erfassen, welcher mit dem Namen der Odontoblastenzellen verknüpft ist. 
Der Name Odontoblastenzellen stammt von Waldeyer, welcher ihn in seiner Arbeit: 
"Ueber den Ossificationsprocess, " Archiv f ür microscopische Anatomie, Band I, p. 354- 
375, zuerst gebrauchte. Dieser Name war jedoch nur die Nachbildung eines Namens, 
der ein Jahr früher in der wissenschaftlichen Medicin aufgetreten war, nämlich des 
Namens der Osteoblastenzellen. Als Osteoblasten zellen bezeichnete Gegenbaur in der 
Arbeit: "Die Bildung des Knochengewebes," Jena'sehe Zeitschrift für Medicin und 
Naturwissenschaften, 1864, Band I, p. 341-369, eigenthümlich gestaltete Zellen, welche 
in epithelähnlicher Anordnung an der äusseren und inneren Oberfläche, sowie an den 
Wänden der Havers'schen Räume des jugendlichen Knochens zu finden sind, und 
welchen Gegenbaur die specifische Fähigkeit der Knochenbildung zuschrieb. Er griff 
damit in den Streit ein, welcher zwischen Heinrich Müller ("Ueber die Entwickelung 
der Knochensubstanz," Zeitschrift für wissenschaftliche Zoologie, 1858, Band ix, p. 147- 
253, und " Ueber die Verknöcherung," eine Erwiderung an N. Lieberkühn, Würzburger 
naturwissenschaftliche Zeitschrift, Band IV, 1863, p. 29-55) und Lieberkühn ("Ueber 
Ossification des hyalinen Knorpels," Reichert, du Bois' Archiv, 1862, p. 702-761) über 
die Lehre von der metaplastischen und neoplastischen Knochenlehre entbrannt war. 
Gegenbaur stellte sich auf die Seite seines inzwischen verstorbenen Freundes und 
Lehrers, Heinrich Müller, und indem er den Namen der Osteoblasten schuf, gab er 
dadurch der Lehre von der neoplastischen Knochenbildung ihren schärfsten Ausdruck. 
Er behauptete damit, dass die Knochenbildung nicht zu Stande käme durch Umwand- 
lung, Metaplasie, eines anderen Gewebes der Bindesubstanzreihe, sondern dass sie 
zurückzuführen sei auf die Thätigkeit von Zellen, welche die specifische Fähigkeit 
der Knochenbildung in sich trügen, und welche deshalb mit dem Namen der Osteo- 
blasten zu belegen seien. Als nun ein Jahr später Waldeyer die Knochenbildung am 
menschlichen kindlichen Unterkiefer untersuchte, bestätigte er die Anwesenheit der 
Gegenbaur'schen Osteoblastenzellen an allen freien Rändern des wachsenden Knochen- 
gewebes. Er fand aber gleichzeitig, dass die Innenfläche der in der Bildung begriffenen 
Zähne von einer Zellenlage bedeckt sei, welche gleichfalls in der Form von Epithel- 
zellen, und zwar von cylindrischer Gestalt, dicht nebeneinander lagen. Diese Zellen, 
denen er die specifische Fähigkeit der Dentinbildung zuschrieb, benannte er im 
Anschluss an den ersteren Namen Odontoblastenzellen. Wenn man nun den Namen 
der Odontoblastenzellen nicht als leeren Schall oder allenfalls als bequeme Bezeichnung 
auffasst, sondern wenn man mit demselben den Begriff verbindet, welchen der erste 
Autor hineinlegte, so sind die Odontoblastenzellen die einzigen Zellen des menschlichen 
Körpers, welche die Fähigkeit der Dentinbildung in sich tragen ; und wenn man nun 
mit diesem Begriffe an die Fragen der Bildungsstätte der freien pulpären Dentikel 
herantritt, so ist es selbstverständlich, dass auch die Bildung dieser Dentikel, sowie die 
Bildung jedes Dentins, das überhaupt im thierischen Körper entsteht, auf die Thätig- 
keit der Odontoblastenzellen zurückgeführt werden muss, wie das auch schon von 
Wedl betont ist. Die Pulpa der Zähne besteht, abgesehen von ihren Odontoblasten- 
zelen, eben nur aus Blutgefässen, Nerven und gewöhnlichem Bindegewebe. Keiner 
dieser Theile, die in derselben Weise an vielen anderen Stellen des menschlichen Kör- 
pers vorkommen, hat die Fähigkeit der Dentinbildung, denn an keiner anderen Stelle 
des menschlichen Körpers kommt normal oder pathologischer Weise Dentinbildung 
vor, abgesehen von den Dermoidcysten des Ovariums, welch.e eine ganz andere Erklä- 
rung erfordern. Ich trage daher kein Bedenken, jede Dentinbildung des Thierkörpers 
auf die Thätigkeit der specifischen Odontoblastenzellen zurückzuführen, und wenn 
man eben mitten im weichen Gewebe der Pulpa Dentikel vorfindet, so sind dieselben 
entweder als abgeschnürte, seitliche Dentinauswüchse aufzufassen, oder man muss 596 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
annehmen, dass hier durch Einstülpung, resp. sogenannte Verirrung eines Häufchens 
von Odontoblastenzellen in das Gewebe der Pulpa hinein die Brutstätte entstanden ist, 
aus welcher solche Dentikel ihren Ursprung genommen haben. 
Eine ganz eigenthümliche Bildung sind nun die interstitiellen Dentikel. Für die 
Erklärung derselben bietet der Stosszahn des Elephanten wegen seiner grossen Ver- 
hältnisse den günstigsten Boden. Hier zeigt sich nun mit voller Klarheit, dass an 
allen denjenigen Stellen, an welchen die Ablagerung des Elfenbeins durch irgend 
welchen Reiz störend beeinflusst wurde, dasselbe sich nicht in der Form regelmässiger 
Röhrchen ablagert, sondern in der Form von Kugeln, welche im Querschnitte ein 
höchst characteristisches Aussehen haben. In den Präparaten No. 58, 144, 149 und 158 
zeigt es sich auf's Deutlichste, welche merkwürdigen Formen das unter dem Einflüsse 
chronischer, entzündlicher Reizung abgelagerte Elfenbein annimmt. Ich halte es nun 
für sicher, dass das Elfenbein diese Kugelform nur zu deijenigen Zeit annehmen kann, 
in welcher seine Ablagerung erfolgt. Dass ein normal abgelagertes Elfenbein später 
die Fähigkeit hätte, in Kugelform überzugehen, scheint mir in unlösbarem Wider- 
spruche mit allen Erfahrungen zu stehen, welche wir über die Physiologie und Patho- 
No. 58. 
No. 165. 
logie der verkalkten thierischen Gewebe besitzen, und ich glaube auch kaum, dass 
irgend ein Forscher diese Behauptung jemals aufgestellt hat. 
Es handelt sich nun noch darum, zu erklären, wie dieses in Kugelform abgelagerte 
Elfenbein seine Trennung von dem umgebenden Gewebe soweit vollziehen kann, dass 
es als freier interstitieller Dentikel in dem soliden Elfenbeine eingebettet liegt, ohne 
mit der umgebenden Wand den geringsten Zusammenhang zu haben, und diese Erklä- 
rung stösst allerdings auf einige Schwierigkeiten. Das Präparat No. 147 zeigt einen 
solchen freien interstitiellen Dentikel in seinem Elfenbeinbette, und das Präparat 
No. 165 zeigt einen freien Dentikel erheblicher Grösse von 9 cm. Länge, 3.5 cm. Breite 
und 2.5 cm. Dicke, ohne die umgebende Elfenbeinhülle ; doch glaube ich berechtigt 
zu sein, auch diese Dentinbildung als interstitiellen Dentikel auffassen zu dürfen. 
Meiner Ansicht nach spielt bei der Umwandlung der Dentinkugel zum freien intersti- 
tiellen Dentikel die Austrocknung eine erhebliche Rolle. Während des Lebens des 
Thieres standen die Elfenbeinkugeln mit der umgebenden Dentinwand vielleicht noch 
in einer, wenngleich wenig festen Verbindung. Als nun aber das Thier getödtet wurde 
und das Elfenbein seines Zahnes wie jedes andere thierische Gewebe der Austrocknung 
verfiel, da lösten sich die letzten Verbindungszüge, und die Kugel zog sich auf ihr 
Centrum zurück und entfernte sich dann etwas von der umgebenden Zahnwand. Der SECTION XVIII-DENTAL AND ORAL SURGERY. 
597 
Process ist wohl derselbe, wie derjenige, durch welchen sich in einer ausgesägten Holz- 
platte der Ansatz eines Astes, dessen Holzlagen circulär angelegt sind und mit dem 
umgebenden Holze des Stammes nur in loser Verbindung stehen, durch Austrocknung 
zusammenzieht und dadurch seine letzte Verbindung mit dem umgebenden Holze des 
Stammes löst. Die Aehnlichkeit eines in seinem Dentinbette frei beweglich liegenden 
interstitiellen Dentikels mit der Anlage eines Astes, der sich von den umgebenden 
Holzlagen getrennt hat, ist eine so auffallende, dass wohl ohne Bedenken die Gleichheit 
der veranlassenden Ursache erschlossen werden kann. Diese Deutung findet an den 
No. 147. 
aus dem nördlichen Sibirien stammenden Mammuthzähnen, von denen ich ein Präparat 
(No. 172) vorlege, welche seit Jahrtausenden der Verwitterung und Austrocknung 
überlassen sind, eine wesentliche Stütze. Obgleich das Elfenbein an diesen Zähnen, 
wie auch an denen der jetzt lebenden Elephanten, sicherlich nicht in concentrischen 
Schichten abgelagert ist, so hat es doch der lange Process der Austrocknung und Ver- 
witterung mit sich geführt, dass das Elfenbein sich in concentrischen Lagen trennt, 
woraus folgt, dass die zum Centrum gehende Verkleinerung der Masse im Stande ist, 
selbst die Verbindung normal abgelagerter Elfenbeinschichten zu lösen und dadurch 
postmortale freie interstitielle Dentikel zu schaffen, wo während des Lebens sicherlich 
nichts Anderes als gleichmässig abgelagertes Dentin vorhanden war. Auch an mensch- 
NO. 232. 
lichen Zähnen sind schon freie interstitielle Dentikel beobachtet, wenngleich hier die 
Kleinheit der vorliegenden Verhältnisse eine sichere Deutung ausserordentlich erschwert. 
Das letzte Präparat, welches ich hier vorzuf iihren mir erlaube, betrifft das bekannte 
Verhalten des unbeschränkten Wachsthums der Zähne der Nagethiere, wenn durch 
Störung des Bisses die normale Abschleifung an den Kauflächen derselben aufgehoben 
ist. Das Präparat No. 232 stellt den Schädel eines Kaninchens (lepus caliculus) dar, 
bei welchem sowohl an den Schneidezähnen, als an den Molaren dieses unbeschränkte 
Wachsthum in sehr deutlicher Weise hervortritt. Die Veranlassung für die Unregel- 598 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Mässigkeit des Bisses liegt aber hier nicht etwa in einer Verletzung, sondern in einer 
angeborenen Missbildung. Während das rechte Schläfenbein mit seinem knöchernen 
Gehörgange normal entwickelt ist, ist das linke Schläfenbein durch angeborene Miss- 
bildung verkümmert und hat überhaupt keinen knöchernen Gehörgang. Dadurch ist 
die linke Hälfte des Schädels und auch des Unterkiefers in ihrer Grösse erheblich 
zurückgeblieben, so dass der ganze Schädel schief gebildet ist mit einer nach rechts 
gerichteten Convexität. Durch diese schiefe Bildung des Schädels ist nun wieder die 
Articulation der Zähne aufs Schwerste gestört. Der rechte obereSchneidezahn articu- 
lirt mit dem linken unteren Schneidezahne, und diese beiden Zähne haben, da sie sich 
gegenseitig an einander abschliifen, ihre normale Länge bewahrt. Der linke obere 
Schneidezahn mit seinem kleinen hinter ihm liegenden Schneidezahne und der rechte 
untere Schneidezahn sind dagegen, da sie jeder Articulation und dementsprechend der 
erforderlichen Abschleifung entbehrten, in Form langer Haken weit herausgewachsen. 
Aber nicht nur die Articulation der Schneidezähne, sondern auch die Articulation der 
Molaren ist schwer gestört. Auf der rechten Seite tritt das weniger deutlich hervor, 
obgleich auch hier der erste Molar des Unterkiefers den Knochenraud seiner Alveole 
7 mm. überragt, bevor er die Articulation mit dem ersten Molare des Oberkiefers 
erreicht. Auf der linken Seite ist aber die Störung eine viel grössere. Hier überragt 
der erste Molar den Knochenrand seiner Alveole um 12 mm., ohne überhaupt einen 
Gegenzahn des Oberkiefers zu erreichen. Er arbeitet daher mit seiner Kaufläche 
direct gegen die harte Gaumenplatte und hat sich in der Knochenwand derselben eine 
kleine Vertiefung ausgegraben. Der zweite Molar des Unterkiefers articulirt schräg 
gegen den ersten Molar des Oberkiefers, und an beiden Zähnen haben sich infolge dessen 
tiefe, schräge Schliffflächen ausgebildet. Die anderen Molaren treffen mit ihren Kau- 
flächen aufeinander, und zwar so, dass auch noch der letzte Molar des Oberkiefers 
einen Antagonisten im Unterkiefer erreicht. Es kommt das dadurch zu Stande, dass 
die Molaren des Unterkiefers schräg stehen und dadurch eine so lange Fläche ein- 
nehmen, dass die vier hinteren Molaren des Unterkiefers den fünf Molaren des Ober- 
kiefers den erforderlichen Gegendruck gewähren. Die veranlassende, auf Missbildung 
beruhende Ursache der Störung der Articulation der Zähne giebt diesem Falle ein 
grösseres Interesse, als es diejenigen Fälle haben, in welchen die Articulation der Zähne 
der Nagethiere durch Verletzung oder durch zu weiches Futter hervorgerufen ist. 
REMARKS. 
The paper was illustrated by a large number of beautiful specimens and a num- 
ber of photographs, some of which are here presented. 
Prof. Busch then spoke in the German language, his remarks being interpreted 
by Dr. F. H. Rehwinkel, of Chillicothe, Ohio, one of the Secretaries, who said :- 
Prof. Busch says that, though the specimens which he has presented here are 
not those of human teeth, he finds that, in cqjnparative anatomy, many diseases of 
the dental organs in the larger class of animals are, in many respects, so similar to 
those of the human species, that he thinks he will be able to trace very closely rela- 
tions of causes and effects. lie presents you here with a specimen of the teeth of an 
animal of a small type of a whale. Here (indicating) is a defect which resembles 
caries in many respects, nearly in all respects. It, however, has nothing to do with 
the pulp chamber. The pulp chamber is entirely protected by the lime salts thrown 
off. 
Prof. Busch says that it comes very near caries, but he does not wish to be under- 
stood as saying positively that it is caries. He thinks there is a slight probability 
that some gnawing or boring animal may have bored the commencement of the SECTION XVIII-DENTAL AND ORAL SURGERY. 
599 
injury, and that afterward disintegration proceeded from that. He says that there 
is at least a strong probability of that, though there is nothing to show that it was 
positively the fact. It is, to some extent, a riddle and a mystery how this defect did 
occur in this tooth. I will hand down the specimen and ask gentlemen to pass it 
around. 
Prof. Busch further remarks that caries in these large animals is of rather rare 
occurrence (but it does occur), but that alveolar abscess is a disease of very frequent 
occurrence. That is found in all species. He has some specimens here which show 
us the effect of alveolar abscesses in the partial destruction of the root of the 
elephant's tooth, showing the destruction of the solid part of the tooth, and after- 
ward of its edges, and showing the destructive operation. He has a second speci- 
men here which shows a pus cavity very near the pulp chamber. The third speci- 
men shows the needle formation of secondary dentine. It is in the shape of needles 
and was also produced by the irritation of an alveolar abscess. This one (indicating) 
shows a partial destruction of the root. This one (indicating) shows destruction 
outside of the root, through the walls into the pulp chamber ; and this one (indi- 
cating) shows the formation of secondary dentine in the shape of needles. 
The specimens were handed around, and Prof. Busch proceeded :- 
These three specimens show the same effect. This one (indicating) shows the 
cavity of the abscess close to the pulp chamber, but separated from it by sufficient 
dentine to protect it. This one (indicating) shows a chamber of the abscess proper. 
This one (indicating) shows the pulp chamber, and here (indicating) you see the 
formation of secondaiy dentine. 
Dr. W. C. Barrett remarked that the abscess cavity seemed to have been 
originally connected with the pulp, and inquired whether this was so. 
Prof. Busch replied that Dr. Barrett is correct. The abscess was originally in 
the pulp chamber and extended upward, and the protecting or separating wall was 
a new production of bone. 
This specimen (indicating) shows a remarkable production of secondary dentine. 
It shows here, from an abscess in the pulp itself and from a subsequent reproduction 
of secondary dentine, that it was so much in excess that the pulp chamber was not 
quite obliterated, but was very much circumscribed and very much crowded. This 
specimen (indicating) shows the cavities here where they were not entirely filled out, 
where the process was slower, and where eventually the pulp dried out and left these 
cavities. Here is a remarkable and interesting specimen, for the reason that, from 
the outside, it does not show any injury or any cause why there should be such a 
cavity in that solid dentine. Prof. Busch thinks it entirely impossible that an abscess 
could be produced and could exist in the solid part of the dentine, and he is of the 
opinion that this must have originated in the pulp chamber, and that gradually, by 
extending and pressing against the sides of the dentine, it has opened its way through, 
because, he says, it would be impossible for the pus corpuscles to traverse this solid 
dentine. The only explanation then would be that it gradually bulged out from the 
chamber and, by a process of very slow disintegration of the dentine, found its way 
here and exhausted its force, and the production of new dentine was not sufficient to 
fill out the cavity. He calls attention to the fact that the growth of an elephant's 
tusk never ceases, but it grows as long as the animal lives. 
Prof. Busch shows here some specimens of the effect of the irregular development 
and irregular deposit of dentine. From some cause or other it is frequently found 
that the deposit of lime salts in the dentine takes place in an irregular way, that 
the ordinary process is, from some cause or other, changed. Then there is a 600 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tendency to mass the dentine in parts. These parts enlarge and assume the shape 
of spherical pellets. There can be plainly seen here, with the naked eye, very 
irregular shapes, and the separation from the original dentine in these two specimens 
(presenting them). But this specimen (presenting another) places the suggestion 
beyond a doubt. There is no doubt about this one. It shows the results of this 
peculiar abnormal deposit. In the deposit of dentine and the formation of pellets 
there comes a process of desiccation or drying up. This is why the separation takes 
place from the balance of the dentine, and this is why the seams occur which are 
perceptible in these specimens. 
Prof. Busch, with other specimens in hand, proceeded with his remarks, which 
were interpreted by Dr. Rehwinkel as follows:- 
These two specimens (indicating them) represent the process of dentine nodules 
in the soft pulp. The Professor thinks that the origin of these nodules proceeds 
from the walls of the pulp chamber, and that they have there an attachment; but 
that, in the course of time, through reaction, they become settled, and then the de- 
posit is entirely within the soft parts of the pulp. This specimen (indicating) shows 
the attachment to the side of the wall completely, and this specimen (indicating) 
represents the condition of these nodules after the attachment to the walls has been 
severed, and after they have been deposited entire in the soft tissue of the pulp. 
He says that it is safe to assume that the deposit of nodules always has its origin at 
the side of the wall of the pulp chamber, and that, after certain processes, a reaction 
and separation takes place, and that they are then found loose and entirely independent 
of the walls in the pulp chamber itself. 
This specimen (indicating it) shows the union of fracture in the root of the teeth. 
It shows a large callus here. It is a longitudinal fracture, as you all see. The 
Professor says that we all know that even in human teeth the roots will occasionally 
be reunited by callus, just as other bones, but very rarely. It is not so rare an 
occurrence in the tusk of the elephant. There it is found much more frequently. 
The process is the same as that of the union of parts of bones by callus. 
This specimen (indicating) represents the effect of injuries on the dentine. This 
specimen (indicating it) shows the effect of a bullet. The bullet has penetrated 
the dentine and pierced the pulp and lodged in the opposite side of the pulp 
chamber. You see here a swelling, a thickening out from the inside, and this 
cavity here seems entirely closed, but still the bullet is found on the opposite 
side. You find here a slight chamber of depression, which shows that it was 
filled out with secondary dentine. On the other side you see the bullet, which 
has shattered and fractured the whole wall of the tooth. This other specimen 
(indicating) presents a case of much more interest. It is interesting because the 
bullet, which is a leaden one, embedded itself in the dentine and did not penetrate 
deeply enough to interfere with the pulp chamber. The point of interest is that 
there should be a new formation of dentine at the entrance of the bullet, while, as is 
generally supposed, the formation of secondary dentine proceeds exclusively from 
the pulp. Thçre is but one way to account for it. It must have been either pro- 
duced by the alveolar membrane or by the pulp itself. The pulp itself, not having 
been touched or interfered with, could not have produced it, and the question then 
is, where did the formation of the secondary dentine have its origin ? That is the 
point of interest presented in this specimen. 
Prof. Busch exhibited other specimens and made remarks about them, which 
were interpreted by Dr. Rehwinkel as follows :- 
I present to you here a novel thing which has been of great benefit to me in the 
quick and almost painless removal of moles. Any one who has ever undertaken an SECTION XVIII-DENTAL AND ORAL SURGERY. 
601 
operation of that kind knows how tedious and painful it is, and how loath patients 
are to undergo such an operation. In order to facilitate the process, I have had 
manufactured, and present to you here, a series of cutting cylinders of different sizes. 
The first step in the operation is to measure the circumference of the wart or mole. 
It is of some importance that the instrument should not be large ; that it should be 
large enough, but not much larger than the wart or mole. After the selection of the 
instrument, a quick rotary movement of it cuts so rapidly and quickly that it goes 
right through the layer of skin. Then, by lifting the lower portion of it by a pair 
of pliers and cutting underneath with a pair of scissors, the whole operation is done. 
After the cutting process is complete all the dressing that is necessary is to stop the 
hemorrhage, and then dress the wound with simply a little cotton wadding. This 
must be left for eight or ten days, when a crust will be formed, which will afterward 
fall off, leaving a cicatrix of a white color, which is scarcely perceptible, or which, at 
any rate, is a great improvement over the original wart. 
The Professor cautions against attempting to close the wound with sutures. He 
says that it is much better to let the process of healing be that of granulation instead 
of trying to make it by first intention. He cautions, also, that the operation has its 
limits ; that if the wart or mole is too large, an operation, perhaps, would not be 
advisable. The largest instrument that he has here is of one and one-half centimetres. 
That is the largest he has ever attempted. The little bottles which he has here are 
specimens of moles which he has removed in the last course in the University of 
Berlin. There are five of them, which I will hand around. 
This closed Prof. Busch's remarks, which were much applauded. 
DISCUSSION. 
Dr. Atkinson, of New York, said that he was rather overwhelmed with the 
presentment just made, and how to analyze it in his own mind so as to communicate 
the value which it was to him, he did not quite understand. In the first place, he 
wanted to thank Prof. Busch, from his heart, for the magnificent display which he 
had gathered together in a sort of condensed presentment, which would recall to 
many, a lifetime, almost, of observation in the shops of ivory workers who had dis- 
carded as useless these pieces of ivory which were beginning to be so valuable to 
the dental profession, as a means of revealing something more than they had been 
able hitherto to comprehend in anything like a scientific manner. He was sorry 
that he could not speak German, and more sorry still that he could not understand 
it ; but he could understand the impulses of the human heart, because his mother 
had given him one of goodly proportions. He could not express his thankfulness, in 
any adequate speech, for the presentment just made. It was difficult for him to 
criticise that presentment in the legitimate sense of criticism. If there had been 
less of assumed understanding of causes in the presentment, he should have been 
better satisfied, because almost every attempt to show the "why," had led to a 
difficulty of understanding the ' ' how, ' ' in the bringing about of this abnormal 
presentment. Every dentist who had been in a shop where elephants' teeth were 
cut up, had seen that it was a matter of aging that gave this globular appearance in 
the centre of the tooth. It was this that gave the globular formation. It was the con- 
solidation of the lime salts which constituted the globes in the specimens submitted. 
They showed calco-globine in the soft element. It was something which had to be 
studied much before the cause could be understood, though it was clear to his con- 
sciousness how the matter was brought about. He knew the "why" of nothing ; 
he only knew the " how" and that in so small degree as to make him feel ashamed 602 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to stand before his intelligent brethren and attempt to unravel it, so that they 
might be willing to accept his views until they could get better ones from the revela- 
tion of the truth to their own consciousness. He was so full of irradiancy on the 
occasion of the view of the nodules which were gathered together in these beautiful 
specimens, that he would he had the power of angels to speak forth the feelings of his 
heart, and show where the mistake had been made in telling them that these nodules 
came from the periphery of the pulp, or rather from the already formed dentine on 
the periphery of the pulp chamber, immediately outside of the odontoplasm. It 
was not at all essential to see which were formed first and which were formed last ; 
it was the irregularities they had to deal with. When a part of an elephant's 
tooth got below the point where it was useful as ivory, it would be found that these 
globules were in it, and that there were lime salts enough held in solution to com- 
pletely consolidate the whole mass. It would be seen that this was evidence of a 
bond of consolidation in the centre, which was called secondary dentine. He wanted 
to get rid of bad nomenclature, because it was that which prevented them from 
getting a clear classification, so as to be able to open the door to new revelations, and 
thus be able to interpret what nature had been doing in building up this tooth. He 
had reatl, last night, a translation of Prof. Busch's paper, thus depriving himself 
of the privilege of attending the banquet, but he thought it better to be with the 
angels of science than with the swamp angels. Prof. Busch had suggested in that 
paper, that it was quite probable that, in the African elephant, the tusks in their 
first formation were tipped with an enamel cap. He did not know how closely 
behind the throne of the Infinite Prof. Busch had been in the workshop of organizing 
living bodies, but it seemed a little as if he had been studying close down on the 
formation of the teeth of eels. There were many of the eels which had a tip of 
enamel on the end of their teeth, but there was no instance of teeth which he 
(Dr. Atkinson) was acquainted with, which had not what was called an enamel 
pulp, as the forestep of the dentinal pulp. That was, that there was no dentine 
without a covering of corpuscles, which he would not call dentinal but indifferent 
corpuscles. They were called in the embryon bone-plates, nerve-plates, and muscle- 
plates ; but they could not be differentiated by the sharpest scrutiny of any micro- 
scopist. If a portion of one of these was taken out, no one could tell to which of 
them it belonged. He would merely say that it was epithelial-that they were all 
epithelial. God help him ! Epithelial ! These (referring to specimens) were not 
epithelial. They were only a reminiscence of what the eel was before it became a 
mammal. If they got at those points, they would be able to improvise and speculate 
with more certainty than now. It was so long since he had cut his aboriginal teeth 
-that is to say, when he was one of the cetaceæ-that he could hardly recall the 
stages through which he had passed in making his observation of the building of this 
tissue. They would see that he was a Darwinian, and yet he was not exactly a Dar- 
winian. He believed in evolution, but he also believed in the unfolding of that 
which had been folded. He believed that a thing never could be unrolled before it 
was rolled. There had been a power behind, which had established the order of 
folding and unfolding. He knew of no tooth that was formed at all, which was not 
from a dipping in of those corpuscles, so as to make that which finally assumed a 
flask-shape, and fitted over the papilla. It seemed that there was a reminiscence 
there-a something not yet revealed, which made it a necessary forestep in the form- 
ation of dentine, that there should be a kind of indifferent body that had no blood 
vessels in it, that had no differentiated nerve in it, in which all that appeared as a 
nerve was simply the outer wall of oxidized hydrate of carbon of that body which, SECTION XVIII-DENTAL AND ORAL SURGERY. 
603 
when put together, made nerve-plates, bone-plates and muscle-plates, and were 
obliterated in the formation into bones, nerves and muscles. 
He could talk to them all day upon these specimens presented by Prof. Busch, 
and show exactly what they said to him. He did not see in them a bit of dentine 
that was of secondary formation-that was to say, which had been formed and 
melted down by reason of the impact of the bullet into a mass of lime salts which 
had been called decalcification. That was the trouble with them. Whenever they 
saw those abnormal appearances, they assumed that the lime salts were taken away. 
They were not taken away. The lime was melted and was all there. A chemical 
analysis would show that it was there. There was a something behind that which 
was again concealed, and which did not conform to the dental fibrils or to the den- 
tinal tubuli. That was proved by every one of those specimens. It was made up of 
calco-globine and super-oxidized hydrate of carbon, strung together in corpuscles, 
holding an amount of lime salts in them which no chemical analysis had yet been 
able to discharge. He referred to this as a sort of hint to men not to say that they 
knew the causes of things, and that they knew how all this was. He took it for 
granted (referring to the specimens) that there was no pus there, that there was no 
ichor there, as long as that elephant lived, but that the thing was going on under 
the normal operations of building power. 
Dr. Geo. J. Friedrichs, of New Orleans, La., said that there was one thing in 
Prof. Busch's remarks which he could not understand and which he wished the Pro- 
fessor to explain. It was as to the spaces (seen in the specimens) being produced 
by abscesses. In one specimen shown the space was entirely enclosed. It was 
known that, in human teeth, in the deposit of secondary dentine, a part of the pulp 
was sometimes cut off" and a lacuna thus produced in the tooth; and sometimes they 
found where globular developments were made, or even where there was an imper- 
fect formation from the secondary deposit which was called a horn; and sometimes 
they came upon pulp there without expecting it. Now that was exactly what he 
desired Prof. Busch to explain. Pus was always associated with abscesses. Conse- 
quently the inference which he would draw from that was that they had here in 
these specimens a mass of impacted, enclosed, or encysted, pus-especially in one of 
the specimens. He would like to hear Prof. Busch explain what he actually meant 
when he spoke of an abscess. 
Prof. Busch made answer in German, which was interpreted by Dr. Rehwinkel 
as follows: The Professor says he cannot conceive how it is possible to account for 
these phenomena. Where there are two cavities, he thinks there is but one way to 
explain how these two cavities exist. In the first place, there is the injury to the 
tooth, and there are the consequent stages of inflammation and the formation of pus. 
In the next place there is the formation of new dentine in the separating wall 
between the abscess cavity and the pulp cavity. Furthermore, the Professor says 
he is led to believe that these are abscess cavities filled with pus, because, on cutting 
this specimen (indicating) and on opening the cavity, there was a very penetrating 
odor, such as is given out only from putrid matter. He says that a very unpleasant 
putrid odor is always revealed on opening these cavities. He cannot account for 
it in any other way than by assuming that these cavities must have been formed 
with pus, because it would be altogether too imaginary to suppose that there were 
two pulp chambers in this one tooth. The separation which took place through the 
formation of bone made a separating wall (according to his views) between the pulp 
chamber and the pus cavity. 604 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Friedrichs said that if this occurred as Prof. Busch represented, then the 
functions of the pulp of an elephant's tooth must inevitably be different from the 
functions of the pulp of the human teeth. If pus forme.d in the pulp chamber of a 
human tooth, that pulp was destroyed. At least that was his experience. So that, 
whenever pus was formed in the pulp, and the pulp became inflamed, the death of 
the pulp ensued. He could not realize how pus could be formed after being encysted 
by secondary formation of dentine. 
Dr. W. C. Barrett, of Buffalo, N. Y., said that, in thinking of other matters, 
he had lost the point of connection-he had lost the point of what he desired to say, 
and on which he had prepared himself. He would endeavor to be very brief. The 
tooth of an elephant, he said, was a persistent germ. Its growth was continuous 
throughout the life of the elephant, and was analogous to that of indigenous plants. 
He had drawn a rough diagram to represent the course of the growth and prolonga- 
tion and elongation of the elephant's tooth (pointing it out on the blackboard). In 
the first place, there could be no pus without infraction. If there was pus present, 
there must have been a point of infraction through which microbes could gain access, 
and without which there could be no formation of pus. When the tooth was in its 
early stages of development, it had what he might almost call a definite cap forming 
in the end of it. Perhaps at that early stage there might have been a wound at the 
junction of the teeth with the bone, or through the bone near the base of the pulp; 
and thereby the bone had become infracted. Access, ingress, was therefore given to 
the microbes which brought about the formation of pus. The bullet having entered 
at this point (indicating on the diagram) it had but a very thin shell of enamel to 
pass through. It had passed above the point of dental formation, and there must 
have been an infraction above that. Then there were layers of dentine formed inside 
until finally a coalescence at the lower point gave a slight disc like this. And so it 
continued to grow solid, further and further back, as the tooth elongated, and as 
there was a continuous deposition of dentine from the dentine-forming cells. If 
there had been a point of infraction at the base of the tooth, pointing out the spot 
on the diagram, and if pus had formed at that point, possibly from the pressure of 
the tissue in its inchoate condition, a cavity might be formed within the dentine by 
the progression of the tooth carried forward. First they had it here on the periph- 
ery of the tusk and when it reached this point (indicating) it was entirely covered by 
dentine and would be carried on and on until it was found in the solid portion of the 
tusk. Now, that did not explain why; it did not give the absolute reason for the 
formation of the pus; nor did it necessarily explain the formation of the cavity within 
the dentine of the tooth; but yet it might be that there was a partition of dentine 
formed across, and leaving the cavity. Within the substance of the pulp, beyond 
the reach of the peculiar conditions which there existed, new dentine-forming cells 
might have been organized, and in that way it could be readily conceived that a layer 
of dentine might be formed over the cavity within the body of the tooth. He could 
conceive that condition. It did not seem to him probable that there was a pus 
cavity within the dentine, because when a layer of the dentine was formed over it, 
that must certainly obliterate the pus cavity as far as it went. Within that cavity 
there could be no longer any breaking out of the indifferent corpuscles mentioned by 
Dr. Atkinson, and they were melting down under the influence of the microbes, which 
could melt down gelatine, or the indifferent corpuscles, and reduce them to a solid 
state. Then with the weeping of the first corpuscles they had formed pus. It 
seemed to him quite possible in that way to comprehend the formation of a cavity 
within the body of the dentine which might contain the débris which was originally 
within it. SECTION XVIII-DENTAL AND ORAL SURGERY. 
605 
Dr. A. E. Baldwin, of Chicago, said that he had heard it asserted positively in 
the discussion on this floor, twice, as he thought, that it was necessary, for the 
production of pus, that there must be microorganisms present. As no person had 
protested against the acceptance of that doctrine, he rose to protest. In one sense 
of the word it might be true, in the sense that there were microorganisms everywhere, 
in the blood and elsewhere; but against the acceptance of it in the sense in which it 
was ordinarily used, that the microorganisms (otherwise than as they were present 
in the air or in the surrounding deposits) must be present in the formation of pus, 
he took direct issue. He could not help doing so, having seen what they had all 
seen, that is, simple formation of a felon on the finger. Pus was formed under 
the periosteum. He could conceive of no other way for microbes to get there save 
through the medium of the circulation of the blood; and if so, what was the use of 
germicides ? Because if they were deposited there, they might be deposited every- 
where else. They could not be destroyed in the blood. He simply wanted to go on 
record as protesting against the acceptance of that doctrine with the evidence we now 
have. 
Dr. Barrett said he did not suppose it was necessary, in the present advanced 
state of science, to argue that question here. There was no time to enter into a 
discussion of the question as to how the microorganisms got there. But they got 
there all the same. 
A recess was taken until 3 P. M. 
At the request of Dr. A. M. Dudley, one of the Secretaries, Dr. L. D. Shepard, 
of Boston, read an English translation of the following paper :- 
DE LA DENT DE SIX ANS. 
ÜBER DEN ZAHN DES SECHSTEN JAHRES. 
ON THE SIX YEARS' TOOTH. 
PAR LE DR. E. ANDRIEU, 
De France. 
L'OBJET DE CE MÉMOIRE EST DE DÉMONTRER: 
1° Qu'aux points de vue anatomique, physiologique et pathologique, la première 
grosse molaire permanente, ou dent de six ans, doit être considérée comme une dent 
de transition; 
2° Que la dent de sagesse, bien qu'elle ne vienne pas occuper la place laissée vide par 
la dent de six ans extraite, peut cependant, au point de vue pratique, et à cause des rap- 
ports pathologiques qui existent entre ces deux dents, être envisagée comme la dent de 
remplacement de la première grosse molaire; 
3° Enfin, que les cas sont fort nombreux où. la dent de six ans peut et doit être ex- 
traite, au grand avantage de l'arrangement et de la santé du reste de la denture. 
ORIQINE DE LA DENT DE SIX ANS. 
"La première grosse molaire permanente, dit Goodsir, est la dent la plus remar- 
quable chez l'homme, en ce qu'elle forme une transition entre la dentition de lait et la 
dentition permanente. Considérée anatomiquement et dans son développement dans le 606 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sillon dentaire primitif, en tant que papille et follicule, elle est une dent de lait ; 
considérée physiologiquement, c'est-à-dire au point de vue des fonctions de mastication 
dans l'âge adulte, elle est une dent permanente." * 
Reprenant cette idée de Goodsir, nous allons essayer de la développer et surtout d'en 
développer les conséquences en ce qui concerne l'arrangement des dents, la pathologie 
et la prophylaxie de ces organes. 
Sans passer ici en revue la théorie de Goodsir pas plus que les travaux de Külliker, 
Waldeyer, Kollmann, etc., sur l'origine et la formation des dents, ce qui serait fort 
long et nous entraînerait au delà de notre sujet, nous nous contenterons de puiser dans 
les travaux de Legros et Magitot f et dans ceux de Ch. Tomes, i qui font actuellement 
autorité dans la science, les notions qui peuvent venir à l'appui des idées que nous 
émettons, dans ce Mémoire, sur la nature et le rôle de la dent de six ans. 
Le mode de genèse des dents permanentes n'est pas le même suivant que telle dent 
permanente a été précédée d'un follicule temporaire correspondant, ou que telle autre 
est apparue au sein des mâchoires en l'absence de toute dent temporaire préalable. Or, 
les dents permanentes se divisent en dents de remplacement, au nombre de vingt, et 
en dents permanentes proprement dites, au nombre de douze, de sorte qu'il nous faut 
étudier séparément l'origine de ces deux catégories de dents. 
D'après Legros et Magitot, il existe toujours au niveau du point de jonction de 
chaque cordon primitif avec l'organe de l'émail de la dent temporaire correspondante, 
un bourgeon en forme de cylindre plus ou moins renflé à sou extrémité, dirigé plus ou 
moins verticalement vers la partie profonde des mâchoires, entre la paroi alvéolaire et 
le follicule primitif, sur la face interne de celui-ci. Ce n'est qu'un véritable diverticu- 
lum du cordon primitif, première ébauche des vingt dents de remplacement. Il s'en- 
fonce profondément dans la gouttière dentaire pour s'isoler des follicules primitifs sur 
le point même qui a été le siège de sa naissance. 
Le follicule primitif devient ainsi indépendant de toute connexion de voisinage et 
continue son évolution individuelle, taudis que le bourgéon secondaire reste adhérent 
au cordon primitif et, par lui, à la lame épithéliale et à la muqueuse. 
Le renflement terminal du cordon secondaire devient organe de l'émail, le bulbe 
naît bientôt dans la dépression de cet organe, la paroi folliculaire se montre à la base 
du bulbe, s'élève sur les côtés et atteint le sommet du nouvel organe de l'émail pour 
s'y fermer. Le cordon secondaire se rompt à son tour, et le follicule secondaire se 
trouve entièrement isolé de toutes connexions, absolument comme le follicule primitif, 
pendant les phases ultérieures de son évolution. 
. Tel est le mode d'origine des follicules des vingt dents de remplacement ; mais, pour 
les dents permanentes qui naissent d'emblée en arrière de la série des dents caduques, 
il n'en est plus ainsi. 
La première grosse molaire permanente dont on voit déjà le follicule assez, dévelop- 
pé pendant la vie fœtale, naît, et c'est là le point essentiel à notre sujet, d'un cordon 
épithélial qui prend directement son origine à la lame épithéliale. 
Ce cordon pénètre au sein du tissu embryonnaire dans une région où il ne rencontre 
aucun follicule antérieur. Il est donc exactement dans le même cas que le follicule des 
dents de lait. 
Pour la deuxième grosse molaire, il n'en est pas ainsi: sa genèse s'opère par le même 
mécanisme que celle des dents de remplacement ; c'est-à-dire que la première grosse 
* "On the pulps and sacs of the human teeth." Edin. Med. and Surg. Journal, Janv. 1839. 
f Ch. Legros et Em. Magitot. " Origine et formation du follicule dentaire chez les mammi- 
fères." Paris, 1873. 
| Ch. Tomes. "Traité d'Anatomie dentaire, humaine et comparée." Traduction du Dr. L. 
Cruet. Paris, 1880. SECTION XVIII-DENTAL AND ORAL SURGERY. 
607 
molaire joue, par rapport à elle, le même rôle que les dents de lait par rapport aux 
dents de remplacement. 
C'est, en effet, par un diverticulum du cordon de la première grosse molaire que se 
produit le follicule de la seconde; seulement, le cordon épithélial ne prend pas la direc- 
tion descendante ou verticale, mais se porte horizontalement pour s'infléchir au delà du 
follicule et se placer au bout de la rangée. Pour la troisième grosse molaire ou dent de 
sagesse, le mécanisme est analogue à celui que nous venons d'indiquer, c'est-à-dire que 
le cordon qui donne naissance à l'organe de l'émail est une émation du cordon de la 
dent de douze ans. 
Donc, en résumé, pour Legros et Magitot, le follicule de la première grosse molaire 
permanente naît, comme celui des dents de lait, de la lame épithéliale, tandis que chacune 
des deux dernières molaires dérive directement de celle qui la précède. La première 
molaire née de la lame épithéliale reste par son cordon le point de départ des dernières 
générations de follicules. 
Le follicule de la première grosse molaire apparaît à la quinzième semaine de la vie 
fœtale, c'est-à-dire peu après les follicules temporaires et n'achève son évolution qu'à 
la sixième année. Le début du follicule de la deuxième molaire permanente, ou pro- 
longement cylindrique provenant du cordon épithélial de la première molaire perma- 
nente, apparaît vers le troisième mois de la naissance; celui de la troisième molaire, qui 
se détache du cordon de la deuxième molaire, n'apparaît que vers la troisième année. 
Pour Ch. Tomes, les vingt dents permanentes qui sont précédées par les dents tem- 
poraires naissent d'une portion du germe de ces dernières, les douze vraies molaires 
seules ont une origine distincte : 
Vers la seizième semaine de la vie intra-utérine, du collet de cellules qui unit l'or- 
gane de l'émail du germe de la dent temporaire au stratum de Malpighi, bourgeonne 
un second prolongement réfléchi de l'épithélium dont l'aspect rappelle le premier rudi- 
ment du germe de la dent temporaire ; ce prolongement descend sur le côté interne du 
sac de la dent temporaire et, par une série de modifications en tout semblables à celles 
qui aboutissent à la formation du germe de la dent temporaire, il se transforme en 
germe de la dent permanente. 
Le germe de la première molaire permanente se développe au bout de la seizième 
semaine par un bourgeonnement analogue de l'épithélium, sur le prolongement de la 
lamelle épithéliale primitive d'où les germes temporaires de l'émail ont pris naissance. 
La deuxième molaire permanente naît du collet de l'organe de l'émail de la pre- 
mière molaire permanente, mais à une époque éloignée (trois mois après la naissance). 
Enfin le germe de l'émail de la dent de sagesse se développe également aux dépens 
du collet du germe de la deuxième molaire permanente, mais plus tard (vers trois ans). 
Que la théorie de Goodsir soit erronée, en ce sens que le sillon qu'il a décrit n'ex- 
iste, ainsi que le dit Magitot, qu'en apparence, par suite d'une macération prolongée 
des préparations dans lesquelles s'opère la séparation de la couche épidermique formant 
le bourrelet gingival d'avec la gouttière qui le renferme, comme l'on démontré Kölliker 
et Kollmann ; 
Que les follicules naissent de la bande épithéliale de Kölliker ou de la lame épithé- 
liale de Legros et Magitot, dépendant du même bourrelet épithélial ; qu'ils naissent 
sur le prolongement de la lamelle épithéliale primitive de Tomes ; il n'en est pas moins 
constant que tous ces auteurs sont d'accord sur ce fait que la première molaire permanente 
naît dans les mêmes conditions que les dents caduques, tandis que les deuxièmes et troisi- 
èmes molaires permanentes naissent chacune du cordon de la molaire qui la précède, 
c'est-à-dire dans les mêmes conditions que les dents de remplacement ; 
D'où cette conclusion, suivant nous toute naturelle, que la dent de six ans, ayant 
une origine exactement semblable à celle des dents caduques, ne peut pas, au point de 
vue de sa genèse, être rangée parmi celles qui portent le nom de dents permanentes. 608 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ANATOMIE DESCRIPTIVE ET ROLE PHYSIOLOGIQUE DE LA DENT DE SIX ANS. 
A l'âge de cinq ans, un enfant est muni de ses dents de lait, an nombre de vingt. 
De cinq à six ans chez les uns, de six à sept chez les autres, il se montre au fond des 
mâchoires, de chaque côté des deux arcades dentaires, une dent qui peut rester dans la 
bouche, non seulement pendant la chute des dents caduques et leur remplacement, 
mais encore pendant l'éruption de celles qui seront situées derrière elle et aussi pen- 
dant le reste de l'existence, si des circonstances plus ou moins imprévues ne doivent pas en 
amener la perte. C'est la première grosse molaire permanente, première multicuspidée 
permanente, dent de cinq ans, et mieux dent de six ans. 
Dans la bouche d'un adulte dont les arcades dentaires sont complètes, cette dent est 
située au sixième rang en partant de la ligne médiane, immédiatement après la deu- 
xième bicuspidée, entre cette dent et la deuxième multicuspidée permanente. Abs- 
traction faite des incisives médiane et latérale, de chaque côté, elle occupe à peu près 
le milieu de chaque branche de l'arcade, c'est-à-dire que l'espace situé entre elle et 
l'incisive latérale et occupé par la canine et les deux bicuspidées est à peu près égal à 
celui qui est occupé par les deux dernières multicuspidées. 
La forme de sa couronne est celle d'un cube. A la mâchoire supérieure, c'est la plus 
grosse des molaires. Sa couronne est armée de quatre ou cinq cuspides, et sa face lin- 
guale, moins large que la buccale, présente entre ces deux cuspides un sillon qui se 
continue jusqu'au collet. Ses racines sont au nombre de trois, séparées ou quelquefois 
réunies, dont l'une divergente, plus grosse, plus longue, est située en dedans, et dont 
les deux autres, rapprochées et comme accouplées, sont situées en dehors. La plus 
longue des deux est celle qui est placée près de la deuxième bicuspidée. 
A la mâchoire inférieure, la couronne de la première multicuspidée est surmontée 
de cinq cuspides, deux linguales et trois buccales, dont la plus petite est située tout à 
fait à la partie postéro-buccale de la dent. Sa face buccale est le plus souvent creusée 
d'une petite cavité naturelle et son collet est très étranglé, comme celui, du reste, de la 
première multicuspidée supérieure. Les deux racines sont volumineuses. L'antéri- 
eure, c'est-à-dire celle qui est placée près de la seconde bicuspidée, est plus grosse, plus 
aplatie et plus profondément sillonnée que la postérieure. 
La cavité pulpaire des premières multicuspidées est relativement plus considérable 
que celle des autres molaires, et bien que la dent de six ans, à mesure que l'on avance 
dans la vie, soit toujours plus âgée de six ou de douze ans que la deuxième multicuspi- 
dée et la dent de sagesse, ses canaux pulpaires restent toujours relativement plus consi- 
dérables, ou mieux, sont plus lentement obstrués par la dentine que ceux des autres 
molaires petites oh grosses ; ce qui tient probablement, ainsi que nous le dirons plus 
loin, à ce que cette dent est moins dense que les autres dents permanentes. 
Quant au rôle physiologique de la dent de six ans, il peut être résumé en trois 
points :- 
1° Limiter la partie de l'arcade maxillaire occupée par les dents de lait pendant la 
période de leur remplacement par les dents permanentes correspondantes; 
2° Maintenir l'articulation des mâchoires à la hauteur voulue pendant ce remplace- 
ment; 
3° Servir à la mastication pendant la chute des dents de lait. 
Reprenons ces trois points :- 
Comme la dent de six ans a presque toujours achevé son éruption avant le commen- 
cement du remplacement des dents de lait ; comme ce remplacement ne commence 
habituellement que vers sept ans pour se terminer entre douze et treize ans, c'est-à-dire 
à l'époque où la deuxième multicuspidée permanente achève son éruption, il s'ensuit 
que la première multicuspidée se trouve placée, entre les dents de lait et l'espace qu'oc- 
cuperont les molaires postérieures, comme une borne, un obstacle destiné à empêcher, SECTION XVIII-DENTAL AND ORAL SURGERY. 
609 
d'une part, la deuxième bicuspidée d'empiéter sur la partie postérieure de l'arcade 
maxillaire et, d'autre part, la deuxième multicuspidée d'empiéter sur la partie anté- 
rieure de cette arcade. Elle oblige ces dents, à mesure qu'elles accomplissent leur 
éruption, à distendre, à agrandir l'arcade maxillaire, ce qui est une des conditions du 
bon arrangement de la denture. 
La partie antérieure de l'arc maxillaire doit, en effet, s'agrandir dans des propor- 
tions assez considérables, puisque toutes les dents de remplacement, moins la deuxième 
bicuspidée, sont plus volumineuses que les dents de lait correspondantes et que le sur- 
plus de volume de la deuxième multicuspidée caduque ne peut être comparé à l'excès 
de grosseur des incisives et canines permanentes par rapport à leurs correspondantes 
caduques. Nous ne parlons pas de la première bicuspidée ni de la première molaire de 
lait, qui ont à peu près le même diamètre, d'une face contiguë à l'autre, et qui, par 
conséquent, ne changent rien aux conditions d'espace. 
Quant à la partie postérieure de l'arcade, elle se développe à mesure que se montrent 
les deux multicuspidées permanentes postérieures. 
C'est du moins ainsi que les choses se passent quand la dentition s'accomplit d'une 
manière normale, lorsque les dents sont de bonne qualité et ont toutes chances de rester 
telles ; nous verrons bientôt qu'il en est rarement ainsi. 
Il nous semble inutile d'insister sur le rôle que jouent les premières multicuspidées 
permanentes au point de vue du maintien de la hauteur de l'articulation. Il est évi- 
dent que, pendant le remplacement des molaires caduques et avant que la première 
bicuspidée et, à son défaut, la dent de douze ans n'ait achevé son éruption, si la dent 
de six ans n'existait pas, la hauteur de l'articulation serait incertaine, les dents antago- 
nistes pourraient porter à faux les unes sur les autres, selon le dégré d'avancement de 
l'éruption des bicuspidées, et qu'enfin la mastication serait fort difficile ; ce qui arrive, 
du reste, lorsque l'on est obligé d'extraire en temps inopportun les dents de six ans, pour 
quelque motif que ce soit. 
Enfin, pendant que les canines et les molaires de lait sont ébranlées et sur le point 
de tomber, ou bien lorsqu'elles ont opéré leur chute avant l'apparition des dents per- 
manentes correspondantes, ou bien encore avant que les premières bicuspidées n'aient 
atteint toute leur hauteur, elles seules servent à l'enfant pour broyer les aliments un 
peu résistants, jusqu'à ce que les dents de douze ans et les deuxièmes bicuspidées aient 
achevé leur éruption. 
D'où cette conclusion que, au point de vue physiologique, la dent de six ans est 
d'une utilité extrême depuis son éruption jusqu'à l'achèvement de l'éruption des denis voi- 
sines, époque à laquelle nous croyons pouvoir démontrer que sa présence, dans un grand 
nombre de cas, est moins utile et souvent même nuisible ; qu'en un mot, elle constitue 
un organe de transition entre les dents caduques et les dents permanentes, et que, par suite, 
une fois son rôle accompli, il ne faut pas redouter outre mesure son extraction, lorsque 
les circonstances l'exigent. 
FRÉQUENCE DE LA CARIE DE LA DENT DE SIX ANS ET DE LA DENT DE SAGESSE. 
Mais, avant d'aborder la question même de l'opportunité de cette extraction, il est 
un point qui la domine et sur lequel nous devons appeler l'attention; c'est la fréquence 
extrême de la carie d'abord de la dent de six ans, puis de la dent de sagesse. 
Voici ce que nous avons constaté à l'hospice des Enfants Assistés de Paris, en sept 
ans, de 1863 à 1870 
Sur 1000 enfants de neuf à douze ans des deux sexes, dont nous avons visité la 
bouche dans ce laps de temps, c'est-à-dire sur 4000 dents de six ans, 2957 étaient 
atteintes de carie plus ou moins profonde, ce que l'on peut facilement vérifier en par- 
courant notre statistique. 
Vol. V-39 610 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
HOSPICE DES ENFANTS ASSISTÉS. 1000 SUJETS (GARÇONS OU FILLES INDISTINCTEMENT) 
DE 9 A 12 ANS. 
BOUCHES. 
à 4 dents 
de 6 ans 
cariées. 
à 3 dents 
de 6 ans 
cariées. 
à 2 dents 
de 6 ans 
cariées. 
à 1 dent 
de 6 ans 
cariée. 
à dents 
de 6 ans 
intactes. 
410 
298 
155 
113 
24 
En multipliant chaque nombre de bouches par le nombre correspondant de dents 
cariées, on trouve :- 
410 X 4 = 1640' 
298 X 3 = 894 Qq-7 
155X2= 310 
113 = 113. 
Soit environ 74 pour 100. 
Mais, pourrait-on objecter, cette statistique vraie pour les enfants assistés, c'est-à- 
dire pour des enfants qui sont généralement d'une mauvaise constitution, scrofuleux, 
anémiques, dans une profonde misère physiologique et à qui les soins de toute espèce 
ont fait défaut, ne doit certainement pas être applicable aux enfants élevés dans l'ai- 
sance? Eh bien, e'est une erreur, car si, en regard de cette statistique, nous mettons 
celle que nous avons faite dans notre clientèle de ville, de 1872 à 1880, c'est-à-dire dans 
une clientèle où les enfants, s'il était permis de s'exprimer ainsi, sont plutôt trop 
soignés que pas assez et se trouvent dans des conditions parfaites d'alimentation, nous 
voyons que la proportion des dents de six ans cariées chez ces enfants est encore un 
peu plus forte que chez les enfants assistés, bien que la différence soit cependant assez 
peu sensible. 
Sur 600 bouches de neuf à douze ans, c'est-à-dire sur 2400 dents de six ans, 1784 
étaient atteintes de carie, soit plus de 74 pour 100. 
Voici comment est répartie cette statistique :- 
CLIENTÈLE DE VILLE. 600 SUJETS (GARÇONS OU FILLES INDISTINCTEMENT) DE 9 A 12 ANS. 
BOUCHES. 
à 4 dents 
de 6 ans 
cariées. 
à 3 dents 
de 6 ans 
cariées. 
à 2 dents 
de 6 ans 
cariées. 
à 1 dent 
de 6 ans 
cariée. 
à dents 
de 6 ans 
intactes. 
281 
128 
101 
74 
16 
Soit 281 X 4 = 1124' 
128 X 3 = 384 
101 X 2 = 202 
74 = 74 
= 1784 
C'est-à-dire 74.33 pour 100. SECTION XVIII-DENTAL AND ORAL SURGERY. 
611 
C'est là le fait brut indiqué par des chiffres recueillis avec soin, du moins tel que 
nous l'avons observé à Paris, le seul endroit où nous ayons eu l'occasion de faire ces 
recherches. 
Et si, maintenant, au lieu d'avoir affaire à des bouches de neuf à douze ans, nous 
portons notre examen sur des bouches de personnes ayant passé la cinquantaine, c'est- 
à-dire de personnes dont l'éruption des dents permanentes se faisait à une époque où 
l'unique remède à la carie dentaire était pour ainsi dire l'extraction, nous trouvons un 
résultat plus surprenant encore. 
Il est rare d'y trouver des dents de six ans, ou, s'il en reste, elles sont obturées ou 
cariées, ce qu'il est facile de constater par la statistique suivante :-* 
CLIENTÈLE DE VILLE. 100 SUJETS (HOMMES OU FEMMES) DE 55 A 65 ANS. 
BOUCHES. 
à 4 dents 
de 6 ans 
absentes. 
à 3 dents 
de 6 ans 
absentes. 
à 2 dents 
de 6 ans 
absentes. 
à 1 dent 
de 6 ans 
absente. 
à 4 dents 
de 6 ans 
intactes. 
Les dents de 6 ans restantes sont intactes ou obturées 
41 
31 
17 
11 
2 
Soit sur 400 dents de six ans 
41 X 4 = 164 
31 X 3 = 93 
17 X 2 = 34 
11 = 11 
302 dents extraites, 
c'est-à-dire 75J pour 100. 
Il y a donc là un fait pour nous indiscutable : la dent de six ans se carie dans les 
proportions de 74 à 75 pour 100, et c'est ce fait avec lequel nous pensons qu'il faut 
compter pour le bon arrangement et la conservation des autres dents. 
Après la dent de six ans, la dent qui se carie le plus fréquemment est la dent de 
sagesse, et nous dirons bientôt quelle relation existe entre la présence ou l'absence de la 
dent de six ans et la carie ou l'intégrité de la troisième multicuspidée. 
Puis viennent par ordre de fréquence de carie, les dents de douze ans, les bicuspi- 
dées, les incisives grandes et petites et enfin les canines. 
Mais nous n'avons pas à nous étendre ici sur la fréquence de la carie de ces derni- 
ères dents, nous devons nous borner à ce qui concerne la dent de six ans et, après elle, 
la dent de sagesse. 
Nous savons parfaitement que les statistiques que nous venons de donner ne sont pas 
absolument d'accord avec celles de plusieurs de nos confrères auxquelles nous avons pu 
les comparer. Il est vrai que les points à démontrer n'étant pas absolument les mêmes, 
les rapports étaient assez difficiles à établir. Y avait-il diversité de pays, de milieux 
de clientèle, etc. ? Nous ne pouvons le dire, mais ce que nous pouvons affirmer, c'est 
que, depuis bientôt vingt-cinq ans que nous nous occupons de tout ce qui a trait à la 
* Nous devons faire observer que cette statistique est une des cinq que nous avons faites pour 
cette démonstration, et que nous en avons toujours éliminé les bouches atteintes de pyorrhée 
alvéolo-dentaire généralisée ayant pu amener l'ébranlement et la chute des dents. 612 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
carie de la dent de six ans et de la dent de sagesse, toutes les statistiques que nous 
avons faites concernant ce sujet out donné des résultats à peu près identiques. Nous 
croyons donc devoir nous y tenir. 
CAUSES DE LA FRÉQUENCE DE LA CARIE DE LA DENT DE SIX ANS. 
Mais quelles sont les causes de la fréquence de la carie de la dent de six ans ? 
Il y en a quatre principales, spéciales à cette dent :- 
1° Sa densité plus faible que celle des autres dents permanentes; 
2° La configuration extérieure de sa couronne; 
3° L'acidité constante des liquides de la bouche pendant la remplacement des dents 
de lait; 
4° Le voisinage de la deuxième molaire de lait, presque toujours détériorée long- 
temps avant sa chute. 
D'après le docteur Galippe,* la densité de la dent de six ans est plus grande que 
celle des dents de lait, mais moins considérable que celle des autres dents permanentes ; 
or, comme, d'après cet auteur, la résistance des dents à la carie varie chez un même 
individu avec les différentes espèces de dents, suivant qu'elles sont plus ou moins 
denses, il s'ensuit que le coefficient de résistance à la carie de la dent de six ans moins 
dense est moindre que celui des autres dents permanentes dont la densité est plus 
grande. 
Au point de vue de la configuration extérieure, chacun sait que les sillons qui se 
trouvent sur la face broyante de la dent de six ans, entre les cuspides, sont pour ainsi 
dire dépourvus d'émail, ou bien sont le siège de fissures entre petits îlots d'émail, d'où 
facilité d'altération de la dent ; il en est de même du point buccal ou petite cavité plus 
ou moins profonde qui se trouve naturellement sur la face buccale des dents de six ans 
de la mâchoire inférieure et du sillon de la face linguale des premières multicuspidées 
supérieures, qui, partant de l'interstice des deux cuspides, aboutit au collet ; trous ou 
sillons qui, en somme, deviennent des réceptacles pour les détritus alimentaires. Or, 
comme les enfants ne nettoient que peu leurs dents et, dans certaines classes de la soci- 
été, abusent des bonbons, fondants, caramels, etc., et surtout du chocolat sec, il en 
résulte que ces débris alimentaires se logent dans toutes les infractuosités dentaires 
qu'ils rencontrent, y séjournent, s'y acidifient et y produisent les ravages inhérents à 
l'action des acides sur les dents. 
Mais, au moment du remplacement des dents, ce ne sont pas seulement les fissures 
ou les cavités naturelles des dents qui donnent prise à l'acidité ; il y a encore, à cette 
époque, une autre cause plus puissante de cette acidité, ce sont les interstices que les 
dents caduques branlantes laissent, jusqu'à leur chute, entre elles et la gencive, inter- 
stices où s'infiltrent et séjournent des parcelles alimentaires qui y fermentent rapidement. 
De plus, les dents caduques cariées que l'on ne se donne pas la peine d'obturer, soit que 
l'on regarde en ces cas l'opération comme inutile, soit qu'on la néglige, deviennent 
autant de foyers d'infection, et il s'ensuit dans toute la bouche une réaction générale 
acide bien facile à constater avec le papier de tournesol. 
Quant à l'action délétère de la carie de la deuxième molaire de lait sur la dent de 
six ans, elle n'a jamais été mise en doute par personne. 
Il suffit, en effet, pour en avoir la preuve, d'extraire une deuxième molaire caduque 
cariée sur sa face contiguë postérieure pour voir presqu'à coup sûr la face contiguë cor- 
respondante de la dent de six ans plus ou moins affectée. 
* Dr. Galippe.-"Recherches sur les propriétés physiques et la constitution chimique des 
dents." Paris, 1886. SECTION XVIII-DENTAL AND ORAL SURGERY. 
613 
CAUSES DE LA FRÉQUENCE DE LA CARIE DE LA DENT DE SAGESSE. 
Nous avons dit plus haut qu'après la dent de six ans, c'est la dent de sagesse qui se 
carie le plus fréquemment. Eh bien, cette proposition admise par presque tous les den- 
tistes est vraie et cependant ne l'est pas toujours, et voici comment :- 
Comme, à notre avis, le fait est absolument dépendant, dans la plupart des cas, de 
la présence des dents de six ans dans les bouches à arcades trop petites pour contenir 
toutes les dents, nous croyons devoir, dès à présent, donner l'explication de cette fré- 
quence. 
A l'époque de l'éruption des dents de douze ans, toutes les dents de remplacement, 
moins cependant les deuxièmes bicuspidées, sont en place. La dent de douze ans a 
donc plus de chances de résister à la carie que la dent de six ans puisque les causes 
d'acidité de la salive que nous avons indiquées n'existent pour ainsi dire plus ; mais il 
n'en est pas de même pour la dent de sagesse. 
A la mâchoire inférieure, par exemple, lorsque, par suite de la présence de toutes les 
autres dents permanentes au moment de l'éruption de la troisième multicuspidée, la 
mâchoire se trouve trop petite pour contenir toutes les dents et que la dent de sagesse, 
serrée entre la dent de douze ans en avant et la branche montante du maxillaire en arri- 
ère, ne peut pas faire son éruption d'une manière normale, il se passe un phénomène 
fort important au point de vue de la santé de cette dent. Sa couronne, qui ne peut 
émerger complètement, ne montre encore que ses deux cuspides antérieures et les huit 
dixièmes de sa face broyante restent recouverts d'une languette de chair qui agit à la 
façon d'un couvercle, et cela pendant trois mois, six mois, un an et même davantage. 
Or, pendant tout ce temps, il existe entre la dent et l'opercule de chair un réceptacle 
plus ou moins considérable pour les débris alimentaires qu'aucun lavage ne parvient à 
en expulser, d'où fermentation acide, destruction de l'émail et carie. 
A la mâchoire supérieure, le fait est le même, mais le mécanisme et différent. La 
dent de sagesse a toujours de la place pour accomplir son évolution, puisque rien ne la 
gêne en arrière ; mais, dans les conditions d'arcade dentaire trop petite, au lieu de sor- 
tir verticalement, elle sort obliquement, sa face broyante plus ou moins tournée en arri- 
ère. D'où il résulte une position vicieuse grâce à laquelle les aliments, s'introduisant 
plus facilement entre la dent de sagesse et la dent de douze ans, s'accumulent dans 
l'interstice interdentaire, y séjournent, s'y acidifient et ont une action délétère sur les 
deux dents contiguës, action toujours plus puissante sur la dent de sagesse que sur sa 
voisine, pour la raison suivante :- 
La dent de sagesse, dans ces cas, n'a relativement que des racines faibles, courtes et 
souvent réunies en une seule, et comme elle n'est appuyée en arrière sur aucune autre 
dent, elle cède à la pression des aliments, s'ébranle, s'écarte pour les laisser passer, se 
déchausse, se décolle de la pointe de gencive interdentaire et laisse ainsi entre elle et 
cette gencive un espace toujours rempli de débris alimentaires et presque impossible à 
bien nettoyer. C'est là en effet, qu'est le lieu d'élection de la carie. 
D'où nous pouvons tirer cette conclusion que la dent de sagesse, lorsque son érup- 
tion est gênée par un manque de place provenant soit du peu de longueur relative de 
l'arcade dentaire, soit du volume trop considérable des autres dents par rapport à cette 
longueur, est le plus souvent cariée ; conclusion qui se trouve corroborée par cette 
seconde proposition qu'il nous reste à exposer, à savoir : que si la dent de six ans a été 
extraite (et nous verrons plus loin pourquoi nous disons la dent de six ans et non pas 
une autre) et que si, par suite de cette extraction, la dent de sagesse a eu la place suffi- 
sante pour faire son éruption, alors celle-ci, se trouvant par cela même à l'abri des 
causes de détérioration que nous avons indiquées, se carie fort rarement. 
Les deux statistiques suivantes faites, il y a une dizaine d'années (en 1875), suffisent 
certainement pour en démontrer le bien fondé :- 614 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CLIENTÈLE DE VILLE. 100 BOUCHES (HOMMES OU FEMMES INDISTINCTEMENT) DE 25 A 
30 ANS. 
DENTS DE SIX ANS EN PLACE, 
BONNES, OBTURÉES OU CARIÉES. 
COTÉ GAUCHE. 
COTÉ DROIT. 
Dents 
de sagesse 
cariées. 
Dents 
de sagesse 
saines. 
Dents 
de sagesse 
cariées. 
Dents 
de sagesse 
saines. 
Mâchoire inférieure 
73 
27 
71 
29 
Mâchoire supérieure 
62 
38 
57 
41 
CLIENTÈLE DE VILLE. 100 BOUCHES (HOMMES OU FEMMES INDISTINCTEMENT) DE 25 A 
30 ANS. 
DENTS DE SIX ANS ABSENTES. 
COTÉ GAUCHE. 
COTÉ DROIT. 
Dents 
de sagesse 
cariées. 
Dents 
de sagesse 
saines. 
Dents 
de sagesse 
cariées. 
Dents 
de sagesse 
saines. 
Mâchoire inférieure 
16 
84 
13 
87 
Mâchoire supérieure 
10 
90 
11 
89 
LA DENT DE SAGESSE EST LA DENT DE REMPLACEMENT DE LA DENT DE SIX ANS. 
Appuyé sur ces chiffres et, nous pouvons ajouter, sur les observations moins pré- 
cises, il est vrai, mais constantes d'une expérience de vingt-cinq ans, nous croyons pou- 
voir émettre cette opinion que la dent de sagesse, bien qu'elle ne vienne pas dans l'es- 
pace même qu'occupait la dent de six ans avant son extraction, et bien qu'elle soit 
séparée de cet espace par la dent de douze ans, n'en est pas moins, au point de vue 
pratique, la dent de remplacement de la première molaire permanente presque fatalement 
vouée à la carie. , 
• CONDITIONS D'EXTRACTION DE LA DENT DE SIX ANS. 
Il nous reste maintenant à indiquer les conséquences pratiques que l'on peut tirer 
des considérations que nous venons de développer, c'est-à-dire les conditions d'extrac- 
tion de la dent de six ans. 
Nous allons passer rapidement en revue les principales :- 
Mais commençons par vider une question dont la solution est évidente a priori. 
Lorsque les dents de lait sont de bonne qualité, lorsqu'elles tombent en leur temps, 
sans être cariées, lorsque les dents de six ans sont bien conformées et leur face broyante 
bien saine, lorsque les mâchoires paraissent être de dimensions suffisantes pour contenir 
toutes les dents permanentes, lorsqu'enfin les arcades dentaires ont une conformation 
normale, c'est-à-dire lorsque la supérieure est à plein cintre et non en ogive alors que 
l'inférieure est une ellipse d'un diamètre convenable, il est bien évident, et nous insis- 
tons sur ce point, qu'à moins de circonstances tout à fait exceptionnelles, il ne peut être 
question dans une pareille 'bouche d'extraction de la dent de six ans. 
Mais, il ne faut pas s'y tromper, ces cas privilégiés sont fort rares ; et bien plus fré- SECTION XVIII-DENTAL AND ORAL SURGERY. 
615 
quents sont ceux où les dents caduques, très serrées les unes contre les autres, ne 
laissent aux dents de remplacement qu'une place insuffisante pour se ranger, où les 
molaires de lait se carient rapidement et tombent en détritus après avoir provoqué 
abcès sur abcès, et où la dent de six ans se carié quelques mois, un an, deux ans après 
son éruption et réclame les secours de l'art. 
Ces derniers cas sont les seuls qui doivent nous occuper ici, et nous allons indiquer 
les circonstances principales où il est vraiment rationnel de pratiquer l'extraction de la 
dent de six ans. 
C'est d'abord la carie de cette dent, puis le redressement des dents dans certaines 
bouches de conformation vicieuse et à éruption dentaire anormale. 
1° LA CARIE DENTAIRE. 
En thèse générale, on peut dire que, lorsqu'une dent de six ans est affectée de ce 
genre de carie, molle, blanchâtre, envahissante, qui rend les tissus dentaires semblables 
à de la craie, alors que les autres dents semblent saines et avant que la dent de douze 
ans n'ait achevé son éruption, il est préférable de l'extraire que de la conserver. 
En effet, en l'extrayant à temps, la deuxième multicuspidée envahit peu à peu sans 
se pencher en avant la moitié de la place qu'elle occupait et la deuxième bicuspidée 
l'autre moitié, de telle sorte que l'interstice ne prend pas une forme en queue d'aronde. 
Il ne reste bientôt plus d'espace vide, les autres dents se desserrent, leur position se ré- 
gularise et la dent de sagesse accomplira correctement son évolution. 
Que si, à cet âge, au lieu de l'extraire, on l'obture soi disant définitivement, il est 
rare que l'obturation, quelque habileté et quelque soin que l'on ait mis à la pratiquer, 
tienne longtemps. Bientôt l'émail qui entoure l'obturation se désagrège, la carie con- 
tinue ses ravages et l'obturation s'échappe en masse. Il ne faut d'ailleurs pas, lorsque 
la pulpe a été dénudée, songer à extirper cette pulpe et à nettoyer à fond les canaux 
pulpaires, il est fort difficile, en effet, de ne pas déterminer, en pratiquant cette opéra- 
tion sur cette dent, une périostite alvéolo-dentaire avec abcès et fistule consécutive. 
On pourrait presque ériger en principe, bien qu'il y ait cependant des exceptions, 
qu'une dent de six ans qui se carie entre huit et onze ans, quelque soin que l'on prenne 
pour la conserver, se carie de nouveau peu à peu, soit autour de l'obturation déjà 
faite, soit en d'autres endroits, et se trouve par cela même vouée à une destruction cer- 
taine. 
Que si encore elle se détériorait seule, il n'y aurait que demi-mal, mais c'est qu'il 
n'en est pas ainsi. Se carie-t-elle sur sa face contiguë antérieure? Comme la carie, 
malgré les soins les plus méticuleux, n'en continue pas moins ses ravages, il est presque 
certain que la deuxième bicuspidée s'altérera par voie de contact. Se carie-t-elle sur sa 
face contiguë postérieure? c'est la deuxième multicuspidée qui, grâce au même méca- 
nisme, se prendra à son tour. 
On aura donc ainsi trois dents malades au lieu d'une ; ce que l'on aurait à coup sûr 
évité pour deux, si l'on avait sacrifié à temps la première malade, c'est-à-dire la dent 
de six ans. 
2° LE REDRESSEMENT DES DENTS DANS CERTAINES BOUCHES. 
Au point de vue du redressement des dents dans certaines bouches à éruption den- 
taire anormale ou mal conformées, il est une règle dont nous ne nous départons jamais 
parce qu'elle est le fruit d'une longue expérience, c'est la suivante :- 
Tout redressement qui ne demande qu'un mois, deux mois, trois mois au maximum, 
non seulement pour être obtenu mais encore pour être maintenu, sans extraction adjuvante 
de dents, peut et doit être fait à l'aide d'appareils de redressement seuls. Ce temps est 
rarement suffisant pour amener la détérioration des dents qui servent de point d'appui 
ou de soutien aux appareils. 616 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Tout redressement au contraire qui ne peut être obtenu et maintenu en moins de trois 
mois, au moyen d'appareils, sans extraction adjuvante, si le sacrifice d'une ou deux dents 
( bicuspidée ou multicuspidée) peut faire rentrer ce redressement dans le cas précédent, 
doit être facilité à l'aide de cette ou de ces extractions. 
Les appareils, en effet, qui séjournent dans la bouche plus de trois mois, sont per- 
nicieux pour les dents de soutien, soit à cause de la traction ou de la pression exercée 
sur ces dents, soit et surtout à cause de la malpropreté de la plupart des enfants qui, à cet 
âge, ne prennent pas soin de leur bouche. 
Cela dit, et ici nous revenons à notre sujet, lorsqu'un redressement exige une ou 
plusieurs extractions, nous nous faisons fort de démontrer que c'est la ou les dents de 
six ans qu'il vaut mieux extraire. 
Il y a un grand nombre de praticiens qui soutiennent qu'en laissant agir la nature 
seule ou en ne l'aidant que par l'extraction des dents de lait dont la chute ne s'opère 
pas à mesure qu'apparaissent les dents de remplacement, et en laissant celles-ci (pourvu 
toutefois qu'elles ne viennent pas en rotation) se placer d'elles-mêmes, il y a huit 
chances sur dix pour qu'à un moment donné le redressement s'effectue grâce aux efforts 
seuls de la nature. 
Nous ne partageons pas leur avis, et nous sommes convaincu que si, comme nous 
l'avons fait pendant plus de vingt ans à l'hospice des Enfants assistés, ils avaient été à 
même de suivre l'éruption des dents dans un nombre considérable de bouches non ou 
mal soignées, ils changeraient d'opinion. 
Dans ces conditions, en effet, et presque dans la moitié des cas, les dents perma- 
nentes se rangent mal, ou plutôt il se trouve dans chacune de ces dentures une ou plu- 
sieurs dents placées hors rang, sans qu'elles y puissent revenir d'elles-mêmes, soit 
qu'une des dents antérieures de la mâchoire supérieure passe en arrière des dents du 
bas, lors du rapprochement des mâchoires, soit qu'une incisive et plus souvent une 
canine de la mâchoire inférieure emboîte en avant les dents du haut. 
Dans ces cas et dans bien d'autres, nous pensons qu'il y a mieux à faire qu'à laisser 
la nature agir seule. 
Il ne faut pas non plus, comme l'enseignait autrefois Miel, dentiste fort connu à 
Paris, agir toujours en sens inverse, déblayer la place et sacrifier prématurément pres- 
que toutes les dents de lait, pour permettre aux dents de remplacement d'évoluer tout 
à l'aise. 
Ce moyen ne vaut pas nïieux que le précédent, bien qu'il ait cependant l'avantage 
de maintenir propre la bouche des enfants, et par suite, d'éviter dans de certaines 
limites, la carie des dents permanentes, il faut, par une saine appréciation des circons- 
tances, savoir prendre un juste milieu, suivre attentivement les phénomènes du rem 
placement et agir au moment voulu. 
Supposons, et c'est là un cas assez fréquent, une bouche étroite, à voûte palatine en 
ogive, à dents de lait d'un volume restreint par rapport à celui des dents de remplace- 
ment et très serrées, comment faut-il agir, au moment du remplacement? 
A la mâchoire inférieure, si les deux incisives médianes permanentes poussent de 
face, en arrière des incisives caduques correspondantes qui ne sont qu'à peine ébranlées, 
il faut extraire ces dernières. 
Un peu plus tard, les deux incisives latérales permanentes sortent derrière les deux 
caduques correspondantes, mais, au lieu de se présenter de face, elles se présentent plus 
ou moins en coin, c'est-à-dire plus ou moins de profil; que faut-il faire? sacrifier immé- 
diatement les incisives caduques et aussi, ÿwotgwe les deux canines de lait. 
C'est, en effet, le seul moyen de permettre le redressement naturel et sans appareil des 
deux incisives permanentes.* 
s II ne faut d'ailleurs pas oublier que la rotation des incisives inférieures, sans le sacrifice des 
dents voisines, est une des opérations les plus difficiles du redressement des dents. SECTION XVIII-DENTAL AND ORAL SURGERY. 
617 
Il faudrait agir suivant la même règle si une ou deux incisives médianes, au lieu de 
se présenter de face comme nous l'avons supposé, se présentaient de profil, c'est-à-dire 
sacrifier immédiatement les deux latérales caduques. Tant que les incisives perma- 
nentes se montrent bien de face, quelque loin que ce soit en arrière, il est inutile et 
même nuisible de faire le sacrifice des caduques voisines, la nature trouvant toujours, 
dans ces cas, à moins d'une étroitesse exceptionnelle de la mâchoire, le moyen d'opérer 
en temps voulu la régularisation. 
Quel sera l'effet de ces extractions prématurées? 
La première bicuspidée, qui fait presque toujours son éruption avant la canine per- 
manente, aura une tendance à envahir la place laissée vide par l'extraction de la canine 
ceduque, ce qui, lors de l'apparition de la canine permanente, produira nécessairement 
une surdent. Que si, dans ce cas, comme la canine permanente fait son éruption avant 
la deuxième bicuspidée, l'on extrait prématurément la deuxième molaire de lait, il 
arrivera forcément que la première bicuspidée, au lieu d'envahir l'espace laissé libre 
par l'extraction de la canine de lait, se dirigera en arrière vers la dent de six ans. D'où 
cette règle que, si Von a été obligé, pour régulariser l'incisive latérale, d'extraire la canine 
de lait voisine, il faut, pour empêcher la première bicuspidée de prendre la place de cette 
canine, sacrifier très prématurément la deuxième molaire de lait et fournir ainsi à la pre- 
mière bicuspidée un espace libre vers lequel la poussée de la canine permanente l'obligera à se 
diriger. 
C'est le hioyen le plus sûr, le plus facile, le plus court et le moins dangereux pour 
les autres dents, d'arriver à la régularisation des huit dents antérieures, ce qui, d'après 
les lois de l'Esthétique dentaire la plus élémentaire, est de la plus haute importance. 
Quant aux dents du fond de la bouche, nous verrons bientôt que leur bon arrangement 
n'est pas plus malaisé à obtenir. 
A ce moment la mâchoire se trouve donc garnie pour chaque moitié, ou du moins 
pour celle qui a été opérée :- 
1° Des deux incisives ; 
2° De la première bicuspidée arrivée presqu'à sa longueur et se dirigeant vers la 
place laissée libre par l'extraction de la deuxième molaire de lait; 
3° De la canine qui ne montre encore que sa pointe; 
4° De la dent de six ans. 
Nous allons bientôt arriver au moment critique de la régularisation. La deuxième 
multicuspidée permanente ou dent de douze ans va se montrer et un peu après la deu- 
xième bicuspidée, l'une en arrière, l'autre en avant de la dent de six ans. 
Mais l'espace destiné à la deuxième bicuspidée a été envahi aux trois quarts par la 
première bicuspidée, et la deuxième bicuspidée se dirige en dedans, rarement en dehors; 
d'autre part la dent de six ans n'est pas de bonne qualité, elle est piquée, cariée (74 à 
75 pour 100), ou bien elle a été soignée et obturée; n'est-il pas rationnel en pareille occur- 
rence d'extraire cette dent ? 
La place qu'elle va laisser sera bientôt envahie, moitié par la deuxième bicuspidée, 
moitié par la dent de douze ans, et s'il reste pendant quelque temps encore un petit 
vide entre les deux, il sera comblé plus tard, grâce à la poussée exercée sur la dent de 
douze ans par l'évolution de la dent de sagesse. 
Nous avons supposé que la dent de six ans était cariée, parce que c'est le cas le plus 
fréquent ; mais elle peut ne pas l'être, et, en pareil cas, que conviendrait-il de faire? 
Il y a deux solutions :- 
1° Ou l'extraction de la première bicuspidée, c'est la solution classique; 
2° Ou et tout aussi bien l'extraction de la dent de six ans ; mais dans ce cas nous 
n'y tenons pas absolument, la première solution étant d'un effet plus rapide. Nous 
voulons seulement insister sur cette règle pour nous presque invariable que, dans des 
bouches du genre de celle dont nous parlons, lorsque la régularisation de la denture 618 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
exige un sacrifice de dent, c'est toujours celui de la dent de six ans, lorsqu'elle est cariée 
ou seulement piquée, qu'il convient de faire. 
Tout ce que nous venons de dire se rapporte à la mâchoire inférieure ; quelle est 
maintenant la conduite à suivre pour la mâchoire supérieure ? 
Les grandes incisives de remplacement peuvent se montrer en avant ou en arrière 
du plan des dents temporaires. Si elles sortent en avant, il suffit d'extraire les inci- 
sives caduques correspondantes, elles se rangeront d'elles-mêmes ; si elles sortent en 
arrière et menacent de descendre en arrière des incisives antagonistes de la mâchoire 
inférieure, il faut sacrifier prématurément les deux incisives latérales temporaires. Im- 
médiatement les deux grandes incisives, sans le secours d'aucun appareil, ou à la rigueur 
aidées par l'effet d'un simple plan incliné, gagneront la position normale. 
Mais bientôt les incisives permanentes latérales vont se montrer ; si elles sortent en 
avant, bien de face et ne soulèvent pas trop la lèvre, rien à faire, il faut attendre; mais 
si les surdents sont trop prononcées en avant, si elles sont en rotation, ou bien si elles 
sortent tellement en arrière qu'il y ait lieu de craindre la difformité indiquée plus haut 
pour les grandes incisives, alors il faut sacrifier immédiatement les deux canines tem- 
poraires, et l'on retombera dans le cas de la mâchoire inférieure ; c'est-à-dire que la 
première molaire de lait étant sur le point de tomber, il faudra sacrifier immédiatement 
d'abord la deuxième molaire de lait, de manière à ce que la première bicuspidée se dirige 
plutôt de son côté que du côté de la canine, puis plus tard, comme solution définitive 
de l'arrangement de la denture, la dent de six ans. 
C'est là une méthode qui, judicieusement suivie, ne nous a jamais donné que des 
succès relativement faciles, alors que les autres, que nous avons à peu près toutes 
essayées, nous ont demandé bien plus de temps et ont entraîné bien plus de difficultés 
et d'ennuis, sans donner de résultats plus satisfaisants. 
Cet exemple que nous avons choisi comme type, dans le but de démontrer l'oppor- 
tunité de l'extraction de la dent de six ans, pour la régularisation de la denture dans 
certaines formes de bouche, suffit largement pour la motiver ; mais il est nombre d'au- 
tres cas où elle est tout aussi bien indiquée. 
Ainsi, dans la protrusion de la mâchoire inférieure, la suppression des dents de six 
ans à cette mâchoire non seulement aide singulièrement à la régularisation de la den- 
ture mais encore, ce qui n'est pas moins important, la maintient au moment de l'érup- 
tion des dents de sagesse ; de même dans les cas de volume trop considérable des dents 
d'une mâchoire par rapport au volume de celles de l'autre ; de même dans bien d'au- 
tres encore qu'il serait trop long d'énumérer et que le dentiste expérimenté sait facile- 
ment reconnaître, et, pour tout dire en un mot, dans tous ceux où l'extraction d'une ou 
pl usieurs dents est indiquée comme favorable au bon arrangement des dents. 
ÉPOQUE D'ÉLECTIOX DE L'EXTRACTIOX DE LA DENT DE SIX AXS. 
Mais quel est le moment précis où cette opération doit être faite pour que l'on en 
puisse tirer tous les bénéfices possibles? Il est facile à déduire des considérations 
émises plus haut sur le rôle physiologique de la dent de six ans. 
C'est celui où les dents de douze ans n'étant pas encore sorties ou ne l'étant encore 
qu'imparfaitement, les premières bicuspidées ont atteint toute leur longueur et peuvent 
remplir deux des rôles de la dent de six ans : le maintien de la hauteur de l'articula- 
tion et l'accomplissement de la mastication. 
Plus tôt elle nuit à ces deux fonctions ; plus tard elle laisse un vide que la sortie de 
la dent de sagesse sera impuissante à combler entièrement. 
C'est dire implicitement qu'il convient de conserver le plus possible la dent de six 
ans, jusqu'à cette époque d'élection de son extraction, et que lorsqu'elle est atteinte de 
carie, presque dès son apparition, il faut la soigner et l'obturer provisoirement, de ma- 
nière à lui permettre de remplir le mieux possible son rôle de dent de transition. SECTION XVIII-DENTAL AND ORAL SURGERY. 
619 
Tels sont les faits et déductions qu'il nous a paru utile de consigner dans ce Mémoire 
à l'appui de notre manière de voir au sujet de l'extraction de la dent de six ans ; mais, 
en terminant, nous ne croyons peut-être pas dépourvu d'intérêt de revenir sur nos pas 
dans la carrière, et de rappeler comment, il y a bientôt vingt-cinq ans, nous avons été 
amené à porter spécialement notre attention sur cette dent. 
Au commencement de notre carrière, deux faits nous frappaient continuellement 
lors de l'examen de la bouche de nos clients, faits qu'avait aussi remarqués le Dr Dela- 
barre, mais sans en tirer de conséquences importantes. Nous observions que les per- 
sonnes âgées à cette époque de trente à quarante ans étaient dépourvues de leurs pre- 
mières grosses molaires qui leur avaient été, disaient-elles, enlevées dès leur jeune âge, 
mais que les autres dents étaient presque toujours de bonne qualité ; tandis que nos 
jeunes clients de quinze à vingt ans qui avaient conservé leurs dents de six ans, que ces 
dents fussent bonnes on détériorées, avaient généralement le reste de leur denture en 
mauvais état. Il nous vint à l'idée qu'il y avait corrélation entre ces deux ordres de 
faits et nous fîmes des recherches dans ce sens. 
La raison en était tout simplement que, une vingtaine d'années avant notre entrée 
dans la profession, le seul traitement appliqué aux dents cariées douloureuses était, à 
très peu d'exceptions près, l'extraction, et que, comme la dent de six ans n'était pas 
meilleure alors que de nos jours, c'était toujours elle qui était supprimée. Il n'y avait, 
en effet, plus de carie de contact pour la dent de douze ans ou la deuxième bicuspidée ; 
il n'y avait plus de carie généralisée provenant de l'acidification de la salive causée 
elle-même par la carie de la dent de six ans, espèce de cercle vicieux dont la santé de 
la denture a peine à sortir intacte ; en un mot les autres dents moins serrées s'arran- 
geaient convenablement, la dent de sagesse était saine, et, en définitive, la santé de la 
bouche n'en était que meilleure. 
Tandis que, à l'époque où. nous commençâmes à exercer l'art du dentiste, la mode, 
qui sévit aussi bien en dentisterie qu'en toute autre chose, voulait que l'on ne fit plus 
aucune extraction. 
C'était, disait-on, une opération barbare, et le dentiste qui avait eu la mauvaise idée 
d'en faire une n'était plus qu'un arracheur de dents! 
Il fallait à tout prix les plomber, les conserver toutes, dussent-elles être entièrement 
reconstruites. Or, comme les procédés d'obturation ou mieux les opérateurs ne valaient 
pas alors, à part quelques remarquables exceptions, ce qu'ils valent aujourd'hui, il ré- 
sultait de la conservation quand même de toutes les dents, des dégâts considérables dans la 
bouche des pauvres patients. 
C'était l'ère des abcès, des fluxions et des têtes envéloppées du foulard traditionnel ! 
Ce fut alors que, nous rendant parfaitement compte que la saine voie devait être 
entre les deux extrêmes, nous revînmes à l'extraction des dents de six ans, non pas à 
l'extraction quand même, mais à l'extraction motivée et basée sur les principes ration- 
nels que nous avons exposés dans ce Mémoire. 
DISCUSSION. 
Dr. L. D. Shepard, of Boston, said that he was sorry to have to start with an 
apology for riot having his remarks arranged in such form as they ought to be 
arranged before this body, but he had his notes in his pocket all the week and had 
not had time to arrange them. He had but two or three things to say. He sup- 
posed that if the paper had been presented by any one but some of their friends 
across the water, it would have taken the course of many papers and not have been 
considered a paper to go upon the record as an exemplification of modern practice 
of dentistry. He was sorry to use so harsh an expression as that. In his reading 
of the paper he had met with the difficulty that he could not cut much of it out 620 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
without depriving its author of the benefit of his whole argument, and that seemed 
to him unfair, in the author's absence. His opportunities for observation in regard 
to the sixth-year molar had been, perhaps, better than those of a majority of the 
dentists of the day. It had been the practice of certain very estimable gentlemen 
who practiced at the time referred to by the essayist (from twenty-five to fifty years 
ago), to extract the sixth-year molar almost promiscuously. He had seen hundreds 
of those cases, and he had seen the results of modern practice. He had formed this 
idea-that with thirty-two teeth in the mouth, respect should be paid to each indi- 
vidual tooth ; that no tooth, any more than a suspected violator of the law, should 
be condemned without the benefit of a trial and a jury. There was no more reason 
to select the sixth-year molar and anathematize it, to direct their batteries at it as 
if it was a proved culprit, than there was to do the same thing in regard to any 
other tooth. The thirty-two individual teeth were thirty-two teeth which should be 
respected. 
There was another fact which, it seemed to him, should be recognized, and that 
was that extraction was mutilation, and that whenever it might become necessary to 
amputate, or whenever it might be justifiable to amputate, it was nevertheless muti- 
lation, and should be done only for cause that should be determined, not because it 
was a right ear or a left ear, not because it was a right eye or a left eye, not because 
it was a sixth-year molar or a bicuspid ; but those laws which were immutable, and 
which were concerned in so many of the functions of the teeth, should all be studied, 
and the selections in regard to what amputation should be performed should be 
based upon the study of all these laws, and they included so much that he would 
not take time even to refer to them. Every extraction of a tooth was a question of 
expediency, depending upon the lesions of each individual tooth, upon the arrange- 
ment of the teeth in each jaw, upon the occlusion of the teeth in both jaws, and 
updn many other conditions. It was always mutilation-justifiable, it might be, like 
any other amputation, but always the result of abnormal conditions-not anatomical 
or physiological, but pathological. 
In regard to the foundation of the whole argument just read, that the sixth-year 
molar was a tooth of transition, it seemed to him that the basing of a method of 
practice upon one condition, among many, was putting a superstructure on a very 
contracted foundation. But if the sixth-year molar was in its origin analogous to 
the temporary teeth and not to the permanent teeth, if it were intended that it should 
be a temporary tooth, or even if it were intended that it should be a tooth of tran- 
sition (as the author of the paper called it), why had nature neglected one very 
important provision for it which she had made for the temporary teeth, the provision 
for its self-extraction, its exfoliation, the absorption of its roots? If there was no 
other argument on which to base a complete denial of every foundation on which the 
author had argued, that would be sufficient. It was intended to be a permanent 
tooth, and the simple fact of peculiarity of origin was not enough on which to base 
an argument for its being a tooth of transition. 
The author had referred in his table to the frequency of decay in the sixth-year 
molars. He (Dr. Shepard) suggested that the basing of an argument in regard to 
health on deaths from smallpox, in a community where every victim was allowed 
to die without any medication, or even nursing, would be like basing an argument 
upon tables of the frequency of decay in teeth. There were, so far as he knew, no 
tables which were anything more than an approximation, or a hint of something which 
could come in the future. The only tables that would be good for anything would 
be those showing, not the ratio of frequency of decay, but, to be scientific, there SECTION XVIII-DENTAL AND ORAL SURGERY. 
621 
should be coupled with them tables showing the ratio of preservation under varying 
conditions, where skillful remedial means had been faithfully and consistently applied, 
the same as in all other branches of the remedial art. 
He had no hesitation in making the statement of his conviction, that the sixth- 
year molar was just as good a tooth as the twelfth-year molar, or the bicuspid; or in 
expressing his conviction that under ordinary circumstances and with ordinary care, 
the sixth-year molar is, at the age of fifty, more apt to be in its place than the bicuspid 
is, if attended to in the same manner and as well. He had no hesitation also in 
expressing his conviction that the sixth-year molar, if attended to at a proper age, 
and if lesions were treated properly, had a prospect of durability as good as any other 
tooth in the mouth, with the exception of the cuspids, and perhaps only excepting 
those teeth. Hence it was his invariable practice, with all the families that he treated, 
to insist on treating these sixth-year molars at the age of seven or eight, or as soon as 
they could be got at, and to give as respectful consideration to these teeth as is given to 
other teeth. 
He had notes of various minor points of criticism of the essay, but he would 
not take up time to refer to them. He was sorry to have presented his remarks 
in this way. He owed an apology to the members, but they knew his reason. 
Dr. A. M. Dudley, one of the Secretaries, said that Dr. Paul Dubois, of Paris, 
one of the foreign members of the Congress, had a few words to say on this subject, 
but as he could not speak English he would have to speak in his native tongue, and he 
(Dr. Dudley) would endeavor, to the best of his ability, to let the members understand 
what he said. 
The Professor says that the theory that the extraction of the sixth-year molars 
should always be resorted to in the case of caries of those teeth is a very wrong one ; 
and that extraction should not be insisted upon in regard to those teeth any more 
than in the case of other teeth, except as a dernier ressort. He says that the extrac- 
tion of the sixth-year molar almost invariably interferes with the proper articulation 
of the teeth, and with the occlusion of the teeth ; that they do not occupy the place 
which nature designed for them ; and that its extraction has a bad effect on the 
maxillary bones-a tendency to produce disarticulation and improper occlusion of the 
teeth, and that it interferes with the proper mastication of food. He reiterates 
his statement that the theory of the wholesale extraction of the sixth-year molar, 
because of its being decayed, is entirely wrong, and is not in accord with the opinion 
held by the most scientific men of our profession in France. 
Dr. W. P. Horton, of Cleveland, Ohio, said that he would never accede to the 
proposition, which was so rife a few years ago, in favor of the wholesale extraction of 
the sixth-year molar. He contended at that time that it was a bad practice as a whole. 
So far as his own practice was concerned, he could simply illustrate it by cases in 
his own family. He had two sons. With the first, he had commenced filling a sixth- 
year molar as soon as he saw any signs of decay. That son has his thirty-two teeth 
intact, and was thirty-five years old to-day. With the second son he had extracted 
three of the sixth-year molars. He had left the root of the under jaw sixth-year 
molar, and had put in what he called at that time (twenty-five years ago) a very 
nice gold filling ; and that was there to-day. That son had now only twenty-eight 
teeth. At the age of eight or nine he had to extract the other three, leaving the 
fourth ; and that was good to-day. When this son was thirty years old, he (Dr. 
Horton) was obliged to administer an anæsthetic, and he took out one of the hand- 
somest third molars from the lower jaw that he ever saw. In consequence of the 622 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
want of enlargement in the lower maxillary bone to receive the tooth, it was forced 
into the maxillary muscle to such an extent that it was crowded inside, and every 
time food was masticated there was a contraction of the muscle ; and when climatic 
changes took place there was a good deal of pain until the tooth was taken out. The 
principle on which he acted for all those years was to take into consideration the con- 
dition of nourishment and the probability of an enlarged maxilla to receive the com- 
ing tooth. In no case did he resort to the extraction of the superior molars, but 
confined it to the inferior ones ; and he extracted them only when there was such a 
diseased condition of the enamel that it was almost impossible to do anything with 
them but to prolong them to the stage when they would be of little use, and would 
interfere with the incoming teeth. Then he would remove them, but never in any 
instance would he remove the molars of the upper jaw in the same mouth. If there 
was an enlargement sufficient to receive thirty-two teeth, nature required them, and 
they should be saved, by all means. He generally tried to teach families to bring 
their children to him at an early age. He had begun with his own boys, to fill their 
first teeth, before they were three years old, and had followed it up ; and they had 
their teeth, perfect now. The misfortune was that heads of families did not consider 
this thing. They did not come to the dentist for his advice and assistance until the 
diseases of their children's teeth were too far advanced. Patients rarely came to a 
dentist until they were in a condition where they thought they would have to lose 
one or two or more teeth. That was unfortunate so far as the patients were con- 
cerned, and it placed the dentist in a very embarrassing condition in his practice. 
Dr. George H. Chance, of Portland, Oregon, asked Dr. Horton how he got on 
with the occlusion of the teeth. 
Dr. Horton replied, that would generally take care of itself, and that the second 
molar came forward for the right occlusion if the other was removed in time ; but if 
the extraction was delayed until the second molar was well grown it was a pretty 
difficult matter. 
Dr. F. Abbott, of New York, said that, in relation to the question whether the 
sixth-year molar was originally intended by nature, or by the maker of teeth gener- 
ally, as a permanent or as a temporary tooth, there were two points which seemed 
to him rather essential. In the first place, it would seem from what he had exam- 
ined in the way of teeth, that the assertion that the sixth-year molar was not as well 
calcified as the twelfth-year molar, or the wisdom tooth, was gratuitous. He had 
examined many hundreds of teeth, both permanent and temporary. The difference 
between the temporary and permanent teeth was easily seen under the microscope, 
but he was never able to distinguish any difference between the permanent teeth and 
the sixth-year molar. The essayist had made a point in regard to the manner in 
which the permanent tooth first starts-it being from an independent bud which dips 
down into the epithelium, while the sixth-year molars come in the same way as tem- 
porary teeth ; and from that fact the essayist claimed that the sixth-year molar was 
a tooth of transition. But there was this difference between the action of the sixth- 
year molar and the action of the temporary tooth : the temporary tooth had the bud 
of a permanent tooth, which went down and took its place ; while the sixth-year 
molar budded for a second molar, and the second budded for a third. That was the 
strongest argument he could imagine, that nature had made them in a serial order. 
It would seem that those three teeth were intended as permanent teeth first of all, 
and that there was this difference in the way of their budding and coming into the 
mouth. 
The discussion upon Dr. Andrieu's paper was here closed. SECTION XVIII-DENTAL AND ORAL SURGERY. 
623 
Dr. A. M. Dudley, one of the Secretaries, read the following English translation 
of a paper written in French on- 
APHTHOUS STOMATITIS AND ITS ORIGIN. 
APHTHE DE LA BOUCHE ET SON ORIGINE. 
APHTHÆ UND IHR URSPRUNG. 
BY DR. TH. DAVID, 
Of Paris, France. 
Aphthous Stomatitis in man is not a local lesion, hut rather a general affection, a 
species of eruptive fever, from which a certain number of epidemics has been observed. 
It consists of an initial feverish state for some two or three days, followed by a vesi- 
culous eruption on various points of the buccal mucous region, rarely elsewhere. The 
disease lasts at least from seven to eight days. Sometimes the eruption assumes a 
grave character, even mortal, whether by local accidents, which make it resemble 
diphtheria or gangrene, or because it attacks the digestive passages and provokes gastro- 
intestinal phenomena (typhoidal phenomena, diarrhoea, vomitings, etc.). 
In some animals, above all among cattle, there is an ailment, also epidemic, called 
Cocote Bovine, or apÄtÄous fever. Like stomatitis in man, it begins with an initial fever 
of two or three days, succeeded by a vesiculous eruption in the forward part of the 
mouth, frequently upon the feet, more rarely upon the breast. It is subjected to the 
same gastro-intestinal complications. 
It results, therefore, from this comparison, that aphthous stomatitis in man is analo- 
gous to and is identical with the aphthous fever of animals. 
What is the nature of the malady? Everything seems to make us believe that it is 
a general infectious disease; that its localization in the mouth or upon the feet would 
constitute a critical phase, corresponding to the elimination of the germ, probably a 
parasite. 
The pathogenic agent resides in the wateriness of the vesicles, the secretions, the 
mucus of ulcerations. It is thought to be likewise contained in the blood and in the 
milk, but no alterations have ever been found in this latter liquid, even after mammary 
eruptions. 
What is this agent? In researches already made, there have been found the 
albican oïdium, certain coccus; the tilletia, too, has been described; the special microbe 
does not seem to be definitely known. 
What is the origin of the disease ? According to Hadinger, the parasite should arise 
from a change of fodder, particularly of clover. It should primarily attack animals, 
and then, by contagion, pass from them to man. 
Contagion is proven by numerous and authentic facts- 
a. Isolated cases of transmission to man, by imbibing milk not boiled, by contact, 
and by direct inoculation from contaminated matters. 
b. Epidemics of aphthous stomatitis, coinciding with epizootics of aphthous fever. 
c. Experimental transmission to man by drinking the milk of ailing animals (note 
Hartwig, Mann, Villain). 
d. Transmission from man to animals (see Andréæ). 
There is, therefore, no doubt that aphthous stomatitis in man is only the aphthous 
fever transmitted from animals. 
Conclusion. It is proper then, on this point, to draw the attention of the govern- 
ments to this subject, and invite them to take necessary measures to prevent the con- 
sumption of milk given by animals attacked by aphthous fever. 624 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. A. M. Dudley, Secretary, read the following English translation of a paper 
written in French on 
THE NECESSITY OF AN INTERNATIONAL INQUIRY INTO THE 
STATE OF THE DENTAL SYSTEM AMONG DIFFERENT PEOPLES. 
NÉCESSITÉ D'UNE ENQUÊTE INTERNATIONALE DANS L'ETAT DU SYSTEME 
DENTAIRE CHEZ LES DIFFÉRENTS PEUPLES. 
DIE NOTHWENDIGKEIT EINER INTERNATIONALEN UNTERSUCHUNG DES ZUSTANDES DES 
ZAHNSYSTEMS UNTER VERSCHIEDENEN VÖLKERN. 
BY M. P. DUBOIS, 
Of Paris, France. 
It is a part of the duty of this Congress to lay the foundations of a uniform study of 
the dental system among the different classes of mankind. 
It is not necessary to insist before this company on the paramount importance of 
this study. 
To have the distinctive characteristics of the teeth among the various human groups 
investigated, is to aid in the knowledge of man; it is to aid in discerning the rôle and 
importance of the factors which influence him-germ, sun, water, climate, solid and 
liquid food, education, hygiene, diseases, etc. 
Further, it is to give a rational basis to our practice. What lights upon dental 
ætiology, therapeutics and hygiene would result from such an inquiry ? 
Specialization would, therefore, have, in consequence, not only abler and more 
enlightened practice, but also give contributions to general science; contributions 
which could be brought about only by those who have gone to the foundation of their 
specialty. 
This knowledge, gained by delving at the bottom of the dental system, is so essential 
for the science of man, that one of its founders, my illustrious compatriot, Broca, 
edited, several years ago, an appendix to his general instructions on anthropology, in 
which he showed to physicians and travelers the great lines of the anatomy and phy- 
siology of the dental system of man. 
Except some isolated contributions (Maurel and Kermoroan), physicians and travel- 
ers have not responded to his appeal. If, for uncivilized nations, competition is pre- 
cious, then among civilized people the dentist is more apt to turn such work to good 
account. 
If this Congress will be pleased to adopt the proposition which I have the honor to 
submit to it, we shall have then several years of inestimable elements for the study of 
odontology, and anthropology will likewise be profited by it. 
Therefore, I request that, first, the Congress appoint an international commission of 
three members, charged with editing a question book, to be translated into the three 
principal languages. 
Every one of these commissioners will centralize information and give complement- 
ary instruction to persons who will have a desire to answer the questions laid down. 
Dr. Paul Dubois, of Paris, made a statement in French, which was interpreted 
by A. M. Dudley, one of the Secretaries. He said :- 
Dr. Dubois comes here accredited from the Directors and Faculty of the Dental 
School of Paris and by the general Association of dentists throughout France, to SECTION XVIII-DENTAL AND ORAL SURGERY. 
625 
extend to American dentists (especially to those of this assembly) an invitation to 
unite with them in holding an International Dental Congress in Paris, in 1889-a 
Congress to be composed entirely of dentists. The year selected is the one in which 
the great Paris Exposition is to occur, and, although the date has not been fully 
determined, it seems probable that it will take place in the month of August, that 
being the most favorable month for our profession. He says that the profession in 
Paris and throughout France is united in the movement for this invitation, and that 
France, through its dental profession, will receive you with open arms and give you 
a cordial and hearty welcome. He says that the respect and admiration of the 
French people for the dental profession in America is very great, and it is desired, 
therefore, that there shall be a very large attendance from this country. Initiatory 
steps have already been taken in the matter, and a committee has been appointed, 
consisting of Dr. David, Director of the Dental School of Paris, and of Drs. Bloc- 
mân, Chanvier, Dubois, Godon, Levett and Poinsat, Professors in the Dental Col- 
lege of Paris. 
Dr. T. Fillebrown suggested that the acceptance of the invitation by a Section 
of the International Medical Congress would be out of place and a discourtesy to the 
Congress. He, therefore, hoped that the matter would be withdrawn and allowed 
to drop. 
Dr. W. H. Atkinson, of New York, regarded that view of the matter as a 
very narrow one. This was the Section which gave attention specially to the oral 
cavity and its belongings. That did not divorce it from the other branches of medi- 
cine, but it did pronounce a difference between specialty and generalization. He 
did not see how the acceptance of this invitation would militate against the general 
International Medical Congress any more than the existence of local societies and 
State Associations did, which were finally represented in general meeting. 
No action was taken in the matter. 
The following paper was read by title :- 
IRREGULARITIES OF TEETH. 
IRRÉGULARITÉS DES DENTS. 
UNREGELMÄSSIGKEITEN DER ZÄHNE. 
BY J. J. R. PATRICK, D.D.S., 
Of Belleville, Ills. 
I propose in this communication to discuss the subject of irregularities of the human 
teeth, with a view of determining not only the nature and cause, but also the limits 
assignable to the word irregularity. I shall necessarily have to go over a wide field, 
and cannot hope to treat the subject in an exhaustive manner. If I succeed in direct- 
Vol. V-40 626 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ing the attention of my scientific friends to a more extended study of this most 
important subject, I shall be amply satisfied. I will, therefore, make no apology for 
bringing this subject in its entirety under your consideration, although it might have 
been preferable to discuss each point in detail. I hope, however, to place before you 
facts and opinions that will assist in laying a foundation for future inquiry and discus- 
sion. In the first place, I would explain what I understand by irregularity, for in all 
attempts at exact classification on a scientific subject difficulties present themselves 
that are not easy to overcome; there is always to be found a shading at the edges which 
unites, to a greater or less extent, one phenomenon with another. Thus it will be found 
that irregularity is joined at one extremity with monstrosity, and at the other with 
that which is generally recognized as variability. Now variation is so constant a factor 
in the operations of nature that it is exceedingly difficult to understand what is meant 
by regularity, for we find there is an inequality of development in all living creatures, 
even of the same kind, which renders them unequal in their appointment for their special 
sphere of action. Ducks may appear to swim and dive with equal facility, but close 
observation will show that some surpass others in the art ; the quickness of eye and 
dexterity of limb that belong to the cat in pursuit of a bird is as much to be admired 
as the flight of the bird beyond the reach of the cat ; but as all cats are not equally 
active, and all birds are not equally swift, it follows that the contest is relative. We 
look in vain for a stableness in spring time and harvest; a blighting heat or killing frost 
lays low the fruitful field. There is a noiseless but no less fierce struggle for food, 
sunlight and moisture, constantly going on in the forests. The competition for the 
carbon of which their tissues are built up, is as great and as evident as the competition 
betweèn animals for the food on which they subsist. Carbonic acid is the true 
food of plants, but the supply of carbon is of no use without a proper amount of sun- 
light in the right place to deoxidize it and render it available for the use of the plant. 
It follows that each tree or shrub endeavors to get for itself as much sunlight and carbon 
as it possibly can, and all its neighbors endeavor to prevent or forestall it in the struggle 
for aerial nutriment by overspreading and shading its neighbor. The varying exposure 
to the sunlight of the leaves of a single plant causes them tc be unequally developed, 
so there are few leaves that tremble in the forest or blades of grass that clothe the 
earth that can be said to be truly alike. 
Every germ in its development meets with obstacles, meets with contending forces, 
and countless numbers of the germs or seeds that are produced by both animal and 
vegetable organisms never come to maturity, but rot before ripening, and by far the 
largest number that do mature are warped, gnarled and twisted to such an extent 
that few can be said to be in that condition which physiologists call normal. 
Constant, unrelenting and persistent are the contending forces which govern life ; 
an excess of either one or the other must change and modify the character of the organ- 
ism upon which they act ; and the wonder is to the observant mind, not that nature 
does her work so poorly, but that she does it so well. Monstrosities which graduate 
into irregularities, and from slight irregularities into variations, are so similar in man 
and the lower animals that the same classification and the same terms are used for both ; 
monstrosities, however, are more common with the lower animals, for the reason that 
the number of their progeny is greater at a single birth, and, as might be expected, 
monstrosities are more common with fishes. Notwithstanding the variability of struc- 
ture in all animals, they appear to be perfectly adapted to their field of action, but the 
field of action of all animals but man is limited, and seems to admit of little 
advance ; whereas the anatomy of man is defective, mentally he is deficient (as compared 
with his own genus), and it is from this defective condition that he is capable of 
advancement ; progress is, therefore, possible to man. Were he perfect, it would be 
impossible, for progress means an advance from a lower to a higher condition. It is a SECTION XVIII-DENTAL AND ORAL SURGERY. 
627 
well-known law that widely-ranging species of animals are much more variable than 
species with restricted ranges, and when we consider that all the races of man form but 
one genus, and that genus the only one of its order, his range is enormous and his 
variability equally so. No two individuals of the same race are quite alike. If we 
compare millions of faces, each will be distinct, and there is an equal diversity in the 
proportions and dimensions of the various portions of the body, even within the limits 
of the same race or family. In the preparation of the work on ' ' The Anatomy of the 
Arteries," by R. Quain, so frequently do the arteries take abnormal courses, it was 
found necessary, in order to be useful for surgical purposes, to calculate from 12,000 
cadavers how often each course prevailed. The muscles of the foot were found by 
Prof. Turner not to be strictly alike in any two out of fifty bodies. Mr. Wood has 
recorded the occurrence of 295 muscular variations in thirty-six subjects, and in another 
set of the same number no less than 558 variations, reckoning both sides of the body as 
one. The accurate Soemmering enumerates 248 varieties of sutures in the human 
cranium, and it would be difficult to find a subject that would not be totally wanting 
in departures from the standard descriptions given in our anatomical text-books. 
In the different orders of the lower animals the rugæ of the palate are readily distin- 
guished one from the other, owing to the restriction of each order to one kind of food ; 
but in man, where there exists little or no restriction in the character of his food, the 
ruga of his palate is not constant in its markings and is generally confused. 
The development of the body is not always in harmony with the action of the heart, 
being either in advance of or behind it. When the development is behind the action 
of the heart there is hypertrophy of growth, either in whole or in part, caused by over- 
nutrition; on the contrary, when development is in advance of the heart's action there 
is an insufficiency of growth; and when one part becomes modified, either by insuffi- 
ciency or redundancy, other parts not originally involved will change, through the 
principle of correlation, of which we have many instances in correlated monstrosities. 
Owing to the power of the vital system-almost universal in youth-there is nearly 
always a faulty feature, which the physiognomist may observe, and which continues 
sometimes to exaggerate until, in advanced age, it terminates in relative ugliness. 
Thus, we seldom observe the long upper lip during youth, and yet in after years it 
gives to the features the sober grimace of the baboon. We admire in youth the quick- 
ness of the piercing eye and the bold outline of the aquiline nose; yet these features, 
if not modified in time by the development of adjacent parts, will impart to the owners 
the look of birds of prey. In like manner, we know exactly the effect of an irregular 
developing set of teeth on the beauty and harmony of the features many years before 
they disfigure the face by making the mouth repulsive. 
While it is difficult to find races of men that are not mixed, there can be no ques- 
tion that crossing and recrossing, even among the most isolated tribes, might be the 
cause of irregularity of the teeth ; for as all would not attain the same physical propor- 
tions, the result would be the same that we find in a majority of cases. The size of the 
teeth, in the majority of human beings, has no proportionate relation to the size of the body. 
Thus, very frequently, small persons have very large teeth, while persons of colossal size 
may have narrow and small teeth. Large persons usually have large jaws, but the 
teeth do not correspond to the size of the jaws as often as the jaws correspond to the 
size of the body, either in large or small persons. There are large jaws with small 
teeth, and small jaws with large teeth; the latter occur more frequently in small per- 
sons, while the former are of rarer occurrence in large persons. If we have to seek in 
vain for a single instance of complete regularity, how shall we find a standard for a 
regular set of teeth ? If we take what constitutes one of the most constant characters 
in the jaws of the negro, we will find that the inclination of the alveolar border of the 
superior jaw runs downward and forward from behind, constituting what is known as 628 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
prognathism, the highest form of which is called double; that is, when the inferior 
incisors are alike, the superior projecting obliquely, and the two rows of incisors form 
the angle of a chisel, producing on the posterior surfaces of the superior incisors trian- 
gular facettes. This form of prognathism is not common with the negro, more common 
with the Australian, and rarely met with in other races. Prognathism of this character 
must not be confounded with simple projection of the teeth and, consequently, the 
ridges of the alveoli so frequently met with in the European ; for whatever the position 
of the teeth, the alveolar arch presents to the eye a parabolic curve, whereas the alve- 
olar arch of the negro and the Australian is elliptical. The difference in facial expression 
manifests itself by a different order of increase in the growth of the respective parts. 
While in the European the moderate increase of the jaws and bones of the face is 
compensated, and even surpassed, by a development, or, rather, enlargement, of the 
brain, and especially of the anterior lobe, the contrary takes place in the negro and the 
Australian. Now, if an artificial set of teeth was arranged in a parabolic curve on a 
base-plate, to fit an elliptically formed mouth, it is clear that the harmony of the features 
would be impaired; for the introduction of an artificial set of teeth on the European 
plan in the mouth of an Australian would only serve to intensify his ugliness. They 
might be symmetrical in themselves, but very unsy in metrical in their relationship. 
Regularity cannot exist without harmony-that harmony which makes each part of 
each animal correspond with the whole. It is by the deep study of this harmony, and 
the exercise of the art of design, and by an exquisite sentiment, that great statuaries 
have succeeded in making us feel the just proportions of the works of nature. Thus, 
all the forms, all the outlines and all the parts of the human body have been realized 
in marble, and these statues, which were only copies from man, are now originals, 
because these copies were not made from any one individual, but from large numbers 
selected from the human species well observed-so well, indeed, that no human being 
has yet been found whose figure is so well proportioned as these statues, and we know 
nature better by the representation than by nature itself. It is fair to conclude, with 
these statements before us, that it, would be almost impossible to find a regular 
set of teeth if we had to include other parts of the animal in order to establish their 
just proportions in nature and office. We will, therefore, content ourselves with what 
will be considered a regular dental series of a modern European. They are of two 
kinds- 
1. In the regular dental series of civilized races of men, the inferior canines are 
directed inward and backward, and the incisors vertically ; the superior incisors for- 
ward and the canines outward. The two series are placed on a curve in such a manner 
that when occlusion takes place they are partly over, partly under, and partly on each 
other ; the six superior front teeth slightly overlapping the six inferior ones. 
2. A regular dental series in which the incisive teeth do not lap, but impinge 
on each other at their cutting edges like the molars. The superior canines in early 
life slightly overlapping the inferior ones. This class of occlusion is exceptional in 
modern times, but they have the merit of being firm, compact, and very even as to 
alignment. 
The teeth of primitive man, whether of the prognathous or orthognathous type, 
occluded in the same manner. Cuvier says in his " Comparative Anatomy " that the 
ancient Egyptians used their incisive teeth more for prehension than the modern Euro- 
pean, as the incisive teeth of the mummies were all truncated and with flat coronals. 
The teeth of the ancient British and Gaulish skulls are in the same condition, and it is 
quite probable that the introduction of the knife and fork or chopsticks in modern 
times to convey food to the mouth has modified the form of the jaws and the occlusion 
of the teeth. I have in my own collection of American specimens, taken from the 
mounds of the American bottom in St. Clair and Madison counties, Illinois, nearly one SECTION XVIII-DENTAL AND ORAL SURGERY. 
629 
hundred well-preserved skulls of the so-called mound builders, and it is the exception 
to find among the whole number a sound set of teeth. Not less than four hundred 
graves were opened in order to obtain this number of comparatively good crania, the 
others being too frail to preserve. The marks of alveolar abscess are common : loss of 
incisors, molars and bicuspids frequent, with complete absorption of their sockets. 
I have two cases of antral abscess, with loss of the external wall in one of them. I 
have one case of entire loss of teeth, with absorption so complete that the mental fora- 
mina are obliterated and the nasal process partly gone. I have a number of cases in 
which the crowns of the teeth are in all stages of decay ; others with the roots remain- 
ing in the sockets, the crowns gone entirely. I have but two skulls in which the upper 
front incisors lap over the lower ones ; in all the other cases the masticating surface 
of the upper fits perfectly that of the lower. 
The incisive teeth do not lap, but impinge on each other at their cutting edges like 
the molars, and are worn quite flat, so that when we look along the surface of mastica- 
tion we perceive that it is a perfect plane. 
From the fact that more diseased teeth and more irregularities are being treated 
now than formerly, the mournful conclusion is drawn that a greater proportion of civil- 
ized humanity is succumbing to the stringent requirements of modern life, as the 
tendency of civilization is to call out increased mental exertion, and the nervous strain 
to which modern man is constantly subjected is destructive of his physical equilibrium. 
This statement, however, depends upon the assumption, which there is no ground for allow- 
ing, that the structural capacity for such requirements will not increase simultaneously 
with the mental. Comparisons have frequently been drawn between the savage and 
the civilized man, in regard to their physical condition and their teeth, and the conclu- 
sions have always been favorable to the savage. Since I know of no facts to support 
such a conclusion, a reverse of the picture may be worthy of your attention. 
The families of savages are small; they are subject to great hardships; they do not 
obtain as much nor as regular a supply of nutritious food as civilized man. They suffer 
periodically from famines, and at such times they are compelled to devour much bad 
food, and their health can hardly fail to be injured. The mortality among their chil- 
dren is large, and the sickly or deformed ones are usually destroyed, for infanticide 
prevails to a great extent. Having no artificial increase in the supply of food, they are 
liable to many accidents by land and water in their search for it. They have no 
granaries in time of peace and plenty, they have no commissary in time of war, and 
they are almost always at war with their neighbors. They have no asylums for the 
maimed, the imbecile, the blind or the sick, yet epidemics prevail more frequently with 
them than with civilized people, destroying great numbers. They take no census, but 
the reports of agents, missionaries, travelers, and their own records in picture writing 
furnish these facts. On the contrary, the families of civilized man are more numerous; 
they obtain a regular supply of nutritious food; their excessive production of food 
bridges over the seasons of scarcity and protects them from famine. By their knowl- 
edge of the laws that govern life, they have almost driven pestilence from their midst ; 
they take care of their own helpless ones; they build asylums for the blind, the imbecile, 
and the sick, and by their constant improvements in methods of treating disease, lives 
are saved or prolonged to be carried over on the broad shoulders of civilization, and it is 
thus that the physical and mental imbeciles increase with the increase of population in 
civilized communities. In savage communities it is only the strong and vigorous that 
live and survive the hard conditions imposed by the hand of nature. 
If we reflect for a moment that there are in the adult skull fifty-eight separate bones, 
including the teeth and ossicula auditus, and in the child many more, owing to the seg- 
ments in which the bones are formed, and that these bones have to grow with equal pace 
to meet their opposites in the median line, in order to fulfill the requirements of a 630 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
regular development, there can be no surprise at the great variability of the human 
countenance. Now the growth of one bone is commonly arrested by meeting with another, 
the tendency of both to increase being checked by their mutual pressure. (Fig. 1. ) Thus 
the spreading of the cranial bones beyond their proper limits is, in their normal state, 
Fig. la. 
Fig. 1&. 
Vertical and transverse section of a nearly perfect human face, showing the nasal cavity, sinuses, 
alveoli and teeth. 
prevented when their edges meet. The want of this check is observable in cases of hydro- 
cephalus, where the bones continue to grow because their edges are kept apart. A still 
better example, however, is afforded by the palate. The alveolar and palatine pro- 
cesses of the maxillary and palate bones ordinarily coalesce with one another and SECTION XVIII-DENTAL AND ORAL SURGERY. 
631 
with the vomer in the median line and put a stop to one another's growth. Sup- 
pose, however, that, in consequence of an imperfection in development, the maxillary 
and palate bones fail to meet the median line, then the vomer and intermaxillary bones 
would grow beyond their proper level and project in front beyond the line of the alveolar 
arch. (Fig. 2. ) If the maxillary and palate bones should fail to meet on both sides, then the 
intermaxillary bones would be quite isolated from the maxillaries and hang down in 
the middle line, dependent from the vomer, causing double harelip and cleft palate. 
The imperfection in the progressive development of these bones causing cleft palate and 
harelip might be detected in the third month of fœtal life, as the intermaxillary, occu- 
pying the naso-frontal process, is distinct at that time, but is covered on its facial aspect 
by a process of the maxillary, which unites with it completely before birth. (Fig. 3. ) 
The non-development of the intermaxillary is generally accompanied with cleft palate 
and harelip, but harelip may occur without cleft palate, there being no intermaxillary, 
and yet the palate process united, no nasal process, and the nasal septa deficient. (Fig. 4. ) 
Fig. 2. 
Skeleton of double cleft palate, showing intermaxillary and vomer. From Humphry on the Skeleton. 
Now a non-development of the intermaxillary may occur without cleft palate or hare- 
lip, and therefore carry no incisor teeth, the nasal process and maxillary being well 
developed, exhibiting very little external deformity, no more, in fact, than if the incisor 
teeth had been extracted. (Fig. 5.) The intermaxillary may be so narrow laterally, 
that the lateral incisors will be missing, while the maxillary bones will be developed 
forward, carrying a duplicity of canines on either side; the two posterior ones right and 
left being deciduous in such cases, the occlusion with the lower teeth is generally good. 
(Fig. 6.) In a similar case in which the intermaxillary carried but two front incisor 
teeth, and in which the maxillary bones were not developed forward to compensate the 
arch for the missing incisors, the occlusion was faulty, the two front incisors closing 
inside the lower ones. (Fig. 7, a, b.) So, also, in the case of a laterally contracted inter- 
maxillary, it may carry four incisors, the two laterals immediately behind the two cen- 
trals, after the manner of rodents of the genus lepus. The intermaxillary bone may be 
too short vertically, but broad enough laterally, to carry the four incisors; yet these 632 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
incisors, although well developed, will be too short to occlude with the lower incisors 
when the molar teeth are brought in contact. (Fig. 8.) Now this failure of the supe- 
rior incisors to occlude with the inferior may not be caused by a fault in the intermax- 
illary, but by an excessive vertical development of the maxillaries. This excess of 
development may be either single or double; when single, the action of the levator mus- 
cles upon closing the jaw will indicate the side upon which the development has taken 
Fig. 3. 
Fig. 4. 
Intermaxillary in the second month of fœtal life. 
From description given by Béclard. 
place, as the incisive teeth most distant from the over-developed side will more nearly 
approach each other. All the bones of the superior maxillary may grow forward and 
regular, so that they will project beyond the lower abnormally, as shown in Fig. 9. 
This would be single prognathism of the upper jaw, yet the same effect would be pro- 
duced if the lower jaw was shortened from an arrested development when the upper 
jaw was normal. 
Fig. 5. Fig. 6. 
The principal levator muscles keep pace with the growth of the jaws, increasing in 
size as the jaw's grow forward, and occupy the same relative position to the permanent 
molars as to the deciduous molars. In point of lever power, there is in most adult 
jaws more than a relative increase of power, especially when the dentes sapientiæ are 
well developed. This is owing to the increased length of the ascending ramus; in such SECTION XVIII-DENTAL AND ORAL SURGERY. 
633 
jaws the angle is nearly the same distance from the condyle as from the symphysis. Thus 
the power that moves the lower jaw upon the stationary upper is a powerful lever of 
the third kind, because the power is situated or attached on the lever, midway between 
the fulcrum and the body to be moved, for the force exerted by a lever depends upon 
the point of attachment of the power from the fulcrum ; the lever being straight or 
Fig. 7. 
crooked does not alter the conditions. Now it is clear that if the lower jaw grows for- 
ward and the ascending ramus keeps equal pace in its growth with the rest of the jaw, 
but continues the obtuseness of the angle of the ramus as in childhood, while the supe- 
rior maxillary sustains a normal development, we would have a clear case of single 
prognathism of the lower jaw. (Fig. 10.) 
Fig. 8. Fig. 9. 
In some persons the two front incisors are so far apart that a more or less interspace 
exists between them; in this space there are sometimes one or two very anomalously- 
formed teeth; sometimes these teeth are found on the palatine arch, immediately 
behind the middle incisors, but never occurring beyond the limits of the intermaxillary 
bone. Any of the organs of the body may be abnormally placed and may exceed in 634 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
number that which is usually the normal condition, without presenting any irregu- 
larity of form. An incisor, for instance, may present its margins to the anterior and 
posterior in the place of its anterior and posterior surfaces, and a canine may be trans- 
posed with a bicuspid. The right eye may be smaller than the left and the vision 
not be impaired, and there may be three regularly-shaped bicuspids on one side, or 
six well-formed fingers on one hand. If, however, the shape of a particular organ 
is different from that which is the rule, and if two or more organs are conjoined, 
they are malformations which must be considered as products of a physiological 
process. The dental organs, as might be expected from the complication of their sev- 
eral parts and their numbers, present many anomalies. There are found on the enamel 
of otherwise well-formed teeth spots of various sizes and color, small blind holes, pro- 
jections and depressions, furrows and corrugations. And while some teeth have patches 
of the crown devoid of enamel, others have patches of enamel on the cervical border, 
and even on the roots. Teeth very frequently undergo a change in their form after 
their complete development, and have become joined with adjacent organs by a patho- 
logical process of fusion in consequence of previous inflammation or disturbance ; but 
when teeth become connected, either wholly or in part, during their inceptive develop- 
ment, by a process of intimate union, such union cannot be viewed in any other light 
Fig. 10. 
than that of a process of physiological confusion. Now, the roots of individual teeth 
present the greatest number of examples of confusion ; since, while growing, the exter- 
nal posterior roots of the superior molars are frequently united with the internal or 
palate roots of the same tooth, and the same phenomena occur with the anterior and 
posterior roots of the inferior molars, whereas the fusion of divided roots is very rare, 
and can only take place when they are very near each other, either in their entire length 
or at their extreme points, or when the intermediate root-septum is either absorbed or 
is concreted with them. Fusion of two molars can take place in the fangs only; for, 
owing to the interval of time in the development of such teeth, confusion is impossible. 
How is it possible for a six-year molar crown to be confused with a twelve-year molar 
crown, or a twelve year molar crown to be confused with a dens sapientia, which usually 
appears twelve years later in life? 
Now, in regard to the relative proportion that the crowns of teeth bear to their roots, 
it will be found, as a rule, that teeth with very long or very large crowns have very 
short roots, while teeth that have very low or short crowns have very long roots, and it 
is rarely that the proportion between the crown and the root is well sustained ; there- 
fore, in shifting such teeth, care should be observed, for as these teeth with long roots 
and short crowns will require much time to place them in a new position, on account 
of their deep cells and the small leverage the crown affords, so, likewise, greater care 
and more time will be required in moving teeth with short roots possessing long crowns; SECTION XVIII-DENTAL AND ORAL SURGERY. 
635 
for, with the greater leverage of the crown over the short root such teeth are easily 
lifted out of their cells, which should never be done in regulating teeth, or, if done at 
all, done but slightly. 
Irregularities of the human teeth are, without doubt, questions of unequal growth of 
the parts concerned. To attribute irregularities to any special condition of the body, 
special forms of irregularities ihust correspond to special conditions. 
The cause of the second series of teeth being irregular cannot be attributed to habit 
of body induced by civilizing influences, else the deciduous teeth would be affected in 
the same manner ; and we find by careful observation that the deciduous series are 
rarely, if ever, irregular, either in the alveolar arch or the alignment of the teeth. Nor 
do I believe that thumb-sucking produces the gothic arch in the superior maxillary, 
for children raised on the bottle, who continue its use after the deciduous teeth have 
made their appearance, fail to produce the gothic form of arch, at a time when the arch 
is more flexible than ever afterward. Further, the traction produced by the mechanism 
of thumb-sucking is to the posterior, not to the anterior. 
How far the practice of thumb-sucking has produced the consequences attributed 
to it, in dragging the process and teeth forward, is very doubtful, since only those cases 
of thumb-sucking are recorded in which the deformity has been observed; and the 
deformity is very rare to originate from a practice so general. 
In several cases of this kind that have come under my care or observation, in which 
the parents or guardians have been very ready to suppose that the deformity had arisen 
from the causes alluded to; yet they did not appear to have fallen more into the habit 
than others equally well observed, whose bleached and attenuated thumbs bore unmis- 
takable evidence of continued use without producing deformity of the dental arches. 
Now, it is well enough to observe that the eight bicuspid teeth are not preceded by 
teeth of the same character or form, nor do they occupy as much space in any direction 
as their predecessors; but the six front teeth of the permanent set being larger than 
their predecessors, the contiguity of the teeth is maintained and no interdental space 
appears as in other animals. 
It is clear that by such an arrangement the deciduous series of teeth cannot perform 
the office of regulating guides to their successors, as some maintain. 
Further, the canine must always insert itself between two teeth that have pre- 
viously taken their place in the dental series; the second bicuspid, also, has to find its 
way between the first bicuspid and the first molar, but owing to its form, presenting 
flat surfaces toward its neighbors, it is not as likely to be displaced as the canine, and 
the alveolus being wider in this region, it has fewer difficulties to surmount, and this 
order of development produces the largest number of irregularities. If further proof 
were needed to disprove the theory that deciduous teeth influence the growth or 
position of the permanent set, the fact that the children of prognathous people are never 
prognathous during the first dentition, should be sufficient. 636 
NINTH INTERNATIONAL MEDICAL CONGRESS, 
The following paper was read by title 
L'ENSEIGNEMENT DE L'ART DENTAIRE. 
EDUCATION IN THE DENTAL ART. 
ÜBER DEN UNTERRICHT IN DER ZAHNHEILKUNST. 
CH. GODON, 
De Paris, France. 
La réforme de l'art dentaire s'est plus particulièrement, depuis ces dix dernières 
années, imposée à l'étude des membres les plus autorisés du corps professionnel des 
divers pays d'Europe, et par suite, a appelé l'attention de leurs gouvernements respec- 
tifs. 
Dans plusieurs pays même, des mesures législatives ont été mises à l'étude ou sont 
déjà entrées en vigueur (France, Belgique, Suisse, Russie). 
Parmi les questions qu'a soulevé ce mouvement de réforme, une des plus impor- 
tantes, selon nous, pour l'avenir de notre profession et l'intérêt général du public, est 
celle qui concerne l'enseignement de l'art dentaire ou, pour préciser d'avantage, le pro- 
gramme et les procédés d'enseignement de l'art dentaire. 
On comprend combien la solution adoptée est appelée à exercer d'influence sur les 
prochaines générations de dentistes et sur la marche de l'art dentaire : Aussi, est-il 
utile qu'elle soit étudiée avec toute l'attention nécessaire et qu'il ne soit pris de déci- 
sion, surtout si elle doit avoir force de loi, qu'après en avoir apprécié toutes les consé- 
quences et avoir pris l'avis des principaux représentants de la profession. 
Il nous a donc semblé que la grande réunion scientifique, dont le congrès interna- 
tional tenu cette année à Washington était le prétexte, la part importante que devait y 
avoir l'odontologie dans le pays qui a tant contribué à son développement, la présence 
des dentistes les plus connus et les plus autorisés des Etats-Unis et de l'Etranger, con- 
stituait une excellente occasion pouvant permettre de soulever avec avantage cette in- 
téressante question et de provoquer même, après une discussion compétente, le vote 
d'un vœu pour la solution la plus rationnelle et la plus favorable au développement 
progressif de notre art, vœu dont pourraient s'inspirer les divers gouvernements incités 
à intervenir. 
La part que nous avons prise au mouvement de réforme de notre art en France, à la 
fondation de l'Ecole Dentaire de Paris et à sa direction depuis bientôt dix ans, nous 
ont permis d'acquérir une certaine expérience en ces matières pour nous permettre de 
traiter cette question. 
Des circonstances indépendantes de notre volonté nous ayant empêché de venir 
prendre part en personne, comme nous l'avions espéré aux travaux du congrès, nous 
avons prié notre collègue et ami M. Dubois, de présenter pour nous ce mémoire et d'en 
défendre les conclusions. Sa collaboration importante dans la campagne menée par 
notre groupe en France depuis 1879, pour le relèvement moral et scientifique de notre 
art par l'enseignement professionnel, nous sont un sur garant que la cause gagnera à être 
défendue par un membre aussi convaincu qu'autorisé. 
Pour déterminer ce que doit être l'enseignement de l'art dentaire, son étendue, ses 
limites, il est nécessaire de fixer d'une façon précise le rôle du dentiste moderne, la li- 
mite de sa compétence, de ses fonctions telles que l'a faite le développement et les exi- 
gences de la civilisation. Les différentes polémiques provoquées par les discussions sur 
les conditions d'exercice de la profession de dentiste, ont amené quelques personnalités SECTION XVIII-DENTAL AND ORAL SURGERY. 
637 
très éminentes, mais imparfaitement renseignées sur la question, à donner de notre rôle 
des définitions qui peuvent se résumer ainsi :- 
" Le dentiste est le médecin chargé du traitement des affections de la bouche et de 
ses dépendances." Il suffit de préciser cette définition pour montrer combien elle est 
inexacte : En effet, comme le disait M. le Professeur Pillete à la séance d'inauguration 
de l'Ecole Dentaire de Paris (Novembre, 1881), la bouche comprend les lèvres, les 
joues, la langue, les amygdales et les dents ; par ses dépendances on entend probable- 
ment les glandes salivaires, le pharynx, le larynx, l'œsophase, etc. Or, nous le deman- 
dons aux praticiens de tous les pays, quel est le dentiste qui considère son rôle comme 
aussi étendu, quel est le praticien qui se permet de soigner les affections de ces divers 
organes, et surtout dans quelles villes, dans quel pays se trouve-t-il un public venant 
consulter le dentiste à ce sujet? 
On a voulu, comme disait le Professeur P. Bert,* " exagérer notre rôle pour mieux 
nous combattre, nous couvrir de fleurs pour nous mener à l'autel." 
Plus modeste quoique non moins utile est notre rôle. 
Le dentiste moderne a pour toute fonction :- 
La surveillance, la conservation et la restauration du système dentaire pour lui permettre 
de remplir toujours d'une façon normale son rôle physiologique ; pour cela : 
1° Il soigne par une thérapeutique spéciale les différentes affections des dents. 
2° Il restaure, par des procédés mécaniques, les destructions partielles ou totales des dents 
ou du système dentaire. 
3° Il soigne les complications de voisinage que peuvent déterminer les affections dentaires 
pourvu qu'elles n'affectent pas un caractère spéciale de gravité. 
Cette définition nous paraît être actuellement beaucoup plus exacte que la première 
et exprimer plus fidèlement ce que tous nos confrères sont appelés à faire journelle- 
ment, ce que le public vient quotidiennement réclamer d'eux. 
Complétons cette définition :- 
1° Soigner par une thérapeutique spéciale les altérations du système dentaire; c'est-à- 
dire soigner la carie dentaire, les affections de la pulpe et du périoste dentaire par le 
traitement conservateur ou par l'extraction, etc. : 
2° Restaurer par des procédés mécanique :- 
(n) Les altérations ou destructions partielles ou totales des dents, c'est-à-dire pratiquer 
l'obturation au ciment, à l'amalgame, l'aurification, l'ablation du tartre, etc. 
(&) Les altérations ou destructions partielles ou totales du système dentaire, c'est-à-dire 
remplacer les dents naturelles détruites ou extraites, exécuter et poser des dents artifi- 
cielles à l'aide d'appareils prothétiques construits en différentes matières, tels que l'or, 
le platine, le caoutchouc vulcanisé, le celluloïd, etc. ; redresser les dents irrégulière- 
ment placées à l'aide d'appareils spéciaux confectionnés également en ces mêmes mati- 
ères, etc. 
3° Soigner les complications de voisinage que déterminent les affections dentaires pourvu 
qu'elles n'affectent pas un caractère spécial de gravité : 
C'est-à-dire, soigner les abcès ou kystes provoqués dans les alvéoles ou le corps des 
maxillaires par des affections des organes dentaires ; les différentes inflammations des 
gencives, tartriques ou professionnelles ; les quelques ulcérations provoquées par la 
présence de racines ou de dents cariées, sur la langue ou les joues ; nous disons, powrcw 
qu'elles n'affectent pas un caractère spécial dp gravité, et nous l'expliquons : Nous fixons 
ainsi la limite, c'est-à-dire que ces complications sont de notre domaine, tant que la 
desparition de la cause qui les a provoquées et un traitement local suffisent pour les 
guérir ; mais dans tous les autres cas, elles sont du domaine de la médecine générale. 
Quoique nous soyons forcés de nous tenir dans les généralités, il nous semble que 
* Séance d'inauguration de l'Ecole Dentaire de Paris. Novembre, 1884. 638 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
toutes les opérations du ressort de l'art dentaire, sont suffisamment indiquées dans cette 
définition et qu'elles prennent toutes leur place dans le cadre d'une des trois divisions 
que nous avons établies. 
A peine serait-il bon d'y ajouter pour être complets, les appareils prothétiques pour 
certaines restaurations buccales ou faciales, pour lesquelles les chirurgiens viennent ré- 
clamer le concours des dentistes, mieux préparés pour leur exécution. 
Voici ainsi déterminée toute la fonction que remplit actuellement le dentiste et qui 
lui vaut, lorsqu'il y met le zèle et la compétence nécessaires, la reconnaissance de sa 
clientèle et l'estime de ses confrères. 
Nous croyons ce programme, quelque modeste qu'il puisse paraître, suffisamment 
étendu pour suffire à remplir honorablement une carrière et à dépenser l'activité d'un 
homme. Son étude exige un certain temps, des aptitudes spéciales, et offre des diffi- 
cultés égales et mêmes supérieures à bien des professions. Tout en faisant honnête- 
ment sa fonction, consacrant le temps nécessaire aux soins de la clientèle, le praticien 
sérieux peut y trouver encore de quoi satisfaire ses aspirations intellectuelles et ses 
aptitudes, propres et concourir au progrès général en se livrant à des études ou à des 
recherches des plus intéressantes sur des points ignorés ou mal connus de la science ou 
de l'art dentaire, comme le prouvent les comptes rendus de nos sociétés odontologiques. 
Nous ne croyons donc pas utile, pour justifier certaines théories, certains désidératu 
très honorables, mais peu pratiques, d'étendre ce programme en y joignant toutes les 
affections de la bouche et de ses dépendances, dans le but de faire du dentiste un méde- 
cin spécialiste de la bouche, un "stomatologiste," comme le nommait récemment cer- 
taine pétition,* et comme le voudraient certains médecins qui croient aussi relever la 
profession du déscrédit qui la frappait. Ils oublient que, pour qu'une fonction soit 
honorable, il suffit qu'elle soit utile à la société et honorablement remplie. Or, dans 
les limites que l'usage et la pratique lui ont assignés dans la généralité des pays, notre 
art est utile et ceux qui l'exercent sont honorés quand il en sont dignes. 
Dans ces limites on ne peut vraiment considérer notre art comme une spécialité de 
la médecine générale au sens que l'on veut donner à ce mot. On ne peut le comparer 
à l'ophthalmologie, à l'otologie, à la laryngologie, etc. Sa pathologie et sa thérapeu- 
tique restreintes autant que l'étendue et la composition de sa technique propre, le dif- 
férencient assez pour en faire un art spécial ayant de nombreux points de rapport avec 
les sciences en général, les sciences médicales en particulier, mais en ayant également 
d'autres avec des arts nombreux. Il doit donc constituer une profession indépendante 
de l'art médical, au moins au point de vue de l'exercice et surtout de l'enseignement 
comme la pharmacie ou l'art vétérinaire par exemple. 
Conséquemment, par suite des considérations qui précèdent, le programme d'en- 
seignement de l'art dentaire doit être, à notre avis, un programme spécial et contenir 
l'ensemble des connaissances composant la science dentaire, et, la série d'exercices pra- 
tiques devant rendre apte à exécuter les diverses opérations composant l'art dentaire 
et que nous venons d'énumérer. 
Si l'on examine attentivement le programme que nous avons tracé plus haut du rôle 
du dentiste, on remarque combien la médecine proprement dite, tient une place res- 
treinte, l'art, au véritable sens du mot, y occupe la place prépondérante; combien enfin, 
alors que le médecin ne fait qu'examiner le malade, reconnaître la maladie, ordonner 
le traitement, le dentiste doit exécuter l'opération, la restauration lui-même, et que si 
il est quelque peu thérapeute, il doit être encore plus habile artiste, et même ouvrier 
de talent, (que ceux de nos confrères qui s'en trouveraient choqués me pardonnent l'ex- 
pression, si tant est qu'elle demande à être excusée). . Aussi, s'inspirait des considéra- 
tions précédentes, le programme devra avoir en vue de développer l'habileté manuelle 
* Voir "l'Odontologie," No. de Juillet. SECTION XVIII-DENTAL AND ORAL SURGERY. 
639 
du candidat ; il faudra donc nécessairement que ce soit avant tout un enseignement pra- 
tique. De même que c'est en forgeant qu'on devient forgeron, en art dentaire on apprend 
à obturer ou à aurifier les dents en les obturant ou les aurifiant. 
L'étudiant dentiste devra donc : 
1° Apprendre à soigner ou extraire, restaurer ou remplacer les dents, en les soignant, 
les extrayant, les restaurant et les remplaçant suivant les divers procédés et méthodes 
employés, et cela sur les malades, et non sur des cadavres comme l'indiquent quelques 
programmes d'examens d'état (examen d'état en Belgique et rapport Lefort en France).* 
Cela constitue une des parties de l'enseignement pratique, enseignement clinique, étude 
pratique de la dentisterie opératoire, f 
L'étudiant doit également appendre la fabrication des appareils, de dents artifici- 
elles, de redressements, de restaurations buccales ou faciales, tout ce qui constitue enfin 
la prothèse. 
C'est encore un enseignement pratique qui est nécessaire, enseignement de labora- 
toire, et qui, plus encore que le précédent, exige de l'étudiant, de l'habileté et du 
goût. 
On a prétendu il est vrai, qu'il n'était pas utile pour le dentiste d'apprendre cette 
partie de son art, qu'elle pouvait être laissée à une classe inférieure d'ouvriers qui eu 
auraient fait leur occupation exclusive. Ceux qui défendent cette solution sont, il est 
inutile de le dire, les partisans de l'assimilation de l'art dentaire à l'art médical. Pour 
justifier leur théorie, ils ont dû amputer l'art dentaire de sa partie presque la plus im- 
portante ; d'après eux le dentiste devenu le médecin de la bouche, ne devrait pas plus 
faire les appareils prothétiques que le médecin ordinaire ne fait les différents appareils 
orthopédiques qu'il ordonne. 
Cet argument a contre lui, comme nous l'avons déj à démontré, dans le même ordre 
d'idées, l'usage et la pratique de tous les pays, ce qui pourrait suffire. Nous ajouterons 
cependant les arguments suivants. 
Tous les praticiens savent par expérience que, pour bien comprendre, faire exécuter, 
rectifier et placer un appareil de prothèse, il faut pouvoir l'exécuter soi-même. Il y a 
là, une partie importante de la construction de l'appareil, qui est faite sur le malade, 
telle que la préparation des dents ou de la bouche, l'empreinte, l'articulation, l'es- 
sayage, l'ajustage, la pose, etc. Ces diverses opérations nécessitent la connaissance de 
la prothèse. 
Enfin, si un certain nombre de dentistes des grands centres peuvent occuper un ou 
plusieurs ouvriers mécaniciens, la grande majorité des praticiens, par suite du chiffre 
restreinte de leur clientèle, sont obligés de s'en passer et d'exécuter leurs appareils eux- 
mêmes. Pour la bonne exécution de l'appareil, il y a du reste avantage à ce qu'il en 
soit ainsi, car le dentiste qui a soigné le malade, examiné la bouche, se rend mieux 
compte de ce qu'il faut faire, que l'aide à qui il serait obligé de transmettre ses ordres. 
Ces vérités sont du reste admises sans conteste par la grande majorité des prati- 
ciens. 
L'enseignement pratique de la prothèse doit donc faire partie du programme au 
même titre que celui de la dentisterie opératoire. 
Mais, quels que soient les avantages incontestables de l'enseignement pratique, pour 
l'étude de la profession qui nous occupe, il faut évidemment qu'il soit complété par un 
enseignement théorique qui le commente, l'explique et permette de comparer et de 
juger les procédés et les méthodes. 
Cet enseignement théorique devra donc contenir des cours sur les diverses sciences 
* Voir " l'Odontologie," année 1881 et 1883. 
f Nous préférons ce mot, quoique d'origine étrangère, à celui de chirurgien dentaire qu'em- 
ployaient les auteurs Français et Anglais. 640 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
qui ont leurs applications en art dentaire. L'anatomie, la physiologie et la pathologie 
de la bouche et des dents ; la thérapeutique et matière médicale dans leurs applications 
à l'art dentaire ; la physique, la mécanique, la chimie, la métallurgie appliquées à la 
prothèse. 
Mais, il ne devra pas se borner à l'étude même approfondie, des applications, il faut 
nécessairement qu'il soit précédé, pour les sciences médicales, de leur étude d'une 
façon plus rapide qu'on ne le fait en médecine, mais pourtant de manière à en avoir des 
notions générales et à en connaître les grandes lois. 
Il en doit être de même pour les sciences accessoires, c'est-à-dire pour la physique, 
la mécanique, la chimie, l'histoire naturelle qui viendront former ainsi le début de cet 
enseignement théorique. 
Le développement du programme de l'enseignement théorique nécessite alors de la 
part de l'étudiant, un certain degré d'instruction préliminaire. Cet enseignement pré- 
paratoire devra être assez étendu pour permettre à l'étudiant pour comprendre et de 
s'assimiler facilement l'enseignement, mais il ne devra pas l'être assez pour l'empêcher 
de commencer de bonne heure vers 16 ans au plus tard, l'étude pratique de la prothèse 
dentaire par laquelle il est bon de débuter dans la profession afin d'acquérir et de dé- 
velopper l'habileté manuelle. 
Ainsi donc, pour nous résumer, le programme d'enseignement de l'art dentaire 
devra comprendre deux parties distinctes :- 
1° Un enseignement pratique comprenant des cours pratiques de 2 à 3 heures par 
jour sur :- , 
(a) La prothèse dentaire (enseignement de laboratoire). 
(è) La dentisterie opératoire (enseignement clinique). 
2° Un enseignement théorique comprenant des cours spéciaux d'une heure par 
chaque jour sur :- 
(a) Les sciences accessoires. 
(à) Les sciences médicales. 
(c) Les sciences appliquées en art dentaire. 
L'enseignement pratique et théorique peuvent être donnés simultanément. 
Ce programme devra, pour lui servir d'introduction, être précédé d'un enseignement 
préparatoire tel qu'on le donne dans les lycées et collèges des divers pays et notam- 
ment en France, sous le nom d'enseignement secondaire spécial limité à 16 ans par ex- 
emple. 
Ce programme ainsi indiqué, répond au plan que nous nous sommes tracé, celui de 
faire des praticiens suffisants. Il n'est et ne peut être qu'un minimum établi en tenant 
compte des nécessités actuelles de la vie, le temps comme les dépenses qu'exigent son 
étude devant être limités de telle sorte que ces considérations ne soient, aussi peu que 
possible, une cause d'exclusion pour les candidats, et pour le public une cause de sur- 
élévation des honoraires. 
Nous allons maintenant déterminer d'une manière plus précise les matières compo- 
sant ce programme et indiquer les méthodes et procédés d'enseignement ainsi que le 
mode d'applicatiou. 
Nous citerons cependant, au point de vue documentaire, ce programme qui traçait, 
en 1882, un dentiste français, L. Læfforgue, dans son traité de Vart du dentiste, ou ma- 
nuel des opérations de chirurgie gui se pratiquent sur les dents et de tout ce que les dentistes 
font en dents artificielles, obturateurs ou palais artificiels. 
Il indique ainsi les qualités nécessaires aux dentistes pour pratiquer avec succès :- 
" Connaître l'anatomie et la physiologie en général, et particulièrement l'anatomie 
de la bouche ; 
" L'inflammation, la suppuration et la résolution ; le ramollissement et la carie des 
os ; connaître, au premier aspect, les constitutions et l'état de santé des divers sujets ; SECTION XVIII-DENTAL AND ORAL SURGERY. 
641 
avoir une taille moyenne, n'avoir rien de désagréable dans son apparence ; avoir des 
dents bonnes et propres ; avoir les doigts longs et menus ; 
"Beaucoup d'adresse ; 
" De l'invention ; 
' ' Une conception facile ; 
" Un prompt et bon jugement ; 
" Un caractère aimable pour patient, complaisant et honnête ; 
" Il faut aussi une mise propre sans luxe." 
On remarquera combien, à part certains détails de peu d'importance, nous sommes 
d'accord avec notre confrère du No. 2. 
PROGRAMME PROPREMENT DIT : ENSEIGNEMENT PRÉLIMINAIRE. 
Nous avons dit que, le jeune homme qui se destine à la pratique de l'art dentaire 
doit, avant d'aborder l'enseignement proprement dit, posséder une instruction prélimi- 
naire à peu près égale à celle que l'on peut acquérir, jusqu'à seize ans en moyenne 
dans les collèges ou lycées ; 
Une bonne instruction d'enseignement secondaire spécial. 
Elle doit par conséquent comprendre :- 
La connaissance de la langue nationale, de l'arithmétique de la géométrie, de l'al- 
gèbre, de l'histoire, de la géographie ; 
Les éléments de chimie, de physique, de mécanique et d'histoire naturelle. 
Nous ne croyons pas nécessaire, pour le future dentiste, l'étude plus ou moins im- 
parfaite du Grec et du Latin, dont M. le Professeur Lefort faisait récemment le procès 
à l'Académie de Médecine, lors des discussions sur le surmenage. Nous préférons de 
beaucoup la connaissance d'une ou de deux langues vivantes, l'Anglais ou l'Allemand 
par exemple. 
En effet, les auteurs Grecs et Latins se sont trop peu occupés des dents pour qu'il y 
ait autre chose qu'un intérêt historique à les consulter. Au contraire, la littérature pro- 
fessionnelle écrite en langue vivante, Français, Anglais et Allemand, contient des 
ouvrages et des revues sur l'art dentaire des plus utiles, des plus nécessaires même à 
connaître, sans attendre des traductions plus ou moins fidèles ou qui ne se font même 
pour toujours. 
Quant aux étymologies de la plupart des mots employés dans les sciences ou la mé- 
decine ; 
Il est absolument nécessaire de connaître entièrement la langue qui les a formés, 
pour comprendre et retenir l'explication de leurs racines et de ses dérivés. 
Nous avons dit qu'une bonne instruction nous paraît suffisante. 
Par conséquent pour la France, nous repoussons l'obligation du baccalauréat es- 
lettres et du baccalauréat es-sciences. Parmi les titres universitaires, celui qui repré- 
sente mieux notre programme est le baccalauréat de l'enseignement secondaire spécial 
qui a été créé récemment, mais, nous nous contentons même du programme des trois pre- 
mières années de l'enseignement secondaire spécial des lycées. Nous ajouterons, l'étude 
du dessin afin de développer et de former le goût si nécessaire au dentiste. Nous sou- 
haitons également, qu'à cette étude préparatoire, il soit joint une année environs d'ex- 
ercices pratiques sur le travail des métaux, etc., tel qu'il est donné dans certaines écoles 
professionelles de la ville de Paris par exemple, et une année de stage dans le labora- 
toire d'un praticien pour l'étude de la prothèse. 
Nous avons supprimé de ce programme, comme nous allons le faire du programme 
professionnel, tout ce qui ne nous paraît pas absolument nécessaire, en nous appuyant 
sur ce principe : L'activité, l'habileté, les facultés d'assimilation, la capacité du cer- 
veau enfin, étant limitée, tout ce que l'on ajoute d'un côté est aux dépens d'une 
autre partie ; qu'il faut donc que le futur dentiste ne soit obligé à s'assimiler que ce qui 
Vol. V-41 642 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lui est absolument nécessaire. A ceux à qui le temps, les aptitudes et la fortune le 
permettent de faire plus. 
ENSEIGNEMENT PROFESSIONNEL. 
Nous avons dit que l'enseignement professionnel devait comprendre un enseigne- 
ment pratique et un enseignement théorique. 
Nous montrerons plus loin, que ces deux enseignements peuvent se donner simulta- 
nément, et que, dans ce cas une période de trois années est nécessaire pour permettre à 
l'étudiant de se les assimiler avec fruit. 
Ceci admis, nous allons reprendre en détail toutes les parties de ce programme si 
complexe. 
Nous avons dit que l'enseignement pratique comprenait la dentisterie opératoire et 
la prothèse dentaire. 
DENTISTERIE OPÉRATOIRE. 
L'enseignement de la dentisterie opératoire ne peut se faire à part quelques leçons 
préliminaires, que sur le malade. C'est donc un enseignement clinique ! 
La période de trois années d'étude que nous avons fixée est loin d'être trop étendue, 
non que les règles et les principes de la dentisterie opératoire soient longs à énumérer, 
longs à apprendre, mais, elle comprend de nombreux procédés, nous pourrions dire des 
tours de mains que l'on ne de rend familiers que par une longue pratique; elle se com- 
pose d'opérations faciles à expliquer, mais que l'on ne fait bien qu'après les avoir exé- 
cutées souvent et longtemps. Enfin, le maniement des nombreux instruments exige une 
longue habitude. Pendant la première année l'élève doit débuter par le nettoyage de 
la bouche et l'ablation du tartre. Cette opération très simple, facile à démontrer et à 
exécuter, sans grande complication possible, donne à l'étudiant, lorsqu'elle est souvent 
répétée l'habitude d'examiner les dents ; elle le familiarise avec le milieu qu'il est 
appelé à soigner. 
L'étudiant continuera par la préparation de petites cavités de faces triturantes ne 
demandant aucun traitement (premier et second degré), puis des faces latérales, et leur 
obturation à l'amalgame ou aux divers ciments. 
L'élève devra être exercé aux extractions en commençant par les dents temporaires 
ou les dents chancelantes des vieillards; 
Il devra assister à la consultation afin de s'exercer à examiner les malades et prendre 
l'habitude de reconnaître les altérations dentaires et leurs complications. 
Deuxième Année.-Pendant la deuxième année, on répétera les opérations précé- 
dentes que l'on complétera par le traitement et la préparation de cavités plus impor- 
tantes comme grandeur et comme gravité. 
(Deuxième et troisième degré). Pulpe exposée (coiffage ou destruction), obturations 
plus difficiles avec les divers ciments ou amalgames. 
Puis l'on commencera l'étude des aurifications en proportionnant la difficulté aux 
capacités de l'étudiant. Il en sera de même pour les extractions. 
L'élève pourra faire également quelques redressements de dent. 
L'assistance à la consultation où il s'habituera à examiner le malade et à établir le 
diagnostic, complètent l'enseignement pratique de la deuxième année. Nous pensons 
que l'usage dutour à fraiser ne devra être autorisé qu'à partir de la deuxième année, 
afin d'habituer l'étudiant au maniement des instruments. 
Troisième Année.-Pendant la dernière année, l'étudiant aborde les traitements plus 
difficiles, tels que ceux des caries du troisième et du quatrième degré avec leurs diverses 
complication ; traitement des canaux, obturations et aurifications compliquées ; les ex- 
tractions difficiles, avec ou sans anesthésie, ainsi que les divers travaux du domaine du 
dentiste, tels que les dents à pivot, le bridge work, les redressements, les restaurations 
buccales et faciales etc. Il doit être à même en un mot de procéder à la restauration 
complète d'une bouché dans laquelle la carie a exercer de nombreux ravages. SECTION XVIII-DENTAL AND ORAL SURGERY. 
643 
Ce programme paraîtra peut être, à première vue, peu chargé. Il devient cependant 
difficile dans la pratique d'obtenir que, pendant ses trois années et en travaillant tous 
les jours trois ou quatre heures, l'étudiant ait fait un nombre de fois suffisantes pour 
les savoir, chacune des opérations que nous venons d'énumérer. 
PROTHÈSE DENTAIRE. 
Nous avons déclaré au début de ce programme que le futur dentiste devait être pré- 
paré à l'étude de la prothèse par une année de travaux pratiques ; que de plus il lui 
serait très utile de faire précéder l'entrée dans une école dentaire d'une année d'ap- 
prentissage passée exclusivement dans le laboratoire d'un praticien suffisamment 
•occupé. 
Pendant cette première année, l'étudiant se familiariserait avec ce qu'exige notre 
art, apprendrait à connaître la prothèse et ses divers procédés, et acquérerait avec 
l'habitude du maniement des instruments, une certaine habileté pratique. 
La tâche de l'instructeur se trouve alors facilitée. Il est possible d'aller plus vite, 
et c'est utile, car, pour cette partie de notre art, trois années études, à raison de trois 
ou quatre heures par jour ne sont pas de trop. En effet, la prothèse dentaire est un 
art très complexe, qui pourrait constituer, à lui seul, une profession spéciale s'il n'était 
à peu près impossible en dentisterie, comme nous l'avons démontré, de tracer la limite 
qui sépare le domaine du mécanicien de celui de l'opérateur ; le domaine de la prothèse 
de celui de la dentisterie proprement dite. 
Pour l'étude de la prothèse nous pensons qu'il y a avantage à la séparer du travail 
sur le malade, à en faire un travail de laboratoire. 
Nous conseillons même d'adopter pour cet enseignement une série de modèles types 
contenant les difficultés que l'on peut rencontrer en prothèse, et sur lesquels sont exé- 
cutés d'avance des appareils modèles que l'étudiant copie, en passant graduellement du 
simple au composé. 
Première Année.-Exercer l'étudiant au maniement des instruments et à la connais- 
sance des caractères distinctifs des dents, en lui faisant sculpter sur le bois ou l'ivoire 
une série de dents naturelles. 
Continuer par l'étude des appareils prothétiques sur caoutchouc vulcanisé en sui- 
vant une série d'appareils d'une dent, de deux, de trois, de quatre, de cinq, de six, de 
sept, de huit, de neuf et de dix dents ; pratiquer de même pour l'étude des appareils 
prothétiques sur celluloïde. 
Ceci doit constituer le programme de la première année. Il est certain que le nom- 
bre des appareils peut être augmenté ou diminué suivant le temps dont on dispose. 
Deuxième Année.-La deuxième année est consacrée à l'étude du travail des métaux. 
Elle débute par la construction d'une série de dents à pivot, suivant les divers procédés, 
puis continue par une série d'appareils sur métal d'une dent, de deux, trois jusqu'à 
•dix dents. 
Il peut refaire la même série d'appareils sur métal combiné avec le caoutchouc ou le 
celluloïd. 
Enfin, il faut également une série d'appareils types employés pour les redresse- 
ments. 
Comme on le voit, pendant la deuxième année l'étudiant apprendra à mouler, à 
estomper, à souder. 
Troisième Année.-La troisième année peut être consacrée à l'étude des appareils 
prothétiques à succion, des dentiers complets montés sur différentes matières employées 
en art dentaire, exterminer son enseignement par la construction de quelques appareils 
types de restaurations buccales ou faciales. 
Ce programme de laboratoire que contient sommairement l'ensemble de la prothèse, 644 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
pourra être combiné à certaines périodes avec l'enseignement clinique, de façon à 
montrer à l'étudiant la partie de la prothèse qui s'exécute sur le malade, telle que la 
prise des empreintes, l'articulation, l'essayage, la pose, etc. 
ENSEIGNEMENT THÉORIQUE. 
Nous conservons pour l'enseignement théorique la division en trois années ; 
Nous avons vu précédemment qu'il devait comprendre : 
1° Les sciences accessoires. 
2° Les sciences médicales. 
3° Les sciences appliquées. 
PREMIÈRE ANNÉE : SCIENCES ACCESSOIRES. 
On entend généralement par sciences accessoires, la physique, la mécanique, la chi- 
mie, l'histoire naturelle. 
Chacune de ces sciences concourt à former l'art dentaire qui en comprend de nom- 
breuses applications. 
Elles sont utiles à connaître pour le dentiste. 
Cependant elles ne le sont pas au même point de vue que pour le médecin ou le 
pharmacien. 
Le programme devra en être établi en vue de faciliter l'explication des nombreuses 
applications. 
Ainsi, pour l'histoire naturelle, il faudra dans la zoologie et après la classification, 
examiner le règne animal surtout au point de vue des différences du système dentaire ; 
en botanique les différences employées en art dentaire. 
La physique dont les applications sont si nombreuses au point de vue de l'hydros- 
tatique, de la chaleur de l'électricité, de l'acoustique la chimie dans les diverses mani- 
pulations de cabinet et de laboratoire et la mécanique, par les divers appareils pour 
être étudiés dans les mêmes conditions. 
Nous avons réclamé de notre candidat une certaine connaissance préliminaire de ces 
sciences, on peut donc eu admettre l'étude en vue de leurs applications dans cette pre- 
mière année. 
DEUXIÈME ANNÉE : SCIENCES MÉDICALES. 
Cette partie du programme est très importante. C'est la véritable introduction à 
l'étude de l'art dentaire. 
Là encore, le dentiste va étudier des sciences qu'il ne lui est pas absolument néces- 
saire d'approfondir, mais qu'il doit connaître pour comprendre et retenir l'enseigne- 
ment spécial pour en saisir les applications. 
Mais pour cela, faut-il qu'il passe plusieurs années à les étudier ? Ce n'est pas notre 
avis. 
L'étude des tumeurs ou des accouchements, l'anatomie du pied ne doivent lui de- 
mander qu'un temps très restreint (voir le discours de M. P. Bert). 
Il nous paraît plus logique de faire un choix dans ces sciences vastes et qui suffisent 
pour faire la seule occupation d'un savant, nous croyons que l'on peut faire la part de ce 
qui est nécessaire au dentiste et que par exemple : 
Un cours d'une heure par semaine, pendant une année, peut suffire pour donner au 
dentiste des notions suffisantes sur les sciences médicales. 
Notre programme de deuxième année comprendrait donc un cours sur l'anatomie et 
la physiologie générales, un cours sur la pathologie générale, un cours sur la thérapeu- 
tique et un cours sur la matière médicale. 
On pourrait y ajouter un peu de dissection et une étude du microscope et de l'his- 
tologie SECTION XVIII-DENTAL AND ORAL SURGERY. 
645 
TROISIÈME ANNÉE : SCIENCES APPLIQUÉES. 
Pendant la troisième année l'étudiant se consacrerait aux diverses sciences appli- 
quées à l'art dentaire. 
Ainsi, il étudierait pendant une année, l'anatomie de la tête, de la région du sys- 
tème dentaire dans ces moindres détails, la physiologie dentaire, l'histoire normale et 
pathologique de la dent, son embriologie, sa genèse, ses lois de formation ; la patholo- 
gie spéciale de la bouche et du système dentaire ; la thérapeutique et la matière médi- 
cale spéciales, ainsi que l'anesthésie. 
La prothèse dentaire dont un cours théorique s'expliquerait peu vu sa nécessité d'un 
enseignement pratique, si on ne l'élevait à une sorté de philosophie de cette branche, 
à une étude critique et comparative des divers procédés, de leurs indications et contre- 
indications. 
On pourrait consacrer pour chaque cours une ou deux heures par semaine, l'étendre, 
le compléter. 
Dans cette dernière année, la plus importante du programme théorique, l'on doit 
réunir toutes les applications des différentes sciences qui ont été examinées au point de 
vue général, et qui constitue l'art ou mieux la science dentaire. 
MODES D'APPLICATION. 
Quel est le meilleur mode d'application de ce programme ? 
Il est pour notre art plusieurs procédés d'enseignement indiqués par l'usage ou par 
les polémiques : 
1° L'enseignement médicale donné dans les écoles de médecine ; 
2° L'enseignement mixte donné pour la partie scientifique et médicale dans les 
Écoles de medecine, l'élève bifurquant après deux ou trois années pour suivre un en- 
seignement spéciale. 
3° L'enseignement spécial : 
(a) Comme apprentissage chez un dentiste exerçant ; 
(&) Dans une école professionnelles d'art dentaire. 
MODE D'APPLICATION-DU PROGRAMME. 
1° Enseignement donné dans les écoles de médecine. 
Il est certain qu'à priori. Le programme que nous venons de tracer est absolument 
inapplicable dans une école de médecine. 
L'enseignement y est fait en vue de créer des médecins, non des dentistes, et que 
quand même on ajouterait, comme on l'a proposé, aux cours déjà existants un cours 
d'odontologie, cela serait encore insuffisant. On réussirait tout au plus à donner aux 
jeunes médecins, quelques notions sur l'art dentaire qui pourraient leur être très utile 
plus tard dans leur pratique mais qui, en aucun cas, n'en pourraient faire des dentistes 
dans l'acception admise par ce terme ; à moins qu'il ne termine par un apprentissage, 
ce qui serait beaucoup trop long. 
Par conséquent, nous repoussons absolument l'école de médicine comme école d'en- 
seignement de l'art dentaire. 
2° Ecole de médecine servant d'introduction à l'étude de l'art dentaire pendant 
deux ou trois années pour l'étude des sciences accessoires et médicales et l'enseigne- 
ment complété par une étude spéciale de l'enseignement professionnel dans une école 
d'application dentaire ou par un stage chez un dentiste. 
Ce système est beaucoup plus séduisant que le premier et réunit plus de défenseurs 
et parmi eux des hommes autorisés en matière d'enseignement comme M. le Professeur 
Lefort (voir rapport à l'Académie de Médecine). 
C'était également ce que nous disait M. Liard en 1886, dans une visite que par nos 
fonctions nous avons été amené à lui faire. 646 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Il semble possible que le bagage scientifique nécessaire au dentiste soit pris dans le 
programme des écoles de médecine. 
Les sciences accessoires et les sciences médicales étant nécessaires au dentiste, il ne 
peut mieux les trouver que dans ces écoles ; il ne sera pas obligé de les poursuivre jus- 
qu'au bout, et, à une époque déterminée, après avoir pris de cette enseignement ce qui 
lui est nécessaire, il bifurquera pour se livrer à l'étude de l'enseignement spécial. 
A cela, nous ferons cependant deux objections qui nous paraissent très impor- 
tante :- 
1° Si l'on adopte çette solution on se verra obligé de réclamer de l'étudiant dentiste 
des études préliminaires et des titres universitaires semblables à ceux de l'étudiant en 
médecine, c'est-à-dire des titres que l'on ne peut posséder qu'à l'âge de 18 ans environ. 
Par conséquent un minimum d'études préparatoires trop élevé pour la profession à ex- 
ercer. 
2° L'étudiant dentiste suivant les cours faits pour l'étudiant en médecine, suivra 
des cours trop étendus qui ne seront pas faits pour lui et qui, en anatomie, en patholo- 
gie, etc. l'obligeront à des études qui ne lui sont pas nécessaires et qu'il serait obligé 
ou d'abandonner au milieu, ou de poursuivre trop longtemps. Enfin, il y aurait là un 
temps trop long consacré à la partie la plus accessoire du programme, ou partie théo- 
rique, et ce serait encore au dépens de la partie spéciale qui se trouverait ainsi allongée 
sans nécessité. 
Nous repoussons donc l'entrée de l'étudiant dentiste dans les écoles de médecine. 
Nous demandons que muni des études préparatoires déterminées, il aborde de suite 
l'enseignement spécial crée pour lui. 
Il peut aborder ce programme suivant deux procédés :- 
1° Comme élève chez un praticien expérimenté. 
2° Dans des écoles spéciales. 
1. COMME ÉLÈVE CHEZ UN PRATICIEN. 
Cette solution meilleure que les précédentes est un véritable enseignement pratique; 
l'étudiant s'assimile vite par la pratique les connaissances qui lui sont absolument 
nécessaires ; mais le programme se trouve trop réduit, l'enseignement insuffisant. 
Car, outre que le dentiste peut très bien n'exercer couramment que certaines parties 
de l'art dentaire, il négligera d'enseigner à son élève tout ce qui n'aura pas un carac- 
tère d'absolue nécessité pratique, de plus, cet enseignement incomplet serait sans mé- 
thode. 
Nous pouvons l'admettre comme procédé préparatoire à l'entrée dans une école spér 
ciale, ou comme complément de cet enseignement, mais non comme un procédé d'ap- 
plication du programme. Il est certain que tant qu'il n'y a pas en d'écoles spéciales et 
dans les contrées ou il n'en existe pas encore, c'est le seule procédé employé, et il a 
donné des résultats qui ont suffi longtemps. 
2. ÉCOLES SPÉCIALES. 
Il nous reste les écoles spéciales, professionnelles,, d'application comme on voudra 
les appeler : c'est-à-dire les écoles créées en vue d'approfondir une profession déter- 
minée. 
Il est certain que c'est pour celles-là que nous avons créé notre programme, c'est 
dans celles-là qu'il a sa raison d'être et qu'il peut être appliqué d'une façon complète. 
C'est là que seulement il se développera, s'étendu suivant ses besoins ; qu'il sera com- 
pris, perfectionné dans ses moindres détails. 
En effet, c'est là seulement que l'on peut créer un cours de phyisque ou de chimie, 
en vue du dentiste, que l'on peut restreindre l'étude de l'anatomie, de la pathologie, 
de la thérapeutique à ce qui est nécessaire au futur dentiste ; c'est-à-dire choisir dans SECTION XVIII-DENTAL AND ORAL SURGERY. 
647 
ces sciences pour former ces cours la partie que le dentiste a le plus besoin de connaître 
pour comprendre l'enseignement spécial en négligeant ce qui ne lui est pas nécessaire. 
Réunir en un mot une somme de grandes notions générales pour en faire un cours à 
usage de dentiste. 
Du reste, c'est ainsi qu'on l'a compris en France et dans nombre de pays étrangers, 
vu les nombreuses écoles dentaires existantes, dont les plus anciennes sont celles des 
Etats-Unis. 
L'école dentaire se prête du reste parfaitement à l'organisation de l'enseignement 
tel qu'il est indiqué. 
Enseignement pratique de la dentisterie opératoire par une clinique spéciale des 
affections dentaires. 
Enseignement pratique de la prothèse par un laboratoire avec travaux pratiques sur 
des modèles types. 
Enseignement théorique à l'aide de cours spèciaux. 
DURÉE. 
Nombre d'écoles dentaires, les américaines surtout ont fixé à deux ansâ la durée des 
études. Comme chaque année ce cours est de cinq mois, il s'en suit qu'en dix mois on 
peut devenir dentiste. Ces dix mois pouvaient même, il y a encore peu de temps se 
faire en une seule année. Cela ne nous paraît suffisant. 
C'est trois années qu'il faut, à notre avis, à l'étudiant pour s'assimiler méthodique- 
ment et avec fruit le programme que nous avons tracé. 
En France, avant la création des écoles, trois années d'apprentissage au moins 
étaient réclamées par tous les praticiens à un j eune homme pour lui enseigner la pro- 
thèse dentaire et nous savons que ce n'était pas de trop. 
Pour enseigner l'art dentaire en entier chirurgie et prothèse ces trois années sont 
bien juste. 
C'est ce qu'ont pensé les fondateurs de l'école dentaire de Paris après avoir fixé â 
deux ans ils l'ont augmenté d'une année. 
C'est ce que nous serions heureux de voir imiter par toutes les autres écoles dentaires. 
Quelle doit être la situation de cet enseignement, doit-il être dirigé par l'Etat, doit- 
il être libre. 
L'état possède pour créer et diriger ses différentes institutions en général et l'en- 
seignement, en particulier un grand pouvoir et de puissantes ressources. 
Il peut mettre à la disposition, des savants de grands monuments, de vastes labora- 
toires et pour nombre de sciences et d'arts il en est ainsi. Mais pour un art comme le 
nôtre dont l'utilité ou la nécessité est plus contestée nous pensons que l'état tiraillé 
par les différentes sciences pourrait faire peu et qu'il risquera de s'étioler étouffé par 
les aspirations jalouses des autres sciences ; la médecine, le droit que la place au ban- 
quet scientifique sera pour lui la plus petite, que sa part sera trop restreinte. 
Aussi pensons nous que notre profession a tout avantage que les écoles destinées à 
donner l'enseignement de l'art dentaire soient libres, créées pour l'initiative privée des 
dentistes ou des associations dentaires et qu'elles se contentent de recevoir de l'état son 
appui, son patronage, sa surveillance même. Obligées perpétuellement à la lutte elles 
se perfectionneront, feront progresser l'art, formeront des générations instruites de den- 
tistes et pourrons devenir prospères. 
Le programme que nous avons exposé là est à part quelques détails celui adopté 
depuis huit ans par l'école dentaire de Paris et que nous aurons contribué à constituer 
par notre projet de fondation d'une école dentaire, et par la série de modifications que 
nous avons contribué à y faire apporter chaque année. 
Nous avons voulu en présentant ce programme au congrès défendre les idées que 
consistent à considérer l'art dentaire comme une profession spéciale par ce que nous 648 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sommes persuadés comme un certain nombre de nos confrères français et américains 
que c'est à cette voie qu'elle a suivie en Amérique qu'elle doit, depuis 40 ans, son 
développement vraiment prodigieux et que son avenir est dans sa persistance dans cette 
voie. 
ENSEIGNEMENT SUPERIEUR LIBRE-ECOLE DENTAIRE DE PARIS. 
ANNÉE SCOLAIRE 1886-87. 
TABLEAU RÉSUMÉ DU PROGRAMME DE L'ENSEIGNEMENT. 
COURS THÉORIQUES. 
COURS PRATIQUES. 
CHIRURGIE. 
PROTHESE. 
Assistance â la consultation. 
Nettoyage de la bouche 
Traitement et obturation 
des caries des premier et 
deuxième degrés. 
Extractions. 
Série d'appareils sur le tra- 
vail de l'hippopotame, du 
caoutchouc et du celluloïd. 
Cours de 
Première 
Année. 
Chimie. 
Histoire naturelle. 
Eléments d'anatomie. 
Cours de 
Deuxième 
Année. 
■ Anatomie descriptive et physi- 
ologie. 
Dissection. 
Pathologie générale. 
Thérapeutique et matière 
médicale. 
Physique, chimie et métallur- 
gie appliquées. 
Histologie, micrographie. 
Assistance â la consultation. 
Traitement des caries des 
premier, deuxième et 
troisième degrés. 
Obturations. 
Aurifications simples. 
Redressements. 
Extractions. 
Dents â pivots. 
Série d'appareils sur le tra- 
vail du métal. 
Série d'appareils en caout- 
chouc ou celluloïde et 
métal. 
Série de redressements. 
Cours de 
Troisième - 
Année. 
' Anatomie et physiologie den- 
taires humaines, comparées. 
Dissection. 
Pathologie spéciale : 
1° Maladie de la bouche ; 
2° Affections du système den- 
taire. 
Thérapeutique spéciale : 
1° Traitement et obturations, 
Aurifications, Extractions. 
2° Anesthésie. 
Histologie générale, histologie 
dentaire, applications du mi- 
croscope. 
Anatomie topographique de la 
bouche et de ses annexes. 
Applications Chirurg. 
Prothèse dentaire. 
1° Prothèse proprement dite. 
2° Orthopédie dentaire. 
Restaurations buccales et faci- 
ales. 
Odontologie professionelle. 
Assistance à la consultation. 
Traitement des caries des 
troisième et quatrième de- 
grés. 
Obturations. 
Aurifications : 
1° A l'or adhésif; 
2° A la méthode rotative de 
Herbst ; 
2° A l'or non adhésif. 
Redressements. 
Dents à pivots. 
Extractions avec l'anes- 
thésie. 
Traitement des différentes 
affections buccales du res- 
sort de la chirurgie den- 
taire. 
Restaurations buccales et 
faciales. 
Série d'appareils sur le tra- 
vail du Continuous-gum. 
Série de dentiers sur Te tra- 
vail du métal, du caout- 
chouc et du celluloïd. 
Esthétique. 
Restaurations buccales et 
faciales. 
Appareils pour fractures des 
maxillares. 
ENSEIGNEMENT THÉORIQUE. 
I.-COURS DE PREMIÈRE ANNÉE. 
Art. 53.-Le cours de première année comprend:- 
1° L'enseignement de la physique ; 
2° L'enseignement de la mécanique; 
3° L'enseignement de la chimie ; 
4° L'enseignement de l'histoire naturelle ; 
5° L'enseignement de l'anatomie générale ; 
1° Mécanique.-Du temps et de sa mesure.-Du mouvement.-Duplan incliné.-Des poulies. 
-Du treuil.-Unité de force de la masse.-Unité de travail.-Equilibre, centre de gravité.-Des 
pompes. SECTION XVIII-DENTAL AND ORAL SURGERY. 
649 
2° Physique.-Définitions.-Pesanteur.-Hydrostatique.-Chaleur.-Electricité.-Optique et 
acoustique. 
3° Chimie.-Définitions.-Corps simples et composés.-Cristallographie.-Nomenclature.- 
Equivalents.-Principaux métalloïdes, leurs composés oxygénés et hydrogénés, classification.- 
Métaux, alliages, composés binaires, sels, description des principaux métaux et des sels usuels.- 
Caractère des acides et des bases.-Généralités de chimie organique ; un type usuel de chaque 
classe (alcool, acide acétique), chimie biologique. 
4° Histoire Naturelle :- 
(a) Zoologie.-Animaux et plantes.-Grands embranchements du règne animal.- Vertébrés. 
- Mammifères.- Oiseaux.- Reptiles.- Batraciens.- Poissons.- Annelés.- Insectes.- Arach- 
nides.-Crustacés.-Helminthes.-Mollusques.-Rayonnés.-Protozoaires. 
(b) Botanique.-De la cellule.-Des appareils et des fonctions.-Les membres (tige, racine, 
feuille).-Fleurs et reproduction.-Axonomie.-Végétaux utiles et nuisibles. 
(c) Géologie.-Phénomènes volcaniques.-Chaleur centrale.-Succession des divers dépôts de 
terrains régulièrement stratifiés, etc.-Succession générale des êtres organisés et divers change- 
ments de la forme de la surface de la terre. 
5° Anatomie et Physiologie Générales.-Considération générales.-Squelette.-Muscles.-Cir- 
culation.-Respiration.-Digestion. 
II.-COURS DE DEUXIÈME ANNEE. 
Le cours de deuxième année comprend :- 
1° L'enseignement de l'anatomie descriptive et de la physiologie ; 
2° L'enseignement des éléments de la pathologie générale; 
3° L'enseignement de la thérapeutique et de la matière médicale; 
4° L'enseignement de la physique, de la chimie et de la métallurgie dans leurs rapports avec 
l'art dentaire. 
1° Anatomie et PhysiologieGénérales.-Considérations générales.-Squelette.-Muscles.-Cir- 
culation.-Respiration.-Digestion.-Organes génito-urinaires.-Système nerveux. 
2° Eléments de Pathologie Générale.-Maladies, définitions.-Causes.-Siège.-Diagnostic.- 
Pronostic.-Pathologie générale, spéciale, médicale chirurgicale.-Pathologie de la circulation, de 
la nutrition, de la respiration. 
3° Thérapeutique, Matière Médicale.-Médicaments.-Astringents.-Emollients.-Excitants. 
-Irritants.-Caustiques.-Anesthésiques.-Chloroforme.-Ether.-Protoxyde d'azote, etc.-Pa- 
rasiticides, antiseptiques, etc. 
4° Physique, Chimie et Métallurgie Appliquées.-Physique et chimie dans leurs rapports avec 
l'art dentaire.-Chimie générale, appliquée.-Physique.-Métallurgie.-Manipulations pratiques 
de chimie. 
III.-COURS DE TROISIÈME ANNEE. 
Le cours de troisième année comprend :- 
1° L'enseignement de l'anatomie et de la physiologie dentaires (humaines et comparées) his- 
tologie dentaire comprise ; 
2° L'enseignement de l'anatomie topographique de la bouche, et des applications à la patho- 
logie; 
3° L'enseignement de la pathologie spéciale :- 
(a) Maladie de la bouche; 
(b) Affections du système dentaire. 
4° L'enseignement de la thérapeutique spéciale :- 
(a) Traitement et obturations (aurifications, extractions) ; 
(b) Anesthésie. 
5° L'enseignement de la prothèse, ainsi divisée :- 
(a) Prothèse proprement dite. 
(Z>) Orthopédie dentaire, restaurations bucales et faciales. 
6° Cours de déontologie professionnelle. 
Le cours de troisième année est, comme nous l'avons dit plus haut, spécial; c'est le plus im- 
portant, et les étudiants soucieux de faire de bons praticiens feront bien de le renouveler. 650 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
1° Anatomie topographique de la bouche et de» partie» avoisinante».-Applications à la pa- 
thologie. 
Ostéologie, arthiologie, myologie, névrologie de la face et du cou. Description des fosses nasales, 
de la bouche et du pharynx.-Luxation et fractures des maxillaires, tumeurs des maxillaires et des 
parties molles de la bouche, langue, joues, lèvres, nécrose des maxillaires. 
2° Anatomie et physiologie dentaires (humaines et comparées), histologie dentaire comprise. 
Des dents.-Email.-Dentine.-Cément.-Pulpe.-Périoste. Alvéolo-dentaire.-Gencives.- 
Germe dentaire.-Embroyologie.-Embryogénie.-Eruption.-Dents de lait.-Dents permanentes. 
-Maxillaires, sinus.-Ostéologie de la tête.-Muscles.-Glandes.-Nerfs.-Application à la pa- 
thologie.-Anatomie comparée. 
3° Pathologie spéciale : Maladies de la bouche. 
Secrétion salivaire.-Stomatites, primitive, secondaire.-Maladies de la langue.-Accidents de 
dentition. 
Affections du système dentaire. 
Anomalies.-Accidents de l'éruption.-De la carie dentaire.-Fracture des dents.-Luxation. 
-Maladies de la pulpe.-Du périoste alvéolo-dentaire.-Ostéo-périostite alvéolo-dentaire.-Tu- 
meurs.-Kystes.-Affection des gencives. 
4° Thérapeutique spéciale. 
(a) Traitement et Obturation des Dents.-Définitions.-Carie dentaire.-Degrés.-Subdivi- 
sions.-Carie de l'émail, de la dentine, de la pulpe.-Matières obturatrices, plombages, ciments.- 
Aurifications.-Or adhésif Non adhésif.-Périostite alvéolo-dentaire.-Ostéo-Périostite.-Traite- 
ment.-Contracture de la mâchoire.-Régression graisseuse.-Traitement.-Redressements.-Ex- 
tractions. 
(b) Anesthésie Générale et Locale.-Agents anesthésiques. 
5° Prothèse et mécanique dentaires. 
Préparations de la bouche et empreintes.-Moulages.-Surmoulages.-Articulation.-Modèles 
métalliques.-Estampages.- Métaux, or, platine.-Rétention des appareils.-Crochets métal- 
liques.-Succion.-Ajustement des dents simples, à gencive, à tubes, etc.-Soudure.-Hippopo- 
tame.-Dents naturelles.-Dents à pivots. 
Orthopédie dentaire.-Restaurations buccales et faciales : Redressement des dents.-Prothèse 
des maxillaires.-Obturateurs.-Prothèse bucco-nasale.-Appareils pour fractures des maxillaires. 
-Esthétique. 
Substances plastiques ; Vulcanite.-Celluloïd.-Appareils métallo-plastiques.-Appareils céra- 
mo-plastiques. 
6° Odontologie Professionnelle.-Droits et devoirs du dentiste. SECTION XVIII-DENTAL AND ORAL SURGERY. 
651 
OPERATION FOR THE CURE OF A PERSISTENT NEURALGIA OF 
BOTH TEMPORO-MAXILLARY ARTICULATIONS AND REFLECTED 
PAIN IN THE RIGHT BRACHIAL PLEXUS OF EIGHT YEARS' DU- 
RATION. WITH RESULTS, AND ALSO SOME STATEMENTS CON- 
CERNING BONE GRAFTING. 
OPÉRATION POUR LA GUERISON D'UNE NÉVRALGIE PERSISTANTE DES DEUX 
ARTICULATIONS TEMPORO-MAXILLAIRES, ET D'UNE DOULEUR RÉFLEXE 
PENDANT HUIT ANS DANS LE PLEXUS BRACHIAL DROIT AVEC LES RÉSULT- 
ATS, ET AUSSI UN EXPOSÉ DE LA GREFFE DES OS. 
OPERATION ZUR HEILUNG EINER HARTNÄCKIGEN NEURALGIE BEIDER KIEFERGELENKE 
UND EINES REFLEX-SCHMERZES IM RECHTEN PLEXUS BRACHIALIS VON ACHTJÄH- 
RIGER DAUER, NEBST RESULTATEN; SOWIE EINIGE ANGABEN IN BEZUG AUF KNOCHEN- 
VERPFLANZUNG. 
BU JOHN S. MARSHALL, M.D., 
Of Chicago, Ill. 
Gentlemen:-I do not expect to throw any new light upon the general subject of 
trifacial neuralgia, but trust the matter which I shall lay before you will prove interesting, 
from the fact that it presents a cause of persistent facial neuralgia with reflex symp- 
toms which is, so far as I have been able to learn, unique as to the causes which pro- 
duced it and the means used for its cure. 
The causes of trifacial neuralgia are generally divided into five groups, viz., con- 
stitutional, infectious, toxic, local and reflex.* 
Under the head of constitutional causes are classed hereditary nervous irritability 
(predisposing to hysteria, epilepsy, diseases of the mind and neuralgias), anaemia, 
chlorosis, malnutrition, excessive child-bearing and lactation, sexual excesses, hepatic 
and nephritic diseases, gout, rheumatism, mental strain from over-study or anxiety, 
drunkenness, bodily fatigue, insufficient and innutritions food, and the abuse of tea, 
coffee and tobacco. 
Among the infectious causes are mentioned malaria, typhoid and eruptive fevers, 
and syphilis in its early stages. 
The most common toxic causes are mercurial, lead, antimony and arsenical poison- 
ing. 
The local causes are direct irritations and injuries to the nerves, such as exposure to 
cold, traumatic injuries, surgical operations, neuritis, compression from inflammations, 
exostoses, and gummata in the bony canals through which these nerves pass, and at 
the base of the brain, the result of the later stages of syphilis, encroachment of aneu- 
risms and new growths, diseases of the teeth, especially subacute and chronic pulpitis, 
chronic pericementitis, exostosis of the roots, gingivitis phagedenic pericementitis, 
impacted wisdom teeth and anomalies of second dentition. 
The reflex causes are very numerous, among which may be mentioned as the most 
common, irritations at the base of the brain, pregnancy, uterine, ovarian, gastric and 
intestinal diseases, compression of nerve filaments in cicatricial tissue after surgical 
operations and the extraction of teeth, irritations of the dental pulp, pericementum 
and gums. 
Neuralgia of the joints sometimes occurs, but I am not aware that a case has ever 
been published in which the neuralgic pains were situated in the temporo-maxillary 
articulations, or intimated that neuralgia might be caused by a malposition of these 
parts. 
* Vide Eichhorst. 652 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Eichhorst* says: " The disease occurs generally in anæmic and hysterical women, 
more rarely in robust individuals or in men. The hip or knee joints are generally, 
other joints are rarely, affected; sometimes the small joints, the fingers, for example, are 
affected." 
Hamiltonf believes the affection to be "apparently due to a disordered condition of 
the whole nervous system, or to a hysterical diathesis. The knee, hip, ankle and 
shoulder joint are most liable to this affection." 
Sir W. MacCormac J says: " Neuralgic pains in the articulations may arise from dif- 
ferent circumstances. It may be referred to pain, unattended by local lesions, which is so 
frequent in the knee in cases of hip-joint disease. Neuralgic paius in various joints 
are observed in the preliminary or early stages of chronic myelitis. In the first stages 
of locomotor ataxy the knee may be affected by severe neuralgia when the disease is 
low down in the cord ; or the shoulder when it is at a higher point. Lastly, so-called 
neuralgia of a joint may really indicate some obscure lesion, as chronic inflammation 
of the bones entering into the formation of the articulations." 
I now desire to call your attention to another cause persistent neuralgia of the 
face and temporo-maxillary articulations, namely, the irritation produced by the mal- 
position of parts resulting from extended operations upon the inferior maxilla, which 
require exsectiou of large portions of the bone, and in which sub-periosteal operations 
are not admissible, as, for instance, in the removal of malignant growths, and in gun- 
shot injuries where large portions are carried away. 
Operations and injuries of this character always result in more or less deformity, 
from the fact that the lost bone is not reproduced and the contraction of cicatricial 
tissue is often so great as to draw the parts out of their normal relations, the cut or 
fractured ends of the bone abnormally approximate to each other, and by these means 
pressure may be induced at the temporo-maxillary articulations, followed by irritation 
of the auriculo-temporal nerves and result in an intensely severe and persistent 
neuralgia. 
The character of the pain and its long continuance is similar to that produced by 
the pressure upon the nerves of cicatricial tissue, inflammatory products, aneurisms, 
and new growths. 
As an illustration, I present the following history of a case which came under my 
care March 30th, 1886, through the kindness of Prof. Edmund Andrews, of Chicago, 
with a deformity of the right lower maxilla and right side of the face, accompanied 
with severe neuralgic pains in both temporo-maxillary articulations and in the right 
brachial plexus. 
History.-Miss Ada S. ; aged forty-two years; American; occupation, seamstress; had 
been operated upon eight years before for the removal of an osteo-sarcoma of the right 
inferior maxilla. The entire bone was removed from the right first bicuspid back 
to and including the angle and about half an inch of the ramus. Extensive suppu- 
ration followed the operation and the wound did not heal for several months, leaving 
an ugly cicatrix about an inch in width at the base and four inches in length, and a 
malposition of the jaw, which was considerably displaced, the right ramus being brought 
forward and the jaw carried backward and to the right, so that the median line of the 
chin was fully half an inch to the right of the median line of the face. Fibrous union 
had taken place between the ends of the bone, but was so flexible as to afford but little 
support. The distance between the ends of the bone was about one-fourth of an inch. 
Motion of the jaws produced spasmodic pain in the temporo-maxillary articulations and 
in the right shoulder and arm. Movement of the arm, as in sweeping or using a pen 
* " Diseases of Nerves, Muscles and Skin." 
I Quain's "Dictionary of Medicine." 
t Hamilton's "Surgery." SECTION XVIII-DENTAL AND ORAL SURGERY. 
653 
or needle, brought on the spasmodic pains in the arm and shoulder. Walking, riding or 
any motion which jarred the body also excited the paroxysms. Whenever the body 
could be kept at rest she was free from pain. The mouth could be opened only three- 
fourths of an inch, due to the malposition of the jaw. The teeth were free from caries, 
but were all more or less affected with phagedenic pericementitis. The teeth of the 
upper jaw had all been lost for several years, and the patient wore a full upper artificial 
denture. 
All the usual remedies for neuralgia had been tried under the supervision of noted 
practitioners, but no relief had been afforded. 
After several careful examinations, I came to the conclusion that the neuralgic pains 
in the articulations were the result of the contraction of the cicatricial tissue and the 
displacement of the jaw, and in all probability the pain in the right brachial plexus was 
purely a reflex neurosis, depending upon the same cause. 
Prof. Walter Hay, of Chicago, also carefully examined the patient for me, and con- 
firmed the diagnosis. 
On April 23d, with the assistance of Prof. Andrews, an operation was made for the 
relief of the malposition of the jaw, with the hope that the suffering of the patient 
might be mitigated, if not entirely relieved. This was done within the mouth, by 
cutting through the fibrous tissue which bound the ends of the bone together. The 
jaw could then, by traction, be placed in its normal position, and as soon as hemor- 
rhage had ceased, the wound was packed with sterilized sponge to keep the ends of the 
bone apart and to relieve the pressure upon the articulations, and the edges of the 
wound closed with sutures. It was hoped that the sponge might become organized, 
and thus materially assist in maintaining the jaw in a proximately normal position. 
A solution of the bichloride of mercury, 1 in 1000, was ordered as a mouth wash, to be 
used every two hours. 
The sponge remained until May 7th, when suppuration took place, and it was 
removed. Up to the time of the removal of the sponge there had been no return of 
the pain after the operation, but the following day the pains returned, though less 
severely than before, in the articulations, but not in the arm. 
This proved the diagnosis to be correct, and encouraged me to believe that if the 
jaw could be permanently held in its normal position a cure could be effected. 
May 13th adjusted the following described appliance for holding the jaw in its nor- 
mal position while a second attempt should be made to reproduce the lost tissue by 
means of a sponge graft. 
A gold crown was made to fit the only remaining bicuspid tooth of the right side ; 
to the posterior surface of this was soldered a round gold rod one-eighth of an inch in 
diameter and one and one-eighth inches long, upon the free end of which was cut a 
coarse tapering screw. A hole corresponding to the size of the screw was drilled in the 
ramus and the screw inserted ; cement was placed in the crown and by forcible exten- 
sion of the jaw the crown was slipped upon the tooth and driven home. By this means 
the median line of the jaw was brought to its normal position, and the ends of the 
bone separated to the distance of one inch and firmly held in their new relation. An 
artificial denture was then made on vulcanite to fill the spaces between the remaining 
teeth and held firmly in position by means of gold clasps fitted to the tooth which had 
just been crowned, and the first and second bicuspids and the second molar of the left 
side. The object of this was to obtain counter-pressure upon the anterior surface of 
the bicuspid tooth which was carrying the gold crown and rod, so as to prevent its 
being tipped over or loosened. 
May 17th, all being ready for the operation, an incision was made externally in a 
line with the cicatrix of the original operation, down to the ends of the bone, a flap of 
periosteum was raised from the body of the bone on one side and from the ramus on 654 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the other, and stitched down with carbolized catgut sutures ; upon this was placed, 
after hemorrhage had ceased, a piece of sterilized sponge-after Atkinson's method- 
about one and a half inches long by half an inch square, and the wound closed with 
silk sutures and dressed antiseptically, drainage being secured by a few strands of 
silk thread. 
The wound healed rapidly, and the sponge caused no irritation until the 26th, when 
suppuration was discovered. All attempts to combat this proved futile, and on the 
30th the sponge was removed. 
June 17th the wound had entirely healed and the screw in the ramus was causing 
no inconvenience or appreciable irritation. 
September 3d, during a fit of sneezing, the screw was displaced, and it was found 
upon examination that the rod was now too short, as the ramus had been carried back- 
ward nearly half an inch, and that the 'mouth could be opened wider than formerly. 
The appliance was, therefore, removed, and its construction changed so as to provide 
for lengthening it without the necessity of removing it from the mouth. This was 
accomplished by soldering a tube to the crown, half an inch in length, that would receive 
the rod, and providing a set screw near the posterior end with which to hold the rod 
from slipping after extension had been made. It was then replaced as before. 
September 24th the screw was again displaced; deepened the thread and set it more 
firmly into the ramus. 
September 27th patient complained of soreness in the right articulation. This was 
due to pressure upon the ramus, which had been carried back still further by the 
increased length of the appliance. 
September 29th the soreness had entirely subsided and the jaw was again used with 
comfort. 
January 6th, 1887, the screw was still firmly held in the ramus and caused no incon- 
venience. There had also been marked improvement in the position of the jaw and 
the distance to which the mouth could be opened. Originally, by the greatest exten- 
sion the jaws could be separated only three-fourths of an inch; at this time they can 
be opened an inch and a half. 
The operations with sponge grafts and periosteal flaps having both proved failures, 
two attempts were afterward made to reproduce the lost bone tissue by means of bone 
grafts taken from the lower epiphysis of the femur of a young rabbit. 
The first operation was performed January 26th, 1887, and was partially successful 
in filling the gap. Twelve small pieces of bone from two to six lines in length, one to 
two lines in width and about one line in thickness, and covered with periosteum on one 
side, were placed in contact with the jaw and ramus (after the ends had been denuded 
of periosteum), and in two rows across the space every piece became attached and the 
wound healed without a particle of suppuration. 
Later it was found that union of the grafts had taken place with the ramus, but 
not with the anterior portion of the jaw, and that a space of about half an inch yet 
remained to be filled. 
The second operation was made May 18th, 1887, by transferring a piece of bone, 
also from a young rabbit, large enough to fill the space. This proved a failure after 
sixteen days, from necrosis. Further attempts in this line were, therefore, abandoned, 
from the fact that four operations had already been made upon the parts, and it did 
not seem wise to repeat them. 
July 20th, 1886, the screw was again displaced-this time while yawning, and as 
the malposition of the jaw was overcome, it was decided best to remove the apparatus 
which had done such good service for fifteen months, and attempt to maintain the jaw 
in position by means of an artificial denture. 
The teeth had been lost, one by one, from the effects of pyorrhœa alveolaris, except SECTION XVIII-DENTAL AND ORAL SURGERY. 
655 
the wisdom tooth on the left side and the bicuspid which had been crowned ; the latter, 
however, was so loose that it was finally extracted. 
July 30th, 1887, a full upper denture on vulcanite, and a lower on Weston's metal 
and vulcanite, were inserted. The lower was made very heavy, especially upon the 
right side, and attached to the wisdom tooth with a gold clasp. 
This was worn for about two weeks, when it was found that the jaw had been 
carried to the left fully one-fourth of an inch, and made it necessary to rearrange the 
teeth. 
The patient has not experienced a single paroxysm of pain in either the articulations 
or the arm since the 8th of May, 1886, and I think the treatment may fairly be con- 
sidered a complete success. Personally, I should have been better pleased had the 
attempts at reproduction of bone tissue been more successful; this, however, was only 
a side issue, but it nevertheless has its lessons. 
The causes of failure of the first sponge graft, I believe, was due to septic influences 
consequent upon the difficulty in excluding the fluids of the mouth, the low vital con- 
dition of the patient, who had been reduced by long and severe suffering and pressure, 
due to the tendency of the jaw to fall back to its old position. 
The failure of the second sponge graft was also largely due to the condition of the 
patient and the large size of the graft; a small piece would have been more likely to 
have succeeded. 
With regard to the subject of bone grafting, I must say that I am most favorably 
impressed with its possibilities. In no department of plastic surgery is there, it seems 
to me, greater opportunities for brilliant successes; for its applicability extends to a 
great variety of cases. 
The patient upon whom I operated was forty-two years of age, and with vital 
energies greatly depressed by long and severe suffering, and yet the first operation was 
successful, so far as the attachment of the grafts was concerned, and, I think, would 
have been completely so had not two of the grafts become displaced at the anterior 
portion of the gap, and which were found, at the second operation, attached just under 
the skin, but which I dissected out. The second operation failed, from the fact, I 
believe, that the piece of bone engrafted was larger than the tissues could successfully 
nourish; and had I followed the original plan, doubtless this operation would likewise 
have proved successful. 
To be successful with bone grafting I believe three conditions should be observed:- 
I. Thorough cleanliness during the operation and after-treatment. 
II. The grafts should be small and covered on one side with periosteum. 
III. The bone should be taken from a young and growing subject, best from the 
epiphyses of long bones. 
Fig. 1. 
Median Line. 
vRamus. 
Ramus. 
OUTLINE OF ALVEOLAE ARCH BEFORE OPERATION. 
March 30th, 1886. 656 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Fig. 2. Fig. 3. 
Fig. 4. 
Median Line. 
Ramus. 
Ramus. 
OUTLINE OF ALVEOLAR ARCH AFTER OPERATION. 
July 20th, 1887. 
Fig. 5. SECTION XVIII-DENTAL AND ORAL SURGERY. 
657 
DISCUSSION. 
The President stated that it had been expected that the discussion on this paper 
would be opened by Prof. F. H. Peck, of Davenport, Iowa ; but illness prevented 
Dr. Peck's presence. Tie therefore asked Dr. Atkinson to open the discussion, 
because of his large experience in that line of work. 
Dr. W. H. Atkinson, of New York, said that he regarded it as almost a 
special Providence that the case mentioned in the paper just read had been brought 
forward at this time. lie wished to make his most profound acknowledgments to 
the author of the paper, for the beautiful and faithful manner in which he had 
detailed the case. It set before the mind very clearly the principles involved in all 
cases of flesh grafting, or sponge grafting, which was one of the modes of grafting. 
It also showed the folly of the old method of using, whenever new growths of flesh 
were expected, any kind of drainage. Whenever a surgeon used drainage in a 
wound which he desired to heal by first intention, he acknowledged decidedly that 
there was some foreign element there capable of producing mischief. It was a pity 
that they could not have a whole day, or even a week, to enter upon the discussion 
of the question, so that they could get clearly into their minds the whole subject, 
instead of being cut off from that best inspiration which came to men when they are 
in dead earnest. There were piles of trash in the description they listened to, and 
that trash was attributable to the attempt to give causes for the various kinds of 
neuralgia. That was all bosh, but it did not deprive them of getting hold some- 
what of what neuralgia was. It was not defined in that paper, nor was it defined in 
any book he had ever read. It had only been defined in speech by some illuminated 
mind which had heart and soul in what it was dealing with. Neuralgia was the 
result of dynamic or mechanical compression, and they should not let that slip their 
minds. What was neuralgia ? It was pain in a nerve. That was the etymology 
of the term. Pain in a nerve. Where else did people have pain ? Was there pain 
anywhere else than in the nerve ? How did pain come about ? In the axis of every 
sensitive nerve was a waxy, semi-fluid substance, capable of being moved and pushed 
out of the way. By undue measure of this compression pain was brought about. 
It was brought about by the thinning to a thread-like tenuity of the interior magma 
(neurine), thus forcing the current of energy, which is called sensation, to run over 
it with such celerity as to constitute the pain ; and when the thread breaks into 
globules sufficiently near to each other, that dangerous kind of neuralgic spasm 
(described in the paper just read) was produced by the current "ticking" from 
globule to globule till they were "joined," when the pain ceases. Here was a field 
wide open for investigators, if they would only have the humility to follow out their 
own notions, and let books go to the dogs. He thought that dentistry was the last 
and best chance of understanding the subject, without going through the old effete 
trash which had so overloaded the books. The point to be learned from the case 
stated in the paper was, that the sponge-graft had not taken because there was not 
perfect cleanliness in the part. The statement had not been clear enough to let him 
know whether it had been sterilized. There was a beautiful suggestion that small 
sponge-grafts take better than large ones ; but if he had been in Dr. Marshall's 
place, he would not have given up the attempt at bone grafting. He would have 
tried again and again. He would have prayed for light from the world above, and 
he would have asked for the light in all his brethren's mind to illuminate him so 
that he could get the confidence of the patient, so that he could get within him the 
divine radiance which irradiated the patient and which had often made a patient say 
Vol. V-42 658 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to a physician, '1 When you put your hand upon me I felt that I was safe. I had 
complete confidence that you knew what you were about. ' ' 
Dr. W. C. Barrett said that, as he understood Dr. Marshall's paper, he had 
stripped the periosteum from each end of the bone and laid it down under or around 
the sponge-graft, and he asked why did not that enter into and reproduce the bone. 
Dr. Atkinson replied that it was simply because there was not enough of the 
soft tissue containing pabulum to form the osteoblasts. In conclusion he said : The 
thing which you feel in your inmost consciousness you ought to do, do that, if every- 
body be against you and the devil backing them. Just do the thing which you feel 
you ought to do, and be assured, as God is true, that you will be led in the way of 
light, from one step to another, until you shall conquer. 
Dr. Marshall said (in reference to Dr. Atkinson's suggestion that he ought to 
have persevered in his operation) that while the patient was very willing to submit 
to whatever he proposed, he thought he had gone as far as his judgment and con- 
science warranted him in going, and so he stopped. In regard to the sponge-graft, the 
reason why he put in such a large graft was that he did not wish to open up the 
tissue again if he could avoid it. 
Dr. Atkinson remarked that the permanent part of the inferior or superior 
maxilla should never be removed in making an operation. If the entire contour of 
the base of the inferior jaw was to be kept, there was no need of putting anything 
in, and all the mischief would be escaped which followed the old plan of surgery that 
removed the entire bone. As to Dr. Marshall's suggestion that he had not persisted 
because he was too tender-hearted, he (Dr. Atkinson) considered that he had been 
hard-hearted in not persisting. If he had cut through the periosteum and made 
the least bit of a perforation, the patient would not have been hurt at all. It was 
in the gum the pain was-not in the periosteum, except in an infinitesimal degree. 
The following paper was read by title:- 
ARTICULATION OF ARTIFICIAL TEETH. 
ARTICULATION DES DENTS ARTIFICIELLES. 
GLIEDERUNG KÜNSTLICHER ZÄHNE. 
BY H. L. CRUTTENDEN, D.D.S., 
Of Northfield, Minn. 
Gentlemen :-Who has never had trouble in getting a true articulation in the 
manufacture of artificial teeth ? 
Who is always certain that it is correct without testing it in the mouth of the 
patient ? 
Is there a positive system that can be relied upon without such a test ? 
The first two questions I will let my professional brethren answer; the third I will 
endeavor to do in this paper by giving you my way of operating with the articulating SECTION XVIII-DENTAL AND ORAL SURGERY. 
659 
guide. Much in this article will be taken from a paper I gave to the Minnesota State 
Dental Association. 
ARTICULATION. 
In the process of taking the articulation we find the only operation in which the 
assistance of the patient is absolutely required ; in all other cases the patient can remain 
passive. We could operate upon the teeth, or take an impression of the jaws, of a 
corpse ; or even work while the patient is under the influence of an anæsthetic ; such 
operations, however, depend upon the skill of the dentist alone. But in the process of 
taking the articulation, or what is often called the bite, the patient performs the opera- 
tion under the direction of the dentist, who has no power to contract or relax the 
muscles, except through the will of the patient. The dentist, therefore, takes but a 
minor part in the operation. The fact that much depends upon the patient makes the 
operation the more difficult, and the result more uncertain. As long as we rely upon 
some one else, the less are we likely to succeed, and as long as we operate by guess, so 
long are we liable to fail. There should be but one way to perform an operation, and 
that is to perform it right. The error, if any, may be in our j udgment of what is right; 
and as the judgment in different persons will vary, so the result of their work will like- 
wise vary. If we depend upon our j udgment alone to prove an articulation, or to correct 
a wrong one, we are liable to find ourselves mistaken. Judgment may vary, but figures 
will not lie. For by actual measurement we can obtain the exact relation of the jaws 
to each other, thus producing a positive system, so that the youngest student can 
acquire the same result as the old experienced practitioner. The process of taking the 
bite, as taught in our text-books and dental colleges, and practiced by many dentists, 
•differs so much from the system I use in connection with the articulating guide, that 
special attention is called to this portion. 
Taking the Bite.-After an accurate impression of the jaws has been secured, the 
next step in importance is to obtain a correct bite in order to form the articulation. 
This is taken at the same sitting as the impression, and in the following manner : 
Require the patient to close the mouth so that the lips will meet and the face will have 
the natural expression, then, keeping the jaws in the same position, open the lips with 
your fingers so as to see the distance the jaws should be apart. Then taking some 
softened wax, forming it into a crescent shape so as to conform to the arch of the jaws, 
place this in the mouth and request the patient to close the jaws upon the wax to the 
distance they should naturally be apart, placing the wax in direct contact with the 
gums or teeth. Then, keeping the jaws in the same position, press the wax about the 
gums or teeth, so as to get the imprints of both jaws in the wax. Draw a mark down 
across the anterior part of the bite with an instrument, so that it will be in a perpen- 
dicular line with the centre of the face. In order to remove the wax without changing 
the shape of the bite, request the patient to open the mouth wide and push the wax out 
with the tongue. 
FORMING THE ARTICULATION. 
The models of the jaw having been taken from the impression, they can, at pleasure, 
he articulated by placing them in the imprints in the wax bite. Or, if there should be 
but one model, place that in the imprint, then oil the wax and fill the opposite part of 
the bite with plaster, so as to form plaster teeth with which to antagonize the artificial 
ones. After they are placed in an articulator, mark upon the upper and lower models 
the continuation of the line made in the wax. This mark must guide you in placing 
the teeth, it being the centre of the jaws, and the cutting edge of the teeth should be 
at right angles with it. After placing it in warm water to remove the wax we have the 
articulation. But whether it is right or wrong we are unable to tell. What is to be 
done ? Wait for the patient to make another visit to test the articulation, thereby 
wasting time, and putting yourself, as well as the patient, to much inconvenience. 660 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Grind on the teeth and try in a pattern plate, and if it is wrong, regrind the teeth,, 
thereby making poor joints. Or take the chances and finish the case, often to find the 
necessity of remaking them. Or, if a little out of the way, resort to the use of the 
corundum wheel and grind away much of the natural appearance of artificial teeth ; or, 
as is often the case, dismiss the patient with an ill-looking and ill-fitting set of teeth. 
It is just at this time and for this purpose that the articulator guide is used; to 
prove, beyond a doubt, that the articulation is right or wrong. 
Once knowing it to be wrong, correct it in time; or, knowing it to be right, work 
with that confidence which will prove a more satisfactory result. I now go back to the 
time when the impression and bite were taken, for then the relative measurements of 
the jaws were taken with the articulating guide. 
Using the Articulating Guide.-Place the instrument in the mouth of the patient in 
such a manner that the cap A (see Fig. 1) will press up against the hard palate or roof 
of the mouth, and the projections B C will rest outside of the upper gum, about where 
the canine teeth were, or a little in front, giving three supports on the upper jaw, with 
G in a median line. The jaws are closed, the lower projection on the slide F is placed 
just outside the lower gum or teeth, as the case may be. Before the instrument is 
placed in the mouth, all the adjustments are made except one 
Fig. 1. 
The cap A is raised or lowered in the graduated tube, to conform to a high or low 
palatine arch. It should be so adjusted that when placed in the mouth the bars M M 
will be placed in a horizontal position, or nearly so. 
The distance from the upper projections, B C, to the lower projection should be the 
length of the bite, or the distance the jaws should be apart; and the same as they were 
in the wax bite. This is obtained by raising or lowering the lower bar at the binding 
screws, G and H (H to be the screw between O and K), the bar K nearly on a parallel 
with the bars M M. 
Having made these adjustments, standing at the right of the patient and holding 
the appliance with the left forefinger and thumb at C, place it in the mouth, so that it 
rests upon the upper jaw at A, B and C. 
Holding it gently but firmly in place, require the patient to close the jaws, then 
adjust the slide F so that the lower projection will fit outside of the lower gum or 
teeth, as described before. Fig. 2 represents a part of the face and superior jaw 
removed so as to show the instrument as it is applied in the mouth. It is a good 
idea to have the patient close the mouth a number of times, moving the slide if the 
lower jaw should go back any. The mouth being open, and nothing in the way to SECTION XVIII-DENTAL AND ORAL SURGERY. 
661 
obstruct the view, it can be readily seen whether the jaws are in their normal position, 
a thing not easy to determine when the mouth is filled with wax or trial plates. 
When yon are satisfied that the jaws are right, that is, that the lower jaw is at the 
furthermost point back, then set the screw I, and remove the instrument from the 
mouth. 
This last change is the only one necessary to be made while the instrument is in the 
mouth. 
RECORDING THE MEASUREMENTS. 
A record may be made of the measurements should the instrument be required for 
another case ; also to guard against accidental change in any of its parts. 
Fig. 3 represents a piece of paper with name of patient. The 3 above the line 
represents the height the cap A is raised out of the graduated tube. I is the distance 
the tube is above the block. 7 is the place G is set. This gives the length of the 
bite, or the distance the jaws should be apart, and 6} is the exact measurement on 
Fig. 2. 
the lower graduated bar at F. Yet all parts are lettered and can be recorded as you 
wish. 
PROVING THE ARTICULATION. 
When the models are placed on the articulator, and you are ready to grind on the teeth, 
be it a day, a week, or a month after the impression and bite were taken, you have 
simply to take the articulating guide and set it to the measurements recorded, and try 
it on the articulation, in the same manner it was placed in the mouth of the patient. 
(See Fig. 4.) And if the measurements are the same, the articulation is correct. 
But if the cast of the lower jaw does not rest inside of the lower projection D, then 
the patient has protruded the lower jaw just as much as the measurements indicate. 
For it has been inside the projection once and it must be right, for you cannot bite with 
the lower jaw back further than is natural. When the lower cast is beyond the pro- 
jection it can be moved back in a direct line to conform to its measurements, providing 
it is not too far out of the way. But when much out of the way I would advise anew 662 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bite, if it can be secured ; yet a great deal depends on what articulator is used. I prefer the 
Hayes Articulator, manufactured by the Buffalo Dental Manufacturing Company, as the 
lower cast can be moved backward in a direct line without any danger of the models 
moving sideways; a movement liable to occur in trying to change an articulation on 
some of our instruments. 
With the advent of rubber plates and cheap teeth, one is liable to become careless 
in the articulation. 
Fig. 3. 
Patient's name. 
3 7. 61. 
I. 
Before we dismiss the subject, let me urge upon the profession not only to keep up 
a high standard of dentistry in our own isolated offices, but to seek to radiate about us 
what light we can. 
Operative dentistry should come first; to save the teeth is our noblest work, and 
there is yet much to be done. Prosthetic dentistry is not without honor. There is a 
demand for artificial substitutes, and ever will be as long as there are mouths. When 
Fig. 4. 
nature fails, art comes forth to help her out. Art is the most perfect when it imitates 
nature best. Where is there a better field for art than is found in this department ? 
Let us keep this in view, and when we hear the cry for divorce, and see about us a 
desire for cheap teeth, let us look to our work and see if the fault does not lie partly 
with us. Let us clear the plaster and dirt from our laboratories and give the world 
something better. Let us not be ashamed to own we do mechanical work, and then, 
our work will not be a shame to us. SECTION XVIII-DENTAL AND ORAL SURGERY. 
663 
The following paper was read by title :- 
POWER AS APPLIED TO DENTISTRY. 
FORCE APPLIQUÉE À LA CHIRURGIE DENTAIRE. 
KRAFT AUF DIE ZAHNHEILKUNDE ANGEWANDT. 
BY W. ST. GEORGE ELLIOTT, M.D., D.D.S., 
London, England. 
I am not bringing forward anything new in advocating the use of power in our spe- 
cialty. Attention has been drawn to the subject from time to time during the last fifty 
years. Generally, however, the question has not been looked at in a broad or analytical 
way, but has been merely the report of the use of, and advantage to be derived from, 
some particular motor. Nor can I, at this time, give you all the facts attainable; but 
from the odd moments of a crowded practice I have gathered together some material 
which may be a help to those who are looking for some help outside their own muscular 
power. 
Is power a necessity ? No, but a very material advantage. Are the dental engine, 
the rubber dam and other important inventions of our day essentials? No; probably 
as good work can be done without as with, but under what disadvantageous circum- 
stances ! 
I believe there is no one but will admit that a motor that will relieve him from the 
slavery of the treadle, without the introduction of greater evils or undue expense, is a 
good thing; but I will go further than this, and not only advocate a dental engine 
motor, but one that will do your laboratory work as well. Before giving you the 
results of my own experience, let me examine, with you, the claims of a variety of 
motors now on the market, with the view of comparing their cost, running expenses 
and efficiency. 
I think it was about 1872 that a dentist in Maine advocated, in The Cosmos, the use 
of a small steam engine, and wrote enthusiastically of the satisfaction and comfort he 
derived from its use. As we hear but little of the claims of steam since then, I fancy 
continued use has not verified early expectations. 
Small steam motors are generally far more extravagant in fuel than are the large 
ones. A first-class engine of large size will give a horse power at the break for 1.3 lbs. 
of coal per hour, while a small one will consume three times as much, and more. An 
engine is made by Hathorn, Davey & Co., Leeds, of only one horse power, that will 
give its full power on less than 2 lbs. of coal per hour, and, as the engine is a vacuum 
one, not using pressure above 1 lb., it may be considered perfectly safe. Yet, although 
this engine comes the nearest, of any steam motor, to what we want, there are the fol- 
lowing objections: It is too noisy; it takes half an hour to get up power, and there is 
the litter of coke and ash. The same objections apply to the Shipman American 
engine, except that, as it uses oil, there is no litter, without the same economy in run- 
ning expense. 
Next let us consider the claims of water. This power has received more attention 
from the profession than any other, and properly so ; for where water can be obtained, 
and at not too great expense, it comes the nearest to what we want; but all small 
motors are extravagant in water for the power they give out, and if that power is 
required continuously the expense is excessive. The price of water in London, although 
not as high as in some other places, is 25 cts. per 1000 gallons. As an ordinary motor 
for dental purposes will consume at least 10 gallons a minute, the cost would be some 664 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
10 cts. an hour. I am not thinking now of the occasional use of water with the dental 
engine, but the continual use, either in the office or laboratory, or both. Even if used 
to polish plates, etc., the use is very intermittent. Were it continual, or nearly so, it 
must be expensive; for water from the street mains is necessarily so. In the use of 
water motors, that one should be selected best suited to the circumstances of the case. 
If you have plenty of water, with but little pressure, then a Shirlmen, the Baccus, or 
other motor on the breast-wheel principle, will perhaps give the best results. If you 
have pressure enough, and water is expensive, then choose a cylinder motor, as the 
S. S. White, the Bailey, or the Hartie. These engines are not adapted to low pressure, 
as they consume so much power in friction. I have experimented with some five water 
motors, having first introduced the high-pressure service at much expense. I used the 
Shirlmen, the Ash, the S S. White and two home-made. I got the best results from a 
simple wire wheel, two feet in diameter, mounted between centres, with cups on the 
periphery. This motor gave me power sufficient to run the dental engine on a pressure 
of five pounds only, and would, in fact, revolve idle with a single drop. I had to 
abandon the use of water motors, as my pressure from the mains varied fifty pounds in 
a few minutes. At times I could get no water. I could, of course, have had recourse 
to accumulators, reservoirs, etc.; but I was unwilling to do this, as something better 
had come up. 
Now a word about the H. N. air motors. Ericsson made successful motors years 
ago, although his designs were crude, and when applied on a large scale to a steamship, 
were not a success. Yet for small powers they have filled a place of some importance, 
and for pumping they have had a large sale. There are many other makes now in the 
field, but they are all open to the common objection that they require time to get up 
power-from five to thirty minutes, according to size, though those which burn coke, 
although much the most economical, have the litter resulting therefrom. The most 
prominent objection to those that burn gas is the small amount of power they give out 
for the gas consumed. A good compression gas engine will give one horse power for 
twenty-five feet of gas consumed per hour, while the hot-air motors consume from 
three to six times as much, and even more. 
Next we will consider the claims of petroleum engines, as the Brayton, the Spiels, 
etc. The Brayton was too noisy and ill smelling when I saw it, some ten years ago. 
The new candidate, the Spiel, may, in economy, compete with some gas engines, but 
it is too noisy, and although the price of oil is low now, there is little probability that 
it will remain so. 
Gas engines were introduced practically by Lenoir about 1850, I think. The charge 
of gas and air was exploded by the electric spark from a primary battery. Otto pro- 
duced an economical but very noisy engine in 1875; some of you may remember the 
noise it made in running the Graphic press at the Centennial. But, first, a word about 
non-compressors, or those engines which, having taken in a supply of air and gas, do 
not compress it before ignition or explosion. In this class we have the Bisschop, 
probably the best known in Europe. The one-man power consumes, by their own 
statement, twelve feet of gas per hour, and makes some noise at each explosion. The 
Economic, of New York, consumes fifteen feet, and the Crown pumping engine, all about 
one-man power, the same. So much for non-compressors. Now for the compressors, of 
which the Otto is the type. It is found that by compressing the mixture of gas and air 
a more diluted mixture will explode than when it is not compressed, and there is one 
point in economy. Then as the compression is done in the working cylinder, the 
friction of a separate compression is avoided. 
When I first looked into the question of gas engines for dental purposes, and recog- 
nized the economy of compression, I was inclined to invest in a one-half horse Otto, 
but did not see how I could utilize the power. When my water pressure gave out I SECTION XVIII-DENTAL AND ORAL SURGERY. 
665 
then found that Crossley Bro. had brought out a five-man power Otto, which I soon 
after purchased, and have had it in almost constant use for the last eighteen months 
with the greatest satisfaction. 
There are other makes that give good results, hut all are too large for our purposes 
except the non-compressor above alluded to. Within a few months the Otto people 
have brought out a still smaller one, called the ' 1 Domestic. ' ' For my purposes the five- 
man power is quite satisfactory; but for a dentist whose laboratory requirements are not 
very extensive, the smaller one might suit. 
My engine stands in the corner of the laboratory, some twenty-two feet from the 
chair, and separated from it by two wooden partitions. The engine drives by a belt, as 
shown in the drawing, a counter-shaft with three speeds. This shaft has at the other 
end a grooved pulley carrying the cord that goes to the dental engine without break, 
as shown in the second drawing. The cord is carried in two tubes under the floor, and 
comes up at the dental engine. 
The gas engine runs almost constantly, from three to ten hours daily. The dental 
engine and cord do not move unless the pin shown in the drawing is pressed by the 
foot. This draws down the lever, tightening the cord, when it moves at once, the speed 
being governed by an electric bell, there always being some one in the laboratory. On 
releasing the pin the engine and cord stop at once. Practically the pin is only depressed 
sufficiently to do the work. Should the bur get caught, the engine stops automatically. 
If power is deficient, the pin is depressed still more. If the cord is too slack you can 
take it in by raising the standard at the clamp nut. The great advantage of this 
delicate control of the bur cannot be fully appreciated without trial. I stop and start 
the bur a dozen times a minute. This is a great comfort to the patient, who soon 
notices how fully the instrument is under command. 
I have found practically that two speeds are sufficient. Although I have three,*800, 
1500 and 3000, I seldom, in fact never, use the slow speed. Nearly all work is done on 
the middle speed, the high being mainly used to run my straight and right angle 
mechanical mallet. No lower speed gives the same satisfaction, even in excavation. 
The work can be done quicker, but I find patients object to the additional noise induced 
by the high speed. 
The gas engine is kept going regularly at almost its lowest speed, 110 revolutions 
per minute, all work requiring a higher speed being speeded from the engine by shafts 
and countershafts. At the speed alluded to the engine consumes four feet of gas per 
hour by meter, which, at the price of gas in London (4s. 6d. a 1000), gives us two 
hours' use for a cent. When work is being done in the laboratory in addition to 
the dental engine, the governor takes more I have in this room three lathes ; one 
polishing lathe ; one grindstone ; one wire draw bench and mechanism to drive a punkah 
or swinging fan in the office, in addition to which I am now putting in an air compressor 
to supply air to the blowpipe and forge, and also the ejector ventilators on the Green 
system. I am also putting in a small 10 Volt 1 Amp. dynamo to light up the mouth 
lamp for diagnosis. All these are worked by the little Otto, and at an expense of 
2200 feet for three months ending June 14th last, or at the rate of two and a half cents a 
day for that time. 
I think this record of economy exceeds anything known in mechanisms for small 
motors, and better than any reported by the makers. But this can only be obtained 
by careful management, and shows the advantages of using an engine above the 
requirements of the moment in power, as it can be consequently run slowly. 
Of course, the Otto, like all other engines, consumes oil, and there is some expense 
to keep duplicate valves in order. We have with this engine, then, the following 
advantages : Not expensive ($200 without fittings, etc.), almost noiseless, almost free 666 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
from smell ; start in a moment full power ; requires but little attention through the 
day ; gives you little or full power automatically and extreme economy in gas. 
Those who are familiar with the scientific aspects of gas engines, know that over sixty 
per cent, of the power latent in the engine is lost in heating the water necessary to 
keep the cylinder cool enough to be lubricated, and yet I recover nearly all this. The 
water used for washing purposes in the laboratory comes from the mains, and is gener- 
ally passed through a Fletcher water heater, but by passing the lead water pipe in a 
coil through the tank supplying the engine, I not only keep this water cool, but heat 
the water we use without further expense. 
When no street gas is to be had, the engine makes its own gas from petroleum. 
It was my intention, when the engine was first put in, to utilize its maximum 
power, 1.3 horse, to drive a dynamo and light the office with incandescent lamps. I 
procured a dynamo and the necessary lights, leads, etc., but found that not only were 
the lights deficient in power, from a faulty dynamo, but fluctuated, from the intermit- 
tent character of the power. This, of course, could be overcome by either a balance 
wheel or accumulators, yet I decided to abandon the electric light, chiefly because it 
was not a necessity, and, secondly, because running the engine up to its maximum 
speed of power, 225 revolutions, made too much noise. 
Finally, gentlemen, you may have noticed that I have not spoken of electricity as a 
power. It is not, however, that I am ignorant of, or not fully appreciative of, what 
it will do. But my paper is to point out the advantages of power in all the depart- 
ments of dentistry, and not merely to drive the dental engine ; for I contend and think 
the above facts prove that I get all the power I can utilize at less than half what elec- 
tricity would cost for the dental engine alone, to say nothing of the very unsatisfactory 
and uncertain nature of primary batteries, which can never compete commercially with 
coal* although very satisfactory, perhaps, to the few. These remarks do not apply to 
those fortunate places where electricity can be drawn like water from street mains. 
Even then the advantages will not be those of economy, but avoiding the care neces- 
sary to the proper management of any machine. 
Now, gentlemen, if you wish to bring forward the claims of any motor that has 
proved satisfactory to you, be good enough to substantiate your statements by facts. 
Don't tell us that your electric, your water, or gas motors are the best, the cheapest, 
etc. ; but tell us what they cost per hour, per day, per man, or horse power, as shown 
by reliable tests. 
[Dr. D. M. Clapp, of Boston, who was to have opened the discussion on this 
paper, was not present, and so no discussion was held. ] SECTION XVIII-DENTAL AND ORAL SURGERY. 
667 
PORCELAIN FILLINGS. 
PLOMBAGE AVEC DE LA PORCELAINE. 
PORZELLANFÜLLUNGEN. 
BY E. C. MOORE, D.D.S., 
Detroit, Michigan. 
By recent improvements in gas furnaces for the fusing of body or porcelain for what 
is generally known as continuous gum-work, a new field seems to have opened up, 
which only needs cultivating and fertilizing by the dental profession to bring forth 
rich fruit. 
It is now not only possible, but practicable, and preferable in a great many cases, 
to substitute porcelain as a filling for that of gold, amalgam or cement, to say nothing 
of the variety and modifications in crowns, or partial crowns, and bridge work, all of 
which may be made by this system, with the aid of these furnaces. 
Some of the advantages peculiar to this process and material for the filling of 
teeth are- 
1. The indestructibility and permanency of color. 
2. Its near approach in color and translucency to the natural teeth, and its being, 
in consequence, less conspicuous. 
3. The ease and comfort in the accomplishment of such happy results to both 
concerned. 
4. Its applicability or admissibility, when other means of arrestation of further 
caries, preservation of nerve and restoration of contour would be accomplished only 
after hours of misery to both operator and patient. This, coupled with the jeopardi- 
zation of the vitality of the pulp, by thorough and proper excavation for anchorage 
and retention of gold filling, or subsequent devitalization of nerve by thermal changes, 
owing to the close proximity of such a body of metal possessed of such conductivity. 
During the past year a great variety of operations, somewhat of an experimental 
nature, have been made with porcelain, from large contours and crowns of the six 
anterior superior teeth, preserving the nerve alive, to very small corners, particularly 
the incisors ; some of these were of that kind where both proximal surfaces were 
decayed until the cavities merged into one, leaving only the thin enamel on the labial 
portion intact ; this was cut away in the preparation and what we will term a horizon- 
tal section substituted. Others were of such character as involved only one proximate 
surface, and perhaps a third or fourth of the tooth, and necessitated what we may term 
a vertical section. Others, again, were of that kind usually denominated ' ' mere shells, ' ' 
a comparatively small opening, but with almost the entire dentine gone ; in such 
cases restoration by gold would be impracticable, where it was desired to leave much 
of the enamel of the tooth intact. 
So far as known by me all of these sections of fillings are in situ. 
While this length of time does not demonstrate the permanency of the work, yet 
of a few facts-which are said to be stubborn things-we are quite sure : they do not 
require ligating or wiring in until they become secure, nor do they, after an uncertain 
period of usefulness, absorb away and drop out in one's mouth ; not even courteous 
enough to leave a root behind, to which a good and useful crown might be attached. 
Therefore, gentlemen, we can with impunity afford to experiment, for even should the 
work fail, we still have the foundation left for the superstructure in some other 
material. 
I anticipate the attack on the weak point in this system, if it should prove to be a 668 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
weak point, and I refer now to the means or material by which the piece is retained 
in position, the cement ; and I meet this attack, Yankee like, by asking a question, 
namely, what is the main dependence in bridge and crown work? Cement, of course; 
inferior as it is, it is the best we can do. The same is the case for this work ; the 
inducement now is all the greater for a superior cement, and when we get it, it makes 
us masters of the situation. 
The system has this advantage over that of crowns or bridge work : so far as the 
cement enters into the system it is better protected from the action of friction or the 
secretions of the mouth, because the joint between tooth and porcelain is closer, but at 
vulnerable points, such as distal portions of proximal cavities, where time has demon- 
strated to us it is vulnerable, it may be filled with tin, gold, or with whatever the cir- 
cumstances seem to require, to a given distance, when it should be finished nicely to a 
corner, so that the porcelain piece and filling will make a good joint. 
While this is the weak point, it seems to be about the only one, and there is no 
other objection to the system, unless it be that the absolute exactness in which the 
preliminary work must be performed is an objection, for "As the twig is bent so the 
tree is inclined;" so, also, if the metal is not properly joined to the tooth, the same 
discrepancy must exist when the porcelain is baked in it. 
And now we arrive at a point where a description of the system seems necessary. 
I would much prefer to demonstrate practically by clinic. Like all other operations of 
superiority, it depends upon the hand and head of an artistic mechanic. The descrip- 
tion, given briefly and simply, is as follows: After proper preparation of the cavity, a 
piece of platina, of suitable size and about thirty to forty gauge in thickness, is placed 
over the cavity, and, by means of suitable burnishers, is made to partake of the shape 
of the cavity, particular care being taken at the periphery to have a complete contact at 
every point; to this matrix of platina loops or pins are soldered, for the double purpose 
of attaching the porcelain and retaining the piece in the cavity when finished; the 
body is then built about these pins or loops, to restore the proper contour, and then baked 
in the gas furnace; usually, two bakings are necessary to give the proper shape and 
finish of surface; the thin platina is then stripped from the back of the piece, when it 
is ready to be placed in position ; if the platina is left it detracts from the translucency 
and makes a dark line at the union or joint. You will also understand the necessity 
of using very thin platina. I am not going into details in this description, but simply 
giving the modus operandi in general, but the object of this short and disjointed paper 
is more for the purpose of bringing this system to the notice of the profession. And I 
must say that in my own practice the results have been extremely gratifying to the 
patient. 
There are a few general rules to be observed in bringing about the desired results in 
this system. The first vital move in this system is the preparation of the cavity. 
While in the main it is after the fashion of one prepared for the reception of a gold fill- 
ing (differing in this particular, a goodly portion of the cavity is filled with quick- 
setting cement, and that portion well undercut), it would be impracticable to try to 
burnish the platina into the full depth of the average cavity where this system would 
be applicable ; neither would it be safe or in good j udgment to try to burnish the metal in 
without a good and solid foundation in all parts to rest the metal against; that portion 
of the cavity remaining unfilled should have something of a flare or outward bevel, 
leaving the edges terminating square or nearly at right angles with the surface of the 
tooth, so that when the metal is burnished over the edges the angle thus formed acts 
as a brace to stiffen the matrix and prevent its changing shape while handling or being 
baked, so that the piece, when placed in the cavity, will be slightly wedged in shape, 
and make a close joint when forced in place. The cement previously placed in the 
cavity having served its purpose is removed and fresh cement put in, in order that the SECTION XVIII-DENTAL AND ORAL SURGERY. 
669 
pins, loops or other means of mechanical attachment may be properly imbedded in the 
cement. If the piece is for a labial or buccal cavity, or in any location where but little 
or no force is exerted against it, no pins or loops need be attached or soldered to the 
metal matrix, but j ust lift carefully from the cavity and place the body in and bake. 
While in others it may be necessary to take an impression with matrix in position, in 
order to get at the proper amount of contour to be restored; from this impression a 
model is produced, the exact counterpart of the mouth, with the matrix in the cavity. 
To solder on the pins or loops, place the platina matrix on a mixture of plaster and 
white sand ; when sufficiently hard, pierce the metal through into the investing mate- 
rial and place the pins or loop wherever desirable and solder; then drop into a little 
water and the investing mass will crumble away easily. 
The modifications of this work are practically limitless, and the field it offers is 
inviting to skillful and artistic hands. Bunglers had better not apply, but stick to 
their proper sphere of plastic fillings and rubber plates, for they are sure to meet with 
disappointment and bring everlasting disgrace upon the system. 
The Section then took a recess until 8 o'clock P.M. 670 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
EVENING SESSION. 
The following paper was read :- 
DOES FUNCTION CONTROL THE EVOLUTION OF STRUCTURE? 
LE FONCTIONNEMENT DETERMINE L'EVOLUTION DE LA STRUCTURE? 
BESTIMMT FUNKTION DIE EVOLUTION DER STRUKTUR? 
BY ALTON H. THOMPSON, M.D., 
Topeka, Kansas. 
Some time since, Dr. C. N. Pierce discussed a subject similar to that at the head of 
this paper, and presented some interesting arguments bearing upon the subject. After 
noticing the mechanical forces involved in and influencing the evolution of the teeth, 
he says : " These cumulative forces are utilized through heredity, and, while so potent 
in tooth evolution, exert a similar influence in the development and modification of 
all other structures and organs. All departments of biology bear testimony to these 
same originating and modifying influences, and recognize the fact that heredity, adap- 
tation and growth, being of special importance in the evolution of the organic body, 
must, therefore, be regarded as especially formative functions. In speaking of the 
evolution of function, we cannot isolate it from the evolution of organs, so nearly do 
they develop together, by the process of adaptation. Adaptation to environment might 
be called the ancestor of function, as function is of organization. If function takes 
precedence of structure, if life consists of inner actions, so adjusted as to balance 
outer actions, then this continuous change, which is the basis of function, must come 
before the structure which brings function into shape. If every advance is the effect- 
ing of some better adjustment of inner to outer actions, it follows that function is 
from the beginning the determining cause of structure. 
" Illustrations of modifications of structure in response to function, are veiy numer- 
ous, in which it is shown how an organ may be completely changed, or a mere 
rudiment be fully developed, by the demand for the performance of a function unknown 
before. There is réadaptation to environment, in response to a call for a new exist- 
ence." 
A century ago that prince of speculative naturalists, Lamarck, laid down the fol- 
lowing laws concerning the development of organic life, which we, with our accumu- 
lated facts, can change but little. In his famous second law, he said, that the produc- 
tion of a new organ in an animal body results from the supervention of a new want, 
continuing to make itself felt, and a new movement which this want gives birth to 
and encourages. Third law : The development of organs and their force of action are 
constantly in ratio to the employment of these organs. Fourth law : All that has 
been acquired, laid down or changed in the organization of individuals, in the course 
of their life, is conserved by generation, and transmitted to new individuals, which 
proceed from those which have undergone those changes. SECTION XVIII-DENTAL AND ORAL SURGERY. 
671 
It is the second law-his hypothesis of the evolution of organs in animals by long- 
ing or appetence, " that altered wants lead to altered habits, which result in the forma- 
tion of new organs, as well as in the modification, growth, or dwindling of those 
previously existing "-that has made his name famous; although he founded it on a 
visionary basis of spontaneous generation, and distorted it by the fanciful physiology 
of his day and of his own vivid imagination, yet his was the valuable hypothesis of 
" the influence of new wants acting directly by stimulating growth and use." 
In our study of the subject we will confine our observations to that field in which 
we as dental and oral specialists, are most interested, i.e., the masticating apparatus, 
the mouth and teeth. In our department we have the advantage, that no other organs 
so fully illustrate the influence that function has exercised in modifying form, as does 
the masticating apparatus. ' There is, in the first place, no doubt as to the most refined 
and perfect adjustment of means to ends, of organs to materials, of tools to work. In 
all the differentiation and complexity of form exhibited throughout the animal world, 
there is the most exact adaptation of instruments to purpose in the relation that the 
teeth and masticating machinery bear to the work of reducing the food to each species. 
So exact is this adaptation that the teeth and jaws are the most valuable diagnostic 
mediums to the naturalist, especially in the work of identifying fossil remains. Spe- 
cialized structure is so marked, and variation so distinct, as to render them the most 
invaluable means of differentiating species, and on them alone are founded the stories 
of the lives of many species that have lived and died in the great geological past. 
It is most essential that the structure and adaptation of the teeth should be highly 
specialized, for upon their adaptation to the food employed depends the life of the spe- 
cies. All life depends, first of all, upon the food supply, for existence and continuance, 
and ability to utilize that food is the first requirement for life. Food, as a potent power, 
is second only to cosmical influences in determining the course and forms of organic life. 
As being the channel of dependence for the nutritial supply, the masticating region of 
animals must be perfectly adapted to the kind of food employed. This is the most 
apparent fact of their existence. All animal life, throughout all time, has been thus 
dependent upon the food supply, and variations of the quantity or quality of food have 
caused more or less modification of all the forms that have ever lived upon the earth. 
The importance of what might properly be called food-selection, as a potent modifying 
influence, cannot, therefore, be over-estimated, and necessitates perfect adaptation of the 
organs that procure, reduce, digest, and assimilate that food, that the species may live. 
Slight changes will cause general alterations of organs, that there may be perfect adapta- 
tion to new conditions. Great changes, as to an entirely new food, and sudden with- 
drawal of the old, cause extinction of life, through incapacity for great and sudden 
alterations. Gradual, slow, and persistent deviations are the most potent for change, 
for almost any species can tolerate slight alteration in its food, with inconveni- 
ence. Persistence of the change in one direction will surely bring about a corresponding 
modification of animal structure, through the law of adaptation to environments, upon 
which the persistence of species, as well as of individuals, depends. This necessarily 
compels function to control and modify structure. 
In the remaining living species of animals we witness the results of extensive differ- 
entiation of structure in accordance with this law, by slow process, in ages past, the 
effect of compulsory adaptation to food environment. All this complexity of structure 
cannot be the result of an accident. The laws of development are governed, if governed 
at all, by the purposes for which development takes place. Organs are not evolved to 
await a function. Tools are not made before their uses are discovered. Every organ, 
tissue and cell has its appointed work, and takes its place in response to the demand 
to prepare for its life duties. Everything is made for a purpose, and the purpose 
must precede the thing made for effecting the purpose. Nature plans her work as 672 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
deliberately as man plans his actions. The means for accomplishing an end are not 
the cause of creation, but the effect. The organ is the effect, the function is the cause 
of structure. 
As food-selection is the cause of the function, so the function of the acquisition and 
preparation of food is thus the cause of the masticating apparatus. It imposes upon 
animal organization the necessity of ever changing in conformity to new conditions ever 
being presented. It is the power that dictates change. The masticating region is the 
most variable of the entire organism, and is peculiarly susceptible to influences inducing 
change. This mutability of structure must be due to the variability of food demanding 
constant réadaptation. 
The homology and relationship of the teeth with the dermal tissues (such append- 
ages being especially variable under conditions inducing alteration, and consequently 
inconstant in form and structure) explains this variability. The teeth, like other 
epithelial products, were developed for a protective purpose, and supporting tissues 
were, of course, developed to accommodate and support them. The history of the 
origin and evolution of the teeth, taken throughout the animal kingdom, shows that 
they were produced from the epithelium of the jaws, merely for the protection of the 
skin and for greater effectiveness in the manipulation of food. This step reached, 
specialization began, and many different and complex organizations arose, as required 
by the different foods of different species. From elementary forms, which afforded the 
rudest protection to the gum tissue of the jaw, all subsequent and higher forms were 
progressively evolved and elaborated. Thus we see that as mastication was developed 
from a simple to a complex function in any species, the organs for performing it were 
correspondingly developed, in simple obedience to the new-felt want. The teeth, like 
other dermal structures, can be altered in form and numbers most readily and safely, 
and the species continue to exercise the functions of life. Every species exhibits the 
effects of this susceptibility in which teeth have been lost or altered through changed 
habits concerning food. Rudiments remaining in the jaws illustrate this most forcibly, 
where teeth have been suppressed through disuse, and the masticating area reduced or 
its whole character changed, by changed habits. 
This brings us to the consideration of the final question : what of the disappearance 
of the function of mastication in man, and the effects upon his masticating apparatus ? 
Some years since the writer devoted a series of articles to the elucidation of the fact 
that mastication is passing into disuse, and that the teeth of man, in consequence, in 
obedience to well-known laws, are in process of suppression. If function is the cause 
and support of structure, if an organ developes or atrophies as it is used or disused, if 
the impulse of active employment dictates the evolution of parts and tissues in succeed- 
ing generations, if organs have been suppressed through disuse, or remain in various 
forms as mere rudiments, their functions having passed away-and these propositions 
no one can deny-then, indeed, must the teeth of man be tending toward final and 
inevitable suppression. That is, unless a higher civilization and education brings 
about an artificial cultivation of the habit of mastication, for the preservation of the 
teeth, of which there is little hope. If, in the future physical education for the per- 
fection of physical form, there shall be found a place for education in the accomplish- 
ment of masticating food, then, indeed, may the teeth be improved, and developed by 
exercise, as the muscles and lungs are improved and developed. But, if the habit of 
disuse is to persist, if the natural function of the teeth is to be superseded by the arti- 
ficial preparation and reduction of food to encourage our indolence, if organs atrophy 
from disuse, if the structure of the teeth is to become weaker and weaker because of the 
withdrawal of the creative stimulus of use-and they thereby become more susceptible 
to the attacks of disease in various forms-if they are already disappearing by the fre- 
quent suppression of certain of the series-as of the wisdom teeth and, occasionally, the SECTION XVIII DENTAL AND ORAL SURGERY. 
673 
laterals-then is the suppression of the teeth of man in progress to-day. We have only 
to submit, in conclusion : If the function disappears, can the organ persist ? 
DISCUSSION. 
The discussion of this paper was to have been opened by Dr. W. C. Barrett, of 
Buffalo, N. Y., but in his absence the President called upon Dr. W. II. Atkinson, 
of New York, to open the discussion. 
Dr. Atkinson said that the paper just read seemed to him to be a series of 
assumptions without having sufficient reasons lying back of them. In this paper, 
function seemed to be standing simply as an antecedent and a sequent without the 
naming of what was to follow or of what it was that gave the movement which 
agreed with type or adhered to type. The mammalian lung was prepared in all its 
magnificence and beauty before there was any air at all in it, and what was the best 
test of infanticide in courts of justice ? It was the hydrostatic test. If a piece of 
the lung was cut out, and if it sank in water, it was a proof that that lung had never 
been permeated by atmosphere, because air, when once received into the lung, can- 
not be discharged by any mechanism known to man. It would still float. So gen- 
tlemen had better be a little careful in pronouncing their opinions on such a subject. 
There were cases of men who, in these scientific inquiries, had gone to the very 
portico of knowledge, had reached the very door, and had even smelled through the 
keyhole, and yet they did not discover it, but came away and swore that there was 
no door there, no lock, nor keyhole. Those were the kind of naturalists that the 
world had. These Lamarcks and all the rest of the intelligent geniuses who had 
contributed so much to progress, had failed entirely to comprehend what life is, what 
death is, what forms they assume; what an organ is and what its function is; and 
that all are but preparations of machinery, to perform a purpose which lay behind 
the whole of them. Those who said that all this was the result of creation had 
attributed it to about as vague a source as any. But the true naturalist was the 
honest man; and if they would first study principles they would learn that life 
began with the lowest mode of aggregation of elements. That was crystallization. 
The physiology of the mineral kingdom was crystallization. The physiology of the 
vegetable kingdom was cellulization. The physiology of the animal kingdom was 
corpusculization; and the order of consciousness which understood the whole of this- 
was what was called mentation. This was the argument which men would have to 
see and comprehend and reduce to milk before they could have the nourishment 
which came from that thing which men called milk of the word. An Amoeba 
performed every function of a mammal. It bouched and debouched at the same 
part of its body. In other words, it lacked a mouth. He begged pardon-a mouth 
was improvised for it, and an entire alimentary canal. It felt without nerve; it 
moved without muscle; it digested without a differentiated organ of any kind, only 
morally. And yet men thought they were going to get away with this question when 
they said that function was the parent of organism. That was a curious denomination. 
It had to go back into mentality. It had to go back outside of time and space into 
pure consciousness. That was what was called God, but these men called it environ- 
ment. Shame upon them for dishonesty when they went back on Him who gave 
what little inspiration they had, and said that He did not inspire it ! That was too 
weak. But the discussion could not be entered upon without a preliminary clearing 
out of the brush that is in the way. But instead of asking who did it, they had better 
ask, how was it done ? Education meant a drawing out, and this was a thing which 
Vol. V-43 674 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
could not be drawn out. But when a sense of need, mentally and consciously, threw 
men into an asking condition, and when they asked for light, then the blessed 
radiance from without took the first opportunity of even an approach to a vacuum 
within, and rushed in and filled it just as far as the asking went. If men asked only 
for a very little whiff of superficial breath, that was all they got. If they asked for 
a medium breath, they would get that much. If they asked for a deeper breath, 
they would get their lungs still more distended. And if they asked for a whirlwind, 
they would get the last air-cell on the crest of the mountains, and every cell would 
be filled with divine radiance. When they took into consideration just the act of 
respiration and studied it thoroughly, they would find such a key as would enable 
them to unlock every other department of function, of every kind of matter on the 
planet. There was a within, a without and a between. The sense of deficiency 
threw men into an aspirational state, and then inspiration came to the periphery of 
the machinery of consciousness and produced feeling. When that was thoroughly 
ripened or gestated, ideas were produced and formed; when ideas were completely 
gestated they were born into thought; when thought was complete, it became 
opinion; when opinion was complete it became belief ; and when belief was put 
to the last test, and when the last two opposing problems were settled, it became 
knowledge. That was all in consciousness; and men had to assume a machinery 
because of the mentality of all the teachings which had gone behind them, and which 
always attributed energy to the chips in the workshop of the house of spirit. 
Dr. Thompson. - And I say, nevertheless, that function is the cause of 
structure. 
Dr. A. M. Dudley, one of the Secretaries, read the following paper :- 
HARMONY AND DISCORD, HEALTH AND DISEASE, HEALERS 
AND HINDERERS. 
HARMONIE ET DISCORDE, SANTÉ ET MALADIE, CURATIFS ET ENTRARES. 
HARMONIE UND MISSKLANG, GESUNDHEIT UND KRANKHEIT, HEILENDE UND HIN- 
DERNDE. 
BY ISAAC B. DAVENPORT, M.D., 
Paris, France. 
Gentlemen :-The life of an individual in this entirety is the result of the total 
functional activities of every organ in the body. 
Life is manifest from the cerebrum to the enamel of the teeth. 
All are vital organs, since all are endowed with vitality. Yet certain organs are 
more immediately essential than others, for " continued adjustment of internal condi- 
tions to external conditions," which is Spencer's definition of life. 
The life of an individual in relation to all the functions of the body may be com- 
pared to an army. The medulla may be likened to the general, who, by a single sur- 
render, may paralyze the entire force; the cerebrum to the staff officers, or minister of 
war, whose counsels may be either good or bad; the heart and lungs might represent 
the trusted corps, whose failure would bring destruction to all; the pneumogastric and SECTION XVIII DENTAL AND ORAL SURGERY. 
675 
sympathetic nerves connecting the heart and lungs with the central organs, to the lines 
of communication between the corps and the central command, and if broken, favors 
irregular action that would be disastrous. 
The rank and file of private soldiers are the representatives of the many simple 
functions, such as the special gland and nerve cells, whose extensive destruction brings 
direct disaster, and any destruction is dangerous to all in proportion as such loss yields 
the balance of advantage to the enemy. 
Perfect health is the result of the perfect relation and perfect functional performance 
of all the organs in the body. 
Perfect health can continue only when all the functions of the body are perfectly 
performed. 
Any degree of bodily vigor is consistent with health so long as all the functions are 
performed in harmonious relation-the powerful athlete and the frail woman may 
possess equal health, although the forces or quantity (so to speak) of life possessed by 
each are widely different. 
If one could imagine a being endowed at birth with organs and functions so related 
as to constitute perfect health, and preserving all those fine adj ustments till each and 
every organ had done its share of work, and served out its appointed time; death to 
such a one would be but the opposite boundary of the total endowment of vitality 
bestowed at its conception; a mere disunion, just as the ripened golden fruit, which 
always grew in harmony with nature's law, falls loosened by the dew on evening's fail- 
ing breath. 
Organs are so intimately related that derangements of the function of one affect 
the working of others, and the fine balance which constitutes the basis of health is 
disturbed, imperceptibly at first, perhaps, but unless corrected always tends further 
from health and nearer recognized disease, just as two parallel lines made to diverge 
ever so little, at last are widely separated. 
Certain derangement of certain functions (termed vital by those who used to con- 
sider vitality as an entity instead of a phenomenon) will, as already suggested, directly 
cause death-for instance failure of the heart to beat, or an injury to the medulla. 
Other derangements react upon the so-called vital functions and thus indirectly cause 
death; excessive accumulation of urea in the blood. 
More remote derangements, or the same in slight degree, may cause great bodily 
suffering or lingering disease-e. y., chronic diffuse nephritis, chronic gastritis, valvular 
derangements of the heart, etc. Others may only mark a simple departure from health, 
as a slight disturbance of the stomach, or of the circulation, producing perhaps merely 
a sense of discomfort or slight uneasiness, or perhaps only some unconscious impression. 
These deranging influences vary only in their force; they are in gradations; the 
extreme ending in death, and the others tending always to lessen or shorten life. 
The failure of one function means extra work for another, or others, and a disturb- 
ance of the general harmony of the functions. How severe a derangement a certain 
cause may produce will depend much upon the comparative strength of the related 
organs-e. y., suppose twins, of equal health, capable of living to the same age, but 
one able to accomplish twice as much as the other, the stronger might easily recover 
from the effects of a poison which would be deadly to the weaker but healthy brother. 
In practice we may know that the functions are not working in harmony, but we 
never know they are in harmony, even when there is no evidence to our senses of 
disease. 
Certain organs may be performing vicarious functions and be loaded to so near their 
own limit that a little extra emergency, which ordinarily they would be competent to 
withstand, determines their failure. " The last straw broke the camel's back." 
We never know the weak point in our organic machinery till it breaks or begins to 676 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
break. Nature's handiwork should be looked upon with reverence, and we are surely 
wrong if ever we oppose the laws which govern them. Nature left alone may fail to success- 
fully combat disease, but meddlesome treatment, that which is opposed to natural laws, will 
surely hasten the failure. 
Nature at times seems prodigal with her supply, but often her provisions are not 
so abundant as we think. " The sands run out," and nothing turns the hour glass to 
restore our growth; wasted energy does not come back. 
Man is not provided with new organs for those removed by the surgeon's knife; his 
sun of life is lessened by disease, even though he live out his appointed years. 
There is more life lived in a year of health than in the same time spent with the 
functions clouded by disease. 
The stream is as much lessened by baling out of its side as from one end where it 
falls over the precipice into the sea. 
Organs are the vehicles, and nutrition the force of life, digestion the process upon 
which that force depends, and food is the substance upon which digestion acts. 
Man needs a varied supply, to meet which the digestive organs constitute a series of 
chemical laboratories stationed along the food stream, for the contraction of every 
needed principle of force. 
Dentists stand guard over the beginning of this holy process, this doing of the work 
by organs prepared for them to do-this silent worship, in nature, of nature's God. 
Shall he mar and mangle what was deemed fit to do a certain work, or shall he 
strive by all his acts to restore the harmony of any disturbed function ? 
We have not learned the full significance of all that part of digestion which ought 
to take place in the mouth, and which, in its beginning, is coincident with mastica- 
tion, insalivation, the sense of taste, and beginning of deglutition. 
Man's life may be sustained for a time by transfusion of blood, by rectal enemas, or 
by direct introduction of food into the stomach, but something needed is left out of the 
process of digestion by all these modes. It is not enough that the food reaches the 
stomach simply well reduced. 
Of course, thorough reduction of food is essential, and digestion is active or slug- 
gish, according to whether the reduction was perfect or imperfect. 
Insalivation is directly related to mastication. Dalton showed that on the side 
engaged in the act of mastication, the corresponding parotid gland secreted three times 
as fast as that of the opposite side, and besides facilitating the reduction of food, it is 
more and more evident in physiological studies that the thorough mixing of saliva with 
the food in the mouth is essential, and that the saliva is a true digestive of certain food 
elements. 
Until we can exactly calculate the importance of a normal mixing of saliva with 
the food upon the process of digestion, and know all the remote effects traceable to it, 
we must assume that that process is essential, and that the best interests of the body 
require its perfect performance. 
We may also suppose, and the supposition is proved to be true by clinical and per- 
sonal experience, that the well being of the individual requires that mastication be per- 
fectly performed, not simply for the mere reduction of food, but that insalivation may 
also be completely accomplished, and to that end both sides of the dental arches ought 
to be equally competent to perform their functions. 
A patient had lost all her right lower molars and all the upper teeth, and mastica- 
tion was accomplished entirely on the left side, between the molars and a plate worn 
above. There was an excessive development of the masticatory muscles of that side 
and a corresponding atrophy of those on the opposite side, the left masseter was more 
than twice as thick as the right, and this difference added to the sunken condition due 
to the loss of the right molars, caused the deformity of the face to be very marked. SECTION XVIII DENTAL AND ORAL SURGERY. 
677 
The patient objected to wearing a lower plate, so to partially correct the deformity, 
a large plumper was added to the right side of the upper plate. 
To supply the function of mastication, natural man was given thirty-two teeth, and 
so far as any one knows, that was what he needed. That no doubt included provision 
for not only the regular actual need, but somewhat in excess of that need, in order to 
supply certain extraordinary conditions incident to a savage life, yet only sufficiently in 
excess of the ordinary need to insure the health of all when not exercised to their 
greatest capacity. 
It is supposed that civilized man uses his teeth less than the savage; certainly he so 
prepares his .food that he may use them less; but perhaps it would be better to prepare 
the food with less reference to softness, and to use the teeth more. 
It also happens, as a general rule, that the teeth of civilized man are more subject 
to disease. It is not settled whether dental diseases are due to civilization, or happen 
merely to be coincident with civilization. 
I don't know that the new race of Americans, with their soit teeth, are more civil- 
ized than their hardy English and Scotch cousins, or that the peasantry of Normandy, 
with their notoriously bad teeth, are more highly civilized than the French nobility. 
Yet if civilization is the whole explanation (which I don't believe) we might turn our 
argument to prove that such were the case. • 
Because civilized man uses his teeth less than natural, savage man (it is a pure 
assumption that savage man is a more natural man than civilized man; the savage may 
be as degenerate a son as his so-called civilized brother), ought we to logically conclude 
that he ought to have fewer teeth, just enough, for instance, to preserve their health by 
actual use ? 
Some have assumed to answer this question affirmatively, and have extracted teeth. 
When the wisdom teeth were selected for extraction, the other teeth were not dis- 
tributed in their general relations or functions, and the features were not visibly 
deranged; even after all the second and third molars had been lost, the remaining teeth 
were undisturbed in their relations or functions, and the person might be able to divide 
his food sufficiently to enable it to reach the stomach, and if he had time to spare, or 
the food was made pultaceous by cooking, mastication would be sufficiently performed. 
To what point one might go on dropping off teeth from the end of the arches of a 
race of civilized men and the race not suffer, I do not know. 
We can't safely reduce this question to its lowest terms and say that civilized man 
needs just twenty-four or twenty-eight teeth, and no more, and remove the excess. 
It would be more logical to restore their use and proper exercise. 
Excepting for the gravest reasons to remove a tooth one must assume that all the 
biological relations between that tooth and all the surrounding parts are unimportant. 
But the size, shape and relations of the jaws to each other have to do with the num- 
ber of teeth that they contain and with the relation of the muscular attachment and 
nervous distribution. The position, form and size of glands are related to such forms 
and positions; so also is the size and shape of the jaws related to the general architec- 
ture of the face. 
One must assume that the (slight, perhaps, ) changed manifestations of action and 
reaction which would be exerted upon the entire machinery of the face are unimportant, 
and that the total derangement would not be disadvantageous to the whole body. 
It is to assume to know the means and ends of creation, and he no less surely 
sets himself up in the Creator's business, to become an unsuccessful rival to the 
Almighty. 
Civilized man may be thrown upon the same resources as savages. 
In wars, voyages of discovery, in famines and poverty incident to great public 
calamities, the hardships of civilized man may exceed those of savage man. 678 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
We see that although certain conditions of civilization would seem to render the 
possession of thirty-two teeth unnecessary, many contingencies are likely to arise (and 
possibly to any individual) when the functions of the teeth up to their full limit may 
need to be called into action. 
We see nature's abundance was limited in the supply of teeth to man, for while it 
is undoubtedly in excess of his ordinary needs, possibly to provide for such a misfortune 
as the accidental loss of a tooth, she was not sufficiently extravagant in the supply to 
provide against wholesale destruction of grinding surfaces, either by extraction or by 
excision of teeth; neither was she so extravagant as to supply a sufficient number of 
teeth to provide against widespread disease of these organs; nor did she provide for a 
third dentition after entire loss. 
Nature may do better at times if left to herself, 
I have not seen the teeth all lost before the age of twenty without man's aid, but by 
his hand, guided by his feeble brain, I have often seen the march of disease exceeded, 
and the jaws stripped bare of every tooth that had dared to erupt, and all before the 
age of sixteen years; but that does not prove that nature is prolific in tooth supply. 
In fact, prolific or extravagant supply of organs is everywhere denied, under the law 
of adaptation according to need. If an organ was evolved to meet a need, it was by 
such gradations that time entered in a proportion, that years were cyphers and ages 
only units of measurements, and evolving thus, there was permitted all those accessory 
developments of structure and functions in such relations that the equilibrium of the 
entire organism was maintained during the entire process of such an evolution. 
Where supply at first seems most prolific, and in excess of need in the provision for 
reproduction of the individuals of a species, perhaps only one out of ten thousand 
embryos of certain fishes develops to maturity. 
Why this excess of embryos? To meet the necessity of the great destruction to 
which the young of the species are exposed ; a lessened number of embryos would 
mean extermination of the species after a time. 
There is always a check in nature ; the fight for existence is a close one, and slight 
advantages determine the result. The fittest survive. 
No one knows that the teeth of man are becoming rudimentary, that they are 
undergoing suppression, under the law of natural selection. Any slight variations we 
may observe from the common type may be multiplied in future ages into a regular 
production, but the chances always are that these changes will be transitory, only 
enduring, at the most, for a few generations. 
They are merely as the ripples on the surface of the ever-varying but unchanging 
ocean. 
We find many abnormalities of teeth, both in man and in the lower animal, but there 
are few as compared with the number which sufficiently approach the type to be 
considered true. 
The wisdom tooth is at times suppressed, at others it is the lateral incisor, or it 
may be any other tooth ; and on the other hand, we have supernumeraty teeth appear- 
ing contemporaneously with either the first or second dentition, and occasionally a few 
teeth develop after all have been lost. 
It is doubtful if we have any good reason to consider the teeth of man as becoming 
rudimentary, öwf if they are rudimentary, they are still needed as rudiments to preserve the 
present functional adjustments of the organism, just as much as if they were fulfilling the 
highest functions of teeth and bound to a different organism by a stronger band of 
relationship. 
Rudimentary organs may point to lessened need, but to forcibly remove them, 
thinking them useless, would be to show one's ignorance of the relation of organs and 
of the forces which govern their development and final suppression. It would be to SECTION XVIII-DENTAL AND ORAL SURGERY. 
679 
derange the forces which are alone capable, in time (reckoned, perhaps, by ages), to 
prepare the remaining organs for the event of entire suppression. 
The importance of the loss of a tooth from the mastication point of view is not 
simply in proportion to the amount of grinding surface which it removes, unless this 
loss is at the end of the arch, as already instanced by loss of the wisdom tooth, but 
depends upon the total derangement which will be caused to the remaining teeth. 
For instance, loss of first molars removes a large share of grinding surface and causes 
much immediate disturbance of the function of mastication ; but all that is of slight 
importance compared with the effects produced upon the other teeth, such as the 
robbing of their support and loss of function due to their tipping out of relation. 
In many mouths the arrangement of the teeth is very imperfect; an extraction may 
ruin an articulation on the only side capable of perfect mastication. 
In another mouth the relation of surfaces may be defective forward of the second 
molars, and mastication is principally performed by the second and third. It is plain 
that the third molars in such a case are of unusual importance; but don't imagine that 
the first may as well be last as not, since it is not employed in mastication; for its sup- 
port is needed to preserve the relation of the second and third, and its loss would be 
disastrous by allowing those teeth to tip out of relation. Better to save the roots, even 
of the first molar, in such a case; for that will arrest the tipping of the others earlier 
than otherwise, and the root will protect the gums. 
In some the inner cusps of the bicuspids are short, and these teeth seem capable of 
little work, yet they support other teeth and preserve the contour of the arches in rela- 
tion to the typal plan of the features; whereas, their loss might cause the hooking 
inward of the lower incisors, or ugly spaces between upper incisors. 
I am forced to confess the belief that an enormous proportion of all the derange- 
ments of the articulation of teeth have been directly or indirectly caused by bad den- 
tistry-bad because opposed to the natural laws and forces governing the arrangement 
of the teeth. 
There is a tendency among dentists to classify cases and to formularize the princi- 
ples of practice into a series of set rules, and when a certain case presents, adapt the 
classification and rule they are accustomed to apply almost mechanically, without sub- 
jecting themselves to the trouble of a little special reasoning to exactly adapt the 
treatment to the case. The patient suffers from this plan in proportion as his case 
happens to differ in detail from the classified type. 
Authors must classify cases and treat of them in groups; the principles and laws of 
treatment may thus be communicated to all; but in practice the dentist deals with 
individuals, and not with groups; therefore he must not only consider the general laws 
in their general application, but he must also study and determine the fine variations 
of his case, and adapt the treatment accordingly, and he will be successful in propor- 
tion to the skill and judgment exercised in such adaptations. 
Some misunderstood my recent paper, and some misunderstand this, and I shall be 
called an extremist; and the reason was and will be that both papers, dealing mostly in 
principles, could not go down into all the details of special causes without confusing 
the idea of the reader and perhaps obscuring the main principles. 
Now, supposing a line of principles to have been established, one's practice should 
have a general correspondence to that line, but necessarily varies from the line according 
to conditions and circumstances not subject to the general laws. 
If these principles, then, might be represented by a straight line, their common- 
sense application to special cases by an intelligent dentist would be shown by a wavy 
line, always crossing and recrossing, but never varying far from the straight line. 
To plead for eclecticism because the principal line does not follow all the little 680 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
undulations of the special line, would be as absurd and unnecessary as would be the 
need of a direct statement that every dentist ought to possess common sense. 
While we must vary our practice to meet the minute needs of a case, we are liable 
to overstep our rightful limit of freedom, unless we so broaden our views as to include 
the higher laws which govern and which establish the main lines, along which we 
must follow. 
If a man's knowledge could be as broad as the universe and the laws that govern it, 
then he might cease making mistakes. 
The discussion was to have been opened by Dr. W. H. Atkinson, of New York. 
The President called upon Dr. Atkinson, who said: "In proof-reading, 
when we think we cannot improve a word, after marking it for correction, we write 
' Stet. ' I say, ' Let it stand. ' ' ' 
MANAGEMENT OF PULPLESS TEETH. 
The discussion of the paper read by Dr. Cravens, of Indianapolis, Ind., at the 
afternoon session of Tuesday, on the subject of the Management of Pulpless Teeth, 
was resumed, and the following paper was read :- 
ON THE CURABILITY OF PULPLESS AND ABSCESSED TEETH; 
MAINLY BY THE IMMEDIATE METHOD ; WITH STATISTICS 
OF THE CASES. 
SUR LA CURABILITÉ DES DENTS SANS PULPE ET ABCEDEES, PRINCIPALE- 
MENT PAR LA MÉTHODE IMMÉDIATE AVEC LA STATISTIQUE DES CAS. 
ÜBER DIE HEILBARKEIT PULPALOSER UND VEREITERTER ZÄHNE, HAUPTSÄCHLICH 
DURCH DIE UNMITTELBARE METHODE, NEBST STATISTIK DER FÄLLE. 
BY DR. GEO. CUNNINGHAM, 
Cambridge, England. 
The principal work which I wish to lay before this Section, and that to which I 
attach the most importance, is the statistics. In presenting a record of such a large 
number of cases, it is impossible for every one to examine them in detail. I shall now 
hand round among the members copies of the actual records from which the tables are 
prepared, so that they can have an opportunity of examining them, and may be con- 
vinced that the figures, carefully compiled from these records, have a reliable founda- 
tion and basis. The work has proved of a more Herculean nature than I had thought, 
and I may be excused for saying that I have not exhausted all the information deriv- 
able from the tabulated records, but that the present communication might be taken 
as an earnest of my sincerity and interest in the investigations. The relativity of the 
various teeth to the condition of being pulpless or abscessed was shown by these tables, 
but time will not permit of my now entering on that subject. The system on which 681 
the records were kept was embraced in a paper * I read before the American Dental 
Society of Europe, and has been employed for several years with success by myself and 
others. I should like to observe that when these cases were recorded I had not the 
slightest intention whatever of preparing a paper on this subject. The large detailed 
tabulations are simply the exact copies of the every-day record of each and every case 
as it came under notice. From the attention which the immediate method has recently 
received in the Cosmos and other American dental journals, and from the disbelief with 
which Dr. Craven's paper has been received, I am more glad than ever that I felt 
impelled to tabulate the results of this method and place it before this Section of the 
Ninth International Medical Congress. 
The troublesomeness, the tediousness and the disasters attending the treatment of 
pulpless and abscessed teeth were only too well known. The literature on the subject 
was so very extensive and the views expressed so very divergent, that a perusal of it 
was absolutely perplexing. Peculiarly interesting and severe cases had been reported 
in detail ; but no writer on the subject had yet given any general statistics illustrative 
of the results of ordinary practice. It would be only fair, however, to mention one 
exception, more especially as it was from the conviction carried by the clinical notes 
of these cases that I was induced to adopt the present line of treatment. It mainly 
arose out of a criticism of his book on "Dental Surgery," that Mr. A. Coleman pre- 
pared a paper which was read before a meeting of the British Dental Association, on 
October 14th, 1882. It wasapaper on the treatment of " dead teeth" (as he called them) 
by an antiseptic process. He says :- 
"Such cases may be briefly described as teeth in Which the whole, or nearly the 
whole, of the dental pulp has lost its vitality, and where the adjacent dentine, either 
through decomposition of the contents of the dentinal tubuli, or saturation with the 
septic fluids from the decomposed pulp, has become putrid and offensive, and, according 
to the degree of its putrescence, coupled with the state of health of the individual, 
more or less affects the cementum and its contiguous vascular membrane." 
Mr. Coleman, in describing the process which he recommended for the generality of 
such cases, says :- 
" After removing all the softened dentine and the contents of the pulp cavity, but 
not those of the fangs, and well syringing and drying, carbolic acid on cotton is placed 
in the pulp cavity and left there for a few minutes, the time being generally occupied 
while preparing the filling. This latter being made ready, the carbolic acid is then 
removed and the cavity again dried, and over the fine cavity or cavities, as the case 
may be, is placed a small disc of stout writing paper moistened with carbolic acid, on 
one side of which has been taken up the twentieth to the fifteenth of a grain of arsenic, 
this side being applied to the fang cavity. Over this zinc-oxychloride, as usually mixed 
for a filling, is placed, as much as nearly or quite fills up the pulp cavity ; and when 
this has set, the remainder of the cavity may be filled with any suitable filling. In the 
case of molars, and where it may be supposed there is any possibility of a second appli- 
cation of arsenic being necessary, I fill temporarily with gutta percha." 
Mr. Coleman then proceeded to give the records of a certain number of cases ; and 
it was from those cases being reported so fully that I had the confidence to adopt that 
operation. I must explain that my practice is in a university town, and I have there- 
fore a very peculiar practice-a constant succession of patients who come to me and 
then disappear. It must not be assumed that these patients necessarily went away 
because of the ill-effects of my treatment, but because they removed to other spheres 
on the conclusion of their academic career. I purpose making an effort to complete 
SECTION XVIII-DENTAL AND ORAL SURGERY. 
* " A Suggested System of Dental Notation for the Use of Dentists in Recording Operations." 
Dental Manufacturing Company, London. 682 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the history of those cases, and to get a much fuller report as to the cases which have 
not been reseen. As these proceedings would be reported in the English journals, I 
would appeal to the profession, when possible, to assist me in filling out the history of 
any cases I have reported, especially by sending me notice of my failures. The 
intractable nature of many patients had led me to endeavor to get over the difficulty, 
especially with these troublesome students, by treatment at the one sitting ; because 
otherwise, before the dressings had come to an end, the patient would have disap- 
peared. I could not make up my mind to continue what I considered at best a some- 
what filthy kind of practice. I was too strongly imbued with the training I had 
received in this country not to appreciate the fact that, contrary to what Mr. Coleman 
advised, before I did anything I should remove the contents of the pulp canals more or 
less thoroughly, and that any extra expenditure of time which this operation demanded 
would be well repaid. The consequence was that I have endeavored to make a com- 
promise between the two plans. 
I may say that in many instances in my practice the pulp canals have never been 
completely filled. A certain percentage of our fellow-practitioners, as was known from 
their own statement, did things perfectly; but a .great number did not do things per- 
fectly. I belong to the latter category. By referring to the diagram which I have 
drawn upon the blackboard, it may be seen that when I do not know to what extent 
the root or roots of the tooth were filled, I try to form some conception of it by means 
of a similar diagram in the case book. It is only in very rare cases, where the root 
canal is unusually patent, that we have found it necessary to extend the cleansing 
process to the immediate neighborhood of the apex of the root. All root canals which 
were found too small to admit a fine nerve bristle were left untouched. When we 
remember the frequency of curved and other irregular formations of the ends of the 
roots, it might be well to recognize the fact that the operative difficulties of complete 
removal to the very apex must often be insurmountable, and that from the danger of 
perforating the root at some other spot than the apex, there may be a danger in over- 
thoroughness of excavation. 
When I was on the Continent last year, visiting the German dental schools, I had 
the opportunity of inspecting the interesting school of Leipsic, under the care of Pro- 
fessor Hesse. We very quickly found out that each was anxious to communicate 
something of importance to the other, and that was as to the immediate treatment of 
teeth. Professor Hesse was carrying out that system in his school, and was doing so 
with success. 
The present record of cases treated by the immediate method went back as far as 
the earliest part of 1883, soon after the publication of Mr. Coleman's paper. Before 
discussing the record, I would call your attention to one case in particular. I was 
going to operate for a personal friend, and having put on the rubber dam, I had just 
removed a zinc phosphate filling from the superior right second bicuspid, thereby expos- 
ing the putrescent pulp, and was about to clear out the carious cavity, when a very 
urgent message came to me from another patient. The gentleman on whom I was 
operating said he would take it as a favor if I would attend to the message and let him 
go. I did so, after removing the rubber dam, without even inserting a dressing, so you 
can imagine my surprise when he appeared next day with as big a face as any I have 
ever seen in the whole course of my professional experience. If a filling or even a 
dressing had been inserted, I would have ascribed this condition to the occluding and 
shutting up of the putrid matter. As it could not possibly be due to that, this case 
seems to indicate that the sudden development of a so-called blind abscess into an acute 
one is not necessarily due to the occlusion of the root canal, nor to the passage of putrid 
débris beyond the apex of the root. 
As my friend was an eager experimentalist, he encouraged me to carry the test of SECTION XVIII DENTAL AND ORAL SURGERY. 
683 
the immediate method further than I had hitherto ever dared. On November 8th, 
1884, the second day after the removal of the stopping, while the abscess was in this 
acute stage and the face much swollen, I applied the rubber dam, cleansed the cavity 
and root canals, inserted a minute dressing of arsenious acid and oil of cloves, and filled 
each root canal with zinc oxychloride, finishing the main cavity with Ash's phosphate 
cement. After removing the rubber dam, the gum was lanced. The case progressed 
favorably, and the tooth has never given any subsequent trouble. 
The various agents employed under the dressing method were eucalyptus oil, the 
same combined with iodoform, creasote and iodoform, oil of cloves, carbolized resin, 
tincture of aconite, and oxychloride of zinc. The tables show a record of 122 teeth so 
treated-the majority of them (seventy-four) having been treated with eucalyptus oil 
or with eucalyptus and iodoform. The number of extractions which I was obliged to 
make in those cases was six-a percentage of 4.918. I do not claim that as the total 
percentage of teeth extracted under the dressing method, because I am sure that there 
was a certain number of cases the further history of which had been lost, and which, no 
doubt, included several extractions. But at the same time, that figure, small as it is, 
would be sufficient for the purposes of comparison with the results of the other method. 
The next thing which had been noted was the number of subsequent occasions when 
the patient had returned, generally in the course of having other teeth treated, com- 
plaining of slight inflammation of the periosteum. This number was thirty-six, or a 
percentage of 29.5 ; while the number of subsequent swollen faces and abscesses was 
thirty-two, or a percentage of 26.2. The next point of importance noted was the num- 
ber of permanent stoppings inserted at the time of filling the root canals. It was found 
that in the years 1883-4 there were only two such out of thirty-eight cases, or a per- 
centage of 5.26. 
In the course of the immediate method, the first dressings employed were arsenious 
acid and oil of cloves. The modification of Mr. Coleman's plan, which I adopted, was 
simply to take the merest shred of cotton wool on a fine nerve bristle, the difficulty 
being to get this shred small enough. I am ready to admit that even this amount of 
cotton wool was a disadvantage, but I had not found anything which would do better 
as a vehicle. Having dipped the wool in oil of cloves, I simply touched the end with 
the smallest possible portion of arsenious acid, and carried it up as nearly as I thought 
it safe to go in the direction of the apex of the root. Finding that that was occasionally 
an unsatisfactory method in other hands, I feel that I ought to give a warning and a cau- 
tion about it. I have the incomplete and careless records of one assistant, who acted as 
locum tenens for a time-an otherwise able man, who contributed to the literature of the 
profession, and who thought he knew all about this treatment at once. If I were to 
collate the extractionsand the extensive necroses which followed that assistant's treat- 
ment, the members would certainly condemn this use of arsenious acid ; but, in the 
proportions which Mr. Coleman had advised as quite permissible in the pulp cavity (a 
few milligrammes), the amount was so small that no deleterious results followed. It 
was evident that too large a proportion of arsenious acid had been used, and in 
several cases I found that the root had been perforated and the dressing forced 
beyond the opening. The results which followed were only what might have been 
expected from such careless and reckless manipulation. It was impossible to make out 
a record of the locum tenens above referred to, as he had failed to inscribe the necessary 
data, evidently thinking that such a tax on his time was superfluous. In none of the 
cases treated by my brother or myself has there been, so far as I know, a single case of loss 
of a tooth due to an overdose of the arsenious acid. Not from any failure by the employ- 
ment of the first method, but in an endeavor to adopt a more exact method, I next 
employed a solution of arsenious acid in glycerine. By careful and prolonged manipu- 
lation over a sand or water bath, I made a one per cent, solution, which answered admi- 684 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
rably, and has been very favorably commented on by several other practitioners who 
have used it. My brother got a chemist to make up for him a solution of arsenious 
acid in alcohol, with oil of cloves, which formed a two per cent, solution.* After a time 
it was desired to test the efficacy of bichloride of mercury in this method, and, there- 
fore, a solution of one in one thousand had been employed in forty-five cases, and another 
of one in one hundred in seventy-five cases. The one per cent, solution of arsenious 
acid had been employedin 165 cases. Eucalyptus oil, I am confident, would also prove 
efficient; while eucalyptus oil in combination with iodoform and oil of cloves had been 
used in a few cases. I have also tried dressings of a mouth wash, consisting of thymol, 
benzoic acid and tincture of eucalyptus in water, which was published as emanating 
from Professor Miller, of Berlin, in one or two cases. 
In order to prevent possibly erroneous conclusions from these facts, it may be well 
to state that the decision to employ the mercuric chloride in place of the arsenious acid 
was not arrived at from any dissatisfaction with the latter, but from a recognition of the 
enormously greater power of the former over the latter as an antiseptic and germicide. 
Indeed, while I was trying the mercuric chloride, the use of arsenious acid was continued 
both by my brother and an assistant. 
The mode of use of the mercuric chloride is very simple. After the preparation of 
the root canals, they are well syringed out several times with the one per cent, solution. 
During the preparation of the instruments, the zinc oxychloride and the cotton wool 
dressings for carrying the latter well into the root, the canals are left soaking in the 
solution. The excess only is then absorbed, thus leaving the walls of the canals moist, 
a matter of some importance, as if they are wet the zinc oxychloride will penetrate 
further into the finest canals than if they are dry. The addition of mercuric chloride 
to the first oxychloride mixture is no disadvantage, but is possibly unnecessary. 
In the absence of any generally recognized scientific classification of pulpless and 
abscessed teeth, these cases have been tabulated under three distinct conditions, viz. :- 
(a) Those where the pulp was removed at the time in a fairly healthy or non- 
putrescent condition. 
(ö) Those where the pulp, or what remained of it, was in a putrid state, including, 
therefore, all cases of so-called blind abscess. 
(c) Those where a fistulous opening indicated with certainty the presence of an 
apical abscess. 
Out of a total number of 512 teeth treated by the immediate method, the total 
number of known extractions was three. Two of these had been marked at the time 
before beginning, the operation as " forlorn hope," and one of them was removed partly 
for artificial work. The tooth was loose. My assistant had made a very pardonable 
mistake. It was a left superior bicuspid with that rather uncommon abnormality a 
bayonet-shaped root. After its extraction, it was found that in drilling out the root 
canal the instrument had perforated the root just at the bend, and the arsenical clove 
dressing was found protruding through this perforation, thus setting up a chronic 
periodontitis, whether by acting as a mechanical or a chemical irritant, but not improb- 
ably as both, is uncertain. One tooth which had been extracted has not been included 
in this list, for the following obvious reason. On 19th November, 1884, my brother 
treated and filled with the arsenious acid and oil of cloves and phosphate cement a 
iS Lt. Acid, arsenios gr. ij 
Sp. vini rect 5j 
01. caryoph gj 
Misce. 
If the arsenious acid does not dissolve at once, it will do so in time. Gentle heat over a sand bath 
will promote solution. SECTION XVIII-DENTAL AND ORAL SURGERY. 
685 
right upper lateral incisor, for a lady student at Newnham College, and on 5th Feb- 
ruary, 1885, he filled the tooth permanently with gold. On the 25th June, 1886, 
whether by over-study, by excess of exercise, or from what cause we know not, the 
hitherto absent right upper canine tooth was erupted directly over the lateral incisor. 
It therefore became necessary to sacrifice one tooth or the other, and it was deemed 
better to extract the lateral incisor. Under these circumstances, it would be an error 
to include that extraction as coming among these cases. 
The next point to which I would call your attention is the number of subsequent 
cases of slight periostitis calling for treatment under this immediate method. My 
record shows six cases as against thirty-six under the dressing method, or a percentage 
of 1.152, as against a percentage of 29.5. Under the immediate method, the number 
of cases of swellings and abscesses treated subsequently was five, or a percentage of 
.976 as against thirty-two, or a percentage of 26.2. I do not ask members to take these 
percentages as absolutely exact ; but as they were calculated from tables in which both 
methods had been recorded with equal faithfulness, so far as statistics went, they 
represented faithfully the relative advantages of these two distinct methods of treat- 
ment. There was no partiality or favor shown to the one system more than to the 
other. Under the dressing system, in 1883-4, only two teeth out of thirty-eight, or a 
percentage of 5.26, had been permanently stopped at the time of filling the root canals ; 
whereas, under the immediate method, in 1886-7, sixty-one teeth out of 150, or a per- 
centage of 40.66, had been permanently filled at once. That surely showed in the most 
emphatic manner the gradual conviction to which I have come as to the results 
obtained by the immediate method in my practice. The rubber dam was recorded as 
having been used in 200 out of 270 cases, or in about 75 per cent, for the immediate 
treatment, and in 52 cases out of 153, or about 33 per cent, for the dressing method. 
In order to give some idea as to the number of cases which I have seen again, my 
records are not fully made up ; but in one case book, out of a total of 114 cases, 70 of 
them had been seen again ; in another, out of 109 cases, 66 ; and in a third, out of 49 
cases, 40. I believe, therefore, that the extractions under the immediate method (taking 
into consideration the number of cases seen again, and making a libera] allowance for 
the patients who have consulted some other practitioner) have not exceeded 2 per cent. 
Making a still larger allowance for the patients in pain who have sought other advice 
in cases of subsequent acute periodontitis, I should say that the number was about 3 
per cent., but possibly less. 
The success of the operations seemed mainly to depend on the old axiom, Sublata 
causa, tollitur effectus. No observant practitioner can have failed to notice the inherent 
curability of numbers of abscessed teeth. Who has not noticed the frequency of cica- 
tricial tissue marking the existence of former fistulous tracks, even where the 
putrefactive contents had been allowed to remain ? It was to this inherent property 
of spontaneous curability that we look for the relief and cure of all the inj urious con- 
ditions arising from a putrescently diseased pulp. In my opinion the best mode of 
sterilization for infected dentine is excavation; therefore I use the nerve drill freely 
where the presence of microorganisms is suspected. By removing the greater part of 
the diseased tissue, even although the naked eye might not be able to detect the existence 
of any diseased process accompanied by microorganisms, they might fairly anticipate 
that the strife between diseased processes and healthy action would come to an end. 
If the general condition of the individual was good, such a case would probably have a 
favorable termination. Is it not possible that the pathogenic functions of microorgan- 
isms in these conditions are exaggerated ? It should be remembered that many of 
these organisms found in the mouth and tooth cavities were non-pathogenic. Certainly 
a large number, if not the majority of recorded cases, could be treated by the removal 
of all fairly accessible degenerated pulp tissue and infected dentine; and that, with the 686 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
complete occlusion of the cavity, would result in a cure (unless there was a distinct 
discharge of pus from the apex, or unless a fistulous track was present). The 
impossibility of diagnosing with any absolute certainty the existence of an abscess sac 
at the apex of the root had to be recognized. On the occlusion of the pulp canal or 
canals of such a tooth, a slight amount of subsequent inflammation should be regarded 
rather as an aid than as an obstacle in the complete removal of the existing conditions, 
while a more acute inflammation would ultimately promote the complete absorption 
and removal of any old existing inflammatory product. In a large number of cases it is 
probable that merely a quiescent condition is established. The pain and constitutional 
disturbances arising in the more severe cases of inflammation might be successfully 
combated by the employment of local counter-irritants, and depletion aided by aperi- 
ents and the internal administration of some such drug as quinine, which possessed the 
power of diminishing the activity of the inflammatory process-whether by checking 
the activity of the cells, by diminishing the exudation, or by reason of the oxidation 
process, I do not know. But I can vouch for its extreme use and benefit in those 
conditions; and I can also vouch for the subsequent gratitude of patients (when they 
got into a state of despair) to thé dentist for such remedy, instead of meekly yielding 
to the not unnatural desire for extraction. 
In the majority of cases the inflammatory process was so slight as to pass unnoticed, 
or was not excited at all ; and yet the existence of an abscess sac might be assumed as 
being present in many of them. In most cases it might be anticipated that either the 
walls of the sac adhered and became united together, or that the contents gradually 
dried up and became converted into a caseous mass, in which state it was absolutely 
innocuous and perfectly harmless, remaining where it was. 
In the very small number of cases where the diseased condition persisted, resort 
might be had to the heroic treatment by the burring of the necrosed part of the root 
and alveolus, or by the injection of aromatic sulphuric acid into the diseased part. In 
several cases, where extensive excavations of the alveolus had occurred, it might be 
assumed, from their healing so rapidly, that granulation tissue had formed in the inte- 
rior of the sac, followed by a gradual contraction of the newly-formed tissue, convert- 
ing it into a small knot of old cicatrized fibrous tissue. 
I believe that the operation called rhizodontrophy and the insertion of a drainage 
tube within the tooth were unnecessary. Rhizodontrophy might afford a temporary 
and convenient relief to the patient, and (should I say it?) to the busy operator; but 
in several cases I have seen it result in a renewal of the abscess, or in the loss of the 
tooth. 
Finally, no matter how much these suggestions as to the pathological conditions of 
pulpless and abscessed teeth and the changes produced by treatment might be subject 
of debate, there could be no question as to the silent eloquence of the facts showing the 
results of treatment as set forth in the statistics of cases which I have presented. 
Contrasting, then, the relative advantages of the dressing method as compared with 
the immediate method of treatment, I am led to the following conclusions:- 
1. That under the immediate method there were fewer extractions and failures. 
2. That there were fewer subsequent attacks accompanied by swellings and acute 
abscess, and therefore the immediate treatment was attended with less pain. 
3. That it required a considerably less expenditure of time on the part of both the 
patient and operator, the average time of treating and filling such teeth being consider- 
ably under an hour. 
4. That in consequence of these considerations, we were able to treat and were able 
to save more desperate cases, many of the cases mentioned in the record having large 
perforations of the roots, while others had been already condemned by other practition- 
ers as utterly hopeless. SECTION XVIII-DENTAL AND ORAL SURGERY. 
687 
5. That method, rather than medicine, had a good deal to do with the results, and 
that probably the operation would have succeeded equally well in a very large number 
of cases without any medicine whatever. 
6. That, from the difficulty of diagnosing such cases, it is better to conduct every 
operation with all antiseptic precautions. 
7. That casualties, such as perforation of the root, under the immediate method of 
treatment, had been fewer, probably because of the less complete removal of the con- 
tents of the root canals. 
Conscious, as I am, of the incompleteness of the record in some respects, I hope at 
some future time to complete the work, and meanwhile present a few actual tracings 
from my case book, some of them showing desperate cases where I scarcely anticipated 
success, and which I could only treat, either in justice to my patient or with satisfac- 
tion to myself, by the immediate method. 
STATISTICS OF THE CURABILITY OF PULPLESS AND ABSCESSED TEETH BY THE 
DRESSING AND THE IMMEDIATE METHODS, 1882-87. 
Total Number of Cases. 
Percentage. 
Dressing. 
Immediate. 
Dressing. 
Immediate. 
All root canals cleansed, treated antiseptically, 
and filled with oxychloride of zinc {in most 
cases 
122 
512 
100 
100 
Cases requiring subsequent treatment:- 
1. For slight periostitis 
36 
3 
29.5 
1.15 
2. For swelling or abscess 
32 
5 
26.2 
0.97 
3. By extraction * 
6 
3 
4.91 
0.58 
Cases compared in equal periods of 
1833-84 
1886-87 
1883-81 
1886-87 
Total Number 
38 
150 
ICO 
100 
Number of these in which permanent fillings 
immediately followed 
2 
61 
5.26 
40.66 
* These figures do not include all the extractions under either method, as no doubt others were ex- 
tracted by other hands, but the results are fairly comparable, since the conditions were identical in both 
periods. 
DISCUSSION. 
Dr. E. C. Kirk, of Philadelphia, related a case in which, some fourteen years 
ago, he had filled a root canal with chloride of zinc. He did not know then what the 
result would be, but the patient was leaving town, and did not get back for three 
months. After he got back, he (Dr. Kirk) dodged him for a week, as he was afraid 
to see him; but when he did see him, the man had nothing for him but commenda- 
tion for the work done, which, he said, had given him perfect satisfaction. The 
same morning he (Kirk) found his bootblack with a swollen face, and he took him 
into his office and treated him in a similar manner. He got him to come to his office 
daily, so that he might watch the effect of the operation, and he found that the 
result was good. For ten years he had practiced that, under the full belief that it 
was chloride of zinc that was curing his cases. Then the gutta-percha filling came 
into vogue and he learned of it, and commenced filling with that. Then he filled 
with gutta-percha without any treatment. He had a record of all these cases, 
and the results were good. Occasionally some of his patients had a swollen 688 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
face, but he defied any man who treated with disinfectants to say that he did not 
have such cases. He filled the apex of a root often with a small piece of gutta- 
percha, and washed it sometimes with alcohol, often using dry air. A nerve canal 
which was large enough to be enlarged did not need enlargement, and he would say, 
" Keep your drills out of nerve canals." 
Dr. W. B. Ames, of Chicago, said that he wished to state a method which he 
had been using about five years, in the management of those cases where it was abso- 
lutely necessary that the pulp canal should be immediately filled. The advisability 
of immediately filling pulp canals depended upon the possibility of thoroughly disin- 
fecting, and thoroughly removing the contents of the pulp canal; and that depended 
a great deal on the accessibility and size of the canal. He had practiced a process 
by which he thought he could more readily disinfect the canal than by any other 
process he could imagine; and that was by decomposing the contents of the canal, 
through means of an electric process. He placed his electrode in such a way as to 
thoroughly decompose the contents of the canal if they were fluid, and, if they were 
not fluid, the canal was saturated with a solution, or with ordinary water; and, by 
passing a very fine platinum probe up to the apex of the root, or nearly so, he could 
thoroughly decompose the contents of the canal, breaking up the pus. After he 
had passed the electrode to the point of the root, thoroughly disinfecting it, he 
could go on with his reamers with impunity. 
Dr. William Conrad, of St. Louis, expressed his thanks that the subject had 
been brought up at the present time, and that this last session of the Section should 
be made memorable by it. In answer to a request from the clinic committee, he had 
written that he would give a clinic on the immediate treatment of root canals, and 
asked for a date when he was to offer it. The committee had asked him if he had a 
patient, and he had written to the committee to select a patient for him. He did not 
care where or how they got the patient. He had perfect confidence in the treatment, 
and, as Dr. Cunningham had said, great confidence was gained by the frequent repe- 
tition of this treatment. In the treatment of these roots he used peroxide of 
hydrogen. 
Dr. A. E. Baldwin, of Chicago, said : Mr. President and Gentlemen, as the 
President stated at the beginning of this session that we would be reported just as 
we spoke, and wanting to say just what I mean, I have jotted down the notes of 
what I desire to say on this subject. Unfortunately for myself I did not hear all of 
Dr. Craven's paper. Some of the statements made in the portion I did hear were 
new to me, and others were different from the ideas held by me, and which seem cor- 
rect to me. I do not object to, but rather favor, in many cases, the immediate fill- 
ing of roots ; and, in most cases of blind abscesses where soreness is not present, I 
immediately fill them, provided I can get thorough dryness at the apical foramen 
and in root canals. Where any treatment is necessary, I think that better results 
can be obtained from outside. In all cases, my rule is to fill immediately if the above 
conditions are present or can be obtained. I fear the microorganisms less than does 
Dr. Barrett, and I take direct issue as to the correctness of his positive statement 
(as I understood him) that microorganisms must be present in the formation of pus 
-that is, using the statement in the sense that microorganisms can be removed by 
the use of germicides ; and I here affirm my belief that, in many cases, more harm 
than good is caused by the use of these many medicinal agents, such as germicides, 
etc. 
In regard to the record of cases presented to-night by our esteemed guest, Dr. SECTION XVIII DENTAL AND ORAL SURGERY. 
689 
George Cunningham, of England, I was greatly interested in his remarks, and feel 
that the very careful record made by him will do us much good. I am free to say 
that, in this democratic country, and especially in a scientific gathering like this, each 
man's thoughts and opinions should be respected, and credit for honesty and ordi- 
nary good sense should be given to every one on our floor. We assume that all 
recognize the fact that ridicule is not discussion, nor are sneering remarks in regard 
to the scholarly attainments of the writers of papers or of those who discuss them. 
We believe that such remarks reflect more on the speaker than on the one criticised; 
and, as was stated the other day, such a means of discussion has a strong tendency 
to keep the young men in the background and to make them feel that progress is 
not to be expected of them. When two gentlemen took that method the other day 
to discuss Dr. Craven's paper and, under the guise of discussion of the paper, 
stooped to use such language, their action was neither professional nor gentlemanly. 
But, as Dr. Barrett said on that occasion, "nothing personal is intended." 
Dr. Geo. D. Sitherwood, of Bloomington, Illinois, said that he wanted to 
express his gratification and his pleasure at hearing the statements made by his 
friend across the water (Dr. Cunningham). It had been his (Dr. Sitherwood's) prac- 
tice for some six years to fill root canals at a single sitting, where it was possible ; 
and, like his friend, Dr. Cunningham, he had not hurt his patients. He was a firm 
believer in the theory that success depended almost entirely on a thorough cleansing, 
and on using such medicines as a germicide that there might be nothing left. If he 
found a failure in this practice, he simply looked at the preparation which he was 
using as a germicide and changed it and made a new preparation, and then success 
was the same as before. He had comparatively no failures. Of course, every man 
was left to his own judgment in the matter, but he supposed that, at this time, all 
dentists filled root canals at a single sitting. 
Dr. J. C. Storey, of Texas, said that the very great success of many practitioners 
with the great variety of treatment which he had heard of here to-night confirmed 
him in the opinion that it made very little difference whether the root canal was 
filled at all or not, provided it was cleaned out thoroughly, and that there was nothing 
left in it to be decomposed. He presumed that he had filled nearly as many teeth as 
any man present. He did not want any drills run in. He did not care much about 
whether he got any matter out or not. He was satisfied that, in a practice of twenty 
years, his success was about equal to that of the average dentist. Some patients did 
not come back to him, but whether they went to the other fellow or not he did not 
know. He did not believe they did. He did not have many cases of swollen faces, 
nor many cases of periostitis. If he had a blind abscess, he brought it at once to 
light by plunging an instrument into the root of the tooth, and he filled the root 
up when he could. But where there was no abscess he did not care whether he filled 
the root or not. 
Dr. Stack, of Dublin, Ireland, said that the American people were so educated 
to the proper treatment of their teeth that it was comparatively rare in this country 
to find that teeth were so neglected as teeth were which came into the hands of 
British or Irish dentists. The dentist who said that he had very seldom a swollen 
face in his practice went far beyond anything which he (Stack) had seen in his own 
country. As to the remarks of Dr. Cunningham, they appeared to him to be a great 
heresy; but, at the same time, Dr. Cunningham had brought forward very con- 
vincing statistics, very carefully kept, and had given strong reasons for the faith 
which was in him, and until he (Dr. Stack) had tried further this method of treat- 
Vol. V-44 690 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ment, he would not be the person to raise a stone against Dr. Cunningham. As 
dentistry was practiced in America, and as the American people were infinitely better 
educated and more appreciative of the services of dentistry than the people in his 
countiy, he did not think that the American dentists were, perhaps, fair judges of 
this question of difference in treatment. 
Dr. J. E. Cravens, of Indianapolis, Ind., said: I desire to thank Dr. Fille- 
brown for the fair, scholarly and gentlemanly manner in which he discussed my 
paper on the management of pulpless teeth. Some points in Dr. Fillebrown's 
remarks demand reply. In the essay I said : "If at time of presentation a tooth is 
too sore to admit of the operation of the opening of the pulp cavity for initial relief, 
the policy of waiting for a favorable decline of soreness is always preferable and 
better than attempting to force a conclusion by medication, and, in the end, is really 
more expeditious. ' ' 
I insist that cases are presented so sore that any manipulation whatever is out of 
the question-at least, it is so for me. In such cases, where I have to refer the 
patient back and to wait, I give him instructions by which he can reduce the inflam- 
mation and either dispel or modify the pain. Then the patient can return as soon 
as the tooth is ready for manipulation, and the pulp cavity can be opened. It is not 
necessary to wait very long for that. I am not at all afraid of this bugaboo of septic 
condition being kept up in the pulp cavity. The term " apical space, " which is 
objected to by Dr. Fillebrown, has become so fixed, apparently, in dental nomencla- 
ture that I find it easier to employ it than to dispose of it; and, therefore, I used it. 
Now, in regard to the various points brought up in the discussion-as, for instance, 
that I had failed to say what should be done with imperforable pulp canals : An 
essay on this subject is necessarily lengthy, and to have attempted to embrace 
every possible condition or complication of pulpless teeth would have occupied too 
much of the time of this Section, and too much space in the printed Transactions. 
I recognize that there may be canals sometimes too slender to admit of filling with 
foil or with any solid; but if such canals can be explored at all they can be easily and 
effectively stopped throughout, by introducing shellac varnish with a suitable bristle, 
cut from a brush; and the bristle should be left in the canal permanently. Neither 
the shellac varnish nor the bristle should be forced beyond the usual constriction 
near the apex. My rule is always to stop at the constriction if I can find it, and 
I nearly always can find one. That is the point of safety. Dr. Fillebrown objects 
to my remarks about phosphate of lime, because I said that the roots of deciduous 
teeth might be filled with phosphate of lime, and because I also said that no medi- 
cine was used. He took exception to that because, he says that phosphate of 
lime is a medicine. But phosphate of lime is not always a medicine. If Dr. 
Fillebrown were to ask his cook whether she put any medicine in his biscuit she 
would probably reply: " No, sir; I put in nothing but a little salt and baking pow- 
der, save a bit of lard." When employed in the filling of pulp canals in roots of 
deciduous teeth, phosphate of lime first answers a mechanical purpose as a stopping; 
secondly, the magma is soluble to the same degree as dentine; while the originally 
dry and insoluble phosphate, if used to thicken the magma, for the purpose of 
manipulation, will be easily shifted and stowed to accommodate the physical 
demands of the organ of resorption, and thus the process of resorption may not be 
interfered with. The subject for my essay was a sort of inspiration, caused directly 
by reading a monograph on this subject purporting to emanate from, or under 
the sanction of the Odontological Society of Chicago. I was quite aware that 
the reading of the essay would be followed by a storm, because when a man has been SECTION XVIII-DENTAL AND ORAL SURGERY. 
691 
successfully advertised before the profession as an eminent therapeutist, and the 
prophet of new remedies, or as an author on pathology, physiology, embryology, etc., 
he does not tamely submit when he sees the mountain of special greatness which he 
has reared about to be razeed to the level of ordinary events. 
In closing I ask not more than a fair trial of the method presented in the essay, 
with a warning that it requires some courage to pursue such a practice in the first 
few cases. Afterward it will be easy enough. 
The following paper was read by title, on the subject of- 
IMPLANTATION AND PERICEMENTAL LIFE. 
IMPLANTATION, OU LA VIE PÉRICIMENTALE. 
IMPLANTATION UND PERICEMENTALES LEBEN. 
BY W. J. YOUNGER, M.D., 
Of San Francisco, Cal. 
By implantation, I mean that operation which consists in forming an artificial socket 
in an alveolar process that is edentulous, either from the long loss of the tooth or when 
it is virgin from non-development of one. I have applied this term to the operation 
not only on account of its fitting etymology, hut to distinguish it from the kindred 
operations of replantation and transplantation. 
The reasons that led me to try the operation have heen so fully stated in my brochures 
on the subject, and in excerpts and articles in medical, dental and literary journals, as 
also in the public press, that I think it unnecessary to present to you here the same 
thing again in detail. But, as some of our brethren from abroad may not have seen 
these articles, I shall, with your permission, epitomize what I have already written. 
To begin:- 
I concluded that transplantation had been generally a failure, from one or all of the 
following causes:- 
1. The use of improper or unhealthy teeth; 
2. Because the pulp was not removed, nor the pulp chamber and root canal perfectly 
cleansed and filled to the apex; 
3. Want of cleanliness and antiseptic treatment ; 
4. Want of sufficient pericementum on the root ; 
5. Because the socket into which the root was planted was not in a sufficiently healthy 
condition. 
Therefore, in commencing this operation, I was careful to select only healthy teeth 
from sound subjects, filled the pulp chamber and root canal, finished at the apex with 
gold or tin, used only those teeth that had enough of the peridental membrane to secure 
firm attachment, was careful to bathe the tooth and socket and the instruments used, as 
well as my hands and those of my assistants, in some sterilizing solution, as corrosive 
sublimate, 1 to 1000 water, to guard against septic trouble, and when the socket was 
diseased, treated it until it became healthy, keeping the walls from collapsing by the 
use of an artificial root made of shellac. 
When I commenced transplantation, finding the teeth often larger than the 692 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sockets, I reduced the roots to fit the cavity, always preserving, however, sufficient 
pericementum to insure attachment. At that time I believed in a periosteum, lining 
the alveoli, necessary for its preservation and to insure attachment with the root. Reflec- 
tion convinced me that this practice was bad, because it exposed the denuded portion of the 
root to the danger of erosion and subsequent resorption ; and reasoning from the results of 
the experiments of John Hunter, verified by my own, in planting teeth in cocks' combs, 
that the pericementum would attach itself to any vascular substance, and, therefore, 
to a socket bared of periosteum, I changed my practice, and thereafter cut away from 
the socket instead, and shaped it to fit the root. I found that the root attached itself to 
the abraded portion of the socket as readily as to that which had been left intact. This 
led me to the conclusion that an artificial socket could be formed in the alveolus, and a 
tooth planted therein, with the same successful result as that of an ordinary transplanta- 
tion. At last a person was found who would submit to the experiment, and on the 17th 
of June, 1885, I performed my first operation of implantation, and it was successsful. 
Since then I have repeated this operation about two hundred times. I have had, so 
far, about twenty failures, the causes of which are known, are independent of, and 
therefore should not be used to the prejudice of the operation; because these failures 
were often due to wanton carelessness on the part of the patient, include experiments 
where little hope for ultimate success was entertained, and those made to simply illus- 
trate the operation. 
When teeth had been loosened by tartar and the pericementum destroyed, and 
when other teeth could not be made to match, the crown of the loosened root was sawed 
off, the sound root of another tooth made firm to it and inserted. In sockets where 
teeth were loosened by tartar, the bone of the socket was scraped by a chisel, and the 
fleshy part abraded by ammonia on cotton, wiped rapidly around the socket, and imme- 
diately after rinsed out with copious injections of tepid water. Thus a fresh, healthy, 
granulating surface was induced throughout the whole extent of the socket. 
The greatest difficulty was to obtain teeth, believing at the time that it was abso- 
lutely necessary they should be freslily drawn. On the other hand, good teeth had 
often to be extracted, and were wasted for want of an opportunity for immediate trans 
plantation. Finally, I hit upon the expedient of preserving their vitality by planting 
them in cocks' combs; but would they stand another operation and be made useful in 
the human mouth ? On November 28thr 1882, a bicuspid that had been in a cock's comb 
for ten days was transferred to the mouth of a gentleman, where it fastened itself as 
though there had been no gallinaceous period in its existence. But keeping teeth in 
cocks' combs was exceedingly troublesome. 
One day, in looking at a bicuspid that had been extracted for over thirteen months, 
the idea occurred to me that perhaps, in that dry, shriveled membrane surrounding 
the root, there lurked a dormant vitality, which, under favorable circumstances, might 
rouse its energies and make the tooth it invested again a living, useful organ. So, on 
the 11th of March, 1886, this tooth, after being well soaked in warm water to soften 
the membrane, was implanted. The result verified my hope. Not only did the tooth 
become firm in the socket, but the encircling gum attached itself to the membrane 
around the neck, proving that it was a living union and not a mechanical adaptation 
that held the tooth in position. Thereafter, the comb of the troublesome cock was dis- 
carded and the teeth simply laid aside for future use. 
Feeling that the profession refused confidence in the operation from a misunderstand- 
ing of the nature of the tooth and alveolar process and their relations to one another; 
that they were led astray in their judgment by the belief that a periosteum formed and 
lined the socket and was necessary for the attachment oFa tooth. That a socket formed 
by violence did not possess this necessary membrane, and that, therefore, physiological 
union was impossible. That the tooth so implanted might become firm for a while, in SECTION XVIII-DENTAL AND ORAL SURGERY. 
693 
consequence of the deposition of cicatricial tissue around it, which would penetrate 
into the lacunae and canaliculi of the cementum, and would even fill the cavities formed 
by erosive action, instituted by the offended alveolus, to destroy and get rid of the 
intruder. That this apparent firmness was, therefore, only a mechanical consequence 
that would last until the inevitable result ensued, resorption of the root and the 
tumbling off of the crown. 
I argued, that in the natural process of eruption, it was the impaction of the dense 
crown upon the softer alveolus, in the developmental force of growth and afterward on 
the gum, that induced the absorption of these tissues and enabled the tooth to assume 
its designed position. That the crown being wider than its continuation when it was 
erupted, left a space between the cavity thus formed and the body of the tooth, which 
was filled up from the walls of the cavity. 
That this showed that there was no periosteum engaged in or present in the forma- 
tion of the socket, and that the filling up of this space was due to the proliferation of 
osseous material from the endosteum, which is the delicate continuation of the perios- 
teum in the interstices, or, in other words, the lacunæ and canaliculi of bone, and 
having all the functions of the mother membrane. That this also showed the power of 
reparation in the alveolus, and was, doubtless, the way all bones repaired their injuries 
at points remote from the periosteum. 
That the formation of the socket in the physiological process was, in this view, as 
much a violence as that produced by instrumental means, and that at the time the 
tooth stood in this space, formed by the eruptive crown, the condition of at least a large 
portion of the walls of the socket and the relation of that tooth to the socket, was 
identical with that existing in a tooth just implanted, and that the alveolus, having no 
special intelligence of its own and being existent for the sole purpose of bearing teeth, 
adopted the new comer with the same avidity and as naturally as it did that organ 
developed in its own structure. That the operation was consequently within the realms 
of physiological action and success therefore assured on scientific principles. That a 
further proof of a living natural union being established in implantation was, that in 
those instances where, from carelessness or otherwise, the teeth had become malposed, 
they resisted the effort to correct their position, and, in case of premature or accidental 
removal of the regulating strain, they would return to their rebellious position exactly 
the same as those that had never undergone extraction. 
The operation of implantation must not, however, be confounded with my theory 
of persistent vitality in old pericementum. This is an entirely different and inde- 
pendent subject, and should, therefore, not be allowed to cloud the judgment and pre- 
judice against the operation the minds of those gentlemen who do not accept any 
theory, because implantation, in its inception, and as presented to the profession in my 
pamphlet, presumed the use of fresh teeth only. The other was an after-thought. It 
was not until after nine months after my first operation of planting a tooth into an arti- 
ficial socket that the idea of persistent vitality in the peridental membrane was born 
and tested. 
The great obstacle my theory has had to contend with is the universal belief that a 
tooth, as soon as extracted, becomes dead, and even those teeth that had lost their pulps, 
either through disease or manipulation, though doing equal service in the mouth with 
those having living pulps, were regarded as dead organs also. Hence the intense 
thought and delicate skill employed and the agony inflicted-often fruitlessly-in an 
effort to save a living pulp to a tooth. These gentlemen have not stopped to consider 
that the tooth has another living connection with the system, which, when it is fully 
developed, is of far more importance to this organ than the pulp; and that in view of 
the great conservative skill to which our profession has attained, to a tooth that is per- 
fectly developed the pulp is of but little consequence. They ask: "How can a dead 694 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
substance unite with a living ?' ' As that is impossible, the success of implantation is 
impossible. It is unphysiological, unsurgical, and, therefore, must result in fail- 
ure, and they shut their eyes to the fact that the fact of a union having taken place 
between two tissues is evidence that neither is dead, and, consequently, both must be 
living, and that when a so-called dead tooth establishes a vascular connection with the 
tissues of a living jaw, that is proof, to a demonstration, that that tooth is not dead, 
but, instead, a living organ, But after all, what is-Dead? As we know but little of 
life, so we know but little of death, and we are too apt to regard a change as death, 
whereas, that change may be but a different expression of life. What seems death to 
us in a thing is often but the passage from one condition of life to another. I believe 
that every animal tissue has an inherent, independent vitality; that the blood is simply 
its pabulum from which it draws those elements necessary for its characteristic growth, 
development and repair. When separated from the blood, it is simply rendered inca- 
pable of performing these functions, and, as its vitality was not derived from the blood, 
neither does it yield it with its loss. Tissue is dependent on the blood only, on the 
necessities of its organization and in proportion to its activity, and when separated 
from its pabulum it simply starves, and this starvation is also in proportion to its needs 
and activity. The brain and nervous matter, for instance, being in a state of constant 
activity, probably requires the blood most of all other tissues, to immediately supply 
the waste that activity necessitates. But the bones, ligaments, tendons, membranes, 
being comparatively inactive, starve slowly, and are, while in a normal state, almost 
independent of the blood, and can, therefore, prolong their vitality indefinitely. 
Therefore, when the pericementum, which, after it has performed the function of 
perfecting the cementum, becomes a tissue to connect the root it invests with the 
environing walls of its alveolus, requires for the exercise of its simple duty but little 
blood. If you will only ponder on it, you will see that there is nothing so wonderful 
or improbable in the theory of persistent vitality in the pericementum. For nearly all 
of the lower orders of animal life-as the Infusoria, and even those of higher organiza- 
tion, as the Rotifera-may be desiccated for years and yet revive all their former 
energies and functions by the application of moisture. The whole theory of the spread 
of epidemics and contagious, infectious diseases, lies in the ability of the noxious germs 
to preserve their vitality, through years of desiccation, only to revive their pestilential 
energies when the conditions are favorable. If, then, organized creatures can shrivel 
up and retain vitality, through this death-like condition, for indefinite time, why 
should not the pericementum, as well as the other tissues of an equal organization, also 
retain vitality long after their separation from the system ? 
Why, even vertebrates, as reptiles and fishes, can be frozen solid for years and pre- 
serve their life intact ! 
My whole theory of the success of implantation and the use of teeth that have long 
been extracted lies on the ability of the pericementum to retain this vitality, and that 
it has this vitality is sufficiently proven by the facts- 
1. That it will unite firmly with the gum ; 
2. That it will unite with other vascular tissues, as the comb of a cock ; 
3. In two cases where, in consequence of the insufficient rooting of the teeth, due to 
too great previous alveolar absorption, the teeth remained loose and annoyed the 
patients, and had to be removed, the attached portion of the pericementum was fresh 
and bleeding, and had all the appearance of that on a newly-extracted tooth. The 
pericementum also preserves the root from erosive action. For erosion, I have found, 
takes place only on those points that are denuded of this membrane. 
In a long series of experiments in replantation and transplantation of teeth in dogs' 
mouths, conducted by Leon Fredel at the Laboratory for Normal Histology at the Uni- 
versity of Geneva, and reported by Michael Morganstern, of Baden Baden, in the SECTION XVIII-DENTAL AND ORAL SURGERY. 
695 
Vierteljahrsschrift für Zahn Heilkunde, this fact was proved, that erosive action did not 
occur in teeth protected by pericementum ; also that erosive action, though frequent, 
did not necessarily occur in those portions of the teeth that were deprived of this tis- 
sue. And he has also demonstrated, by these experiments, that pericemental presence 
is absolutely necessary for obtaining a permanent and firm union, and that this union 
is a nutritious one ; also that, in some cases, after resorption had been established, this 
process became stationary. 
He found that attachment begins about the body, thence proceeds toward the apex, 
which he considers favors success by preventing infection of the root. He further says : 
"Periosteal attachment is reestablished in a comparatively short time. In Case VII, 
within seven days, the parts had acquired such a union and the circulation had been so 
well established that if we had not injected cinnabar it would have been impossible 
tor us to discover the line of rupture. It shows an infiltration of a large quantity of 
young cells, most probably arising from two different sources :- 
"1. In consequence of the immediate regeneration of the cells within the tissue ; 
"2. In consequence of the immigration of foreign cells. 
" This infiltration causes the original fundamental tissue to disappear. It is, how- 
ever, later on, regenerated. 
"It is absolutely necessary for every transplantation that a vital connection be 
established in a short time. Whether the original blood vessels regain their vitality 
cannot be proved, but in every successful case-and that is a fact-new vessels were 
formed, which could be recognized by their thin, fragile coats. 
' ' The enormous hypertrophy of the periosteum is caused- 
"1. By the return of the periosteum to its embryonal condition ; 
' ' 2. By an extensive resorption of the alveolar bone. 
" During the act of normal teething analogous phenomena to the above are observed, 
viz., extensive resorption and regeneration of osseous tissue. As soon as the peri- 
cementum has been regenerated the process of resorption stops. The consolidation is 
greatly promoted by the dilatation of the Haversian canals, through which a free com- 
munication to the gum is established. In every one of our cases, consolidation was due 
to the renewed vitality of that part of the periosteum that had remained attached to 
the root. 
' ' Whenever a portion of the pericementum of any part of the tooth has been 
destroyed, resorption will begin at this place and form Howship's lacunae. Sometimes 
it will soon become stationary, which is recognized by the fact that the lacunae contain 
no osteoclasts but fibrous tissue with a few blood vessels." 
In my theory of persistent vitality in the pericementum I am sustained by so emi- 
nent an authority as Professor Joseph Le Cont, of the University of California, who, to 
testify his belief in the operation as well as the theory, had a bicuspid of uncertain 
age implanted in his mouth. This eminent scientist, in answer to a letter addressed 
to him on the subject, sent me the following :- 
Berkeley, Cal., April 3d, 1887. 
Dr. W. J. Younger. 
Dear Sir :-In reply to your inquiry concerning the persistent vitality in the pericementum, 
I would say, that although it seems at first sight surprising and unexpected, yet a little reflection 
ought, I think, to diminish our surprise, if not to remove it altogether. It is well known that 
the lower forms of life, after a desiccation of several years, still retain a dormant vitality, which 
may be revived into activity by the application of moisture. It is not improbable that the same 
may be true of the lower or less specialized tissues in the higher animals. The pericementum is 
exactly such a membrane as, in my opinion, might be endowed with such persistent vitality. 
Very truly yours, 
Joseph Le Cont. 696 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
With this distinguished support, I feel that I stand before you with my theory 
backed by an authority that is, as it were, ' ' ex cathedra, ' ' and must elicit from you a 
respectful consideration, which otherwise I could not hope to command. 
Nevertheless, while I believe in the presence of pericementum to insure success, 
since learning of that living tissue that spreads its bioplastic network over the entire 
surface of the root, permeating every interstice in cement and dentine, and reaching 
into the tubuli of the enamel, enveloping every granule of its ossifie and fibrous tissue 
in one continuous vital embrace, I think it possible that even teeth that have no peri- 
cemental covering may establish a vital union, if they are sufficiently fresh. And if 
but a fragment of the peridental membrane remained attached, I see no reason why it 
should not proliferate its tissue, until one continuous and protective covering envelops 
once more the entire root. In conversation with Dr. Joseph H. Wythe, a member of 
the Royal Microscopical Society and Professor of Microscopy and Histology in the 
Cooper Medical College of San Francisco, finding that he had read my articles, and 
approved the substance of my theory, and leading him on to this particular topic, he 
said, " Modern histology, as shown byHeitzman, Klein, Flemming and others, exhibits 
the living material or bioplasm as a fibrous reticulum in all the tissues. It exists in 
the tubules of dentine and the canaliculi of bone as well as in the softer tissues. 
Therefore there is no physiological improbability in considering this reticulum capable 
of reunion after solution of continuity, as long as vitality remains." 
But theories are theories, and facts, facts ! and they do not always correspond. It 
seems to me, however, that in view of the success that has attended the implantation 
of old teeth, and in the light of advanced science as revealed by Heitzman and others, 
the announcement that cavities could be drilled into the alveolar bone and teeth 
implanted therein, that would be adopted by the jaw and retained in a similar manner 
as the teeth of its own development, and that the vitality of the pericementum con- 
tinues long after its separation from the system, is one that is and must be in perfect 
accord with physiological laws. 
Occasionally an old tooth, without a particle of pericementum and without hope of 
bioplasmic energy, may be retained and do some service in the mouth for years, if its 
retention is insisted on and care taken not to disturb it, for a few months after inser- 
tion. In proof of this, I know a lady, at present a resident of San Francisco, whose 
age is about fifty. She came to my office a few months ago to show me a left superior 
canine that had been transplanted into her mouth over six years before. This tooth 
she herself selected, immediately after her own tooth had been extracted, from a number 
of teeth that had been kept in alcohol for over a year. Her dentist at first positively 
refused to put the tooth in, but on her persisting, he, with many misgivings, did so, first, 
however, scraping the whole root carefully with his knife and afterward polishing it on 
his lathe. He kept it in place by ligatures. The tooth remained loose for a very long 
time, but at the end of six months, by persistent care on her part, it became firm and 
has remained so ever since. She, however, has never used it severely in mastication. 
The gum, however, has retracted so as to leave the labial surface denuded almost to 
the apex. This would not have been the case had that portion of the root been 
covered by pericementum, for the gum to havo formed attachment with. In cases of 
this kind, the tooth is only tolerated, not adopted, the union mechanical, not natural. 
But it evidences the disposition of the alveolus to maintain a tooth, even though it be 
one with which it cannot form a living union. 
I wish to impress you with this fact in my operation (the absence of which, as a 
rule, in both transplantation and replantation has been the principal cause of their 
failures), the absolute condition of health in both tooth and socket. Another feature 
in this operation that I do not think I have before stated, except in the quotation from 
Fredel, is that the gum around the neck of the tooth seems to form the first point of SECTION XVIII-DENTAL AND ORAL SURGERY. 
697 
attachment, holding the tooth in position and vital connection, while the proliferation 
of ossifie matter and formation of connective tissue is going on. 
A remarkable operation, performed by Prof. Rose, in the Berthunien Hospital, 
Berlin, October 11th, 1881, and reported in Kölliker's " Histology," shows the wonder- 
ful regenerative power of the jaw, which, I think, favors and proves my theory and 
practice of implantation. In consequence of an extensive idiopathic mandibular 
osteomyelitis, causing total necrosis, the whole of that part of the lower jaw and 
alveolar process included between the ascending rami was removed, leaving the teeth 
dangling in the wound, supported only by the gum encircling their necks. In eight 
weeks, when the patient was dismissed, sufficient regeneration of bone had taken 
place to solidify all the teeth, with the exception of the incisors and canines. In three 
years there had not been sufficient deposition taken place to cover these roots, and they 
were still a little loose, but in six years' time, when the case was last seen, the jaw had 
been entirely restored, and all the teeth solid in the new formation; not only this, but 
in color, timbre and sensitiveness they all remained the same as before the jaw exhibited 
any symptoms of disease. 
I have here given you, in general terms, the plain truths and results in the operation 
of implantation and the theory of persistent pericemental vitality, and I leave to you, 
who are so much more learned in the science of histology, and skilled in the use of 
that marvelous ferreter of concealed anatomical minuteness-the microscope-to elabo- 
rate, when opportunity offers, the delicate and hidden means by which these results 
are obtained. 
And now, gentlemen, I will close this imperfect paper by illustrating to you the 
method of performing the operation of implantation, so as to insure an artistic result 
as well as a surgical success :- 
This diagram illustrates a space between two teeth, A and B, from which a tooth 
has been some time extracted ; the dotted lines, c and d, represent, respectively, the 
buccal and palatine surfaces of the gum ; line E E shows the extent and form of the 
incision, and F the small, crescent-shaped piece cut from the palatine portion of the 
gum to receive the neck of the new tooth. The line of the incision, E E, being estab- 
lished, the gum should be rapidly dissected from the alveolar process, about as high as 
the insertion of the muscles-taking care not to cut out on the sides-so that when the 
gum is lifted from the alveolus it will be, in its whole extent, on a plane with the gum 
covering the adjoining teeth. The reason for making the incision in this peculiar 
manner is to obtain the same thickness of gum over the new tooth that is possessed by 
the other teeth, and to secure sufficient prolongation of this tissue to bring it to the 
marginal line of the adjacent gum. The small semilunar piece should now be cut out 
of the palatine portion, and that gum only slightly dissected. If there has been much 
absorption from this surface, then this cut is unnecessary. The buccal portion should 
now be raised and the trephine fixed on the centre of the edge of the alveolar process, 
and drilling commenced on the prolongation of the line the tooth is to occupy. Having 
secured the necessary depth, the cavity is enlarged and fashioned to conform to the 
shape of the root. This being perfected, the tooth is inserted. Should there be motion 
of the tooth in the socket it should be ligated to the adjoining teeth, and these liga- 698 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tures should be retained for at least two weeks. Care must be taken to prevent the 
scraping off of the pericementum in fitting the tooth, also that the tooth is not impinged 
on when the jaws are occluded. Variations from these rules will be necessary in pecu- 
liar cases; but as it is presumed that no one will attempt this operation who has not 
sufficient skill, judgment and artistic sense, so the operator will recognize when a 
departure from the general method here prescribed is required, and determine upon 
the form of the variation. 
The following paper was read by title :- 
PORCELAIN CROWN AND PORCELAIN BRIDGE WORK SHOWN IN 
COMPARISON WITH THE ARTIFICIAL DENTURES OF 
THE LAST TWENTY-FIVE CENTURIES. 
COURONNE ET PONT DE PORCELAINE, TRAVAIL COMPARÉ AUX DENTURES 
ARTIFICIELLES DES DERNIERS VINGT-CINQ SIÈCLES. 
PORZELLANKRONE UND PORCELLANBRÜCKE IM VERGLEICH MIT DEN KÜNSTLICHEN 
GEBISSEN DER LETZTEN FÜNFUNDZWANZIG JAHRHUNDERTE. 
E. PARMLY BROWN, D.D.S., 
Of Flushing, N. Y. 
To superficially cover the entire ground of ancient and modern artificial dentures, 
we can commence no further back, with any degree of accuracy, than about two thou- 
sand five hundred years, at which period the student of ancient dentistry is convinced 
that the human front teeth were lost, and replaced by other human teeth, the teeth of 
animals, various carved bones and ivories, and, with the Mongolians, some of the pearl- 
like minerals. The precious metals were employed, in conjunction with all the fore- 
going tooth substitutes, and sometimes independent of them, to replace a lost tooth, 
and without any attempt to imitate nature. 
Ancient dentures, with which these teeth were used, include bridges of one or more 
teeth, with gold bands and wires fastening them to the pier-teeth or posts ; and also 
base-plates, with and without clasps, composed of various carved woods, bones and 
ivories, and the roots of trees of a gummy or oily nature, made with and without any 
attempt to imitate the lost teeth. The precious metals were used with these plates as 
clasps, and wire and pin fastenings. 
Referring to the specimens of the collection which are exhibited with this paper, 
and the drawings which illustrate them in part, I shall take you over the ground of 
the past as far as many thousand teeth and dentures can carry us, and gradually bring 
you to the present, pure and perfect porcelain crown and bridge and plate tooth. Pure, 
because of the glassy surface of the porcelain composing all its surfaces, and perfect 
because vying with Nature in appearance, and defying the action of time with greater 
resistance than the natural teeth. 
No. 1 takes us back six hundred years before Christ, being the Etruscan denture 
obtained over a year ago from a recently opened tomb at Capadimonti, and sent to Dr. 
W. C. Barrett, of Buffalo, by our enterprising countryman, Dr. J. G. Van Marter, of 
Rome, which, with other contributions of the same nature, was so beautifully illus- 
trated in the Independent Practitioner. This is probably the most ancient specimen of SECTION XVIII-DENTAL AND ORAL SURGERY. 
699 
dentistry in existence, being, as you see, human teeth banded together for mutual sup- 
port with gold. 
No. 2 is a piece of Phœnecian dentistry, being human teeth, which were fastened to 
the natural teeth in the mouth, with gold wire, somewhat as loose teeth are ligated 
with silk by the dentist of the present. This specimen is in the Museum of the Louvre, 
Paris, and it is questionable whether this, or that shown in No. 1, is the older. 
Nos. 3 and 4 are two specimens of bridge work, now in the Museum at Corneto, on 
the Mediterranean coast. They are Etruscan dentures of 2400 years ago, being human 
teeth, and carved ivory bridged in between two natural teeth ; with ribbons or bands 
of pure gold encircling the adjoining teeth as well as the substitutes, which are fas- 
tened to the band with gold rivets. 
From twenty-five centuries in the past we will, for brevity, drop down to hundreds 
of years ago, there appearing to have been no very great intervening features of dental 
advancement until the full dentures came upon the scene, carved in ivory with the 
teeth of the one piece, or having human and animal teeth inserted. 
No. 5 is the double set of dentures made by Dr. John Greenwood, of New York, for 700 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION XVIII DENTAL AND ORAL SURGERY. 
701 
Gen. George Washington, which was presented by Dr. Greenwood's son to Dr. John 
Allen, of New York, and by him donated to the oldest dental college in the world, to 
whose museum it now belongs. The plates were carved from walrus tusk; the pala- 
tine portion of the upper plate is 18-carat gold. 
Nos. 6 and 7, companion pieces to the last, are plates which were carved from the 
same material in France; one has human teeth fastened with hard wood and gold pins 
to the ivory plate, and was worn by the Duke of Brunswick less than a hundred years 
ago. The other, all carved of one piece less than fifty years ago, was the work of the 
late Dr. George, of Paris. 
These plates were presented by Dr. George to his former partner, Dr. T. J. Thomas, 
who presented them to me. 
No. 8 consists of a collection of four thousand teeth, the stock from which Dr. John 
Greenwood selected, in his office, to make pivot and plate teeth. You will find four 
kinds of stock in this interesting collection, which I obtained at the auction of Dr. 
Greenwood's son's effects, after his death in New York, many years ago. There are 
here- 
1. Pieces of walrus ivory, and the same material carved into bridge pieces, plates, 
teeth, etc. 
2. Human teeth from the tomb, grave, battle-field or Catacombs of Paris, Rome or 
elsewhere, or taken from mummies, showing the cementum and dentine much dark- 
ened. 
3. Human teeth which have been extracted during life or immediately after death 
in the hospitals, or on the battle-fields before burial. 
4. The teeth of calves, from which the roots had been sawed, which were obtained 
by the dentist at the slaughter house, and filed into shape as wanted for use. 
You will observe many attempts at working the teeth into shape for use, and also 
many old ones in the lot which have been worn both on pivots and plates. You will 
also observe the scarcity of central and lateral incisors for the superior jaw, they having 
been culled out for use perhaps for half a century, as this collection is between one and 
two hundred years old. 
No. 9 is a collection of teeth which introduce us to the beginning of mineral tooth 
manufacture, these teeth being made of the material which ale bottles and stone jugs 
are, in other words, earthenware teeth, and the body and enamel resemble that of the 
jug of the present day. They are of French production. 
No. 10 is a collection of about five thousand teeth, being intermediate between the 
earthenware ones of an hundred years ago and those of the present manufacture, and 
showing teeth made in Europe and America, of every kind except the natural-looking, 
strong tooth of the present day. This collection probably covers the entire ground of 
old styles, body, enamel, etc. 
In bidding adieu to this style of porcelain tooth, it will be interesting to know how 
a great bulk of them made their exit, i. e., those without platina pins. The late Dr. 
Samuel W. Stockton, the oldest and most extensive tooth manufacturer in this country 
previous to the advent of his nephew, Dr. S. Stockton White, took five large trunks 
full of these teeth and graveled the garden walks with them at his country home near 
Philadelphia. This I was told recently by Dr. Stockton's widow, who survives him. 
Now, coming by a stride to the dentures of the present day, I should say that the 
advancement in tooth-crowning systems was the first step in the development of the 
fixed denture, and the objectionable features of metal in conjunction with porcelain for 
crowns, both for backings and bands, made me hesitate about adopting so imperfect a 
system, one which my judgment failed to indorse in at least four important respects : 
1st, want of truth to nature, as even the palatine surface being metal is lack of art ; 
2d, want of cleanliness where metal is exposed to the oral secretions, as every metal 702 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
surface will be a bacteria breeding ground, which cannot be or is not reached in the 
cleaning process ; 3d, want of strength in the union of porcelain and metal and in the 
pin attachment, which weakness causes the necessity of gold caps on bicuspids and 
molars in fixed bridges ; and 4th, the necessity of impressions, band-fitting torments, 
detention of patients during soldering and making, and lack of good teeth in a large 
variety to make the crowns, plate teeth having gone out so completely. These objec- 
tions, and the inability or the indisposition of the majority of dentists to go through 
with the tedious details of manufacture, even when they are able, are sufficient to have 
caused a more practical and more perfect system. 
Six years ago, when I had the pleasure of meeting the Dental Section of the 
Medical Congress in London, on the first occasion which the Congress had met in an 
English-speaking country, and when the dentists were first admitted as a Section, I 
read an illustrated paper on "Gold Building on the Natural Teeth," principally dwell- 
ing on extensive contour. My English cousins, generously discussing the paper, insisted 
upon asking : ' ' Why put so much gold in sight on the front teeth ? Why not crown 
instead?" My reply was that contour building was under discussion, that crowning 
was under serious consideration and experimentation, and I promised them something 
in the way of crowns when they should meet in America and returned our visit; and I 
not only keep my promise by giving you six new crowns (four porcelain with platino- 
iridium pins, one porcelain and one platina cap, and one gold shell crown), but I throw 
in, for good measure, the all porcelain bridge work, of which I treat in this paper, and a 
new tooth for base-plates, to be shown in another paper and clinic. The platina cap and 
ferrule, baked on a porcelain crown, was abandoned because of the difficulty of manu- 
facture and application, and mainly because a ferrule, in nineteen cases out of twenty, 
is an absolute harm, and in ninety-nine cases out of a hundred not required. It is an 
unnatural, irritating, bacteria-breeding band, which discourages that healthy condition 
of the festoon of gum which exists without it. A porcelain crown, with a proper shaped 
pin or pins baked therein, without any collar or band, except in very rare instances, has 
proved itself, to me, to be the best, after several years' close study and practice of the 
subject. 
Nos. 11 and 12 are front and lateral views in section of the new single pin porcelain 
crown, which has been on the market a year, in which we see the porcelain creeping 
upon the improved pin to add to the strength, which must be ground to suit the case, 
having as much material left at the cervix, for strength, as the root to which it is fitted 
will permit. 
Nos. 13 and 14 are front and lateral views in section of the new two-pin porcelain 
crown for bicuspids, the two forms of pins used in manufacture being shown. 
No. 15 shows the bringing of the pins together in the same crown for a single root 
tooth. 
Nos. 16 and 17 are the latest forms of pins for a crown, a double-ended screw and 
a somewhat similar form. These bring the least metal in the porcelain to weaken it 
for the retaining strength and the most at the point of greatest strain, and the least in 
the narrow confines of the root canal for its retaining ability, and in all making the 
best pin for the purpose, for the weight of metal and for facility in adaptation, as the 
screw or ridged form of pin entering the root does not require barbing by the operator, 
a work generally done poorly, one would judge, by the failures observed. 
No. 20 is the gold shell crown, used for posterior teeth and in connection with 
bridges, made from a single piece of 22 or 23 carat or pure gold, and soldered without 
the blowpipe, entirely from within, by being held over a spirit-lamp, the four sides 
being bent over into position after the cap is struck up, much as a pasteboard box is 
formed. Such a crown will be made at the clinic. SECTION XVIII-DENTAL AND ORAL SURGERY. 
703 
Porcelain bridge dentures, of from one tooth to a full set, are seen in the subsequent 
drawings. 
No. 18 is a single tooth, as it appears ready to be fastened into the adjoining tooth 
or teeth by the extending bars. Two, three, four or more teeth may also be inserted 
in this manner. 
No. 19 is a superior first bicuspid, and as the canine is usually sound, the tooth is 
fastened into the second bicuspid only. Two cases have been done in this way, one of 
nearly three years' standing, and both are now intact. 
No. 21 is a lateral view of a plate tooth, ground ready to receive the bar, before 
having the pins bent over the bar to temporarily sustain it during the application of 
the tooth body on the back, and during the baking. 
No. 22 is a bridge of two teeth, being composed of a porcelain crown attached to a 
root, and a bridge tooth attached. There is a great necessity for this variety of bridge, 
as a good root is often found next to a space from which a tooth has been extracted. 
From two to six teeth may be safely inserted by this plan of attachment, the platino- 
iridium bar being bent at a right angle at one end, forming a long and strong pin, 
which is inserted in the root, the other end of the bar being attached by a gold filling 
in the tooth intact. 
No. 23 is a bridge in which both piers are porcelain crowns to be attached to their 
respective roots. Bridges of from three to seven teeth have been successfully inserted 
on this plan. 
No. 24 is a bridge composed of a gold cap crown for posterior teeth as a means of 
attachment, and a porcelain bridge tooth winged on to the gold cap crown by the bar, 
which is baked in the porcelain tooth, being inserted into a hole in the proximal 
surface of the crown ; and, as the gold crown covers a pulpless tooth, the bar is bent at 
a right angle with the root of the tooth. 
No. 25 is the same bridge as the last, except that the gold cap crown covers a tooth 
with a living pulp, and the bar, after entering the hole in the side of the gold crown, 
is flattened at the end to give it a firmer hold in the cement fastening. It is a bridge 
composed of a first bicuspid and first molar saddled across the second bicuspid, which, 
if necessary, may be crowned with gold, the bar projecting from the anterior end of 
the bridge to be fastened into a filling in the canine. 
No. 26 is a bridge of twelve teeth, anchored to four natural teeth and roots. Such 
a bridge may be inserted successfully in many cases, as the canine roots and two molars, 
one on each side, are often found on the superior jaw. In this case one molar is crowned 
with gold, and the bar enters a hole in the gold crown as described. The other end of 
the bar is fastened to the molar, in a large gold filling, and the two canine roots are 
crowned by the respective teeth in the bridge, which have strong pins baked therein. 
No. 27 is a model of a jaw, showing the anchorages of a bridge of eleven teeth, two 
natural molar teeth and one canine root. The three anchorages are here made by the 
three methods employed in fastening these bridges ; one by a porcelain crown on the 
canine, fastened by a large pin baked in the bridge ; one by a gold crown, capping the 
molar, and having the bar running therein: and one by the bar projecting from the end 
of the bridge, embedded in a gold filling in the other molar. 
The drawings cover the principal modes of insertion of the bridges, and a descrip- 
tion of some of the general features of making and applying them may now be in order. 
Plate teeth of American manufacture should be used, as the English do not stand the 
heat required to fuse the continuous gum body. The John Allen body is now used, 
being found the best, and a little more starch is added to it, improving it for this use. 
The teeth should be straight pins, and not cross pins, as the grinding is to be done 
between the pins to admit the bar to its generally central position in the tooth. Some 
of each pin is ground away, but enough is left to be bent over the square or flattened 704 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bar of platino-iridium of 13, 14 or 15 gauge, as the case may require, to give stability 
to the fixture during the application of the tooth body to the palatine position, and 
during the process of baking. The body is applied in a creamy state, with a spatula, 
and the work is occasionally held over a lamp to dry the body when properly contoured 
on the backs of the teeth. The baking is, in large dentures, repeated after the crevices, 
due to the shrinkage of about one-sixth, are properly filled in. At a single baking, 
which I lately jnade-one slide containing thirteen cases-eleven were perfect, and in 
another baking of nine cases on one slide, all came out perfect the first baking. 
That all-porcelain bridges are truer to nature than gold ones none can deny. That 
they are stronger than gold ones in the long run I am firmly convinced. That they are 
more cleanly needs no argument, as the glassy surface of porcelain is less apt to encourage 
impure deposits in the mouth than a surface of any metal; and, in addition, there are 
no gold backings as lodgments for food in the porcelain work, and no intervening spaces 
between each tooth, as the teeth are united in fusing. 
That anti-bridge workers will throw cold water on fastening many teeth to a few 
roots is to be expected, and that many of them will not be converted until years have 
rolled around and most every other dentist is doing the work is also certain. And 
many others will not see the propriety of the work until patient after patient leaves 
their offices to get the work elsewhere. 
I have succeeded in obtaining, without any trouble, sixty times as much for this 
work as the advertising dentist gets for rubber plates, and about ten times as much as 
I, myself, have been able to induce the same patients to pay for plates. 
That a full upper denture can be successfully fastened to four roots I have no doubt 
-"successfully" meaning that nine out of ten of the patients will be delighted in the 
end with the result, and that is as good a percentage as in any dental work performed. 
It has been said by those who have not made a study of it, that four teeth cannot 
sustain twelve ; but never, to my knowledge, has he who has become conversant with 
the work made this assertion. 
"In union is strength," and time will convince the skeptical that four teeth united 
by a bridge denture are not compelled to sustain much more strain than if they 
were standing in their usual places in the unbroken arch, especially so if the other 
teeth composing the bridge rest firmlyon the gum, each tooth being formed at the 
cervix somewhat like the finger-end, the anterior face of the tooth having the position 
of the nail, in which case a large percentage of the force produced by the masticatory 
muscles is received by the gum and alveolar ridge. 
Gold should nearly always be the filling with which to anchor the bars. In only 
one instance have I seen fit to use amalgam. 
The oxy-phosphates are the best cements with which to fasten bridges, both around 
the pin fastenings in porcelain crowns and for the gold crowns, and, in a very small 
number of cases, gutta percha. Oxy-phosphate cements should be mixed very thin, 
and a slow setting cement used, because, under pressure, the liquid is forced out and 
the setting is hastened. Care should be taken to smear the pins and ends of crowns 
with a surplus of the creamy cement, some being put into the nerve channels to pre- 
vent air bubbles interfering with a thorough cementation. 
In arranging for setting the bridges where gold fillings are used to fasten the bar at 
one or both ends, the rubber dam should, of course, be applied ; the gold being first 
extra-thoroughly anchored, then the bridge inserted, and the gold thoroughly malleted 
over and around the bar, the bridge being tried in occasionally, that the gold may not 
be allowed to interfere with the admission of the bar at the proper location. Where 
other parts of the bridge are to be fastened with cements in the roots and with gold 
crowns, after the gold foundation is ready to receive the bar at one end, circular pieces 
of the rubber dam should be cut out at the points of cement anchorage, dried out, and SECTION XVIII DENTAL AND ORAL SURGERY. 
705 
the bridge cemented in place, and the gold is then to be completed, which holds it 
firmly in position until fixed by the setting of the cement. In a few days the gums 
will be found to have assumed a healthy and natural appearance, hugging around the 
cervical portion of the teeth. 
TESTIMONIAL TO DR. N. S. DAVIS, PRESIDENT OF THE CONGRESS. 
Dr. J. Rollo Knapp, of New Orleans, La., offered a resolution, which was 
unanimously adopted, that a committee of two be appointed by the Chair to present 
a suitable testimonial to Dr. N. S. Davis, as a slight appreciation on the part of 
the members of this Section of his praiseworthy services for the advancement of 
dentistry. 
VOTE OF THANKS TO THE PRESIDENT. 
Dr. W. H. Dwinelle, of New York, said : I hope this Section will not adjourn 
until a vote of thanks be extended to our worthy President, for the able manner 
in which he has presided over the deliberations of this body. Although I have 
not had the pleasure of being with you, except for this day, still I have heard 
so many expressions of commendation for the masterly way in which our worthy 
President has presided over the meetings, that I cannot resist the temptation of 
offering the resolution which I now submit :- 
Resolved, That the thanks of this Body be extended to our worthy President, Dr. J. 
Taft, for the courteous and masterly manner in which he has presided over the 
deliberations of the Section. His position has been a peculiar one, which to one of less 
ability would have been surrounded with difficulties not easily overcome. But he has 
so tempered dignity of office with a spirit of consideration and kindness, as to challenge 
the respect and hearty cooperation of the members, and secure for the Section a success 
second to none other of the Congress. 
The resolution was unanimously adopted, and the President, Dr. J. Taft, of 
Cincinnati, Ohio, said :- 
Gentlemen : I certainly appreciate, in a way which I cannot express, this 
commendation of what I have tried to do ; and, after all, I have fallen so far short 
of what ought to have been done that it seems to me that a resolution of this kind 
is misplaced. 
And now we come to the end of this series of meetings of the Section of Dental 
and Oral Surgery of the Ninth International Medical Congress. It has been one 
about which, as you know, there have been various opinions entertained during the 
last two years ; but it has ultimated in what I think we may regard as a reasonable 
success. So far as I have been able to accomplish anything in this matter, there is 
no credit due to me, as I feel ; but it certainly is due (so far as the work of the 
Section during this week is concerned) to those in attendance here. I feel that I 
owe a vote of thanks to these members of my beloved profession, and I certainly 
entertain a feeling of the highest appreciation for the efforts which have been put 
Vol. V-45 706 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
forth by the members of the Section, in the work which they have accepted, and for 
the manner in which they have accomplished that work. What shall be the result 
of this work? Never before was there such a body of dentists assembled, in this 
or perhaps any other country, working together in such harmony, working for a 
common end, bringing all their energies and efforts together to the accomplishment 
of a given purpose, and doing all they can to strengthen the hand of each and every 
one. And what shall be the result ultimately? Certainly great fruit will grow 
from the seed which has been sown here during this week, how much we cannot 
even proximately estimate. Shall the result be confined to the members who have 
been present here, to those who have participated in these sessions? By no means. 
It will go out to all the world. It will reach our brethren of the profession wherever 
they are, on this broad earth. Those who go out from this meeting will carry with 
them that which will enlighten others, that which will reflect upon others in our 
profession. And not only that, but no one can tell how much good those who come 
after us in the future will receive as the fruit of these meetings and of these efforts. 
And even that is not the sum of the result, but other Sections of the medical 
profession will be improved by these meetings. With very few exceptions, I know 
but little of what other Sections have been doing ; but gentlemen with whom I have 
come in contact have expressed the impression which is abroad, that this Section 
was one of the best in this Congress. (Applause.) To you, gentlemen, is due the 
credit for that reputation which has gone out in regard to our work here. It has 
been said that this Section has been unusually well attended. And what shall I say 
in regard to that attendance? On the first day there were counted in this room 426 
or 427 persons, nearly all of whom were members of this body. And how is it now? 
There is nearly as large an attendance here, in the closing hour of the session, as 
there has been during the last five days. Ordinarily, on such occasions attendance 
dwindles down, members go away ; while the closing hour of this session finds the 
number of members assembled about as large as it has been at any time during the 
week. To me this speaks much. 
Another fruit that will be gained from these meetings is, that their benefit will 
not stop with the dental profession ; nor will it stop with those who come under 
their charge as patients. The doings of this Section will be published in the Trans- 
actions of the Ninth International Medical Congress, and they will go broadcast 
over the world. Every member of this Congress will have a copy of the Trans- 
actions ; and physicians (many of whom, I know, are greatly interested in the sub- 
jects which we have been discussing) will have that to which they may turn to learn 
things which they had not known before. It is true that physicians, in some 
respects, need somewhat of the assistance which dentists can give them ; while 
dentists, of course, need very much the assistance which physicians can give them. 
And so we will have the accumulated knowledge (the effect and work of all these 
eighteen sections) gathered together and focalized, in a permanent form, to which 
reference can be had at any time, on any subject in which we are interested and 
which we may desire to study. This is by no means a small fruit, by no means a 
minor result, of the work accomplished here this week. I have been greatly pleased 
to see the enthusiasm and interest manifested by every member of this Section-not 
only by those of our own land, who might be supposed to have, perhaps, a greater and 
closer interest in it, but also by our brethren from abroad, whom I have found to be 
just as enthusiastic in their patient working with us as those on this side of the 
water. How much pleasure and profit their presence has given to us I cannot tell 
you. I leave you to imagine. But it has been a source of very great pleasure SECTION XVIII-DENTAL AND ORAL SURGERY. 
707 
to me that they have been with us. I am sure that they have brought to us much 
that will be valuable in the future. More than that : the social features, the 
social aspects, the companionships here formed will not be soon broken. They 
will remain. The bond of sympathy established by these meetings between mem- 
bers of the profession in different parts of the world will not wane, but will increase 
and grow ; and hereafter we will desire, more and more, to meet those with whom 
we have associated so pleasantly these past days. 
As usual, on such occasions, there is a vein of sadness present. We have looked 
into each other's faces. There has been a binding cord of sympathy going from one 
to the other. There is a kind of sadness at parting ; but we have joy in this-that 
we will probably have many of these occasions in the future. 
VOTE OF THANKS TO THE EXECUTIVE COMMITTEE AND SECRETARIES. 
Dr. George Cunningham, of England, moved a vote of thanks to the Execu- 
tive Committee and to the Secretaries for the able manner in which they had per- 
formed their duties. During the scientific part of the discussion, he had rather con- 
sidered it a boast that he had no moment of inspiration ; but now, perhaps, the time 
had come when he might legitimately look for inspiration. He would not, however, 
seek for it at this late hour ; and, perhaps, it was better for those present that the 
inspiration did not come. No man could appreciate more than he the very ener- 
getic and great services of the Executive Committee ; while, as to the Secretaries, he 
had special means of knowing how much honest and hard work was forced upon 
them. Of course, it was impossible to carry out an organization of this kind with- 
out a certain amount of friction ; but he must say that, under the circumstances, the 
Executive Committee and the Secretaries had done wonders. Some of the most 
prominent members of the profession in England had been present, and he knew 
that they heartily approved all that had been done for them. It must be a great 
satisfaction to this Section to know that it had been one of the most distinguished 
and, certainly, the best attended of all the Sections, both at the clinics and in 
the reading of papers. He was sure that, but for circumstances, the attendance 
from England would have been larger. He and the other members from England 
owed a special vote of thanks to Dr. Dudley, for what he had done for them. 
The vote of thanks to the Executive Committees and Secretaries was carried 
unanimously; and then, at 10.45, P. M., the President declared the Section adjourned, 
sine die. 708 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CLINICS GIVEN DURING THE SESSION. 
Report of the Clinics in Operative Dentistry given at the Franklin School Build- 
ing, corner of Thirteenth and K streets, Washington, D. C., under the auspices 
of Section XVIII, Dental and Oral Surgery, during the week of the session of 
the International Medical Congress, commencing Monday, September 5th, 1887r 
and every day, from 8 till 10J o'clock A.M. 
FIRST DAY. 
Dr. William Carr, of New York City.-As no patient was obtainable with a 
fracture of the inferior maxilla, the clinic was demonstrated upon models. 
SECOND DAY. 
Dr. T. D. Shumway, of Plymouth, Mass., filled a right upper central incisor in 
the distal surface. The gold was introduced by means of ivory points and hand 
pressure. For the base of the operation White's velvet cylinders were used, but the 
operation was completed with 1000 fine gold foil. 
William Conrad, d.d.s., St. Louis, Mo.-Operation.-Devitalizing pulp of right 
superior first molar, at one sitting. 
Found cavity of decay filled with gum tissue, and the tooth aching. Pulp exposed. 
Removed diseased gum, using carbolic acid crystals. Opened into pulp chamber. 
Destroyed the pulp with crystals of carbolic acid, and removed the devitalized tissue 
with hooked nerve instrument. Deferred filling of root canals, on account of bleeding 
through the root foramen. 
Patient-boy fourteen years of age. 
\ 
Treatment of Gangrenous Pulps, by Geo. H. McCausey, Janesville, Wisconsin. 
The treatment is the result of a firm belief in, and a full acceptance of, the germ 
theory of disease. It consists of a thorough removal of the debris of the pulp already 
putrescent, by the use of hydrogen peroxide repeatedly injected, after having thor- 
oughly laid open the pulp cavity and canal, carefully avoiding any pressure in the 
direction of the apical foramen, and the after-use of 1000 : 6 solution of hydronaphthol 
or mercuric chloride as a germicide, and, after thorough drying, applying a dressing 
of the same, or iodoform paste, and closing for a few days with phosphate cement. 
The method prevents the contact of bacteria with the peridental membrane, thus 
avoiding subsequent periodontitis. 
Louis Ottofy, d.d.s., of Chicago, Ill., U. S. A., performed the operation of 
implantation for George Williams, forty-eight years old, an inmate of the Soldiers' 
Home at Washington. 
The upper right central incisor had been extracted seven years ago, and the alveolar 
process was very much absorbed. The implanted tooth was also an upper right central SECTION XVIII-DENTAL AND ORAL SURGERY. 
709 
incisor, whose history is unknown. The root had been previously filled with gutta- 
percha by being entered at the crown. During the operation the tooth was kept in a 
solution of one of bichloride of mercury to one thousand of water. The socket was 
made principally with Ottofy's crib socket knife (a hollow knife the shape and size of a 
root). The operation was well borne by the patient, and its duration was about one 
hour. After the implantation an impression of the implanted and two adjoining teeth 
was taken in potter's clay, small dies were cast and a gold cap struck to fit the three 
teeth. This was cemented on with oxyphosphate of zinc, and the patient placed in 
care of a dentist. The cap will be removed when sufficient union has taken place, and 
the danger of dislocating the tooth is lessened-in from two to four weeks. The 
patient is also instructed to use a saturated solution of hydronaphthol as a mouth wash, 
to prevent the collection of substances about the tooth and gum which are liable to 
result in septic decomposition. 
Dr. R. F. Ludwig, Chicago, Ill.-Compound proximal cavity, anterior surface, 
right superior second bicuspid. 
Material, non-cohesive and cohesive gold foil No. 4, formed in round pellets. 
The hand mallet was used for impacting the gold. 
Advantages claimed. First. In form of gold used, the ease and rapidity of intro- 
duction, with close adjustment to walls and margins of the cavity. 
The entire column stiffened and finished with cohesive gold. 
Clinic by J. W. Wassall, of Chicago.-Root-canals of right lower second molar 
filled with chloro-percha and gold wire. 
The superiority of gutta-percha over all other materials for root-canal filling is, at 
the present day, admitted by the generality of American dentists. This statement is 
made advisedly, with full knowledge that some distinguished operators successfully 
use other materials, notably the zinc-oxychloride cements and gold wire. Nevertheless, 
gutta-percha is to-day more universally applicable, more easily manipulated, and more 
nearly fulfills the requirements of a perfect root-filling, as regards adaptability, accept- 
ability to the tissues and permanence, than any material yet used. 
The only point peculiar in the clinic described below is the use of gold wire as an 
adjunct in filling canals of very fine calibre. The gold wire point, filed down to fit 
the canal, is found to be more easily inserted into it, and to carry the gutta-percha 
solution more certainly to the apex. The wire point is merely a substitute for the gutta- 
percha point, to be used only in canals of small diameter. 
Clinic.-Mr. F. Age thirty years. General health good. The right lower second 
molar was found pulpless. It had been destroyed one and a half years previously, and 
received no further treatment, remaining unfilled. 
There was no history, sign or symptom of peridental irritation ; therefore, the case 
was considered a favorable one for ' ' immediate root filling. ' ' (The patient was seen 
thirty-six hours later, when this prognosis had proved correct. ) 
The rubber dam was adjusted. The large crown cavity was opened, cleansed of 
débris and disinfected. The pulp chamber was opened under antiseptic precautions, 
free access being obtained to the openings of the three canals. The following charac- 
teristic anatomical features were noted. The distal canal was directly accessible, of 
average size and round calibre, and easily entered with the broach. A small fragment 
of living pulp was found at the apex of this canal, which was removed. 
The mesial root contained two canals, fine and flattened. They were penetrable to 
their apices only by fine Swiss jewelers' broaches (No. 10, temper drawn). The pre- 
caution was taken to flood the pulp chamber with a disinfectant before attempting to 
pass broaches into the canals, this in order to prevent septic matter being forced beyond 
the tooth's apex. The preparation for filling consisted in removal of putrescent matter, 710 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
through cleansing and disinfection, and complete drying. The canals were not reamed 
out or enlarged. 
Hydrogen peroxide was used for cleansing out débris, a mixture of essential oils for 
a dentine penetrating disinfectant, and absorbent cotton wrapped on a broach for desic- 
cating purposes. The materials used for filling were chloro-percha, gutta-percha cone 
and gold wire cones or points. 
The pulp chamber was first flooded with chloro-percha of the consistency of cream. 
This solution was pumped into each of the three canals with a broach wrapped with 
cotton. A gutta-percha cone was dipped into fresh gutta-percha solution (cold), and 
pressed into the distal canal ; one other smaller cone was pressed in to fill completely. 
Two gold wire points were filed to fit the mesial canals. The broach used in the pre- 
paration of the canals being conformable to their size and shape. 
The gold points were then passed deeply into the two mesial canals, being pressed 
to place with a deeply serrated plugger. 
The pulp chamber and crown cavity were then temporarily stopped and the patient 
dismissed. 
Dr. J. P. Geran, of Brooklyn, N. Y., filled with gold, for a dentist, the left supe- 
rior second molar, involving the whole masticating surface, building up about one- 
fourth of the tooth by the " Herbst Method." 
Amount of gold used for the operation, about seventy-five grains. 
Dr. Geran exhibited in the same mouth the right inferior first molar, containing a 
very large gold filling in the mesial and grinding surfaces, which he had filled Novem- 
ber, 1886, at a clinic, by the same method. Surface hard, smooth, and the edges 
perfect. 
M. E. Smith, of Chicago, Ill., filled an anterior proximal cavity of a left superior 
first molar, using, as a means of introducing the gold, the Snow & Lewis automatic 
plugger. The gold used is Ney's No. 4 soft foil, using nou-cohesive for marginal pur- 
poses and annealing for exposed masticating surfaces. 
THIRD DAY. 
Dr. T. D. Shumway, of Plymouth, Mass., filled the right upper central incisor. 
The cavity being in the mesial surface, it was filled by means of ivory points and hand 
pressure. The gold employed for the beginning of the operation was White's velvet 
cylinders, -which was followed by 1000 fine foil. 
Geo. W. Whitefield, m.d., d.d.s., bleached a discolored, pulpless tooth. 
From the infancy of the application of electricity in the arts it had been known to 
possess the power of decomposing chemical compounds into their constituent elements. 
The doctor used an electrode of his device to decompose compounds of chlorine 
(chloride of sodium-table salt-being used) within the cavity of the tooth, the chlo- 
rine gas being liberated by the use of a McIntosh galvanic battery. 
The bleaching was readily and quickly done. 
Dr. W. N. Morrison, St. Louis, Mo.-By this clinic it is proposed to show the most 
simple, rapid, and accurate way of filling pulp canals. With a small drill, open 
through the crown in as nearly a direct line with the root as possible. Then, with an 
olive or round bur that will just pass through the opening, remove the angles from 
the inside of this artificial opening, merely enough to allow the broach to pass freely 
into the root canal. I never use a drill or reamer in a canal for the purpose of shaping 
it to fit a filling, but always adjust the instruments and gold wire to fit the natural 
canal. And, after several trials and measurements, to be sure the gold wire goes to SECTION XVIII-DENTAL AND ORAL SURGERY. 
711 
the apical third of the root, and not through the foramen, a suitable length, from an 
eighth to one-quarter of an inch, is severed one-third or three-fourths of its diameter 
by a revolution under a sharp knife, but still leaving strength enough to carry it to its 
final position, with a thin solution of gutta-percha or oxychloride of zinc. One slight 
rotation leaves this tapering point of soft, pure gold wire in the apical third of the root, 
never to be disturbed. The remainder of the chamber can be filled with oxychloride of 
zinc, churned in with the wire, and packed and dried with paper wads of suitable size 
to act as pistons. I would call attention to an article on canal filling, which gives 
materials, dates and names of the authors of the different methods, in the Missouri 
Dental Journal, Vol. VI, pages 18 and 51. 
R. H. Hofheinz, d. d. s., Rochester, N. Y.-Posterior and compound cavity in 
second bicuspid. Soft cylinder filling in combination with cohesive foil. Five sheets 
of No. 4 foil. 
Time required for filling, fifteen minutes. Automatic mallet. 
Dr. W. C. Marshall made a compound filling in right superior central. Distal 
wall entirely gone, requiring a one-fourth contour cutting edge abraded through 
enamel entirely across, and the underlying dentine very soft. This was all cut away, 
and the palatine wall of enamel found very frail nearly half way to the gum, which was 
also removed. Not being able to get the velvet cylinders of the proper size, Williams' 
nou-cohesive gold was used, annealing as was desired, for the greater part of the work. 
Finished with velvet cylinders of smaller size. 
Pluggers used were broken excavators, which were tempered very hard before break- 
ing. Used hand mallet without an assistant. 
Time required, including interruptions, was two hours and thirty minutes. 
Claim that the crystaled stub resulting from fracture condenses gold as well, if 
not better, inasmuch as the surface is kept more smooth with it than any others, unless 
it is the Varney set. 
The time mentioned was for the entire operation of preparing cavity and finishing 
filling. 
Clinic by William Conrad, d. d. s., St. Louis, Mo.-Operation-the immediate 
treatment and filling of a pulpless root canal. 
Found the left superior lateral pulpless, with pus in the canal and a disagreeable 
odor. Opened into the root canal, using Morey's drills. Treated the root with hydro- 
gen peroxide until there was no action of the medicine manifested. Then dry out the 
canal with chloroform and air. Dry the root perfectly, and fill completely with chloro- 
percha and gutta-percha cones or points. Work this into the canal until the root is 
full and solid to the apex. 
H. F. Harvey, d. d. s.-Operation-restoration of one third left superior lateral, 
including proximal cavity and cutting edge ; using gold and platinum foil. 
Method-hand mallet with assistant. 
R. F. Ludwig, Chicago, Ill.-Restoration. Posterior surface. Right superior 
bicuspid. 
Material-non-cohesive and cohesive gold. 
Method-hand mallet. Dr. Geo. W. Whitefield's combined electric engine and 
bracket was used in the operation. 
Clinic by Dr. Wm. Crenshaw, of Atlanta, Ga.-The operation consisted in restor- 
ing to original form the anterior and grinding surface of a superior right second bicus- 
pid, in the mouth of Dr. R. B. Adair, Gainesville, Ga., concluding, as it did, a series 
of ten similar consecutive operations, extending back and including each surface from 
the first bicuspid to and including the second molar. 712 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. William P. Dickinson, of Dubuque, Iowa, exhibited a patient with some 
contour operations inserted by himself, which attracted considerable attention. 
The fillings were as follows :- 
1st left upper molar, distal and crown fully contoured, gold filling faced with 
iridium gold. 
1st left upper molar, mesial and crown. Same facing. 
1st and 2d left upper bicuspids, double compounds fully contoured. Same facing. 
Right upper central, mesial contour. Gold filling and faced with platinum gold 
(instead of the iridium gold). 
R. Hall Woodhouse, m. r. c. s., l. s. a., l. d. s., England, filled a left upper 
lateral incisor cavity, on mesial surface, with non-cohesive and cohesive gold, commen- 
cing operation and lining cavity with non-cohesive and restoring contour and finishing 
with cohesive cylinders. Operation performed entirely by aid of reflection in mouth- 
mirror, and without separating the teeth, gold used being Williams' No. 1 a, and No. 
1 c cylinders. 
Dr. George W. Whitefield, of Evanston, Ill., gave a clinic with "Steurer's 
Plastic Gold," restoring the contour of the right lateral incisor tooth, mesial surface. 
Operation performed in fifteen minutes, also a filling upon mesial surface of second 
bicuspid tooth, left upper. 
The Whitefield electric engine bracket being used in these operations. 
Clinic by W. J. Younger, m. d.-Implantation.-Two superior lateral incisors 
implanted for Dr. Gartrell, of England. Teeth had been lost over two years. Con- 
siderable alveolar absorption in labial surface. Centrals separated and encroached on 
space of laterals, making it necessary to approximate them, to procure room for teeth 
to be implanted. This was done immediately before the operation, and while the 
laterals were being made ready, by passing a fine silk ligature over and over, around 
the two centrals, nearing them with every tightening strand, until the required spaces 
were obtained. The teeth selected had, as nearly as could be ascertained, been out of 
the mouth five or six years, but their roots were covered with a fair proportion of peri- 
cementum. 
They were prepared by drilling into the pulp chamber, through the lingual aspect 
of the crown. As the pulp tissue was very dry, it had to be moistened to enable the 
broach to seize it. After every portion had been removed, the canals wiped out with 
the sublimate solution and thoroughly dried, they were filled to the apices by Dr. Parr, 
of New York, with Hill's stopping. It had been the intention to fill the crown ends 
of the canals with gold, but the limited time compelled the assignment of this portion 
to some other operator, after the teeth should have become firmly fixed. 
The teeth were now placed in a solution of hydrarg. chlor, cor., 1 to 1000 water, 
temperature 110 Fahr., for about twenty minutes, to sterilize them. This same solu- 
tion was also employed in cleansing the wound and washing the hands. But the 
instruments were rendered innocuous by placing them in liq. ammon. fort., instead, to 
prevent their corrosion. All being now in readiness, the space for the right lateral 
was chosen for the first operation. An incision was made in the gum, at a point nearly 
in front of and to the right of the centre of the right superior central, and carried 
around the edge of the gum to the rear, pressing the knife as deep as the alveolus 
would permit, to a point past the middle of the central. It was then carried across, 
with a slight curvature toward the labial aspect, to the right superior canine, to a 
point also in rear of its middle, thence to the front, along the cervical margin, to a 
point nearly in the centre of the labial surface of the canine. The line of incision being 
now established, the gum was rapidly dissected from the alveolus, between the points 
of commencement and ending, and nearly as high as the insertion of the muscles ; SECTION XVIII DENTAL AND ORAL SURGERY 
713 
care being taken not to cut out of the gum. When the soft tissue was raised, after 
the cutting by the knife, the wound looked like a pocket, and the line of the gum was 
on a plane with that covering the roots of the central and canine. The reason given 
for the separation of the gum tissue from the bone was, that in consequence of the 
deep depression that existed in the alveolus, a large portion of the labial surface of the 
root would, when placed in proper position, be on the outside, and it was necessary for 
artistic success that the same thickness of gum should cover the new root as that 
which covered the roots of the other teeth. The reason for carrying the incision beyond 
the median line was to get a greater length of gum and have the cervical margin on a 
line with that of the other teeth. It was the natural effect and the artistic result pro- 
duced by this care that made the teeth he had implanted a month after the operation 
difficult of detection. A small crescent-shaped piece was then cut out of the palatine 
margin of the gum to receive the distal portion of the neck of the tooth and the soft 
tissue dissected away, but not nearly so much as on the labial surface. 
Two trephines and a long, conical-shaped bur, invented for these operations, were 
then selected, all of which had movable gauges like collars, for the purpose of measur- 
ing the length of the tooth and the depth required. The larger trephine marked the 
thickness of the root at the point it began to diminish, to form the apex, and the 
smaller one the size at the terminal point, and the gauges were set accordingly. 
Both flaps were then separated and the larger trephine placed in the alveolar ridge, 
at a point covering the centre, and drilling commenced in the direction of the line the 
new tooth was to occupy. The trephine was sunk into the alveolus until the gauge 
came to the line of the cutting edge of the central. This marked the point where the 
tapering end of the root commenced. The trephine was then changed for the smaller 
one. This, then, was sunk in the direction of a slight curvature which existed at the 
apex of the root, until its gauge also marked the line of the cutting edge of the cen- 
tral. The full depth and the direction of the root being now obtained, the cavity was 
widened, as indicated by the varying diameters of the root, until it was adapted to the 
shape of the root. The socket was then thoroughly syringed with the warm solution 
of the sublimate and the teeth inserted. This operation was performed slowly, to illus- 
trate in detail to the members present the modus operandi of implantation, and took 
about twenty minutes. The second operation-the implantation of the left superior 
lateral-was undertaken to illustrate the rapidity with which the operation could be 
performed. It was accomplished in exactly the same manner as the first, but in five 
minutes and thirty seconds. The teeth were then ligated by delicate silk threads to 
the adjoining ones, and the occlusion made perfect by grinding off the point of contact 
when the jaws were closed. 
Clinical operation by Robert B. Adair, Gainesville, Ga. Pyorrhoea alveolaris. 
Case i.-Patient, George Williams, inmate of the Soldiers' Home, Washington, 
D. C. Age forty-eight years. Clearly marked case of pyorrhoea, but no deep pockets; 
gums hypertrophied and dark purple color for half an inch up the gums. Pus exuding 
from the sockets of nearly all the teeth. Teeth sound; breath very offensive. Had 
him rinse his mouth several times previous to operation, with a solution of permangan- 
ate of potash about the color of a rose leaf. 
Patient had never used a tooth brush, consequently had considerable accumulation 
of calculus. The calculus I thoroughly removed, using Dr. Allport's pyorrhoea instru- 
ments, with push motion, and scraped edges of the alveolar processes, removing all 
traces of necrosed bone. 
Second sitting. Made careful examination to see if any trace of calculus had been 
left, and after impressing upon the patient's mind the importance of thorough cleaning 
of the teeth, I selected a soft, prophylactic tooth-brush and showed him how to use it, 714 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by brushing the under teeth up and the upper ones down, after which I prescribed the 
following lotion :- 
li . Chlorate of potassa g ij 
Glycerine 3 j 
Tannin g j 
Aqua pura 3 ij. 
Chlorate potassa can be dissolved in hot water or triturated dry, after which add the 
glycerine, when there will be no danger on account of incompatibility. Flavor with 
a few drops of rose water, and use three or four times daily after brushing and freeing 
teeth from all accumulation of food, etc., diluted in a little water. 
No further treatment is necessary for this case, if the instructions as to cleaning teeth 
are carried out. 
Case n.-Charles F. Gillies, residence Soldiers' Home, Washington, D. C. Age fifty- 
five. Union soldier in late war between the States. Patient has rheumatism at 
changes of the weather, and has had erysipelas. Was slightly wounded in scalp and 
right leg. Gums and mouth have been sore and diseased for seven years. Had not 
used a tooth-brush for that length of time. Gums very dark purple. Pus exuding 
from necks of all the teeth, of a very thick and offensive smell. A very large accumu- 
lation of very hard calculus attached to all the teeth, the inferior incisors having a 
larger quantity than the other teeth, and were quite loose in the sockets. The left 
upper lateral incisor was very loose, could readily be pulled out with the fingers; deep 
pockets extending all around it to near the apex of the root-instrument passing up 
readily to apex, pus exuding from it. Gums very much hypertrophied and very sore, 
bleeding at the slightest touch, rendering mastication painful. Had patient first rinse 
mouth thoroughly with the solution mentioned in Case I, to destroy the disagreeable 
odor previous to first sitting. 
First sitting. Dried off gums with absorbent paper and applied 8 per cent, solution 
cocaine, using Dr. Allport's instrument, push motion, going to bottom of pockets, after 
which, with a spoon-shaped instrument, I scraped away all soft and necrosed bone, and 
ligated superior lateral incisor with silk ligature to adjoining central and canine, and 
prescribed same lotion as in Case I, to be used in same way, and directed the patient to 
call next morning at the same hour. 
Second day sitting. Found gums much improved and less sensitive, the patient 
remarking that he slept better and felt better than for six months. Proceeded to 
finish, removing any remaining tartar to be seen or felt with the instrument, after which 
I syringed out the pockets thoroughly with peroxide hydrogen. I then dried off the 
gums, and applied on the end of a small broach, previously wrapped with a little lint 
cotton, a saturated solution of crystal iodine in pure wood creasote (the solution should 
be made as thick as possible, having a sediment un dissolved at the bottom) down to the 
bottom of the suppurating pocketsand all over the inflamed surfaces, waiting a moment 
for the iodine to be imbibed and taken up, still keeping the parts dry. I then applied, 
by means of broach previously wrapped with lint cotton, a preparation of tannin dis- 
solved in glycerine. (This is made by packing into a wide mouthed bottle as much 
tannin as you can with the fingers, then add a little glycerine-say just enough to cover 
the tannin-and set aside for a day, when, if it is found not enough to dissolve to the 
bottom, more must be added from day to day, till it reaches the bottom, when the solu- 
tion is just right.) 
Flowing it all over the inflamed and painted surfaces and down into the pockets, 
the napkin or paper is removed and the saliva allowed to flow over it, which imme- 
diately forms a tannate of albumen, a leathery coating which hermetically closes the 
pockets and keeps them sealed and protects from food and foreign substances being SECTION XVIII-DENTAL AND ORAL SURGERY. 
715 
forced down into them during mastication, and also protects the cells that are being 
built up by nature. 
This treatment I repeated every day at the same hour, brushing the teeth myself, 
upper ones down and lower ones up, removing the ligature and thoroughly cleansing the 
pockets and mouth with peroxide of hydrogen, and, after applying the iodine and tan- 
nin preparations as before, left the patient in the hands of Dr. Ten Eyck, of Washing- 
ton, D. C., to continue the same treatment every twenty-four hours, keeping lateral 
incisor ligated till new cell tissue is built up in the pockets and the teeth become firm 
in the sockets. 
FOURTH DAY. 
Clinic by W. J. YOUNGER, M.D.-The operation of implantation was performed on 
J. H. Miller, M.D., of Buckhannon County, Virginia. A right superior lateral was 
inserted in a manner identical with that employed in Dr. Gartrell's case. The im- 
planted tooth, however, had been extracted about eight years, and was not so well 
supplied with pericementum. 
E. C. Moore, d.d.s., Detroit, Mich., filled a right superior bicuspid. Gold differ- 
ing from the ordinary filling in this particular: the gold used was strictly non-cohesive, 
tightly-rolled cylinders, and condensed with the electric mallet, the time occupied 
being about thirty minutes; almost the same operation by my neighbor (there) occupy- 
ing about one and one-half or two hours. As to the comparative merits or superiority 
of the two operations time must be the judge. 
Dr. Daniel Freeman, of Chicago, Ill., demonstrated his new double foot-spring 
clamp, devised to facilitate the impacting of gold in labial and lingual cavities beneath 
the gingival margins. 
Object.-To fold the rubber dam over and beneath the gingival border, hold it in 
place, make visible and keep dry the cavity of decay during the operation. 
Advantages.-Having the double root is reversible and more universal. 
Three sizes, applicable to all teeth except molars. 
Sherman B. Price, d.d.s., New York City.-Operation.-Filling with soft foil, 
smooth points, hand pressure, and cavity prepared with hand instrument. Second 
bicuspid, right superior anterior proximal cavity. 
Abbey's No. 4 soft gold used. 
Clinic given by Dr. C. A. Timme, of Hoboken, N. J. Filling the first left lower 
molar, involving the distal and whole grinding surface. The German silver matrix 
was used. The whole operation was performed by rotation, or Herbst method, using 
steel and agate points. Wolrab gold cylinders were employed in the beginning, and 
filling completed with Wolrab heavy foil, polished and burnished with granite points. 
E. S. Niles, d.m.d., 241 Boylston street, Boston, Mass. Soft and Cohesive Gold 
Filling. Cavities situated in the proximal surface of left superior central and lateral 
incisors, extending to near the gum and cutting edges. Gold used, Wolrab's and 
Knapp & Co.'s cylinders (soft or accommodating), having been previously exposed to 
the action of gases, to render them soft and free from cohesion. Cohesive gold used, 
No. 3 S. S. White 1000 fine leaf, rolled in four strips to each leaf of common book size 
and cut the size required. 
The cavities are lined and partially filled with the soft gold mentioned, and left in 
such form as to retain the cohesion without relying upon the cohesive attachment of 
that gold to the soft gold. The soft gold was placed with ordinary ebony-handled 
instruments, and condensed. Before introducing the cohesive gold the soft was thor- 716 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
oughly pressed to the walls by the hand and automatic mallet, after which the cohesive 
gold was introduced and condensed by the usual methods-with hand and automatic 
mallet. 
Result.-Perfect adaptation of gold to walls of cavity. A hard surface and two 
large cavities filled in one hour's time, with little fatigue to patient or operator. 
Dr. W. A. Spaulding, Minneapolis, Minn., put a large compound filling in left 
inferior second molar, with a round, bell-shaped buccal cavity extending to and includ- 
ing the grinding surface. Commenced without retaining points, using Steurer's plastic 
gold for first half of cavity, which worked very nicely under smooth points and hand 
pressure, finishing with Hood & Reynold's pellets, under the Hewett pluggers. The 
particular feature of these pluggers is their round face, with serrations but one way, 
operating with an effect similar to iron under a riveting hammer while heading down a 
bolt. 
Time consumed in actual work, one hour. 
Clinic by Dr. T. S. Waters, of Baltimore, Md.-Patient, a student of the Balti- 
more College of Dental Surgery. A compound contour filling of left superior central 
incisor, with electric mallet, and exhibition of similar fillings, made at previous clinics, 
as shown in the cuts A, B and C. 
1 and 2 shows the condition of the teeth before being operated upon. It will be SECTION XVIII-DENTAL AND ORAL SURGERY. 
717 
seen that the teeth are very badly decayed, and the nerves very nearly exposed. The 
nerves were protected with layers of oxychloride of zinc, and all are living. 
The feature of the clinic was not so much the filling, as demonstrating the use of 
the electric mallet, illustrating that peculiar wiping, rotary, or skimming movement of 
the hand and index finger acquired only by experience, and a careful study of this very 
useful instrument, when properly understood and mastered. 
Dr. T. E. Weeks, Minneapolis, Minn., filled a distal cavity in left inferior first 
molar, comprising one-third of grinding surface. Cavity prepared as a " box ' ' or 
"tenon." No retaining pits. Applied matrix, occupying but one interdental space 
made of phosphor-bronze, a semicircular strip No. 34 standard gauge, held in position 
by Week's modification of the " Hewett spring clamp." 
Used "Pack's cylinders, loosely rolled, style A," Nos. 2 and 3, without annealing, 
at cervical margin; then, slightly warming, giving the filling its greatest cohesive pro- 
perties as it approached completion. 
Time actually consumed in work, exclusive of interruptions, one hour. 
When complete, the filling presented a full 1 ' knuckling contour. ' ' 
Charles Richard Butler, m. d.-Restoration operation upon the right superior 
first molar, anterior proximal surface. Thin section of textile metal at the cervical 
border. Used crystalloid gold, R. S. Williams', which has spreading qualities under 
impactment. This operation was accomplished by the aid of hand pressure and a 
mallet. 
Dr. Alfred R. Starr, of New York City, capped the exposed pulp of a left supe- 
rior first molar. The exposure was not a recent one, and the exposed portion was not 
iu a very healthy condition. The softened dentine was removed, and the unhealthy 
portion of the pulp excised as far as possible without too extensively involving the pulp 
chamber. After applying a solution of carbolic acid (about one part carbolic to twenty 
of water) the pulp was capped in the following manner :- 
Ordinary oxyphosphate cement (in this case Weston's slow setting cement) was 
used, and was prepared by diluting the liquid with nearly an equal quantity of water, 
and then incorporating it with the powder (oxide of zinc), making a mixture of the 
consistency of cream. A small portion of this creamy mixture was taken up on the 
point of a small ball burnisher, and conveyed to the cavity, the material being allowed 
to flow over the exposed pulp without making any pressure thereon. 
The slight pain which preceded and followed the operation soon subsided after 
more of the material had been added. It was stated that, ordinarily, with a recent- 
exposure and a healthy pulp, there is no pain during or following the operation; and 
that if the pain should follow, and not subside after a few minutes, it would no doubt 
be due to pressure on the pulp. In such a case the indications would be to remove the 
cap and try again, using the cementa little softer; or, if you thought the pulp had been 
too much irritated for immediate capping, apply clove oil, laudanum, or any soothing 
application, and seal the cavity for a few days before re-capping, being very careful 
not to make any pressure on the pulp. 
In the case operated on at the clinic, although the pain soon subsided, the capping 
was covered with a temporary stopping; it not being deemed advisable, in view of the 
condition of the pulp, to insert a permanent filling. 
If the exposed point is large, or if there should be any doubt about the condition 
of the pulp, it is advisable to always resort to the use of a temporary stopping over the 
capping; but, if the exposure be a recent one and small, the capping may be covered 
with a permanent filling at the same sitting. This can readily be done when neces- 
sary, since the material sets very quickly (in from five to ten minutes), and because, 
from these small and recent exposures, little or no trouble may be apprehended. As a 718 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
further precaution against thermal influences, a layer of gutta-percha may be interposed 
between the capping and the filling. 
Dr. Starr stated that he has been using this method for about four years, and has 
been very successful with it except in cases of old exposure. In beginning his experiments 
with oxyphosphates as a pulp capping, he used muriate or sulphate of morphia with the 
powder (nearly equal parts of bulk), and diluted the liquid as described; but his 
experience has been, that the morphia exerts little if any quieting influence over the 
pulp, and that equally as good results can be obtained without its employment. 
The dilution of the liquid (phosphoric acid) renders the combination less irritating, 
without materially affecting the rapidity or firmness of the setting, and hence lessens 
the danger of immediate or remote disturbance of the pulp. 
It was stated that it was advisable to use a slow setting cement, particularly in warm 
weather; the quick setting cements being unmanageable unless mixed very soft. 
The three great essentials to the success of this operation were said to be : 1st, A 
healthy condition of the pulp; 2d, absence of pressure; 3d, a perfect adaptation of the 
capping material to the pulp and floor of the cavity. Dr. Starr claims no originality 
for this method of treatment, but feels quite confident that, if it is more generally 
known and practiced, it cannot fail to give satisfactory results. 
Lloyd L. Davis, d.d.s., Eaton Rapids, Mich.-Restoration of contour, with tin 
and cohesive gold, by the aid of the electro-magnetic mallet. First right superior 
bicuspid, containing large cavity, involving its mesial and masticating surfaces. After 
application of dam and security of space necessary for the performance of all operations 
of contouring character, cavity was prepared with chisels and burs driven by an elec- 
tric motor. The thin margins of the cavity were removed with the chisel to a point 
where reliability of strength could be depended upon, and débris and decomposed den- 
tine taken away with sharp engine burs. For the retention of the plug grooves were 
run with the burs, just within the line of union of enamel and dentine from cervical 
margin, down both lingual and buccal walls, to a point just within (not through) the 
masticating surface. To insure the retention of the first pieces of filling material at the 
cervical border, the smallest minim wheel bur was applied to the outer wall of each 
groove, near the cervical end, to just roughen the surface to receive the impacted filling, 
which consisted, for this portion of the cavity, of folded No. 6 globe tin foil, cut into 
patches of a length and width to correspond with the cervical surface to be covered. 
Tin was used at this poiut, on account of its comparatively easy manipulation and adapt- 
ability, and more especially because of its well-known qualities for preserving tooth 
structure against further decay. These mats, of suitable size, were put into place, and 
thoroughly adapted to this surface and against the margins, for about one-twentieth the 
depth of the cavity, with a deeply serrated, thin point plugging instrument. Pellets 
of Williams' No. 4 cohesive foil, cut from a roll of suitable size, were now mechanically 
united to the surface of the tin with the same instrument used in applying the latter. 
Just enough of this form of gold was used to completely cover the surface of the cavity, 
and it was used simply as a foundation for the balance of the filling, which was com- 
pleted with narrow ribbons cut from Williams' No. 10 cohesive foil, folded twice upon 
itself, making No. 40 in thickness. These strips were put into place, solidified within 
the cavity, and perfectly adapted to the margins of it by an electro-magnetic mallet, 
operated by a Detroit Motor Company's battery. 
Gold foil, No. 10 thickness, folded to No. 40, can be used much more satisfactorily 
than of any other weight. The lighter foils are picked and chopped into a worthless 
condition under the movement of the mallet, and the heavier ones are too stiff and 
unyielding to be worked into the inequalities of the cavity. With foil of this thickness 
worked upon by an electro-magnetic mallet skillfully handled, a more perfect filling of SECTION XVIII DENTAL AND ORAL SURGERY. 
719 
a contour character can be made than by any other known means. This assertion is 
made because of three special reasons. The blow from the electro-magnetic mallet 
solidifies the gold more evenly, consequently more thoroughly and perfectly. The 
folded strips of gold can be impacted against frail margins of cavities with less liability 
of fracture, and the ease and freedom from fatigue which attends its performance obvi- 
ates any disposition to be careless and hurried during the last steps of a long operation. 
To sum up, the results of a long experience with the electro-magnetic mallet have led 
to the belief that with it the skillful and painstaking operator can get nearer to the ideal 
filling than by any other means of cohesive gold condensation. 
Clinic by Stoddard Driggs, d.d.s., of Lexington, Ky. 
Case i.-Mrs. A. Aged thirty. A large crown cavity in left superior anterior molar. 
Fearing that there might be an exposed pulp, care was taken to excavate slowly and 
cautiously, and the surmise proved true. However, the cleansing and preparation were 
accomplished, and nothing else being at hand, the floor of the cavity and exposed point 
of nerve were touched with carbolic acid, and a little very thin mixture of oxyphos- 
phate of zinc introduced. When it had sufficiently hardened, the remainder of the 
cavity was filled with the same preparation and the patient dismissed. The next day 
she reported favorably, having suffered no pain or inconvenience. It was deemed pru- 
dent to defer the introduction of a gold filling to a future time. 
Case ii.-Master B. Aged fifteen. Large cavity in grinding surface of right anterior 
inferior molar. It involves the fissures in each direction from the central cavity. The 
excavation is made in the usual manner, and formed with the walls as nearly perpen- 
dicular as practicable, and without pits or undercuts. A sheet of No. 4 soft gold foil 
is cut into quarters and folded so that the width will be a little more than the depth 
of the cavity, and then rolled on either a flat instrument, purposely made, or on a 
square drill, a large one being used to form large cylinders and smaller ones to form 
cylinders containing less gold. To form small cylinders the operator has found it best 
to divide the sheet of gold into eighths. A quarter or half sheet of cohesive foil is 
loosely rolled between the fingers and cut into pieces. A small napkin is now folded 
in form to be easily introduced between the tongue and the tooth to be filled. Next a 
strip of soft bleached muslin, one and a half by two or three inches, is folded and placed 
between the tooth and cheek, these being preferred in a large majority of cases to rub- 
ber dam as a saving of time to the operator, and as giving less discomfort to the patient, 
while affording all necessary protection from saliva. After drying the cavity, a cylinder 
of sufficient size to be readily introduced into the posterior fissure is placed with the 
pliers in a standing position in the cavity, and then carried and forced back to its place 
against the posterior wall by the hand plugger. Others of suitable size follow, if 
required, till the main cavity is reached, when large ones are similarly introduced and 
packed until it reaches to the lingual and buccal fissures, when they are to be filled as 
the first. Other cylinders were then introduced, the size being governed by the size 
of the cavity and packed hard against the walls till full. A pointed instrument is 
now forced between the last cylinders used, forcing them against the walls, and into 
that cavity thus made within the filling, cohesive gold is packed, thus keeping the 
whole. As care has been taken to condense the cylinders as the work progressed, there 
will be no other point at which the needle-pointed plugger can be introduced. The sur- 
face of the filling is now to be condensed by going over the whole and subjecting it to 
the. necessary pressure. It may be done with the mallet, if preferred. The surface 
is then cut and polished by engine burs, or corundum points, or both, then with scotch- 
stone until the desired surface is obtained. 
This method is recommended as being one that will enable us to work for a greater 
number of patients, because of the rapidity with which gold can be introduced and 720 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
consolidated, and a certainty of complete adaptation to the walls of the cavity. 
Twenty-five years of constant practice by this method, for families whose teeth I have 
had charge of during that period, have demonstrated to the operator its value. 
Dr. C. S. Case, Jackson, Mich.-The clinical operation was designed to show:- 
1. The usefulness of a combination of tin and gold filling. 
2. The value of wedge-pointed pluggers, applicable for the insertion of all soft foils. 
Patient-Dr. U. D. Billmeyer, Chattanooga, Tenn. 
Cavity-Anterior superior proximal in right inferior molar. Had been filled with 
gold years before, and, decaying along the cervical border, had been removed and the 
space stuffed with amalgam from the lingual side. Upon removal of the entire filling 
the ravages of decay were found still at work, deepening the cavity far below the bor- 
der of the gum, and involving the cervico-lingual portion of the tooth. After the dis- 
integrated portion was removed, and the cavity partially shaped, a thin aluminum 
matrix was formed, and inserted so as to extend below the cervical edge, and lap round 
the tooth on the lingual side; then the^rubber dam was put on to inclose the matrix, 
a wooden wedge being lightly inserted to prevent it from being forced too far away 
from the cervical border. 
When the lingual portion and lower third of the cavity were filled, the wedge and 
matrix were removed and the external surface of the partial filling perfectly finished; 
then the teeth were separated and the balance of the filling inserted, contoured and 
finished, so that when the teeth were allowed to return to their position, a V-shaped 
space, open at the cervix, would remain between them. 
The filling material used for the first two-thirds of the cavity was Robinson's Felt 
Foil, laid between two sheets of Williams' corrugated gold, and cut into little squares 
and ribbons. This was followed by Williams' new crystalloid gold, which was finally 
faced with Williams' rolled platinum and gold No. 2. 
The principal feature of this operation worthy of note was in the use of the wedge- 
pointed pluggers-not exclusively, but for condensing and preparing the surface for the 
next piece-the angle of the points ranging from 30° to 40°, and shaped so as to meet 
every demand. Instead of impacting the material immediately in front of the plugger, 
as in the blunt serrated points, their force is constantly in a lateral direction, expanding 
and spreading the filling against the opposing walls of the cavity, securing the most 
perfect adaptation, condensing it to a remarkable degree of hardness, and obtaining the 
greatest mechanical adhesion. 
FIFTH DAY. 
Clinic given by E. L. Swartwout, d.d.s., Utica, N. Y.-Operation.-Filling one 
cavity on labial surface and extending around the mesial and distal surfaces, with 
Watts' crystal gold, the wallsand margins of the cavity being first lined with Wolrab's 
soft gold foil, and burnished against said walls to secure the most perfect adaptation of 
the gold against the tooth structure, with foil, and then packing the crystal gold on to 
the foil with bur-shaped point instruments (which are not cross-cut), to insure asper- 
fect adaptation or union of one layer with another as possible, building up the gold 
solid from the bottom up to the surface, with no after-condensation, only on the surface, 
with a burnisher, all by hand pressure. 
Dr. J. Rollo Knapp, of New Orleans, contoured right superior cuspid on distal 
surface, the second bicuspid filled on masticating and mesial surfaces, and a gold crown 
with porcelain face inserted upon root of first bicuspid, knuckling firmly against its 
neighbors and articulating accurately with the lower teeth. 
Clinic given by Dr. C. A. Timme, of Hoboken, N. J., filling the right lower molar. 
The cavity was situated in the mesial and grinding surface. SECTION XVIII-DENTAL AND ORAL SURGERY. 
721 
Operation was entirely performed by rotation or Herbst Method, using steel and 
agate points. Wolrab gold cylinders were used in the commencement of the opera- 
tion, and completed with Wolrab heavy foil. 
Dr. G. H. Chewing, of Fredericksburg, Va., contoured a bicuspid tooth; the cavity 
occupied the mesial and distal surface. In the beginning of the operation soft foil No. 
3 was employed. The contouring was done with cohesive gold. 
Dr. G. A. Sprinkel, of Culpepper, Va.-Clinic.-Left upper central incisor filled 
upon labial surface with cohesive gold, and the filling carried across to a large proximal 
cavity, which was converted into a simple cavity with cohesive gold, and then filled 
with non-cohesive. 
Dr. G. L. Curtis, Syracuse, N. Y., implanted a superior bicuspid for Wm. Nelson, 
Washington, D. C. 
Operation satisfactory to patient and gentlemen present. 
Mr. W. H. Woodruff, London, Eng.-Clinic.-Right upper second bicuspid; 
compound filling on proximal, lingual and masticating surfaces, with cohesive foil and 
electric mallet. 
Dr. James G. Palmer, New Brunswick, N. J., contoured a right inferior second 
bicuspid. The cavity was in the anterior proximal surface of the crown. 
Gold used, White's 1000 fine cylinders and Williams' crystalloid gold. 
Special objects: To show fineness of work done with automatic mallet, and advan- 
tages of Williams' new crystalloid gold. This latter was used to contour and finish 
with, giving a hard surface without any pitting, as where crystal gold is used. 
William Conrad, D.D.S., St. Louis, Mo.-Operation.-Extracting left superior 
first molar, using the mixture suggested by Prof. Vine, of Paris, France, as a local 
anæsthetic. The formula is eight drops of a two per cent, solution of carbolic acid and 
three-fourths of a grain of hydrochlorate of cocaine, mixed at time of using and 
injected hypodermically. Introducing the needle at a point between the free margin 
of the gum and the neck of the tooth, as far toward the apex of the root as possible 
without puncturing the membrane. Forcing one-half of the eight-drops mixture on 
one side and half on the other, hold the finger over the openings for a second or two; 
then wash out the mouth with cold water, in order to remove all of the free cocaine 
that may be on the mucous membrane and lips. All of this was done in the above 
case. Lanced the gums, to show the insensibility produced, after waiting four minutes. 
At six minutes after the injection forced the forceps down to the alveolar process.several 
times, to show that there was no pain. Then I extracted the tooth without pain of any 
kind. 
Clinic II.-Extracting left inferior wisdom tooth, using the cocaine and carbolic acid 
mixture as a local anæsthetic. The crown had been broken off three days before. Gum 
highly inflamed and covering the root, which was aching, and patient very nervous. 
Injected, etc., the same as in Clinic I, lancing very extensively, owing to the condi- 
tion of the root. Extracted without pain during any part of the operation. This 
patient manifested cocaine intoxication. Pulse became slow, hands cold, face without 
color-all of which passed off, and the patient reported everything right. 
Clinic III.-Extracting left superior first molar. 
Injected the mixture, etc., the same as in Clinics I and n. Extracted without pain. 
Then took out other teeth in lower jaw, with all the pain usual to such cases. 
Owing to the published reports of fatal cases from the use of cocaine, the operator 
advises not to use more than three-fourths of a grain at any one time without consid- 
ering all of the circumstances of the case. 
Vol. V-46 722 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In private practice Dr. C. used one-twenty-ninth of a grain with perfect satisfac- 
tion. The use of the mixture is recommended in all cases of difficult extraction of 
imbedded or impacted teeth and badly-broken roots. 
For want of the proper patients many of the operations which had been announced 
upon the Programme could not be performed, although the operators were present 
daily. 
C. F. W. BÖDECKER, D.D.S., M.D.S., 
Chairman of Clinic Com. 
M. Chs. Gottschaldt, 
Secretary of Clinic Com. 
Report of the Clinics in Prosthetic Dentistry, given at the Franklin School Build- 
ing, corner of Thirteenth and K streets, Washington, D. C. 
FIRST DAY. 
Dr. H. A. Parr, of New York, exhibited his Universal Separator. He also gave a 
clinic. He began at the two central superiors, and made the circuit of the mouth, 
making the desired separation between each tooth, to the entire satisfaction of a large 
audience. The instrument is simple in its construction and easily adjusted. Figs. 
1 and 2 are cuts of the instrument. 
Fig. 1 
Fig. 2. 
Dr. L. P. Haskell, of Chicago, Ill., made and put in the mouth a full upper set of 
continuous gum teeth. Dr. John Allen, of New York (the inventor of continuous gum), 
followed each step in the progress of the work with lectures and applications. 
Clinic by J. Hall Lewis, d. d. s., Washington, D. C.-Full upper swaged gold 
plate, plain teeth and pink rubber. 
Continuous gold band to plate, extending upward at posterior aspect, until but a 
line of pink rubber was visible, and anteriorly forming a shoulder for the pink rubber 
to rest against. 
No hooks or strips used to fasten rubber to gold, but a firm union of the two was 
established by stippling, with a graver in an automatic mallet, the surface of the gold 
plate enclosed by the band, as well as the inner surface of the latter itself. SECTION XVIII DENTAL AND ORAL SURGERY. 
723 
SECOND DAY. 
The following is Dr. V. H. Jackson's report of his clinics :- 
I presented at your clinics over forty models, representing the position of teeth 
before and after regulating, with the appliances used in each individual case, describ- 
ing- 
1. My method of contracting the arch where the teeth are too prominent. 
2. Method of retaining the teeth in position after regulating, by use of the " crib." 
Fig. 1. 
3. Method of retaining the plate in position by use of metal clasps, extending from 
the plate, around or over and around the teeth, removing, in all cases, the necessity of 
covering the teeth with rubber, and opening the bite, which is objectionable. 
The latter two methods are described in the Transactions of the Odontological 
Society. (See June number of Dental Cosmos, 1887.) 
Fig. 2. 
Fig. 3. 
Especial attention is drawn to my method of contracting the arch where the teeth 
are too prominent. (See Fig. 1.) 
It consists of a rubber plate covering the roof of the mouth only, with the metal 
spring wire extending from the plate (passing usually between the bicuspids on one or 
both sides of the mouth), passing forward, following the curve of the arch (see Figs. 724 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
2 and 3), and formed to press on the labial surfaces of the teeth to be moved, and thus 
get a constant inward pressure toward the plate, which has been cut away from the 
palatal surface of the teeth sufficiently to permit them to move into line. 
If a spring is required on one or both sides of the arch, they must act independently, 
and may, if desired, lap by each other in front, or be so curved as to press on the tooth 
or teeth to be moved. 
The spaces for the passage of the springs between the teeth, if not naturally broad 
enough, can be made so by wedging, usually between the bicuspids ; or, if too many 
teeth, one or more may be extracted, or the wire extended over, between the cusps of 
the teeth, and thence forward as above described. 
Sidney S. Stowell, d.d.s., of Pittsfield, Mass., clinically presented to the Dental 
Section his new method of crown setting, the prominent feature of which was the com- 
bination of an all-porcelain crown with closed cap and dowels, the result being a tooth 
possessing great strength of attachment to the root afforded by the latter, together with 
the beautiful and natural appearance of the former. 
The method of construction, as shown by the accompanying cuts, is, in brief, as 
follows :- 
Fig. 1. 
Fig. 3. 
Fig. 4. 
Fig. 6. 
Fig. 8. 
Fig. 2. 
Fig. 5. 
Fig. 7. 
Fig. 9. 
Fig. 10. 
Fig. 11. 
Fig. 12. 
Fig 13. 
Fig. 1 shows the end of the root prepared for the cap, having been trimmed, and 
the end countersunk, into which the top of the closed cap is burnished when in place, 
as seen in Fig. 2. 
The cap is now perforated, the root canals reamed out, and the dowels of platinum 
and iridium wire are set, being allowed to project slightly, if a plaster impression is to 
be taken ; but, if the tooth is to be fitted directly to the mouth, the dowels are cut off 
even with the top of the cap, Fig. 3. Either a Logan or Brown crown is used, cutting 
off the regular dowels and grinding the tooth to fit the top of the cap. The tooth is 
now invested in plaster and marble-dust, Fig. 4, and pure gold fused on the stump of 
pin, Fig. 5. Surplus gold is then filed or ground away. A slight bevel is now ground 
on the palatal surface, back, until the gold is reached, Fig. 6. Crown is now fastened 
to cap, and dowels already in place on the root, and all removed from the mouth 
together, Fig. 7. The case is now invested. The inside of the cap around the dowels 
is filled with plaster and marble-dust, the rest of the investment consisting of plaster SECTION XVIII-DENTAL AND ORAL SURGERY. 
725 
and asbestos for the final soldering, Fig. 9. Wax having been burned out, a thin clip- 
ping of platinum plate is inserted in the opening caused by the bevel above men- 
tioned. 
The clipping of platinum serves as a lead for the solder. The soldering is done in 
the usual maimer, heating from the under side, drawing the solder down around the end 
of the dowels, and making a firm attachment to the pure gold. Fig. 8 shows a finished 
bicuspid ; Fig. 11, a sectional view of the same. 
Figs. 10, 12 and 13 show the other finished crowns, extreme large and small cases, 
the method being equally applicable to all. 
The clinical demonstration of the method, when finished, seemed to embody every 
desirable feature of a tooth crown. 
The final attachment of the crown to the root was with oxyphosphate of zinc. 
t 
THIRD DAY. 
Clinic by Dr. H. A. Pare, of New York.-He inserted a porcelain face crown, left 
lateral superior. The pulp was dead. He cut off the remaining portion of the crown 
and treated the root with carbolic acid, first removing all the dead matter. The root 
he plugged with wood and gutta-percha. The crown was made by a band partly 
encircling the root, the front portion being exposed. 
This, he claims, is a good method, and is strong and durable, doing away entirely 
with the dark color so often seen around the margin of the gums. 
FOURTH DAY. 
Francis M. Shriver, d.d.s., Glenwood, Iowa.-Operation.-Combination bridge, 
consisting of gold and porcelain faced crowns, bridge resting upon a saddle. This 
bridge was to supply the loss of the right superior second bicuspid, first and second 
molars. The third molar being gone, these were replaced by gold crowns upon the 
cuspid and first bicuspid and three porcelain-faced teeth, the second molar resting upon 
the saddle. 
The first part of the operation was to- 
(1) Prepare the cuspid and bicuspid for the reception of the gold crowns. 
(2) To take an impression, with plaster and pumice, of the teeth to be crowned and 
that portion of the alveolar ridge to be supplied with teeth. 
(3) The impression was invested in an iron jacket with plaster and pumice. 
When thoroughly dried, poured it with zinc. This gave perfect model of the alveolar 
ridge and teeth to be crowned. The saddle was swaged over this and the crowns shaped 
over the teeth. The gold was placed on the teeth in the mouth, passing slightly under 
the margin of the gum. 
A second impression was taken with the plaster, while the gold crowns were in 
position. After the impression was removed, the crowns were placed in position in the 
impression. 
(4) The impression was varnished and oiled, then poured with plaster and sand. 
This gave a model with the gold crowns in position. 
(5) A bite was taken and placed on the model. This gave the articulation of the 
inferior teeth. 
(6) The teeth were ground to fit, after which they were backed with platinum and 
capped with swaged caps made from platinized gold, the saddle being made of the 
same. 726 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
(7) They were now invested with plaster and sand and then flowed up with coin 
gold on the lingual surface. 
(8) They were then placed in position on the model, invested with plaster and 
sand. 
(9) They were now soldered together with 20-carat gold solder. After it was dressed 
and polished, it was cemented on the teeth with phosphate cement. 
Clinics of Dr. C. C. Carroll, Meadville, Pa.-Aluminum cast dentures, crowns, 
bridges and dental plates. Having ready my apparatus and materials, consisting of an 
automatic gas furnace, compound pneumatic plumbago crucibles, special iron flasks, 
the aluminum bases Nos. 1 and 2, and the prepared aluminum solder, I proceeded to 
take the impressions from the mouths of the patients assigned me, with plaster-of-Paris, 
using very soft modeling ccfuposition in one case, this being one of the most difficult 
cases ever presented for restoration. 
The alveolar ridges were so completely absorbed in both superior and inferior max- 
illæ, that a restoration of more than two inches was necessary, the lowest plate resting 
in a deep groove of very soft tissue, the upper on a cartilaginous tissue with very flat and 
hard palatal surface. Having obtained correct impressions and "bite," I made the 
models with plaster-of-Paris and sand, forming a base-plate of paraffine, and moulding 
up the arches, mounting the teeth and making a very great restoration of the face, in 
the temporary paraffine-wax base-plate, carving the gums and contour with great 
precision. 
I then made a matrix by investing in the perforated iron flask, using plaster and fine 
sand as investing material. After separating the flask and removing the temporary 
paraffine-wax form from the matrix, and washing out all wax, the flask was closed and 
dried out. 
I then made the aluminum castings directly to the teeth (the superior denture of base 
No. 1, specific gravity 2.6, and the inferior denture of base No. 2, specific gravity 7.5), 
leaving a flange along the labial border for celluloid gums, to be added after cooling, 
producing finished plates requiring only trimming of surplus and final polishing. 
Plates made from aluminum of commerce heretofore used for dental work were liable 
to disintegration, due to the fluids of the mouth-whether acid or normally alkaline- 
acting upon the iron, silica, or other impurities found in the metal. 
If chemically pure its shrinkage is such that it is useless as a material for dental 
plates. Aluminum is known as the "creeping metal," shrinking one part in twelve 
when molten in the act of cooling. Through a series of numerous registered experi- 
ments during the past twenty years, I have succeeded in rendering aluminum 99.8 
chemically pure, and by a three per cent, alloy of a noble metal which expands as the 
aluminum contracts, practically overcoming all shrinkage and affording a metal for 
dental plates, crowns, and bridge work, which combines stiffness, conductivity, light- 
ness, strength and durability. It takes and retains a polish equal to nickel plate, and 
is perfectly compatible with the tissues of the mouth. 
By my methods either plain or gum section teeth can be used. For artistic and 
life-like work the former are preferable, using pink rubber or celluloid for making an 
artificial continuous gum facing, when the metal is cast directly on the teeth ; or, as an 
attachment, if the base-plate is cast with retaining flange first. 
I also gave a clinic demonstrating my method of cast crown and bridge work. 
The case employed had the two superior cuspids pulpless and right and left two molars 
intact. I cut off the cuspidate about two lines from the alveolus, and reamed out the 
pulp and root canal large enough to admit a tube to line the inner wall. The molars 
were shaped so that the opposing walls should be nearly parallel. An impression was SECTION XVIII-DENTAL AND ORAL SURGERY. 
727 
then taken in plaster, after first inserting a pin of orange wood in the cuspidate root 
canals, the apices of which had been previously closed with Hill's stopping. 
With the plaster impression came away the orange wood pins, giving size and direc- 
tion of canals or tubes that I desired to cast with a cap attached, to cover, as a crown, 
the ends of the cuspidate. 
A model was made of plaster and fine sand. Upon the molar teeth and the cuspi- 
date roots was formed, in wax, crowns, as desired, to cover permanently the teeth and 
roots to which I desired to attach a saddle to carry the teeth intended to occupy the 
arch. This model with wax crown and tube form was invested in the perforated iron 
flask, and a cast made of all four crowns at once, of aluminum, which, when finished, 
were cemented permanently in place. Wooden pins were again inserted in the tubes 
lining the cuspidate, fitting neatly yet loose enough to be again withdrawn when a 
plaster impression is again taken. 
An impression is now taken of the dental arch with the crowns over the molars 
and lining interiorly the cuspidate. 
A new model from this second impression is made of plaster and fine sand. Upon 
this model is mounted, in paraffine wax, a saddle or bridge denture, carrying ten teeth, 
covering the two molars and passing into the root canals of the cuspidate. A proper 
occlusion is secured in the usual manner for ordinary dentures. The model with teeth 
mounted in position is invested in the flask, and when set and hard, separated and the 
wax removed with hot water. The matrix is then dried out slowly and a cast made of 
aluminum, by means of my pneumatic crucible, making the entire denture, including 
telescoping crowns for molars and crowns with pins attached, to pass into the tubes lin- 
ing the cuspidate in one solid, continuous piece, with the teeth firmly attached, which, 
when finished, will go to place neatly and firmly, to be worn as a movable or fixed 
denture, as may be preferred. 
Other things being equal, I prefer the movable bridge or saddle, as the case may be, 
on account of the greater cleanliness and probable permanency in use. As a part of 
this clinic, I soldered four plain teeth upon an aluminum plate with common copper 
soldering iron, using base No. 2 as my solder, and using no flux in the process. 
FIFTH DAY. 
Clinic by Dr. T. S. Waters, of Baltimore, Md. Patient, student from the Balti- 
more Dental College. 
Exhibition of a practical piece of removable bridge work in the mouth, which can be 
understood by referring to Figs. D and E, palatal and lingual view. Fig. 3 shows the 
teeth prepared for the bridge. The bicuspid and molar are incased in gold, first being 728 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
shaped so as to be smaller than at the gum, so as to admit of telescoping. The bicuspid 
has a groove or half cylinder in it, being a natural cavity in the tooth. Over the bicus- 
pid is fitted a metal crown, and into it is fitted a U-shaped spring, which fits into the 
groove in the bicuspid. 
The only claim made to originality is the spring fitted inside of the telescoping 
crown, enabling the patient to have perfect control of the piece, making it tight or 
loose at will. 
Francis M. Shriver, d. d. s., Glenwood, Iowa. Operation.-A porcelain-faced 
bicuspid placed on the root of a first superior bicuspid. 
The operation consisted in- 
1. To prepare the root to be crowned. 
2. A measure was taken with a thin strip of tin, by which the gold was cut» for 
the band; after soldering together it was driven on the root to be crowned until it 
passed slightly under the margin of the gum. 
The length was now taken, after which a swaged cap was soldered on, making a 
complete gold crown, being made with platinized gold and soldered with coin gold. 
3. The crown was then filed away on the buccal surface for the reception of the 
porcelain face. After the porcelain face was ground and fitted, it was backed with very 
thin platinum, set in position, then invested in plaster and sand, with the hollow of 
the crown exposed so as to solder from the inside with twenty-carat gold solder. 
It was now dressed, polished and set with phosphate cement. 
Dr. William B. MacLeod, of Edinburgh, Scotland, presented and explained by 
models a cleft palate obturator and nasal support. 
Dr. H. C. Merriam, of Salem, Mass., demonstrated his method of making tooth 
crowns as described in Cosmos of August, 1886, and January, 1887, the dry grinding of 
porcelain, using the Waltham corundum wheel ; using the wheels made from ink- 
erasing rubber, showing that the operation of grinding and polishing might be done 
without leaving the operating chair. 
In connection with the clinic he showed his method of making root canal twist 
drills from piano wire, without drawing the temper. 
He introduced for soldering blocks a compound of asbestos and magnesia, and his 
hand corundum points for reaming holes in porcelain teeth. 
He aimed to demonstrate the connection of the arts and sciences in the specialty of 
dentistry. SECTION XVIII-DENTAL AND ORAL SURGERY. 
729 
The following new appliances were exhibited during the session of the Congress :- 
4 4 Front Tooth Separator, " A. C. Hewett, Chicago, Ill. 
" Articulating Guide," H. L. Cruttenden, Northfield, Minn. > 
"Double Loop Clamp," Daniel B. Freeman, Chicago, Ill. 
44 New Regulating and Retaining Appliance, " C. H. Angle, Minneapolis, Minn. 
' 'Saliva Ejector, Air Injector, and Atomizer," H. W. Parsons, Wamego, Kan. 
"Oxy-hydrogen Blow-pipe," JohnS. Thompson, Atlanta, Ga. 
4 ' Appliance for supporting a palate when the bony tissues are lost by cancer, ' ' Drs. 
Weeks and Jennison, Minneapolis, Minn. 
"Rubber Dam Holder, Bur Sheath and Gum Protector," John J. R. Patrick, Belle- 
ville, Ill. 
" Medicinal Syringe, " J. Austin Dunn, Chicago, Ill. 
" Root Canal Dryer," J. H. Wooley, Chicago, Ill. 
" Hasty Water Motor," Walter Campbell, Dundee, Scotland. 
"Upright Connecting Shaft between Motor Flexible Arm," Walter Campbell, Dundee 
Scotland. 
" Obturator and Models," Paul Kölliker, Zurich, Switzerland. 
Dr. Paul Alfred Kölliker, Zurich, Switzerland.-" New Obturator for Cleft 
Palate." 
The duplicate of this obturator was made in May, 1885, for a young man, twenty- 
two years of age, who belongs to a family who all have more or less of an indistinct 
pronunciation, though not having cleft palates, as has the one for whom this obturator 
was made. 
The obturator has been in constant use since it was made, and patient and family 
are much pleased with the results obtained. When he speaks slowly he can pronounce 
every word distinctly, and is also able, much to his delight, to whistle-a thing he could 
not do before. 
When the obturator is in the mouth, it is interesting to watch how, in the act of 
swallowing, it opens and shuts, following exactly the movements of the muscles. 
During the whole time the obturator has been in use it has only required new 
springs for the two wings upon the sides once. 
It is hardly necessary to describe the mechanism, beyond explaining how to find the 
correct position of the spring-fastening in the centre. The model shows the size of the 
opening in the palate as that of its smallest contraction in the usual act of swallowing, 
but as there may be a still further slight contraction in a strong effort of swallowing, 
and as the covered spring will ordinarily allow a play of about six or seven centimetres, 
I make it so as to add two millimetres more, for stronger contraction or dilatation. 
See Figs. 1, 2, 3 and 4. 730 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Fig. 1. 
Shows model of teeth, hard palate and soft palate, indicating the position and appearance of the congeni- 
tal cleft. The lines seen about the model indicate the various sections of the model. 
Fig. 2. 
Fig. 3. 
Shows that side of the obturator which goes 
next to the palate. 
Shows the obturator as in No. 2, except that 
the central portion of the velum is thrown 
back, to show the obverse side and the flat 
surface upon which it plays back and forth 
in the acts of speaking and swallowing. SECTION XVIII-DENTAL AND ORAL SURGERY. 
731 
Fig. 4. ' 
Shows the obturator placed in position on the model, just as you would see it in the mouth. The flaps 
or wings upon either side are on gold hinges, and so move with the varying movements of the con- 
tiguous muscles. APPENDIX. 
733 APPENDIX. 
THE HISTORY OF THE ORGANIZATION OF THE NINTH INTER- 
NATIONAL MEDICAL CONGRESS. 
L'HISTOIRE DE L'ORGANISATION DU CONGRES PÉRIODIQUE INTERNATIONAL 
DES SCIENCES MÉDICALES, NEUVIÈME SESSION. 
GESCHICHTE DER ORGANISATION DES NEUNTEN INTERNATIONALEN MEDICINISCHEN 
CONGRESSES. 
BY HENRY HOLLINGSWORTH SMITH, M.D., LL.D., PHILA., PA., 
Chairman of the Executive Committee. 
History has been defined as " an account of facts which have happened, arranged in 
the order in which they have occurred," or " the rehearsal of things which we have 
seen. ' ' 
As the history of any important event or organization is capable of furnishing 
instruction to those who may be subsequently placed in similar circumstances, and as 
such history may also prove interesting to those who have participated in the labors and 
honors of the occasion, it has been deemed an appropriate termination to the volumes 
of scientific papers now known as the Transactions of the Ninth International Medical 
Congress, to place on permanent record the steps and acts which culminated in the suc- 
cessful organization of this large humanitarian assembly. To the Foreign as well as the 
Domestic members of the Ninth Congress, this record will doubtless possess sufficient 
interest to justify, in their estimation, the pages now assigned to it, and the Chairman 
of the Executive Committee has, therefore, acceded to the request of the able Secre- 
tary-General of the Congress and editor of its Transactions, '1 to prepare a condensed 
and chronological statement of its organization," as ordered by the American Medical 
Association, and place it as an addendum to volume V of the Transactions, it not being 
possible to present this information to the reader as a preface to the volumes. 
In preparing the following account, the writer desires to acknowledge his obliga- 
tions to the extended minutes of the Executive Committee as written by its industrious 
Secretary, Dr. Richard J. Dunglison, of Philadelphia, and he trusts that in the pre- 
paration of this paper he will be found to have exercised such judgment in collating 
the material as will do justice to all concerned. 
Philadelphia, August, 1888. 
735 736 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The meeting of the Ninth International Medical Congress in the United States, 
instead of, as heretofore, in the capitals of Europe, was the result of a suggestion made 
by the late Professor Austin Flint, M.D., LL.D., of New York City, in his address as 
President of the American Medical Association, at its meeting in the City of Washing- 
ton, in the District of Columbia, in May, 1884. 
His suggestion that the Eighth International Medical Congress (then soon to meet 
in the capital of Denmark) should be invited to assemble in the capital of the United 
States, being most favorably received by the Association, which represented nearly five 
thousand members of the medical profession of this country, was followed by the 
appointment of a committee of eight of the members of the Association to take the 
necessary steps to accomplish this object, and under these instructions and with an 
appropriation of four hundred dollars made by the Association to meet the necessary 
expenses of the Committee, as Printing, Stationery, etc., Dr. J. S. Billings, of the U. S. 
Army, acting as Chairman of the Committee, and as a representative of his corps, 
visited Copenhagen and presented the invitation to the Congress, tendering it a warm 
welcome on behalf of the Medical Profession of the United States. This invitation, 
after some discussion of other localities, being duly accepted, the Committee, on their 
return home, entered upon the performance of the preliminary duties previously 
assigned them by the Association. 
At the next meeting of the Association, at New Orleans, in April, 1885, this Com- 
mittee made a report, but when objections were raised as to their course in selecting as 
officers of the Congress a limited representation of the profession in the United States, 
the following action on their Report was taken by the Association :- 
1. " Resolved, That the Committee appointed by this Association, to arrange for the 
meeting of the International Medical Congress in America, in 1887, be enlarged by the 
addition of thirty-eight members, one from each State and Territory, the District of 
Columbia, the Army, Navy and Marine Hospital Service, to be appointed by the Chair- 
man at this meeting, and that the Committee, thus enlarged, shall proceed at once to 
review, alter, and amend the motions of the present Committee as it may deem best. ' ' 
(This resolution was amended by the provision, "that the members of the Com- 
mittee should be selected by the respective State Delegations.'') 
2. 11 Resolved, That the Committee appointed in pursuance of a resolution adopted by 
this Association, April 30th, 1885, to constitute an addition to the original Committee 
of eight previously appointed to invite and make arrangements for the meeting of the 
International Medical Congress, to be held in Washington, D. C., in 1887, be, and the 
said Committee is, hereby authorized and empowered to select a Chairman and a Sec- 
retary, and to fill all vacancies that may occur by death or inability to attend in the 
Committee, and to appoint the Officers of the Congress." 
The following is a list of the Committee enlarged in accordance with the first resolu- 
tion as amended :- 
W. E. Anthony, M.D., Providence, R. I. 
G. Baird, M.D., Wheeling, W. Va. 
Robert Battey, M.D., Rome, Ga. 
F. W. Beard, M.D., Vincennes, Ind. 
J. S. Billings, M.D., U. S. Army, Washington, D. C. 
* J. M. Browne, M.D., U. S. Navy, Washington, D. C. 
L. P. Bush, M.D., Wilmington, Del. 
H. F. Campbell, M.D., Augusta, Ga. 
R. Beverly Cole, M.D., San Francisco, Cal. 
E. P. Cook, M.D., Mendota, Ill. 
W. C. Dabney, M.D., Charlottesville, Va. 
Charles Denison, M.D., Denver, Col. 
W. E. Duncan, M.D., Ellendale, Dakota Ter. 
* Resigned. APPENDIX 
737 
J. W. Dupree, M. D., Baton Rouge, La. 
Ellsworth Eliot, M.D., New York City. 
*G. J. Engelmann, M.D., St. Louis, Mo. 
N. F. Essig, m.d., Plattsburg, Mo. 
Austin Flint, m.d., ll.d., New York City. 
E. P. Frazer, m.d., Portland, Oregon. 
George F. French, m.d., Minneapolis, Minn. 
A. Y. P. Garnett, M.D., Washington, D. C. 
S. C. Gordon, M.D., Portland, Me. 
J. W. S. Gouley, M.D., New York City. 
F. M. Gunnell, M.D., U.S. Navy, Washington, D. C. 
John B. Hamilton, m.d., U. S. Marine Hospital Service, Washington, D. C. 
I. M. Hays, M.D , Philadelphia, Pa. 
C. Johnston, m.d., Baltimore, Md. 
George A. Ketchum, M.D., Mobile, Ala. 
R. A. Kinloch, m.d., Charleston, S. C. 
D. A. Linthicum, M.D., Helena, Ark. 
JohnS. Lynch, M.D., Baltimore, Md. 
J. J. McAchran, M.D., Laramie City, Wyoming Territory. 
J. W. McLaughlin, M.D., Austin, Texas. 
R. C. Moore, m.d., Omaha, Neb. 
Robert Murray, m.d , U. S. Army, Washington, D. C. 
R. D. Murray, M.D., Moultrie, Fla. 
J. W. Parsons, M.D., Portsmouth, N. H. 
William Pierson, M.D., Orange, N. J. 
N. J. Pitman, m.d., Tarboro, N. C. 
L. A. Sayre, m.d., New York City. 
X. C. Scott, M.D., Cleveland, O. 
*Nicholas Senn, M.D., Milwaukee, Wis. 
John V. Shoemaker, m.d., Philadelphia, Pa. 
F. L. Sim, M.D., Memphis, Tenn. 
A. R. Smart, M.D., Hudson, Mich. 
D. W. Stormont, M.D., Topeka, Kan. 
J. M. Taylor, m.d., Corinth, Miss. 
E. F. Upham, m.d., West Randolph, Vt. 
W. H. Wathen, M.D., Louisville, Ky. 
W. Watson, m.d., Dubuque, Iowa. 
W. C. Wile, M.D., Sandy Hook, Conn. 
A. H. Wilson, m.d., Boston, Mass. 
At an informal meeting of the Committee, held at New Orleans during the session 
of the American Medical Association, in April, 1885, Dr. R. Beverly Cole, of San 
Francisco, Cal., was elected temporary Chairman, and Dr. John V. Shoemaker, of 
Philadelphia, Pa., was elected temporary Secretary. 
The Committee held its first regular meeting at Chicago, Ill., on June 24th and 
25th, 1885, for the purposes of organization and the transaction of the business com- 
mitted to it by the American Medical Association. 
In order to facilitate the holding of meetings in different sections of the country, 
the Committee deemed it advisable to select a Vice-Chairman, in addition to a Chair- 
man and a Secretary. 
The following named members were present at the meeting held in Chicago :- 
G. Baird, m.d., Wheeling, W. Va. 
Robert Battey, M.D., Rome, Ga. 
F. W. Beard, M.D., Vincennes, Ind. 
*J. S. Billings, M.D., Washington, D. C. 
R. Beverly Cole, M.D , San Francisco, Cal. 
E. P. Cook, M.D., Mendota, Ill. 
W. E. Duncan, m.d., Ellendale, Dakota Ter. 
Ellsworth Eliot, M.D., New York City. 
N. F. Essig, M.D., Plattsburg, Mo. 
Vol. V-47 
* Resigned. 738 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
G. F. French, M.D., Minneapolis, Minn. 
A. Y. P. Garnett, M.D., Washington, D. C. 
John B. Hamilton, M.D., Washington, D. C. 
*1. M. Hays, M.D., Philadelphia, Pa. 
George A. Ketchum, m.d., Mobile, Ala. 
D. A. Linthicum, M.D., Helena, Ark. 
John S. Lynch, M.D., Baltimore, Md. 
J. W. McLaughlin, m.d., Austin, Texas. 
X. C. Scott, m.d., Cleveland, Ohio. 
*Nicholas Senn, M.D., Milwaukee, Wis. 
John V. Shoemaker, M.D., Philadelphia, Pa. 
F. L. Sim, m.d., Memphis, Tenn. 
A. R. Smart, m.d., Hudson, Mich. 
D. W. Stormont, M.D., Topeka, Kan. 
E. F. Upham, M.D., West Randolph, N. Y. 
W. H. Wathen, M.D., Louisville, Ky. 
W. Watson, M.D., Dubuque, Iowa. 
A. H. Wilson, M.D., Boston, Mass. 
The resignation of Dr. Austin Flint, of New York, as a member of the Committee, 
was presented and accepted. Dr. J. W. S. Gouley, of New York, was elected to fill the 
vacancy, and took his seat with the Committee. 
The Committee then organized, a majority of its members being present, by the 
election of the following officers :- 
Chairman, Dr. R. Beverly Cole, San Francisco, Cal. 
Vice-Chairman, Dr. John S. Lynch, Baltimore, Md. 
Secretary, Dr. John V. Shoemaker, Philadelphia, Pa. 
After the organization of the Committee, the number of members necessary for a 
quorum for future meetings was fixed at fifteen. 
The following preamble and resolution were adopted, to apply to future meetings 
of the Committee :- 
" Whereas, It is expedient that the meetings of this Committee shall represent, as 
far as practicable, the profession of all portions of our country. 
" Resolved, That any member of this Committee who may be unable to attend a 
meeting, shall be empowered to send as his proxy for the meeting, any member of the 
American Medical Association, in good professional standing and a resident of his State, 
or a member of his Government Department. ' ' 
In the course of the meeting in Chicago, on June 24th and 25th, 1885, a Plan of 
Organization of the Congress was adopted, and certain officers of the Congress were 
appointed, in accordance with the instructions received from the American Medical 
Association, and the Committee adjourned. 
In August, 1885, the Chairman, the Vice-Chairman and the Secretary, after consul- 
tation and communication with members, called a meeting of the Committee, to be held 
in New York City, September 3d, 1885, for the purposes of completing the revision of 
the rules and the filling of certain vacancies in the list of officers of the Congress. 
Accordingly, the Committee met in New York City, September 3d, 1885, the following 
named members being present:- 
Dr. G. Baird, Wheeling, W. Va. 
Dr. Robert Battey, Rome, Ga. 
Dr. L. P. Bush, Wilmington, Del. 
Dr. R. Beverly Cole, San Francisco, Cal. 
Dr. W. C. Dabney, University of Virginia, Va. 
Dr. Ellsworth Eliot, New York City. 
Dr. A. Y. P. Garnett, Washington, D. C. 
Dr. S. C. Gordon, Portland, Me. 
* Resigned. APPENDIX. 
739 
Dr. J. W. S. Gouley, New York City. 
Dr. J. B. Hamilton, Washington, D. C. 
Dr. George A. Ketchum, Mobile, Ala. 
Dr. R. A. Kinloch, Charleston, S. C. 
Dr. D. A. Linthicum, Helena, Ark. 
Dr. John S. Lynch, Baltimore, Md. 
Dr. R. C. Moore, Omaha, Neb. 
Dr. William Pierson, Orange, N. J. 
Dr. N. J. Pitman, Tarboro, N. C. 
Dr. L. A. Sayre, New York City. 
Dr. X. C. Scott, Cleveland, Ohio. 
Dr. John V. Shoemaker, Philadelphia, Pa. 
Dr. F. L. Sim, Memphis, Tenn. 
Dr. E. F. Upham, West Randolph, Vt. 
Dr. W. H. Wathen, Louisville, Ky. 
Dr. W. C. Wile, Philadelphia, Pa. 
Dr. A. H. Wilson, Boston, Mass. 
The following named members were represented by proxies:- 
Dr. E. P. Cook, by Dr. N. S. Davis, Chicago, proxy. 
Dr. A. R. Smart, by Dr. William Brodie, Detroit, proxy. 
Dr. J. M. Taylor, by Dr. E. P. Sale, Aberdeen, Miss., proxy. 
The Committee was called to order at 12 M , September 3d, 1885, by the Chairman, 
Dr. R. Beverly Cole. 
The resignation of Dr. L. A. Sayre, of New York, as a member of the Committee, 
was received and accepted, and Dr. Austin Flint, Jr., of New York, was elected to fill 
the vacancy, and took his seat with the Committee. The resignation of Dr. Sayre was 
caused solely by ill health. 
The following ' ' Rules ' ' were unanimously adopted :- 
RULES OF THE CONGRESS. 
1. The Congress shall consist of members of the regular profession of medicine, who 
shall have inscribed their names on the Register and shall have taken out their tickets 
of admission ; and of such other scientific men as the Executive Committee of the Con- 
gress may see fit to admit. 
2. The dues for members of the Congress shall be ten dollars each, for members 
residing in the United States. 
There shall be no dues for members residing in foreign countries. 
Each member of the Congress shall be entitled to receive a copy of the Transactions 
for 1887. 
3. The Congress shall be divided as follows, into seventeen Sections:- 
I. General Medicine. 
II. General Surgery. 
III. Military and Naval Surgery. 
IV. Obstetrics. 
V. Gynaecology. 
VI. Therapeutics and Materia Medica. 
VII. Anatomy. 
VIII. Physiology. 
IX. Pathology. 
X. Diseases of Children. 
XI. Ophthalmology. 
XII. Otology and Laryngology. 
XIII. Dermatology and Syphilis. 
XIV. Public and International Hygiene. 
XV. Collective Investigation, Nomenclature, Vital Statistics, and Climatology. 
XVI. Psychological Medicine and Diseases of the Nervous System. 
XVII. Dental and Oral Surgery. 
4. The General Meetings of the Congress shall be for the transaction of business and 
for addresses and communications of general scientific interest. 740 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
5. Questions and topics that have been agreed upon for discussion in the Sections 
shall be introduced by members previously designated by the titular officers of each 
Section. Members who shall have been appointed to open discussions shall present in 
advance statements of the conclusions which they have formed as a basis for debate. 
6. Brief abstracts of papers to be read in the Sections shall be sent to the Secretaries 
of the proper Sections on or before April 30th, 1887. These abstracts shall be treated 
as confidential communications, and shall not be published before the meeting of the 
Congress. 
Papers relating to topics not included in the lists of subjects proposed by the Officers 
of the Sections may be accepted after April 30th, 1887 ; and any member wishing to 
introduce a topic not on the regular lists of subjects for discussion shall give notice of 
the same to the Secretary-General, at least twenty-one days before the opening of the 
Congress, and such notices shall be promptly transmitted by the Secretary-General to 
the Presidents of the proper Sections. The titular officers of each Section shall decide 
as to the acceptance of such proposed communications and the time for their pre- 
sentation. 
7. All formal addresses, scientific communications and papers presented, and scien- 
tific discussions held at the General Meetings of the Congress, shall be promptly given 
in writing to the Secretary-General; and all papers presented and discussions held at 
the meetings of the Sections shall be promptly given in writing to the Secretaries of 
the proper Sections. 
No communication shall be received which has already been published, or read before 
a society. 
The Executive Committee, after the final adjournment of the Congress, shall direct 
the editing and the publication of its "Transactions," and shall have full power to pub- 
lish the papers presented and the discussions held thereon, either in full, in part, or in 
abstract, as in the judgment of the Committee may be deemed best. 
8. The official languages of the Congress shall be English, French and German. 
In the meetings of the Sections, no member shall be allowed to speak for more than 
ten minutes, with the exceptions of the readers of papers and those who introduce 
subjects for discussion, who may each occupy twenty minutes. 
9. The rules and programmes shall be published in English, French and German. 
Each paper and address shall be printed in the " Transactions " in the language in 
which it was presented, and preliminary abstracts of papers and addresses also shall be 
printed, each in the language in which it is to be delivered. 
All discussions shall be printed in English. 
10. The President of the Congress, the Secretary-General, the Treasurer, the Chair- 
man of the Finance Committee, and the Presidents of the Sections shall together con- 
stitute an Executive Committee of the Congress, which Committee shall direct the 
business of the Congress, shall authorize all expenditures for the immediate purposes 
of the Congress, shall superintend and audit the accounts of the Treasurer, and shall 
fill all vacancies in the offices of the Congress and of the Sections. This Committee 
shall have power to add to its membership, but the total number of members shall not 
exceed thirty. A number equal to one-third of the members of the Committee shall 
constitute a quorum for the transaction of business. 
11. The officers of the Congress shall be a President, Vice-Presidents, a Secretary- 
General, four Associate Secretaries, one of whom shall be the French Secretary, and 
one of whom shall be the German Secretary, a Treasurer, and the Chairman of the 
Finance Committee. 
12. The Officers of each Section shall be a President, Vice-Presidents, Secretaries 
and a Council. 
13. The Officers of the Congress and the Officers of the Sections shall be nominated 
to the Congress at the opening of its first session. 
14. The Executive Committee shall, at some convenient time before the meeting of 
the Congress, prepare a list of foreign Vice-Presidents of the Congress and foreign Vice- 
Presidents of the Sections, to be nominated to the Congress at the opening of its first 
session. 
15. There shall be a standing Committee on Finance, composed of one representa- 
tive from each State and Territory, the District of Columbia, the Medical Department 
of the Army, the Medical Department of the Navy, and the Marine Hospital Service. APPENDIX. 
741 
The Chairman of the Finance Committee shall report to the Executive Committee 
of the Congress. 
Each member of the Finance Committee shall appoint a local Finance Committee 
for his State, Territory, District, or Government Department, consisting of one or more 
members from each Government Department or Congressional District. 
Each local Finance Committee shall report through its Chairman to the Chairman 
of the Finance Committee of the Congress. 
Dr. S. C. Gordon, of Maine, recalled his withdrawal from the Committee, which 
action was accepted by the Committee. 
The following named gentlemen were elected to fill vacancies in the Committee of 
Organization:- 
Dr. J. K. Bartlett, Wisconsin. 
Dr. J. H. Baxter, U. S. Army. 
Dr. George Goodfellow, Arizona. 
Dr. Henry Lefimann, Pennsylvania. 
Dr. John Morris, Maryland. 
Dr. J. R. Tipton, New Mexico. 
Dr. Thomas J. Turner, U. S. Navy. 
The following resolution was adopted :- 
Resolved, That the representative or representatives in this Committee from each 
State, Territory, or Government Department, shall organize the Financial Committees 
in their respective States, Territories, or Government Departments. 
It was decided that no person should occupy more than one position in the organiza- 
tion of the Congress. 
It was also decided that, in the published lists of the Officers of the Congress, the 
names of the Vice-Presidents and Secretaries of the Congress, and the Vice-Presidents, 
Secretaries, and members of Councils of the Sections, should be arranged alphabetically. 
OFFICERS OF THE CONGRESS. 
President.-Austin Flint, M.D., LL.D.,t New York. 
Vice-Presidents.- W. O. Baldwin, Alabama; H. I. Bowditch, M.D.,* Massa- 
chusetts; William Brodie, m.d., Michigan; Henry F. Campbell, M.D.,* Georgia; W. W. 
Dawson, M.D., Ohio; R. Palmer Howard, M.D.,* Canada; E. M. Moore, M.D., New 
York; Tobias G. Richardson, M.D., Louisiana; Lewis A. Sayre, M.D., New York; J. 
M. Toner, M.D., District of Columbia; the President of the American Medical Associa- 
tion; the Surgeon-General of the United States Army; the Surgeon-General of the 
United States Navy; the Supervising Surgeon-General of the United States Marine Hos- 
pital Service. 
Secretary-General.-NathanS. Davis, M.D., LL.D., Chicago, Illinois. 
Treasurer.-E. S. F. Arnold, M.D., M.R.C.S., New York. 
Chairman of the Finance Committee.-Frederick S. Dennis, M.D., m.r.c.s.,* New 
York. 
EXECUTIVE COMMITTEE OF THE CONGRESS. 
General Officers.-Austin Flint, m.d., ll.d., President of the Congress. Nathan 
S. Davis, M.D., LL.D., Secretary General. E. S. F. Arnold, m.d., m.r.c.s., Treasurer. 
Frederick S. Dennis, M.D., M.R.C.S., Chairman of the Finance Committee. 
Presidents of the Sections.-General Medicine.-Abram B. Arnold, m.d., Pro- 
fessor of Clinical Medicine, Baltimore, Md. 
General Surgery.-William T. Briggs, M.D., Professor of Surgery, Nashville, Tenn. 
Military and Naval Medicine and Surgery.-Henry H. Smith, m.d., ll.d., Emeritus 
Professor of Surgery in the University of Pennsylvania, and Surgeon-General of Penn- 
sylvania during the first two years of the war, Philadelphia, Pa. 
Obstetrics.-DeLaskie Miller, PH.D., M.D., Professor of Obstetrics, Chicago, Ill. 
Gynæcology.-Robert Battey, m.d.,* Gynæcologist, Rome, Ga. 
Therapeutics and Materia Medica.-F. H. Terrill, M.D.,* Professor of Therapeutics, 
San Francisco, Cal. 
* Resigned subsequently. 
f Deceased. 742 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Anatomy.-William H. Pancoast, m.d., Professor of General, Descriptive and Sur- 
gical Anatomy, Philadelphia, Pa. 
Physiology.-John C. Dalton, M.D.,* Professor of Physiology, New York, N. Y. 
Pathology.-E. O. Shakespeare, M.D.,* General Pathologist, Philadelphia, Pa. 
Diseases of Children.-J. Lewis Smith, m.d., Professor of Diseases of Children, 
New York, N. Y. 
Ophthalmology.-A. W. Calhoun, M.D.,* Professor of Ophthalmology and Otology, 
Atlanta, Ga. 
Otology and Laryngology.-S. J. Jones, M.D., LL.D., Professor of Ophthalmology and 
Otology, Chicago, Ill. 
Dermatology and Syphilis.-A. R. Robinson, m.d., Vice-President American Derma- 
tological Society, New York, N. Y. 
Public and International Hygiene.-Joseph Jones, M.D., LL.D., Professor of Chem- 
istry and Clinical Medicine, Ex President Board of Health, New Orleans, La. 
Collective Investigation, Vital Statisticsand Climatology.-Henry O. Marcy, A.M., M.D., 
Boston, Mass. 
Psychological Medicine and Nervous Diseases.-John P. Gray, M.D., LL.D.,f Pro- 
fessor of Psychological Medicine and Medical Jurisprudence, Utica, N. Y. 
Dental and Oral Surgery.-Jonathan Taft, M.D., Professor of Dental and Oral Sur- 
gery, Cincinnati, O. 
LOCAL COMMITTEE OF ARRANGEMENTS. 
(With power to increase their number.) 
A. Y. P. Garnett, M.D., Chairman, District of Columbia. 
The Surgeon-General U. S. Army. 
The Surgeon-General U. S. Navy. 
The Supervising Surgeon-General U. S. Marine Hospital Service. 
J. H. Baxter, M.D., District of Columbia. 
C. H. A. Kleinschmidt, M.D., District of Columbia. 
N. S. Lincoln, m.d., District of Columbia. 
J. M. Toner, M.D., District of Columbia. 
Lists of Vice-Presidents, Secretaries and Members of the Council for each Section 
were named by the Committee of Arrangements, but as it was not practicable to 
ascertain at once who would accept the places assigned to them, or who, of those who 
had been announced in the medical press as declining to accept positions before the 
present rules and organizations had been adopted, might wish to withdraw such 
declination, the final adjustment of these offices was referred to the Executive Com- 
mittee of the Congress, and all correspondence in relation thereto was transferred to 
the Secretary-General of the Congress. 
On motion, the Committee of Organization adjourned, subject to the call of the 
Chairman of the Committee. John V. Shoemaker, m.d., 
Secretary of the Committee of Organization. 
FIRST MEETING OF THE EXECUTIVE COMMITTEE AT NEW YORK ON SEPTEMBER 
24th, 1885. 
The Committee on Organization having thus partly accomplished its duties, the 
Secretary-General, Dr. N. S. Davis, and the proposed President of the Congress, Dr. 
Austin Flint, in accordance with the instructions of the Committee, referred the com- 
pletion of the organization to an Executive Committee, formed as per Rule 10, and this 
Committee met in New York City on the twenty-fourth day of September, 1885, three 
weeks after the adjournment of the preceding Committee. 
At this meeting the President, Prof. Austin Flint, took the Chair, and on motion, 
Prof. Henry H. Smith, of Philadelphia, was unanimously elected Chairman of the 
Executive Committee, and Prof. Frederick S. Dennis, of New York, unanimously 
chosen Associate Secretary-General, and acted as Secretary of the meeting, the Secretary- 
General being absent. 
* Resigned subsequently. 
f Deceased. APPENDIX. 
743 
The following resolution was then unanimously adopted :- 
Resolved, That the Executive Committee enter upon the management of the affairs 
of the Ninth International Medical Congress in accordance with Eule 10, and with the 
understanding that its powers are not restricted, except by the rules and regulations 
adopted by the Committee of Organization appointed by the American Medical Asso- 
ciation, in April, 1885, and that the actions of the Executive Committee are final; not 
being subject to revision, amendment or alteration by either the Committee of Organ- 
ization or the American Medical Association. 
Eesolutions for the employment of the necessary clerks ; for the publication of the 
methods of work of the Committee ; for the filling of vacancies in officers, etc., were 
also passed. 
Dr. Richard J. Dunglison, of Philadelphia, was unanimously chosen Chairman of 
the Finance Committee. 
The meeting adjourned, subject to the call of the Chairman. 
MEETING OF NOVEMBER 18TH, 1885, IN NEW YORK. 
The Executive Committee met at the call of the Chairman on November 18th, 1885, 
in New York City. Present-Drs. Austin Flint, of New York, President; N. S. Davis, of 
Chicago, Secretary-General ; Henry H. Smith, of Philadelphia ; E. J. Dunglison, of 
Philadelphia; Wm. H. Pancoast, of Philadelphia ; A. B. Arnold, of Baltimore; E. S. F. 
Arnold, of New York; A. E. Robinson, of New York; J. Lewis Smith, of New York; 
W. T. Briggs, of Nashville ; J. Taft, of Cincinnati ; J. P. Gray, of Utica ; and S. J. 
Jones, of Chicago. 
Dr. Richard J. Dunglison was unanimously chosen as permanent Secretary of the 
Executive Committee, and acted accordingly. The Chairman presented the Rules of 
Order and the Order of Business to be observed at all meetings of the Executive 
Committee, which were unanimously adopted. 
RULES OF ORDER OF THE EXECUTIVE COMMITTEE. 
Every Committee being a miniature Assembly, the rules of assemblies are hereby 
adopted as the Rules of this Committee. 
1. No member shall speak more than once to the same question, 
2. No member shall speak more than ten minutes except by unanimous consent. 
3. The Call for any meeting of this Committee shall be made by the Chairman OR 
by the written request of three members. 
4. The object of every meeting shall be stated in the call. 
5. The Executive Committee can only act when regularly convened as a Committee, 
and so assembled, and not by the separate consent of members. 
6. Nothing shall be considered as the agreement of the Committee that is not author- 
ized by a vote, and so recorded on the minutes. 
7. All sub-committees must report to the Executive Committee, and have the 
sanction of the latter for their action. 
8. The Executive Committee, under the rules of organization, has no power to make 
changes in the number and character of the Sections created by the Committee on 
Organization. 
9. All expenditures ordered by the Executive Committee shall be in accordance 
with the regulations adopted by the Committee on Finance. 
ORDER OF BUSINESS TO BE OBSERVED AT EACH MEETING OF THE EXECUTIVE 
COMMITTEE. 
The following shall be the Order of Business:- 
Registration of the members present. Reading of the minutes of the previous meet- 
ing and their adoption. Unfinished business. 744 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Reports of committees and officers. Special business. New business. Adjourn- 
ment to day and hour fixed. 
The items of business stated in the call shall be the special order of the day for 
each meeting. 
The following notice is presented as an illustration of the usual form employed in 
each call for a meeting:- 
NINTH INTERNATIONAL MEDICAL CONGRESS-EXECUTIVE COMMITTEE. 
A meeting of the Executive Committee will be held at the " Riggs House," Washington, 
D. C., on Thursday, September 1st, 1887, at twelve o'clock, noon. 
Henry H. Smith, m.d., Chairman. 
Richard J. Dunglison, m.d., Secretary. 
ORDER OF BUSINESS. 
Registration of members present. Minutes of last meeting. 
Unfinished Business. 
Reports of Officers and Committees. President. Secretary-General (assignment of papers to 
Sections, etc.). Treasurer. Chairman of Finance Committee ; of Executive Committee; of Com- 
mittee of Arrangements. Committee of Reception at New York, Philadelphia, Boston and Balti- 
more. Presidents of Sections, as to the work of each Section. Committee on Printing. Com- 
mittee on General Addresses and Vacancies. Registration Committee (through Committee of 
Arrangements). 
Special Business. Consideration of the Programme of the Congress. Shall non-Graduates in 
Dentistry be invited to become Members of the Congress ? To whom shall invitations be sent to 
attend the Congress as Representative Scientific Men, as per Rule 1, Preliminary Organization? 
New Business. Instructions to be issued as to the editing and publication of Transactions, as 
per Rule 7, Preliminary Organization, and for the payment for the same and of all Bills presented 
after the adjournment of the Congress, as per Rule 10. Shall any publisher be allowed to put his 
imprint on the Transactions in consideration of urging their sale ? Appropriation of money to 
meet the expenses of the Committee of Arrangements. Shall there be representatives of the 
Executive Committee on the trip to Niagara ? 
Adjournment. 
Each member will please note any items of business that may suggest itself as pertinent to this 
meeting. 
Preserve this circular for future reference at the meeting. 
Numerous resignations of officers of Sections made by the Committee on Organiza- 
tion were read and accepted. These vacancies were promptly filled by the Executive 
Committee. Dr. E. S. F. Arnold, of New York, was elected Treasurer of the Congress, 
and it is to his accurate and earnest labors and judgment that the successful financial 
acts of the Congress have been so systematically settled. The Chairman of the Finance 
Committee made an extended and judicious report of a plan for the collection and ex- 
penditure of the funds of the Congress, and the auditing of its accounts, which, with its 
accompanying resolutions, was coincided in by the Treasurer and unanimously adopted 
by the Executive Committee. The Treasurer reported the auditing of the account, and 
the receipt of the balance of the unexpended portion of the fund paid Surgeon J. M. 
Browne, U. S. Navy, the Treasurer of the original Committee of eight appointed by the 
American Medical Association, to carry the invitation to the Eighth International 
Medical Congress at Copenhagen, and for the preliminary expenses of their organization 
($282.47). The Treasurer was instructed to place this balance to the credit of the 
general fund of the Congress. Various liberal donations to the same fund were also APPENDIX. 
745 
reported as received from warm friends of the Congress, to be expended in the prelimi- 
nary printing of the Executive Committee. The Secretary-General (Davis) made a full 
report of the officers of the Congress and of the Sections; of his extended correspondence 
with the nominees, and the refusal of many to participate in the Congress. This list 
of officers, with the Rules for the Congress (see pp. 739-742), was directed to be printed 
in three languages, and widely distributed at home and abroad, inviting all members 
of the regular Medical Profession to attend the Congress and participate in its proceed- 
ings. It was also ordered that all Foreign members should be exempt from the pay- 
ment of fees, and that the social attractions of the Congress should be made known as 
soon as completed. Prof. Dennis, having resigned as Associate Secretary-General, was 
elected a member of the Executive Committee. A design for a Seal of the Congress, 
with its mythological explanation, as prepared by Dr. Toner, of Washington, was 
accepted, and subsequently prepared and used on the volumes of the Transactions 
and the correspondence of the Executive Committee. The date of the meeting of 
the Congress was fixed for the first Monday in September, 1887, in the city of 
Washington, and a sub-committee was appointed to prepare rules prescribing the 
"Duties of Officers." 
As the rules adopted by the Committee on Organization have been printed in 
English on pp. 739-742, only the translations of them as made by order of the Execu- 
tive Committee, in the French and German languages, are here presented:- 
RÈGLES. 
1. Le Congrès se composera de membres de la profession médicale régulière, qui 
auront inscrit leurs noms sur le régistre, et auront pris leurs billets d'entrée ; et de tels 
autres savants que le comité exécutif du Congrès jugera convenable d'admettre. 
2. La cotisation des membres du Congrès sera de dix dollars pour les membres ré- 
aidant aux Etats-Unis. 
Les membres résidant dans les pays étrangers ne payeront pas de cotisation. 
Chaque membre du Congrès aura droit à un exemplaire des ' ' Comptes rendus des 
Travaux" du Congrès pour 1887. 
3. Le Congrès sera divisé en dix-sept sections, comme il suit :- 
I. Médecine générale. 
II. Chirurgie générale. 
III. Chirurgie militaire et navale. 
IV. Obstétrique. 
V. Gynécologie. 
VI. Thérapeutique et Matière Médicale. 
VIL Anatomie. 
VIII. Physiologie. 
IX. Pathologie. 
X. Maladies des Enfants. 
XI. Ophthalmologie. 
XII. Otologie et Laryngologie. 
XIII. Dermatologie et Syphilis. 
XIV. Hygiène publique et internationale. 
XV. Investigation collective, Nomenclature, Statistique vitales, et Climatologie. 
XVI. Médecine Psychologique et Maladies du Système nerveux. 
XVII. Chirurgie des Dents et de la Bouche. 
4. Les assemblées générales du Congrès seront censacrées aux affaires et aux dis- 
cours et communications d'intérêt scientifique. 746 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
5. Les questions mises en discussion au sein de chaque section, seront présentées 
par des membres désignés préalablement par le bureau de cette section. 
Les membres qui auront été désignés pour ouvrir les discussions présenteront à l'a- 
vance les conclusions qu'ils auront admises comme base du débat. 
6. De courts résumés des mémoires à lire dans les sections devront être envoyés aux 
secrétaires des diverses sections le 30 Avril, 1887 ou auparavant. Ces résumés seront 
traités comme communications confidentielles, et ne seront pas publiés avant la réunion 
du Congrès. 
Les Mémoires se rapportant à des sujets non compris dans les listes proposées par le 
bureau des Sections pourrait être acceptés après le 30 Avril, 1887, et tout membre dési- 
rant présenter un sujet qui ne se trouve point sur les listes régulières pour la discussion, 
devra en donner avis au secrétaire général au moins vingt et un jours avant l'ouverture 
du Congrès, et cet avis sera promptement transmis par le secrétaire général aux Prési- 
dents des diverses sections. Le bureau de chaque section se prononcera sur l'accepta- 
tion ou le rejet des communications proposées et indiquera le temps de leur présenta- 
tion. 
7. Tous discours prononcés, toutes communications scientifiques faites, tous mé- 
moires présentés et aussi les discussions scientifiques qui auront lieu dans les 
assemblées générales du Congrès, seront promptement remises par écrit au secrétaire 
général ; et tous les mémoires présentés et les discussions qui auront lieu dans les 
assemblées des Sections seront promptement remis par écrit aux secrétaires des 
diverses sections. 
Aucune communication ne sera reçue, si elle a déjà été publiée ou lue à une société 
quelconque. 
Après l'ajournement final du Congrès, le Comité Exécutif entreprendra la rédaction 
et la publication de ses travaux, et aura plein pouvoir de publier les mémoires présen- 
tés et les discussions auxquelles ils auront donné lieu, soit en extenso, soit en partie ou 
en résumé comme le comité jugera convenable. 
8. Les langues officielles du Congrès seront l'Anglais, le Français et l'Allemand. 
Dans les assemblées des Sections, la parole ne sera accordée que pour dix minutes, à 
l'exception des membres chargés de lire les rapports et de ceux qui présenteront des 
questions pour la discussion ; ces membres pourront parler vingt minutes. 
9. Les statutes ou règlements et les programmes seront publiés en Anglais, en Fran- 
çais et en Allemand. Dans les ' * Comptes Rendus " chaque mémoire, chaque discours 
sera imprimé dans la langue dans laquelle il a été présenté, et des abrégés préliminaires 
des mémoires et des discours seront aussi imprimés, chacun dans la langue dans laquelle 
il doit être lu ou prononcé. 
Toutes les discussions seront imprimées en Anglais. 
10. Le Président du Congrès, le Secrétaire général, le Trésorier, le Président du 
comité de finances, et les Présidents des sections, formeront ensemble un comité exécutif 
du Congrès; ce comité dirigera les affaires du Congrès, autorisera toutes les dépenses 
pour les besoins immédiats, surveillera et réglera les comptes du Trésorier et pourvoir 
à toutes vacances survenues dans les emplois du Congrès et des Sections. Ce comité 
aura le pouvoir de s'adjoindre de nouveaux membres, mais leur nombre total ne pourra 
pas excéder trente. La présence d'un tiers des membres du comité sera exigée pour 
l'expédition des affaires. 
11. Le bureau du Congrès sera composé d'un Président, de Vice-Présidents, d'un 
Secrétaire général, de quatre Secrétaires adjoints (l'un d'eux sera le Secrétaire Français, 
un autre sera le Secrétaire Allemand) ; d'un Trésorier, et du Président du comité de 
finances. APPENDIX. 
747 
12. Le bureau de chaque section se composera d'un Président, de Vice-Présidents, 
de Secrétaires et d'un conseil d'administration. 
13. Le bureau du Congrès et ceux dés sections seront nommés par le Congrès à l'ou- 
verture de sa première séance. 
14. Le comité exécutif quelque temps avant la réunion du Congrès préparera une 
liste de Vice-Présidents étrangers pour le Congrès et de Vice-Présidents étrangers pour 
les Sections, pour être nommés par le Congrès à l'ouverture de sa première séance. 
15. Il y aura un comité permanent de finances composé d'un représentant de chaque 
Etat et de chaque Territoire, du District de Columbie, du département médical de 
l'armée, du département médical de la marine et du service de l'hôpital maritime. 
Le Président du comité de finances adressera son rapport au comité exécutif du 
Congrès. Chaque membre du comité de finances, nommera un comité local de 
finances, pour son Etat, son Territoire, le District de Colombie, et les départements 
ci-dessus nommés comprenant un ou plusieurs membres de chaque district congression- 
nel. 
Chaque comité local de finances, par la voie de son Président adressera son rapport 
au Président du comité de finances du Congrès. 
STATUTEN. 
1. Der Congress soll aus solchen von anerkannten Schulen promovirten Aerzten 
bestehen, die ihren Namen in das Register eingetragen und ihre Einlasskarte gelöst 
haben, und ausserdem aus solchen Männern der Wissenschaft, die das Executiv-Comité 
des Congresses zulassen mag. 
2. Jedes in den Vereinigten Staaten wohnhafte Mitglied soll zehn Dollars Beitrag 
zahlen. Mitglieder aus anderen Ländern zahlen keinen Beitrag. Jedes Mitglied ist 
zu einem Exemplare der Verhandlungen des Jahres 1887 berechtigt. 
3. Der Congress soll in folgende siebenzehn Abtheilungen (Sectionen) zerfallen : 
I. Allgemeine Medicin. 
II. Allgemeine Chirurgie. 
III. Militär- und Marine-Chirurgie. 
IV. Geburtshilfe. 
V. Frauenkrankheiten. 
VI. Therapeutik und Arzneikunde. 
VII. Anatomie. 
VIII. Physiologie. 
IX. Pathologie. 
X. Kinderkrankheiten. 
XI. Augenkrankheiten. 
XII. Krankheiten des Ohres und des Kehlkopfes. 
XIII. Haut- und venerische Krankheiten. 
XIV. Oeffentliche und internationale Gesundheitspflege. 
XV. Collectivuntersuchung, Nomenklatur, Lebensstatistik und Climatologie. 
XVI. Psychiatrie und Nervenkrankheiten. 
XVII. Zahn- und Mundkrankheiten. 
4. Die Generalversammlungen des Congresses werden der Erledigung nöthiger 
Geschäfte, sowie Vorträgen und Mittheilungen von allgemeinem wissenschaftlichen 
Interesse gewidmet. 
5. Fragen und Gegenstände, die zur Besprechung in den Sectionen angesetzt sind, 
sollen von Mitgliedern eingeleitet werden, die vorher von den Sectionsbeamten dazu 748 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bestimmt worden sind. Diese Mitglieder sollen die Schlüsse, zu denen sie gelangt 
sind, im Voraus als zu debattirende Thesen anzeigen. 
6. Von den in den Sectionen zu haltenden Vorträgen sollen kurze Inhaltsangaben 
an oder vor dem 30. April 1887 den Sectionssekretären zugestellt werden. Diese Inhalts- 
angaben sind als confidentielle Mittheilungen anzusehen und werden nicht vor Zusam- 
mentritt des Congresses veröffentlicht. 
Es können auch noch nach dem 30. April 1887 Vorträge über Themata angenommen 
werden, die nicht in den von den Sectionsbeamten angefertigten Listen aufgeführt 
sind ; ein Mitglied, das ein solches Thema behandeln oder zur Sprache bringen will, 
soll den Generalsekretär wenigstens einundzwanzig Tage vor Eröffnung des Congresses 
von seinem Wunsche in Kenntniss setzen, und der Generalsekretär soll diese Anmel- 
dung ohne Verzug dem Sectionspräsidenten zustellen. Die Sectionsbeamten sollen 
über die Zulassung der angemeldeten Vorträge entscheiden und die Zeit dafür 
bestimmen. 
7. Von allen Reden, welche in den Generalversammlungen gehalten werden, Vor- 
trägen, wissenschaftlichen Mittheilungen und Abhandlungen sollen Abschriften und 
von allen Discussiouen schriftliche Aufzeichnungen dem Generalsekretär prompt ein- 
geliefert werden ; ebenso sollen alle in den Sectionen gehaltenen Vorträge und gepflo- 
genen Besprechungen den Sectionssekretären prompt zugestellt werden. 
Es soll keine Mittheilung entgegen genommen werden, die schon veröffentlicht oder 
vor irgend einer Gesellschaft gemacht worden war. 
Nach Vertagung des Congresses soll das Executiv-Comité die Herausgabe der Ver- 
handlungen veranlassen und überwachen, und nach seinem Ermessen die Vorträge und 
Discussionen ganz, theilweise oder im Auszuge veröffentlichen. 
8. Die officiellen Sprachen des Congresses sollen die englische, die französische und 
die deutsche sein. 
In den Sectionen soll kein Mitglied länger als zehn Minuten reden, mit Ausnahme 
Derer, die Vorträge halten oder Debatten einleiten, denen zwanzig Minuten gestattet 
werden sollen. 
9. Die Statuten und Programme sollen englisch, französisch und deutsch gedruckt 
werden. 
Jeder Vortrag soll in den Verhandlungen in der Sprache erscheinen, in der er gehal- 
ten wurde ; so sollen auch Anzeigen und vorläufige Auszüge von Vorträgen in den 
Sprachen gedruckt werden, in denen diese gehalten werden sollen. 
Die Discussionen aber sollen englisch gedruckt werden. 
10. Der Präsident des Congresses, der Generalsekretär, der Schatzmeister, der Vor- 
sitzer des Finanzausschusses und die Sectionspräsidenten bilden das Executiv-Comité 
des Congresses. Dieses soll die Geschäfte des Congresses leiten, alle laufenden Aus- 
gaben autorisiren, die Rechnungen des Schatzmeisters revidiren und vacante Aemter 
des Congresses und der Sectionen besetzen. Dieses Comité hat die Befugniss, seine 
Stärke bis auf dreissig Mitglieder zu erhöhen. Zur Erledigung von Geschäften genügt 
ein Drittel der Comitémitglieder. 
11. Die Beamten des Congresses sind ein Präsident, Vice-Präsidenten, ein General- 
sekretär, vier Untersekretäre, wovon ein französischer und ein deutscher, ein Schatz- 
meister und der Vorsitzende des Finanzausschusses. 
12. Die Beamten jeder Section sind ein Präsident, Vice-Präsidenten, Sekretäre und 
ein Rath. 
13. Die Beamten des Congresses und der Sectionen sollen gleich nach der Eröffnung 
des Congresses vorgeschlagen werden. APPENDIX. 
749 
14. Das Executiv-Comité soll zu einer ihm bequemen Zeit vor Versammlung des 
Congresses eine Liste auswärtiger Vice-Präsidenten des Congresses und der Sectionen 
anfertigen und dieselbe nach Eröffnung der ersten Sitzung vorlegen. 
15. Es soll ein stehender Finanzausschuss gebildet werden, und zwar aus je einem 
Vertreter jedes Staates und Territoriums und des Districtes Columbia, der Medicinal- 
Abtheilung der Armee, der Medicinal-Abtheilung der Flotte und der Marinehospitäler. 
Der Vorsitzer des Finanzausschusses soll dem Executiv-Comité des Congresses 
berichten. 
Ein jedes Mitglied des Finanzausschusses soll in seinem Staate, Territorium, District 
oder Regierungsdepartement ein locales Finanzcomité ernennen, in welchem jeder 
Congressdistrict durch wenigstens ein Mitglied vertreten sein soll. 
Jedes locale Finanz-Comité soll durch seinen Vorsitzer dem Vorsitzer des allge- 
meinen Finanzausschusses Bericht erstatten. 
MEETING AT ST. LOUIS ON MAY 3d, 1886. 
The Executive Committee assembled in the city of St. Louis on May 3d, 1886, at 
11 o'clock A.M. and continued in session until 2 P.M. ; again met at 3 P.M. and sat until 
6 P.M. Present: Drs. Henry H. Smith, Chairman; Dunglison, Secretary; Davis, Arnold, 
of New York ; Arnold, of Baltimore ; Jones, of Chicago ; Jones, of New Orleans ; Taft, 
of Cincinnati ; Briggs, of Nashville; Robinson, of New York; Miller, of Chicago; Marcy, 
of Boston; and Pancoast, of Philadelphia. The death of the President of the Congress, 
Professor Austin Flint, of New York, since the last meeting of the Committee, having 
been announced, Dr. Arnold, of New York, was appointed to prepare an appropriate 
minute expressive of the sense of the Committee at the loss of his valuable services to 
the Congress and the Medical Profession. Numerous resignations of officers of Sections 
were reported and the vacancies promptly filled. After various nominations and ballot, 
Professor Nathan Smith Davis, M.D., LL.D., of Chicago, was unanimously chosen to 
succeed Professor Flint as the proposed President of the Congress, and Supervising 
Surgeon-General of the United States Marine Hospital Service at Washington, Dr. John 
B. Hamilton, was elected as Secretary-General of the Congress, to fill the vacancy caused 
by the promotion of Dr. Davis. Various new officers of Sections were also chosen. 
The retiring Secretary-General, Dr. Davis, made a full report of his labors to this date. 
Various Foreign and Domestic Vice-Presidents of the Congress were also elected, and 
the new Secretary-General was introduced as a Member of the Executive Committee. 
Reports were received from the Chairman of the Executive Committee, from the Chair- 
man of the Finance Committee, from the Chairman of the Committee on Printing, from 
the Treasurer ; and from the Committee on the Special Duties of Officers, a printed 
copy of the latter being sent to all the Officers as well as the Members of the Council 
of the various Sections, as follows :- 750 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CIRCULAR FOR THE INFORMATION OF THE OFFICERS OF THE NINTH 
INTERNATIONAL MEDICAL CONGRESS, 
TO BE HELD IN WASHINGTON, D. C., ON SEPTEMBER 5th, 1887. 
Issued by Order of the Executive Committee, 
Henry H. Smith, m.d., Chairman. 
R. J. Dunglison, m.d., Secretary. 
Officers of the Congress.-The Officers of the Congress shall be those printed in the General 
Circular containing the Rules and Organization of the Congress. 
Officers of Sections.-The Officers of each Section, including foreigners, shall be a President; 
not less than five Vice-Presidents; four Secretaries (two foreign), and not less than ten, nor more 
than thirty Members of Council. 
DUTIES OF OFFICERS OF THE CONGRESS. 
President.-The President shall preside at the meetings of the Congress; shall deliver the 
opening address ; shall decide all questions of parliamentary law, and perform, until his successor 
is appointed, all the usual duties of a President. 
Vice-Presidents.-They shall assist the President when requested, and attend upon the Plat- 
form at all the sessions of the Congress. 
Secretary-General.-He shall be the Executive Officer of the Congress. He shall open the 
Congress by presenting the officers in turn and the Chairman of the Committee of Arrangements. 
He shall receive all communications intended for the Congress. He shall arrange the programme 
of each day's session, and present to each member, on registering, a printed copy of the same, 
arranged for the entire session. With the advice and consent of the Executive Committee, he 
shall notify the members (foreign or domestic) who shall deliver the General Addresses before 
the Congress. He shall arrange and print the Rules of Order and the order of business for each 
day of the session. No item of business shall be presented without his consent or that of the 
presiding officer, and all communications to be offered to the Congress shall be first presented to 
him. His other duties are defined in Rules 6 and 7 of the Preliminary Organization. He shall 
act as Editor, and revise proofs of the Transactions before their publication, when authorized so 
to do by the Executive Committee. He shall insist upon all papers for reference to the Executive 
Committee for publication being placed in his hands as soon as read, and no change, alteration or 
addition shall be made in such papers by the author, under penalty of non-publication in the 
Transactions or elsewhere. 
Associate Secretaries.-The four Associate Secretaries (two foreign) shall preserve a full and 
complete record or minute of each day's proceedings in the general session of the Congress ; read 
the same each day for the approval of the Congress, and present the entire minutes to the Secre- 
tary-General at the close of the Congress, for publication in the Transactions. The foreign 
Associate Secretaries shall be responsible for a correct minute of transactions in the German or 
French languages. 
The duties of the Chairman of the Finance Committee and of the Treasurer are prescribed 
in Rules 10 and 15 of the Preliminary Organization, and in the Minutes of the meeting of the 
Executive Committee, November 18th, 1885. 
DUTIES OF OFFICERS OF SECTIONS. 
President.-The President of each Section shall be its Executive Officer, and solely responsible 
for the efficient work of his Section. He shall nominate all persons to the Executive Committee 
for any office connected with his Section. He shall select and regulate (by conference, when 
desired, with the other officers of his Section) all papers or questions for discussion, and reject, 
only after such conference, such papers or questions as he may deem inadmissible to the Transac- 
tions or for presentation in his Section. He shall preside at and regulate the business of each 
meeting of his Section, punctually at the hour named, making an opening address to the Section, 
if he so desires. He may at any time adjourn the session of the Section, when, in his opinion, it APPENDIX. 
751 
has lasted sufficiently long, as when there are too many papers for the day, etc. He shall strictly 
enforce Rule 8 of the Preliminary Organization. When a paper is read or discussion occurs in a 
foreign language, he shall resign the Chair to a foreign officer of the same nationality as the 
language employed. 
Vice-Presidents.-They shall assist the President in the performance of his duties at each 
meeting of the Section when requested by him, and shall take their seats on each side of the 
presiding officer. They shall aid the President in consultation on the value and character of all 
papers or discussions that are to be presented in the Section or the Transactions. 
Secretaries.-The four Secretaries of Sections shall arrange among themselves, or at the request 
of the President of the Section, the order of their duties. They shall keep accurate records of the 
proceedings of each day in their Section, and make such daily report of it to the Congress as the 
President of the Section shall direct ; the foreign Secretaries acting for their own nationalities. 
At the close of the session they shall present all their minutes, in good order, to the Secretary- 
General, for publication in the Transactions, if so desired by the Executive Committee. 
Members of Council.-It shall be the duty of each Member of the Council to contribute, either 
by paper or discussion, to the subject of his Section. They shall attend throughout the entire 
session of the Section, and aid in making the meeting efficient and instructive. When called on 
by the President, each Member of the Council shall give his written opinion of the propriety of 
admitting or rejecting for publication in the Transactions any paper read in, or discussion held 
in the Section during any of its meetings, and the decisions made in any case thus presented to 
the Council shall be final, on a majority vote. 
DUTIES OF THE EXECUTIVE COMMITTEE. 
The duties of the Executive Committee shall be such as are defined in Rules 10 and 14 of the 
Organization of the Congress. 
Chairman of the Executive Committee.-He shall preside at all meetings of the Committee 
when regularly convened, and enforce the rules of order and business adopted by the Committee 
on November 18th, 1885. He shall conduct all correspondence relating to appointments by the 
Committee, or referring to any business or communications to be presented to the Executive Com- 
mittee for its action ; notifying the President of the Congress and the Secretary-General of all 
action by the Committee in reference to appointments or business of the Congress, prior to its 
meeting. 
Secretary of the Executive Committee.-He shall keep an accurate copy of the minutes of the 
Committee, and conduct such correspondence as may be required by the Chairman. He shall 
promptly notify the Chairman of any Sub-committee of the appointment of such Committee, 
forward to him a list of its members, and inform him of the time when its report will be due. 
He shall issue all notices of meetings of the Executive Committee, and perform such other duties 
as the Chairman may request. 
The following Resolution was adopted by the Executive Committee :- 
Resolved, That 1000 copies of the essential features of this paper be printed and distributed 
to all the officers of the Congress and of the Sections, as a guide to their proper appreciation 
and performance of their duties. 
As the preliminary expenses of Printing, Stationery, Advertising, etc., must be promptly met, 
it is suggested that each officer or member should anticipate the payment of his dues for member- 
ship, and forward the amount, ten dollars ($10) to the Treasurer of the Congress, Dr. E. S. F. 
Arnold, No. 53 West 38th street, New York City, who will return a receipt therefor. 
The issuing of " Circulars " was referred to the Committee on Printing, with power 
to act. Under this Resolution, the Committee on Printing subsequently issued and 
widely circulated the following circular:- 752 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
CIRCULAR NO. 2. 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The Ninth International Medical Congress will assemble in the City of Washington, the Cap- 
ital of the United States, on Monday, September 5th, 1887, at 12 o'clock noon, in accordance 
with the arrangements made at Copenhagen in August, 1884. 
PATRONS. 
The President of the United States, The Hon. Grover Cleveland. The Secretary of State, 
The Hon. Thomas F. Bayard. The President of the Senate of the United States, The Hon. John 
Sherman. The Speaker of the House of Representatives of the United States, The Hon. John 
G. Carlisle. 
OFFICERS OF THE CONGRESS. 
President.-Nathan Smith Davis, m.d., ll.d., Professor of the Principles and Practice of 
Medicine, and of Clinical Medicine, Chicago Medical College and Mercy Hospital, Chicago, Ill. 
Vice-Presidents.-[For the list of these as finally appointed see Vol. I, page 2, of the "Trans- 
actions."'] 
Secretary General.-John B. Hamilton, m.d., Supervising Surgeon-General of the United 
States Marine Hospital Service; Professor of Surgery, Georgetown University, D. C.; Professor 
of Surgery, Chicago Polyclinic. 
Treasurer.-E. S. F. Arnold, m.d., m.r.c.s., Newport, Rhode Island. 
Chairman of the Finance Committee.-Richard J. Dunglison, m. d., Philadelphia, Pa. 
Chairman of the Executive Committee.-Henry H. Smith, m.d., ll.d., Emeritus Professor of 
Surgery in the University of Pennsylvania, Philadelphia, Pennsylvania. 
Chairman of the Committee of Arrangements.-A. Y. P. Garnett, m.d., Emeritus Professor of 
Clinical Medicine, Columbia University, Washington, D. C. 
Associate Secretaries of the Congress.-William B. Atkinson, M.D., Philadelphia, Pennsyl- 
vania; G. B. Harrison, m.d., Washington, D. C. 
The Congress will consist of such members of the Regular Medical Profession as shall have 
registered and taken out their ticket of admission, and of such other Scientific men as the Execu- 
tive Committee of the Congress shall deem it desirable to admit. The books for the Registration 
of Members will be open in Washington from 9 a.m. to 5 P. M., on Thursday, September 1st, 1887, 
and on each subsequent day during the Session, under the charge of the " Reception Committee." 
Any member desiring to anticipate this Registration, can apply by letter to the Secretary General 
and forward his dues, with his address in full, when a receipt will be returned. 
The dues of Membership for residents of the United States will be Ten dollars ($10.00). There 
will be no dues for members residing in other countries. Each member will be entitled to receive 
a copy of the " Transactions " of the Congress, when published by the Executive Committee. 
The General Sessions of the Congress will be devoted to the transaction of business and 
Addresses and Communications of general scientific interest, by members appointed by the Execu- 
tive Committee. A printed " Programme " of the Sessions will be presented to each member on 
registering. A printed " Order of Business" for each day will also be issued. 
The work of the various Sections will be directed by the President of the Section, and the 
order will be published in a daily Programme for each Section. Questions and topics that have 
been agreed on for discussion in the Sections shall be introduced by members previously designated 
by the titular officers of each Section. Members who shall have been appointed to open discus- 
sions, shall present to the Secretaries of the Section, in advance, statements of the conclusions 
which they have formed as a basis for the debate. 
Brief abstracts of Papers to be read in the Sections shall be forwarded to the Secretaries of the 
proper Section on or before AprtT 30tA, 1887. These abstracts shall be treated as confidential 
communications, and shall not be published before the meeting of the Congress. Papers relating 
to topics not included in the list of subjects proposed by the Officers of the Sections, may be 
accepted after April 30th, 1887, and any member wishing to introduce a topic not on the regular 
lists of subjects for discussion, shall give notice of the same to the Secretary General, at least APPENDIX. 
753 
twenty-one days before the opening of the Congress. The titular officers of each Section 
shall decide as to the acceptance of such proposed communications, and the time for their 
presentation. No communication shall be received which has been already published or read 
before a Society. 
The official languages of the Congress shall be English, French, and German. Each paper or 
address shall be printed in the " Transactions " in the language in which it was presented. Pre- 
liminary abstracts of papers and addresses shall also be printed in the language in which each 
is to be delivered. All discussions shall be printed in English. 
The officers of the Congress and the officers of the Sections, including all Foreign officers, will 
be nominated to the Congress by the Executive Committee, at the opening of the first Session. A 
partial list of the officers to be nominated (except the members of Council of the different Sec- 
tions, the list of whom is at present imperfect), is offered herewith. 
The Executive Committee cordially invites members of the regular medical profession, and 
men eminent in the sciences collateral to medicine, in all countries, to participate, in person or by 
papers, in the work of this great humanitarian assembly. Communications relating to appoint- 
ments for papers to be read in the Congress should be addressed to Dr. John B. Hamilton, Secre- 
tary-General of the Ninth International Medical Congress, Washington, District of Columbia. 
All questions or communications connected with the business of the Executive Committee should 
be addressed to Dr. Henry H. Smith, Chairman of the Executive Committee of the Ninth Inter- 
national Medical Congress, Philadelphia, Pennsylvania. Gentlemen named in any position in the 
Congress are requested to notify the Chairman of the Executive Committee, as soon as practicable, 
of any error in the name, title, or address in this circular. 
Ladies in attendance with members of the Congress, and those invited by the "Reception 
Committee," may attend the General Sessions of the Congress when introduced by a member. 
They will also be invited to attend the Social Receptions. The Executive Committee reserves the 
right to invite distinguished persons to any or all the meetings of the Congress. The attendance 
of Medical Students and others interested in the work of the various Sections or in the general 
addresses delivered in the Congress, will be permitted, on the recommendation of the Secretary 
General or the officers of a Section, on their taking out from the Registration Committee a 
general ticket of admission, fee one dollar ($1.00) ; but such persons cannot take part in the 
proceedings. 
All communications and questions relating to the special business of any Section, must be 
addressed to the President or one of the Secretaries of that Section. As many details of the Con- 
gress and numerous appointments of officers are yet to be completed, other Circulars will be issued 
from time to time, as circumstances may demand. 
EXECUTIVE COMMITTEE OF THE CONGRESS. 
Henry H. Smith, m.d., ll.d., Chairman. 
N. S. Davis, m.d., ll.d. 
John B. Hamilton, m.d. 
E. S. F. Arnold, m.d., m.r.c.s. 
Richard J. Dunglison, m.d., Secretary. 
Abram B. Arnold, m.d. 
William T. Briggs, m.d. 
De Laskie Miller, m.d., ph.d. 
James F. Harrison, m.d. 
F. H. Terrill, m.d. 
William H. Pancoast, m.d. 
John H. Callender, m.d. 
Alonzo B. Palmer, m.d., ll.d. 
J. Lewis Smith, m.d. 
E. Williams, m.d. 
S. J. Jones, m.d., ll.d. 
William H. Daly, m.d. 
A. R. Robinson, m.d. 
Joseph Jones, m.d., ll.d. 
Albert L. Gihon, m.d., U. S. N. 
John P. Gray, m.d., ll.d. 
Jonathan Taft, m.d. 
Frederick S. Dennis, m.d. 
A. Y. P. Garnett, m.d. 
[As some changes were subsequently made in the officers and members of the Council of the 
Sections, and the full appointments have already been presented in the volumes of the " Trans- 
actions," at the head of each Section, it is unnecessary to recapitulate them here.] 
Vol. V-48 754 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
General Committee of Arrangements, at Washington, D. C., with power to increase their 
numbers : - 
Chairman, A. Y. P. Garnett, m.d. Vice-Chairman, J. M. Toner, M.D. Secretary, C. H. A. 
Kleinschmidt, m.d. Treasurer, D. C. Patterson, m.d. 
Executive Committee.-Drs. A. Y. P. Garnett, J. M. Toner, N. S. Lincoln, C. H. A. Kleinschmidt, 
Surgeon-General F. M. Gunnell, m.d., U. S. Navy; Surgeon-General Robert Murray, M.D., U. S. 
Army; Supervising Surgeon-General J. B. Hamilton, m.d., U. S. Marine Hospital Service; Chief 
Medical Purveyor, J. II. Baxter, m.d., U. S. Army. 
Committee on Congressional Legislation.-Dr. A. P. Y. Garnett, Chairman. 
Committee on Finance.-Dr. G. L. Magruder, Chairman. 
Committee on Printing.-Dr. J. B. Hamilton, C'/tatrman. 
Committee on Reception.-Dr. J. M. Toner, Chairman. 
Committee on Entertainments.-Dr. N. S. Lincoln, Chairman. 
Committee on Transportation.-Dr. J. W. H. Lovejoy, Chairman. 
Committee on Place of Meeting for Congress and Sections.-Dr. D. C. Patterson, Chairman. 
By Order of the Executive Committee of the Congress. 
Henry II. Smith, m.d., Chairman. 
Richard J. Dunglison, m.d., Secretary. 
It was made the duty of the Presidents of Sections to arrange all papers and discus- 
sions for their Sections, and to report their progress to each meeting of the Executive 
Committee. Drs. Wm. B. Atkinson, of Philadelphia, and G. B. Harrison, of Washing- 
ton, D. C., were appointed Associate Secretaries of the Congress, and the appointment 
of Foreign Secretaries was reserved for the present. 
The Committee of Arrangements at Washington reported their organization and 
proceedings up to the present time. The Chairman of the Committee, Dr. A. Y. P. 
Garnett, of Washington, was instructed to bring the assembling of the Ninth Inter- 
national Medical Congress to the notice of the Committee on Appropriations of 
the United States Congress, and ask them to frame a bill for its proper recognition 
and reception (especially of the foreign medical men who were expected to meet in 
Washington), as an acknowledgment of the attention paid by previous Medical Con- 
gresses to delegates from the United States. Dr. Garnett's efforts in the matter were 
eventually successful, to a limited extent (§10,000.) Dr. Bigelow, of Boston, was 
tendered the thanks of the Executive Committee for his exceptional services in 
Europe in behalf of the Congress. The Section of Otology and Laryngology was 
divided, and Dr. W. H. Daly, of Pittsburgh, chosen as President of the latter Section, 
and the Committee adjourned. 
MEETING AT ST. LOUIS CONTINUED. 
On May 5th the Executive Committee again met in St. Louis, and at the request of 
Dr. F. S. Dennis the office of Associate Secretary General was abolished. Routine 
business completed. 
MEETING AT PITTSBURGH, OCT. 11TH, 1886. 
On October 11th, 1886, the Executive Committee assembled at Pittsburgh, on the 
call of the Chairman. 
Present, Drs. Henry H. Smith, Chairman ; N. S. Davis, J. B. Hamilton, Arnold, of 
New York ; Arnold, of Baltimore; Briggs, Miller, Pancoast, Callender, S. J. Jones, 
Daly, Garnett, Taft and Dunglison (Secretary). It was decided that proxies should 
not vote on the nominations for officers of the Congress or Sections. At the request of APPENDIX. 
755 
Surgeon Albert L. Gihon, United States Navy, President of Section XV, the title of 
" Collective Investigation, etc.," of this Section, was changed to that of "Climatology 
and Demography," and that of the Section of Dermatology and Syphilis was changed, 
at the request of Dr. A. R. Robinson, President of the Section, to " Dermatology and 
Syphilography." Prof. N. S. Davis made a verbal report of his visit to the British 
Medical Association, and the presentation of the claims of the Ninth Congress on this 
representative body of the medical profession in Great Britain. Dr. Davis described his 
warm and courteous reception by the British Association, and the interest shown in 
the success of the Ninth Medical Congress. The thanks of the Committee were tendered 
Dr. Davis for his services, as well as to Prof. Pancoast for his labors on behalf of the 
Congress in Paris and other portions of the Continent of Europe. The Treasurer 
reported the amount in the treasury to date, and especially the generous donations to 
the expenses of the Congress made by various State and County Medical Societies ; the 
Medical Society of the State of Pennsylvania donating $1000, and various others giving 
quite liberally. The Chairman of the Finance Committee and the Chairman of the 
Executive Committee were appointed an Auditing Committee. Appropriations were 
made for the preliminary printing of the Sections. The selection of the persons to 
deliver the general addresses before the Congress was referred to a Special Committee 
of three, Dr. N. S. Davis, Chairman. The Committee on Printing was authorized to 
secure proposals for the publication of the " Transactions of the Congress " and to enter 
into contract with the person making the most advantageous proposal. The Committee 
subsequently accepted the offer of Wm. F. Fell & Co., of 1220-24 Sansom street, Phila- 
delphia, for the entire work-electrotyped and with all illustrations. Adjourned. 
SECOND MEETING AT PITTSBURGH ON OCT. 11TH, 1886. 
At 2.30 P.M., thesame day, the Executive Committee again met, the former named 
members being present, with the addition of Prof. A. B. Palmer, of Ann Arbor, Mich. 
Various resignations of officers of Sections were again reported and the vacancies at 
once filled. Various cordial acceptances were also recorded. The Executive Commit- 
tee expressed their regret at learning of the ill health of Dr. E. Williams, President of 
the Section of Ophthalmology, who resigned, and Dr. J. J. Chisolm, of Baltimore, was 
subsequently appointed to fill this vacancy. Dr. Terrell, of San Francisco, being too 
distant to act as President of the Section of Therapeutics and Materia Medica resigned ; 
Prof. Traill Green, M. D., LL. D., of Easton, Pa., was subsequently appointed in his 
place. Many nominations were made for foreign vice-presidents and officers of Sec- 
tions, and numerous acceptances of foreign appointments were recorded. A vote of 
thanks to Dr. John V. Shoemaker, of Philadelphia, "for his services in behalf of 
the Congress, at home and abroad," was passed unanimously, and the Committee 
adjourned until 8 p. M. On re-assembling reports were received from the President of 
«ach of the eighteen Sections as to the progress and condition of his Section. Dr. 
Oscar Liebrandt, of Berlin, Germany, was appointed one of the Foreign Associate 
Secretaries, and Dr. H. O. Marcy, of Boston, was elected President of the Section of 
Gynaecology, to fill the existing vacancy caused by resignation, and the Committee 
adjourned to meet on June 6th, 1887, at Chicago. 
' MEETING AT CHICAGO, JUNE 6TH, 1887. 
On June 6th the Committee met at Chicago, at 10 A. M. Present, Drs. Davis, 
Hamilton and Arnold, of New York; Arnold, of Baltimore; Callender, Daly, Robin- 
Son, J. Lewis Smith, Andrews, of Buffalo; Briggs, Garnett, Pancoast, Chisolm, S. J. 
Jones, Marcy, Miller, Taft and Dunglison. Dr. Henry H. Smith, Chairman, being un- 
avoidably absent, Dr. N. S. Davis presided. The Committee on printing reported on 756 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the publication of circulars, etc. Various reports were received, and it was resolved 
that all registration fees from members should be retained by the Treasurer of the 
Congress, for the printing of the Transactions. The Chairman of the Committee of 
Arrangements reported progress to date, and that the United States Congress had made 
an appropriation to meet some of the expenses of the International Medical Congress. 
The thanks of the Executive Committee were tendered him for his valuable and la- 
borious services in obtaining the passage of the bill, by Congress, and the Committee 
adjourned. 
SECOND MEETING AT CHICAGO, JUNE 6tH, 1887. 
At 2.30 P. M., the Committee again met and reports were received from the Presi- 
dents of Sections. An allowance of time for the discussion of the papers presented in 
each Section was ordered to be made part of the Sectional programme. A report was 
made by the Committee on General Addresses before the Congress, and the accept- 
ances of those chosen were noted. The gentlemen elected and the subject of their 
addresses were as follows : "Fever : Its Cause, Mechanism and Rational Treatment." 
By Prof. Austin Flint, m.d., LL.D., of New York. "Scientific Medicine and Bacte- 
riology in their Relations to the Experimental Method." By Mariano Semmola, m.d., 
Director of the Therapeutic Clinic of the University of Naples ; Delegate of the Italian 
Government to the Congress. " Die Dermatologie in ihrem Verhältniss zur Gesammt- 
medicin." By Professor Unna, of Hamburg. "The Treatment of Recent Cases of 
Insanity in Private and in Asylums." By G. Fielding Blandford, M.D., F.R.C.P., Lond. 
Further nominations of Vice-Presidents of the Congress and Sections were made and 
approved. The Presidents of Sections in connection with the Secretary-General were 
appointed a Committee to complete the programme of the work of the Congress and its 
Sections. The President of the Congress was made "ex-officio " a member of the Com- 
mittee. The Executive Committee then adjourned to meet the next morning. 
THIRD MEETING AT CHICAGO, JUNE 7TH, 1887. 
The Committee reassembled at 9.30 A.M., June 7th. Present-Drs. Davis, Palmer, 
Chisolm, Taft, Briggs, S. J. Jones, Andrews, J. Lewis Smith, Callender, Garnett, 
A. B. Arnold, E. S. F. Arnold, Robinson, Daly, Pancoast, Marcy, Miller, Duuglison. 
Reports were made by the Presidents of the various Sections as to their progress 
and the condition of their work. The Committee on Printing were authorized to act 
with the Editor as a Committee for the publication of the Transactions. The Secretary- 
General and Chairman of Committee of Arrangements were also directed to arrange 
the hours of meeting of the Congress and Sections. 
The Committee of Arrangements were instructed to appoint a Registration Com- 
mittee, to act under the rules of the Organization. No Section was permitted to have 
separate entertainments, and it was ordered that the Transactions be issued in paper 
covers, except when specially ordered otherwise by a member of the Congress. The 
existing Auditing Committee was made a Standing Committee, with the addition of 
the Chairman of the Committee of Arrangements. A Reception Committee to receive 
Foreign Delegates arriving in New York, Philadelphia, Boston and Baltimore was also 
appointed, and an appropriation was made for their expenses, and the Executive Com- 
mittee adjourned to meet in Washington, on September 1st, 1887. 
MEETING AT WASHINGTON, SEPTEMBER 1ST, 1887. 
The Committee met on September 1st, 1887, on Thursday, at 12 o'clock M. Present 
-Drs. Henry H. Smith, Chairman, Davis, President, J. B. Hamilton, Secretary- 
General, E. S. F. Arnold, Treasurer, A. B. Arnold, Briggs, Pancoast, Chisolm, Ro- APPENDIX. 
757 
binson, Miller, Marcy, Green, Callender, J. Lewis Smith, S. J. Jones, Joseph Jones, 
Gihon, Taft, and Dunglison, Secretary. 
The President of the Congress was authorized to fill vacancies in the list of Foreign 
officers of the Congress by selections from the Foreign Delegates present, and the Presi- 
dents of Sections were instructed to do likewise in their Sections, and duly notify the 
Secretary-General of their action. It was directed that every facility should be afforded 
the Medical and Public Press to report the proceedings of the Congress and Sections, 
and that the Presidents of Sections should be responsible for the daily programme of 
their Sections. 
Papers presented and not assigned to the President of a Section were directed to be 
suitably assigned to a Section in accordance with the judgment of the Secretary-General. 
The Presidents and Secretaries of each Section were also ordered, as soon as possible 
after the adjournment of the Congress, to prepare for publication all papers and notes 
of the discussions offered and authorized for publication in their Sections, and that 
they should be responsible for arranging them in order, and that they should revise the 
final proofs. Adjourned. 
SECOND MEETING IN WASHINGTON, SEPTEMBER 1ST, 1887. 
The Committee met again at 3 P.M. Thirteen members present. Reports were 
received from the Chairman of the Finance Committee, the Executive Committee, the 
Committees on Reception of Foreign Delegates at New York, Philadelphia, Boston 
and Baltimore; the Presidents of Sections as to their condition; the Committee on 
Printing, etc. The following scientific men were then invited to seats in the Congress 
under rule 1: Prof. R. M. McCullough, of Baton Rouge, La., Prof. S. P. Langley, of 
Washington, the members of the Smithsonian Institute, of the American Philosophi- 
cal Association, Biological Society, Anthropological Society, all of Washington, D. C.; 
Prof. G. Brown Goode, of U. S. Fish Commission; Dr. Otis T. Mason, of Washington; 
Major J. W. Powell, of Geological Survey, Dr. Theodore Gill, of Washington; and Dr. 
James C. Welling, of Columbian University; and nominations of scientific men were 
then closed. The thanks of the Executive Committee were respectfully tendered to, 
and the Secretary-General instructed to forward the same to, the members of the 
Cabinet of the United States, the Attorney-General and the Secretaries of Foreign 
Legation, and invite them to seats on the stage of the Congress. 
On motion, it was ordered that no imprint of a publisher should appear in the 
Transactions, and that all monies accruing from " registration fees " should be reserved 
for the printing of the Transactions. After considering other routine business the Com- 
mittee adjourned. 
THIRD MEETING AT WASHINGTON, SEPTEMBER 2d, 1887. 
The Committee re-assembled at 10 A.M. ; present sixteen members. After the usual 
routine proceedings, a French and a German proof-reader were ordered to be employed 
in Washington, by the Secretary-General. Dr. Kleinschmidt, of Washington, was 
appointed a member of the Committee on Printing, in the place of Dr. E. S. F. Arnold, 
resigned. The Surgeon-General of the Russian Army, Professor Francois de Chaumont, 
and the Delegates specially presented by the Mexican Government, were officially 
appointed Vice-Presidents of the Congress, and added to the former list. 
FOURTH MEETING AT WASHINGTON, SEPTEMBER 3d, 1887. 
The Committee met at 10 A.M., and received the final report of Dr. A. Y. P. 
Garnett, Chairman of the Committee of Arrangements, in regard to the programme 
of social entertainments, excursions, etc., proposed for the following week, and an 758 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
announcement was ordered to be made of various private entertainments in honor of 
the Delegates, tendered to the Congress by several prominent citizens of Washington, 
on special invitations. 
A copy of the published Transactions was directed to be furnished, hereafter, to all 
State or County Societies that have given fifty dollars or upward to the funds of the 
Congress. Adjourned to September 7th. 
FOURTH MEETING IN WASHINGTON, SEPTEMBER 7TH, 1887. 
The Committee met at 1.30 p.m., after the adjournment of the Congress and the 
Sections ; present nineteen members. After routine business, free copies of the Trans- 
actions were ordered to be distributed only to the Foreign Members of the Congress 
in actual attendance at the meeting, except in cases of sickness or other good reasons 
satisfactory to the Publication Committee. The price of the Transactions was fixed at 
ten dollars to all desirous of purchasing the same, if the request and the money are 
forwarded to the Treasurer of the Congress not later than the 1st of November, 1887. 
Adjourned. 
FIFTH MEETING IN WASHINGTON, SEPTEMBER 8TH, 1887. 
The Committee met at 1.30 P. M. ; present thirteen members. After routine busi- 
ness, the Committee decided that after adjournment the next meeting should be at 
Cincinnati, on May 7th, 1888. Attention was called to false statements made in 
reference to the Congress by a daily journal of Philadelphia, reflecting on the Congress 
and the Committee of Arrangements; but after discussion, its publication was deemed 
unworthy of public notice by the Executive Committee. Adjourned. 
FIFTH MEETING IN WASHINGTON, SEPTEMBER 9TH, 1887. 
The Executive Committee met at 1.30 P.M. Resolutions of thanks for valuable 
services rendered to the Congress by Drs. N. S. Davis, Henry H. Smith, Richard J. 
Dunglison, John B. Hamilton and A. Y. P. Garnett were received, through the Pre- 
sident of the "Section of Public and International Hygiene." 
The following resolution was unanimously adopted :- 
Resolved, That the Executive Committee of the Ninth International Medical Congress 
present to Professor Charles Douglass Fergusson Phillips, M.D., of London, England, 
their most hearty thanks for his important services, in Great Britain, to the Congress, 
and for his able support of the Congress at its session in the city of Washington. 
Resolutions as to payment of bills, etc., after certification, were passed, and after 
other general business the Committee adjourned to meet in Cincinnati, in May, 1888. 
MEETING AT CINCINNATI, MAY 7TH, 1888. 
The Committee met at Cincinnati on May 7th, 1888. Present, Drs. Davis, 
Hamilton, Garnett, Miller, Daly, Pancoast, Chisolm, S. J. Jones, Taft, Briggs, Dun- 
glison. The Chairman, Dr. Smith, was accidentally absent. 
Dr. Davis in the Chair. 
The minutes of the last meeting in Washington were read and adopted. 
The Treasurer's Report was read, in his absence, by the Secretary. 
The Secretary-General made a statement as to the receipts and expenditures in 
Washington of the funds appropriated to the Ninth International Medical Congress by 
the United States Congress. He also gave a statement of the expenditures for printing, 
and an estimate of the probable amount needed hereafter to complete the printing of 
the Transactions, as these would probably require five volumes instead of the four first APPENDIX. 
759 
calculated on. He also stated the plan of distribution of the published volumes, I and 
II, of the Transactions. 
On motion, it was ordered that the Transactions be distributed as proposed, and a 
copy sent to members in smaller towns by express, at their individual expense, when 
the volumes were completed. 
The price of the Transactions, after May 7th, 1888, was fixed at $15.00. 
Resolutions were also presented in regard to the death of Dr. Palmer. Adjourned. 
I 
SECOND MEETING IN CINCINNATI, MAY 9TH, 1888. 
The Committee re-assembled on May 9th. Present, Drs. Henry H. Smith, Davis, 
Chisolm, Briggs, Taft, S. J. Jones, Hamilton, Pancoast, Daly, and Dunglison. 
On motion, it was ordered that no more copies of the Transactions be offered for sale 
at any price, until the Secretary-General and Treasurer are satisfied that all who have 
claim upon them are fully supplied. 
On motion, the Secretary-General was instructed to retain, at his discretion, at least 
fifty copies of the Transactions for a reserve distribution. 
On motion, the Editor of the Journal of the American Medical Association was re- 
quested to reprint the public document containing the letter of the Secretary of the 
U. S. Treasury to the Speaker of the House of Representatives, transmitting an itemized 
account of the expenditures of the appropriation made by the IT. S. Congress to the 
Ninth International Medical Congress, and that a copy of the same be sent to the 
Treasurer of the latter. 
The Chairman of the Executive Committee submitted two legal points for considera- 
tion : 1. In regard to the legal liabilities of the Printing Committee. 2. As to the 
future of the Executive Committee. 
On motion it was resolved that in withholding or not publishing papers or parts of 
papers presented to be read in the Sections, the j udgment of the Printing Committee 
be recognized as approved by the Executive Committee, and that the latter alone be 
responsible for such action. 
It was ordered that when the Executive Committee adjourns, it be to meet at 
10 A.M. on the first day of the next meeting of the American Medical Association, to 
hear reports of sub-committees, and to transact any other business that may come 
before it. Adjourned. 
The Committee then adjourned to meet at Newport, Rhode Island in June, 1889, 
for the final settlement of the business of the Ninth Congress. 
As at present constituted the following compose the Executive Committee. 
Henry Hollingsworth Smith, m.d., ll.d., of Philadelphia, Chairman. 
Nathan Smith Davis, m.d., ll.d., Chicago. 
John B. Hamilton, m.d., Washington, D. C. 
E. S. F. Arnold, m.d., m.r.c.s., New York. 
Richard J. Dunglison, m.d., Philadelphia, Pa., Secretary. 
Abram B. Arnold, m.d., Baltimore, Md.. 
William T. Briggs, m.d., Nashville, Tenn. 
De Laskie Miller, m.d., ph.d., Chicago, Ill. 
Henry O. Marcy, a.m., m.d., ll.d., Boston, Mass. 
Traill Green, m.d., ll.d., Easton, Pa. 
William H. Pancoast, m.d., Philadelphia, Pa. 
John H. Callender, m.d., Nashville, Tenn. 
* Alonzo B. Palmer, m.d., ll.d., Ann Arbor, Mich. 
* Died. 760 
NINTH INTERNATIONAL MEDICAL CONGRESS, 
J. Lewis Smith, m.d., New York. 
J. J. Chisolm, m.d., Baltimore, Md. 
S. J. Jones, m.d., ll.d., Chicago, Ill. 
William H. Daly, m.d., Pittsburgh, Pa. 
A. R. Robinson, m.d., New York, N. Y. 
Joseph Jones, m.d., ll.d., New Orleans, La. 
Albert L. Gihon, a.m., m.d, U.S. N. 
Judson B. Andrews, m.d., Buffalo, N. Y. 
Jonathan Taft, m.d., Cincinnati, Ohio. 
In concluding this brief history of the labors of the Executive Committee in the Organ- 
ization of the Ninth International Medical Congress, as obtained from the full minutes 
of its meetings kept by its Secretary, we cannot but note the amount of time required, 
in the meetings of the Executive Committee, to overcome the opposition made to the 
organization, by the acts of those to whom the matter was originally entrusted by the 
American Medical Association. Not only were there at each of the primary meetings 
numerous resignations of appointments made by this first Committee, of those deemed 
well calculated to exhibit the high professional qualifications known to exist in the 
United States, but earnest efforts were constantly made by the disaffected to act ad- 
versely on prominent men in Europe. So persistent were the statements made in two 
medical journals (New York and Philadelphia) that the Ninth Congress could never 
be organized or meet in the United States, and so frequent were the statements that the 
Congress should be held in Berlin or some other European capital, that the Executive 
Committee decided to counteract such misrepresentations, and issued the following cir- 
cular, signed by all its members:- 
Philadelphia, November 20th, 1885. 
SPECIAL announcement to the medical profession of all countries. 
The Executive Committee of the Ninth International Medical Congress, to meet in 
the City of Washington on the first Monday of September, 1887, having accepted, under 
Rule 10 of the Committee on Preliminary Organization, the charge of the business of the 
Congress, hereby give notice to the members of the medical profession, that they have 
been engaged upon, and have now nearly completed the arrangements for this meeting, 
and anticipate the hearty cooperation of the profession everywhere in developing this 
great scientific and humanitarian assembly. 
By order of the Executive Committee. Signed by all the Committee. 
With the view of creating harmony, and, if, possible, avoiding all adverse criticism, 
and in the hope of settling unseemly professional bickerings, the Executive Committee, 
at its meeting of Nov. 18th, 1885, decided to augment the numbers of the Executive Com- 
mittee to the limit of thirty originally assigned it, and to invite Drs. J. S. Billings, U. S. 
Army, J. M. Browne, U. S. Navy, Prof. J. M. DaCosta and Prof. Wm. Pepper, both of 
Philadelphia, with Drs. Christopher Johnson, of Baltimore, and G. J. Engelmann, of 
St. Louis, who were members of the first Committee appointed by the American Medical 
Association, to unite with the Executive Committee and participate in its action, several 
vacancies in the list of officers being left unfilled by the Executive Committee until their 
decision was made known. After a consultation with the other members of their original 
Committee, these gentlemen positively declined, ignoring the motto of the Philadelphia 
College of Physicians, in whose hall they met, of 1 ' Non sibi sed toti. ' ' The feebleness of 
this opposition and the slight amount of influence its members exercised on the medical 
Profession at home and abroad, was soon apparent, as shown by the favorable responses APPENDIX. 
761 
to the action of the Executive Committee, when they immediately filled all vacancies 
in the list of officers of the Congress and of the Sections ; by the assurance, promptly 
given to the Committee, of the support of the Profession in the United States and in 
Europe, in response to the circular (No. 2, p. 752) issued by the Committee ; by the 
liberal donations to the funds of the Congress by State and County Medical Societies ; 
by the assembling in Washington of a Congress of medical men from all sections of the 
globe, that has been but once exceeded in numbers in any International Medical 
Congress; by the character of its five octavo volumes of printed and illustrated Trans- 
actions, and the promptness with which, under the labors of the officers of the Execu- 
tive Committee, they have been presented to each member in acknowledgment of his 
comparatively small fee of membership. All must now recognize the fact that medical 
science is not the exclusive property of, or only cultivated by a few, no matter what 
their local greatness may be, but that the rank and file of our Profession are every- 
where its chief basis of support. Norwich, in Great Britain, and Lexington, Ken- 
tucky, furnished noted Lithotomists ; Danville, Kentucky, gave rise to Ovariotomy, and 
Lyons, France, was the residence of one widely known äs a Surgical Pathologist. 
These are but a few of the many instances that can be cited, of the talent found in 
towns that became widely known from the medical reputation developed in them by 
industry and ability, that often surpassed that more frequently sought for in large cities. 
Such lessons should not be forgotten, and, as history is said to repeat itself, perhaps 
the organizers of a future Medical Congress will find the material they desire to collect 
outside the cliques and circumscribed influences of a capital, and more abundant in the 
highways and by-ways of medical life; in towns, rather than in the sumptuous dwellings 
of the Dives of large cities. The progressive work of the Medical Profession in every 
clime is due mainly to the scientific investigations excited by the professional ambition 
of the rising practitioner, rather than to the work of those whose reputation is already 
established, and those organizing a future Congress, if desirous of illustrating the 
progress of medicine, should seek its exemplars in the hard working and practical 
experience of the practitioner, rather than in the less industrious but more opulent 
consultant. 
In organizing the Ninth International Medical Congress its Executive Committee was 
composed of representatives of every district of the United States. Its members 
traveled thousands of miles, at the sacrifice of their private business, and at their own 
expense, to attend its various sessions, and they have their reward in the consciousness 
of a duty well performed and in the publication of a series of investigations in 
medical science developed by the members of a Congress which they, in the face of 
a widespread disaffection, conducted to a successful termination, for the benefit of 
mankind in every clime. 
Philadelphia, August 21st, 1888. 762 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
GENERAL ERRATA. 
VOL. I. 
In list of names, Vol. I, the following changes should be noted :- 
1. For Charles C. li Banker," read Barker. 
2. Add the name of Dr. Roberts Bartholow, Philadelphia. 
3. For "Wm. Stroup Forwood, Darlington, Me.," read Wm. Stump Forwood, Dar- 
lington, Md. 
4. For C. E. "Lundgran," read Lundgren. 
5. For " Herman" W. Miller, read Truman. 
6. For Paul "Redardo," read Redard. 
7. For " Wm. Sloan Blythe, Ontario, Canada," read Wm. Sloan, Blythe, Ontario, 
Canada. 
Page 99. Wm. A. Buchanan. For Paris, "France," read Illinois. 
Page 102. For Edmund Servier "Chisholm," read Chisolm. 
Page 112. For "Alexander P. " Garnett, read Alexander Y. P. 
Page 116. For Oscar Noble " Heiss," read Heise. 
Page 117. For J. Wells " Herbert," read Hebert. 
Page 137. For William Motton Leland " Richards," read Rickards. 
Page 138. For Theophil "Rudolphia," readJRudolphi. 
Page 139. For Edward Martin ' ' Scheaffer, ' ' read Schaeffer. 
Page 140. For Robert Lowry ' ' Sibbett, ' ' read Sibbet. 
VOL. II. 
Lt. Col. Joseph R. Smith, Surgeon U. S. Army, requests the following changes in 
his article in Section in:- 
Page34- Line 9, for "equations 15°2* 60 X 2640 - 42.240,'' read equation 150 * fl0- X 
2640 = 27.720. 
Page 39. Line 20, for "great" ration, read given. 
Page 40. Line 10 from bottom of page, for " vide p. 8," read p. 36. 
Page 40. Line 3 from bottom, under salts, for " 0.576," read 0.0576. 
Page 44- Line 13, for page "40," read 4L 
Page 47- Last line of article, for " 30 oz." read 30.4 oz. 
VOL. in. 
Page 389. For "N. S. Davis," Chicago, Ill., read N. S. Davis, Jr. 
Page 389. Fifteenth line from bottom, read where originally, "not originally." 
Page 392. Second paragraph, fourth line, for " so, " read as. 
Page 392. Sixteenth line from top, read with the, not ' ' with. ' ' 
Page 392. Eleventh line from the bottom, for " Dirckwick-Holmfeld, " read Dirck- 
inck-Holmfeld. 
Page 394. Second line, read " growth while in," not growth in. 
Page 394- First paragraph, sixth line, for "now limited," read more limited. 
Second paragraph, for "this disintegration " read their disintegration. APPENDIX. 
763 
LIST OF SUBSCRIBERS 
TO 
THE TRANSACTIONS OF THE CONGRESS. 
Abbott, Samuel W., Boston, Mass. 
Ayres, S. C., Cincinnati, Ohio. 
Blake, George F., Royal College of Surgeons in Ireland (Dublin). 
Bartholow, Roberts, Philadelphia, Pa. 
Bontecou, Reed B., Troy, N. Y. (3 copies). 
Burwell, Geo. N., Buffalo, N. Y. 
Butler, Frank, Salisbury, Mo. 
Clark, E. W., Grinnell, Iowa. 
Cook, G. F., Oxford, Ohio. 
Cornell, Wm. T., New York, N. Y. 
Davenport, W. F., New York, N. Y. 
Emmett, Bache McEvers, New York, N. Y. 
Holmes, H. R., Salem, Oregon. 
James, B. W., Philadelphia, Pa. 
Jones, H. Webster, London, England. 
Jones, Stanhope, New Orleans, La. 
Kimball, E. S., Washington, D. C. 
Library of the New York Hospital, New York, N. Y. 
Marine Hospital Service, Washington, D. C. 
Marks, Solon, Milwaukee, Wis. 
McGrew, John S., Sandwich Islands. 
McIntyre, C. W., New Albany, Indiana. 
Renshaw, F. G., Pensacola, Fla. 
The Library of Congress, Washington, U. S. A. 
Westermann & Co., B., New York, N. Y. 
"Wisconsin State Board of Health." 764 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
NOTE BY THE EDITOR. 
In concluding the labor of the Editorial Supervision of the Transactions, the Editor 
desires to bear public testimony to the assistance he has received from the Presidents 
and Secretaries of the Sections; the Registrar; Dr. C. H. A. Kleinschmidt, of the Pub- 
lication Committee; and Professor Henri Larroque, teacher of languages, who read 
respectively the German and French text and furnished the titles in those languages ; 
and also to Dr. E. M. Schaeffer, who read the proof of the Section on Pathology. 
His labors have also been lightened by the efficient help of Mr. John C. Rowland, 
whose services as Stenographer and clerk have been given him from the beginning of 
his incumbency of the Secretary-General's office down to this date. 
He also wishes to acknowledge the work of Surgeon Fairfax Irwin, M. H. S., in the 
preparation of the Index to the first volume, and of Passed Assistant Surgeon Car- 
michael, M. H. S., who prepared the Indexes to the remaining volumes. 
Finally, he wishes to thank the Lithographers, Messrs. T. Sinclair & Son, of Phila- 
delphia, for the lithographic work, alike creditable to the Transactions and to the 
country in which they were produced; and the Printers, Messrs. Wm. F. Fell & Co., 
of Philadelphia, Pa., for the faithful execution of their contract, and the pains they 
have taken to meet the wishes of the Editor in the production of a work of the 
highest typographical excellence. 
There are, doubtless, many errors that have escaped observation, arising through 
want of authors' supervision of proof ; but as the work to be of value had to be pub- 
lished while the topics were still fresh, it was found quite impossible to submit proofs 
for correction to authors scattered as they were, throughout the world, and the manu- 
script was therefore followed by the printer as faithfully as possible. 
JOHN B. HAMILTON. 
9 B Street, N. W., Capitol Square, Washington, D. C., 
July 31st, 1888. INDEX TO VOLUME V. 
Abbot, Dr. Frank, 510, 622. 
Abortion, production of, demographically con- 
sidered, 210. 
Adair, Dr. Robert B., 713. 
Address by Pres, of Sec. XVI (Dr. A. L. Gi- 
hon), 2. 
XVII (Dr. J. B. An- 
drews), 226. 
XVIII (Dr. Jonathan 
Taft), 424. 
Air, ground, climatological and hygienic rela- 
tions of, 96. 
use of in dental therapeutics, 447. 
Alleghanies, climate and sanitary qualities of 
in North Carolina, 188. 
Allen, Dr. John, 500. 
Ames, Dr. W. B., 688. 
Amputations, histological changes in conse- 
quence of, 314. 
Andrews, Dr. Judson B., Pres, of Sec. XVII, 
225. 
Address of, 226, 253, 
280, 327, 328, 336. 
Dr. R. R., 503. 
Andrieu, Dr. E., 605. 
Aneurismal disease, miliary, 264. 
Angle, Dr. E. H., 565, 584, 585. 
Aphthous stomatitis, and its origin, 623. 
Appendix, 735. 
Arnold, Dr. E. S. F., 744. 
Arrangements, local committee of, 742. 
Art, dental, education in, 636. 
in dentistry, 494. 
Artificial climates, or house atmospheres, 83. 
teeth, articulation of, 658. 
Asheville, N. C., record of weather at, in 1886, 
198-201. 
Asylums, construction of, for insane, 412. 
English, private, treatment of insane 
in, 239. 
number of patients in, 236. 
State, organized since 1880, 235. 
tables of men and women employed 
in, 237. 
Atkinson, Dr. W. II., 527, 601, 625, 657, 658, 
673, 680. 
Atmospheres, house, or artificial climates, 83. 
Bacteria at certain elevations, table of, 42. 
in air of l'hôpital de la Pittié, Paris, 
table of, 93. 
Baker, Dr. Henry B., 52, 82. 
Bailey, Dr. C. M., 584. 
Bannister, Dr. H. M., 291. 
Baldwin, Dr. A. E., 444, 445, 585, 605, 688. 
Barrett, Dr. W. C., 444, 445, 446, 468, 480, 
583, 599, 604, 605, 658, 673. 
Battle, Dr. S. W., U. S. N., 80. 
Beach, Dr. Fletcher, 366. 
Bishop, Dr. Seth S., 321, 327, 328. 
Bishop's pocket insufflator, 331. 
Blandford, Dr. G. F., 270. 
Bödecker, Dr. C. F. W., 722. 
Bone grafting, 651. 
Borderland of insanity, 337. 
Bower, Dr. David, 279, 328. 
Brain, condition of, in children, 416. 
Brasseur, Dr. E., 447, 468. 
Brockway, Dr. A. H., 473. 
Bronchitis and pneumonia, tables of deaths 
from, 51 
chart of temperature, atmospheric, 
in relation to, 63, 72. 
table of deaths from, 50. 
Brower, Dr. D. R,., 335. 
Brown, Dr. E. P., 584, 698. 
Dr. George, 386. 
Brush, Dr. E. N., 326, 385, 407. 
Bryce, Dr. P. H., 27, 79, 83. 
Busch, Dr. Frederick, 565, 586, 598, 599, 600, 
601, 603. 
Butler, Dr. Chas. R., 483, 717. 
Cancer, 154. 
geographical distribution of, 151. 
California, medical topography of, 141. 
mineral and thermal springs of, 117. 
Caravens, Dr. Junius E., 474, 484, 680, 690.' 
Carmichael, D. A., P. A. Surgeon, M. H. S., 
764. 
Carr, Dr. William, 708. 
Carroll, Dr. C. C., 726. 
Case, Dr. C. S., 720. 
Chance, Dr. G. H., 444, 622. 
Channing, Dr. Walter, 308, 309, 326, 357, 390. 
Chart of temperature, atmospheric, in relation 
to bronchitis, 63, 72. 
of temperature, atmospheric, in relation 
to croup, membranous, 73. 
of temperature, atmospheric, in relation 
to influenza, 61. 
of temperature, atmospheric, in relation 
to phthisis, 70, 71. 
of temperature, atmospheric, in relation 
to pneumonia, 64, 65, 66, 67. 
of temperature, atmospheric, in relation 
to respiratory diseases, 74. 
of temperature, atmospheric, in relation 
to scarlet fever, 68. 
of temperature, atmospheric, in relation 
to small-pox, 69. 
of temperature, atmospheric, in relation 
to tonsillitis, 62. 
Chewing, Dr. G. H., 721. 
765 766 
INDEX TO VOLUME V. 
Chicago, meeting of Executive Committee at, 
755, 756. 
Children, condition of brain in, 416. 
Chorea, geographical distribution of, 151, 157. 
Cincinnati, meeting of Executive Committee 
at, 758, 759. 
Circular for the information of officers, 750. 
insanity, solution of phases of, 266. 
No. 2, 752. 
Cities, effects of overcrowding in, 165. 
Clark, Dr. Daniel, 266, 270, 272, 336. 
Classification of insanity, note on, 291. 
Cleveland, Ohio, meteorological [influence on 
diseases of, in 1886, 160. 
Climate and malaria, 138. 
and sanitary qualities of western 
North Carolina, 188. 
meteorological elements of, and effects 
upon human organism, 17. 
of Swiss Alps in pulmonary cases, 125. 
Climates, American, 109. 
artificial, or house atmospheres, 83. 
Climatic influence in endemic plagues, 180. 
Climatological instrument, use of thermometer 
as, 172. 
Climatology and demography, dependencies of 
medicine on 
domain of, 2. 
Section XVI, 
officers, list of, 
1. 
importance of study of, in science 
of medicine, 21. 
Clinics in operative dentistry, 708. 
Coan, Dr. Titus M., 81, 82, 109, 151. 
Cocaine, experimental and clinical observa- 
tions of, 418. 
Cold weather diseases, order of succession in, 
53. 
Cole, Dr. R. Beverly, 737, 738. 
Committee, Executive, 741, 753. 
first meeting of, 742. 
rules of order of the, 
743. 
to arrange for meeting of the Con- 
gress, list of, 736, 737. 
Congress, Executive Committee of the, 741. 
officers of the, 741, 752. 
rules of the, 739. 
Conrad, Dr. Wm., 688, 708, 711, 721. 
Cowles, Dr. E., 342. 
Cranium, prow-shaped, in neurotic ailments, 
319. 
Crego, Dr. F. S., 335. 
Crenshaw, Dr. Wm., 711. 
Crime, insanity as a defense in, 352. 
Croup, membranous, chart of temperature, at- 
mospheric, in relation to, 73. 
Cruttenden, Dr. H. L., 430, 658. 
Cunningham, Dr. Geo., 484, 680, 707. 
Curtis, Dr. G. L., 721 
Davenport, Dr. Isaac B., 674. 
David, Dr. Th., 623. 
Davis, Dr. Lloyd L., 718. 
N. S. (Pres. Ninth International 
Med. Congress), 563. 
testimonial to, 705. 
Deaths and temperature, tables of average, 77. 
Delusions, religious, of insane, 253. 
Delusions, systematized, cases of, in Boston 
Lunatic Hospital, 290. 
Demography and Climatology, dependencies of 
medicine on domain of, 2. 
Denison, Dr. Charles, 26, 28, 79, 82. 
Dental art, education in, 636. 
fibril, origin of, 503. 
Surgery. (Sec. XVIII) Officers, list of, 
421. 
systems, necessity for international in- 
quiry into, 624. 
therapeutics, use of air in, 447. 
tissues and development of teeth, photo- 
micrographs of, 521. 
Dentine protective, or of repair, 511. 
Dentistry, art in, 494. 
development and progress of, 424. 
operative, clinics in, 708-731. 
power applied to, 663. 
prosthetic, clinics in, 722. 
Dentures, artificial, compared with porcelain 
crown and bridge work, 698. 
Dickinson, Dr. Wm. P., 712. 
Discord and Harmony, Disease and Health,etc., 
674. 
Disease, aneurismal miliary, 264. 
native treatment of in Syria, 218. 
Diseases of cold weather, order of succession in, 
53. 
Dolan, Dr. Thomas M., 210. 
Down, Dr. J. Langdon, 319, 405. 
Driggs, Dr. Stoddard, 719. 
Dubois, Dr. Paul, 624. 
Dudley, Dr. A. M., 439, 447, 585, 605, 621,623, 
624, 674. 
Dunglison, Dr. Richard J., 735. 
Duquet, Dr. E. E., 309, 335. 
Duties of officers, 750. 
the Executive Committee, 751. 
Dwindle, Dr. W. IL, 705. 
Education in dental art, 636. 
Elephant, tusk of, relative to comparative path- 
ology of teeth, 586. 
Eliot, Dr. Gustavus, 331. 
Elliot, Dr. W. St. George, 663. 
Ellis, Dr. II. D., 280, 335, 341. 
Endemic plagues, climatic influence in deter- 
mining exemption from, 180. 
Equivalents, modern, of monomania, 281. 
Errata, general, 762. 
Endarteritis vegetative, cause of hemiplegia, 
410. 
Evolution of structure, function control of, 670. 
Executive Committee and Secretaries of Section 
XVIII, vote of thanks 
to, 707. 
duties of the, 751. 
meeting of at Chicago, 
755, 756. 
meeting of at Cincinnati, 
758, 759. 
meeting of at New York, 
742. 
meeting of at Pittsburgh, 
754. 
meeting of at St. Louis, 
749, 754. INDEX TO VOLUME V. 
767 
Executive Committee, meeting of at Washing- 
ton, 744, 756, 757, 758. 
of the Congress, 741, 753, 
759. 
rules of order of the, 743. 
Face, form and expression of, 500. 
Facial nerve, origin of upper (ocular) division 
of, 311. 
Farrar, Dr. J. N., 573. 
Fazio, Dr. Eugenio, 132. 
Fecundation, evils of prevention, demographi- 
cally considered, 210. 
Fell, Wm. F., & Co. (Printers), 764. 
Ferguson, Dr., 271, 326, 383. 
Fibril, dental, origin of, 503. 
Fillebrown, Dr. Thos., 478, 625. 
Fillings, porcelain, 667. 
Fisher, Dr. Theo. W., 281, 386. 
Fletcher, Dr. M. H., 511, 546. 
Forests, climatic and sanitary influences of, 
132. 
Freeman, Dr. Daniel, 715. 
Friedrichs, Dr. G. J., 494, 603, 604. 
Frigerio, Dr. Louis, 410. 
Genese, Dr. D., 445. 
Geographical distribution of rheumatism, can- 
cer, rickets, chorea, and urinary calculus, 
151. 
Geography, medical, and vital statistics, 179. 
Geran, Dr. J. P., 710. 
Gertstrom, Dr., 336. 
Gihon, A. L., Medical Director, U. S. N., 
Pres, of Sec. XVI. Ad- 
dress of, 2. 
on Orotava, 81. 
Gill, Dr. Henry Z., 160. 
Gish, Dr. J. L., 582. 
Goddard, Dr. C. L., 547. 
Godding, Dr. W. W., 352, 384. 
Godon, Dr. Ch., 636. 
Gottschaldt, M. Chs., 722. 
Great Britain, care of insane in, relative to em- 
ployment of mechanical 'restraint, 238. 
Grevers, Dr. John E., 424. 
Ground air, climatological and hygienic rela- 
tions of, 96. 
Guilford, Dr. S. H., 472, 488. 
Gundry, Dr. R., 339, 369, 391. 
Hamilton, Dr. John B. (Editor), thanks foi- 
assistance rendered, 764. 
Harding, Dr. W. E., 483. 
Harlan, Dr. A. W., 481. 
Harmony and Discord, Health and Disease, 
Harvéy, Dr. H. F., 711. 
Haskell, Dr. L. P., 582, 722. 
Hay fever, pathology of, 321. 
Haviland, Alfred, m.r.c.S., 179. 
Hawaiian people, demographic effects of lep- 
rosy on, 202. 
History of the Organization of the Ninth In- 
ternational Medical Congress, 735. 
Hemiplegia, left, succeeding vegetative endar- 
teritis, 410. 
Hofheinz, Dr. R. IL, 711. 
Homen, Dr. E. A., 314, 318. 
Horton, Dr. W. P., 621, 622. 
Hospital construction for insane, 412. 
House atmospheres, or artificial climates, 83. 
Hughes, Dr. C. IL, 272, 294, 309, 358, 384, 388, 
406, 407. 
Hunt, Dr. R. Finley, 431. 
Hurd, Dr. H. M., 253, 326, 369, 383, 408. 
Idiocy, due to inherited syphilis, 360, 362, 366. 
Implantation and pericemental life, 691. 
Inflammatory processes in oral tissues, 530. 
Influenza, chart of atmospheric temperature in 
relation to, 61. 
table of, 60. 
Ingersoll, Dr. L. C., 530, 546. 
Insane, care of in United States and Great 
Britain relative to employment of 
mechanical restraint, 238. 
in the United States, distribution and 
care of, 226. 
reform in nursing, 342. 
religious delusions of, 253. 
Insanities, primary, classification of, 292-293. 
Insanity, as a defence for crime, 352. 
associated with acute syphilis, 370, 
373. 
circular, solution of phases of, 266. 
early symptoms and treatment of, 337. 
moral, 357. 
nature and definition of, 294. 
note on classification of, 291. 
occupation in treatment of, 273. 
in treatment of, in Eng- 
lish private asylum, 
279. 
relation of syphilis to, 359, 374, 375- 
379. 
International inquiry relative to dental sys- 
tems, 624. 
Irwin, Fairfax, Surgeon M. H. S., 764. 
Jackson, Dr. V. H., 584, 723. 
Jaws and teeth, irregularities of, 550. 
Jennison, Dr. M. G., 494. 
Jones, Dr. J. W., 151. 
Kay, Dr. Thomas W., 218. 
Kelly, Dr. J. E., 26, 28. 
Kirk, Dr. E. C., 687. 
Kleinschmidt, Dr. C. H. A., 764. 
Knapp, Dr. J. Rollo, 705, 720. 
Kölliker, Dr. Paul A., 729. 
Körösi, Dr. Joseph, 151. 
Kretzchmar, Dr. Paul II., 25, 28, 80, 150. 
Larroque, Prof. Henri, 764. 
Leighton, Dr. A. W., 150. 
Leprosy, demographic effects of, on Hawaiian 
people, 202. 
Lewis, Dr. J. Hall, 722. 
List of names of committee to arrrange meeting 
of the Congress, 736. 
subscribers to the Transactions, 
763. 
Local Committee of Arrangements, 742. 
Ludwig, Dr. R. F., 709, 711. 768 
INDEX TO VOLUME V. 
Lungs and air passages, relations of meteoro- 
logical conditions to diseases of, 52. 
Lydston, Dr. Frank J., 439. 
Lynch, Dr. John S., 738. 
Macdonald, Dr. J. D., 96. 
MacLeod, Dr. Wm. B., 423, 728. 
Malaria and climate, 138. 
Marcy, Dr. Henry 0., 188. 
Marshall, Dr. J. S., 430, 651, 658. 
W. C., 711. 
Matrices as adjuncts in filling teeth, 484. 
McCausey, Geo. H., 708. 
McNutt, Dr. W. F., 117. 
Medicine, importance of study of climatology 
in, 21. 
Mendel, Dr. E., 311, 357, 402. 
Mental diseases, international classification of, 
308. 
Merriam, Dr. H. C., 728. 
Meteorological conditions, relations of to dis- 
eases of lungs 
and air passages, 
52. 
table of, 164. 
influence of, on disease, in 
Cleveland, Ohio, 160. 
Metnitz, Dr. J. Von, 423, 490. 
Mickle, Dr. Wm. J., 404, 407. 
Miliary aneurismal disease, 264. 
Mineral and thermal springs of California, 
117. 
waters, American, 109. 
classification of, 99, 100. 
therapeutic action of, 98. 
Monomania and its modern equivalents, 281. 
primary, 286-288. 
Moisture and dryness, table of, 40. 
tables of, 31, 32. 
Moore, Dr. E. C., 667, 715. 
Jno. W., 45. 
Moral insanity, 357. 
Morgan, Prof. W. H., 422, 471, 482. 
Morris, Dr. J. Cheston, 25. 
Morrison, Dr. W. N., 582, 710. 
Mummery, J. Howard, m.r.c.S., l.d.s., 521. 
Nerve, facial, origin of upper (ocular) division, 
311. 
Nerves, peripheral changes in, after amputation, 
314. 
Neuralgia of temporo-maxillary articulations, 
operation for, 651. 
treatment of, in general practice, 
331. 
Neurotic ailments, prow-shaped cranium in, 
319. 
New York, meeting of Executive Committee 
at, 742. 
Nichols, Dr. C. H., 405. 
Niles, Dr. E. S., 715. 
Ninth International Medical Congress, history 
of the organization of, 735. 
North Carolina, western, climate and sanitary 
qualities of, 188. 
Nunn, Dr. Richard J., 25, 180. 
Nursing, for insane, reform in, 342. 
Occupation, in treatment of insanity, 273. 
in treatment of insanity, in Eng- 
lish private asylums, 279. 
Officers of the Congress, 741, 752. 
etc., duties of, 750. 
Oral surgery (Section XVIII). Officers, list 
of, 421. 
tissues, inflammatory processes in, 530. 
Organism, human, effects of meteorological ele- 
ments of climate on, 17. 
Organization of the Ninth International Medi- 
cal Congress, history of the, 735. 
Orthodontia, notes on, 565. 
Osteomyelitis, 490. 
Ottofy, Dr. Louis, 708. 
" Overcrowding," effects of, in cities, 165. 
Owen, Dr. Isambard, 151. 
Palmer, Dr. Jas. G., 721. 
Paranoia, forms of, 285. 
Parker, Dr. Wm, Thornton, 21, 28. 
Parr, Dr. H. A., 722, 725. 
Parrish, Dr. Joseph, 138. 
Pathology, comparative, of teeth, 586. 
of hay fever, 321. 
of syphilis, 408. 
Patrick, Dr. J. J. R., 625. 
Patrons of the Congress, 752. 
Peck, Dr. F. H., 657. 
Pericemental life and implantation, 691. 
Phthisis, chart of temperature, atmospheric, in 
relation to, 70, 71. 
preferable climate for, 28. 
Photo-micrographs of dental tissues and teeth 
development, 521. 
Pittsburgh, meeting of Exec. Com. at, 754, 755. 
Pneumonia and bronchitis, tables of deaths 
from, 51. 
chart of temperature, atmospheric, 
in relation to, 64-67. 
table of deaths from, 50. 
Pneumonic fever, seasonal prevalence of, 45. 
Pocket insufflator, Bishop's, 331. 
Porcelain crown arid bridge work compared 
with artificial dentures, 698. 
fillings, 667. 
Porre, Dr. R. J., 431, 444, 445, 446. 
Porter, Dr., 341. 
Power, as applied to dentistry, 663. 
President of Sec. XVI, vote of thanks to, 224. 
Sec. XVIII, vote of thanks to, 
430, 705. 
Price, Dr. Sherman B., 715. 
Prosthetic dentistry, clinics in, 722. 
Prow-shaped cranium in neurotic ailments, 
319. 
Psychological medicine and nervous diseases 
(Sec. XVII) officers, list of, 225. 
Pulmonary diseases, climatic attributes in 
arrest of, 28. 
Pulpless and abscessed teeth, cure of by imme- 
diate method, 680. 
teeth, management of, 474, 680. 
Pyaemia, chronic, of dental origin, 431. 
Rawls, Dr. A. 0., 545. 
Rehwinkel, Dr. F. H., 445, 598, 600. INDEX TO VOLUME V. 
769 
Respiratory diseases, chart of temperature, at- 
mospheric, in relation to, 74. 
Rhein, Dr. M. L., 494, 547. 
Rheumatism, acute, geographical distribution 
of, 151, 153. 
Rickets, 154. 
geographical distribution of, 151. 
Robertson, Dr. Jno. W., 141. 
Rohé, Dr. Geo. H., 17, 27. 
Rosenthal, Dr. M., 418. 
Rowland, John C., stenographer, 764. 
Rules of order of the Executive Committee, 
743. 
the Congress, 739. 
Russell, Dr. I., 335, 337, 385. 
Salmon, Dr. I. A., 584. 
Savage, Dr. G. H., 252, 266, 270, 318, 357, 359, 
361, 362, 366, 369, 370, 373, 382, 386, 
387, 388, 389, 390, 400, 407, 408. 
Scarlatina, table of meteorological conditions 
affecting prevalence of, 94. 
Scarlet fever, chart of temperature, atmos- 
pheric, in relation to, 68. 
Schaeffer, Dr. E. M., 764. 
Schauffler, Dr. Edward W., 80. 
Secretaries of Section XVIII, vote of thanks 
to, 707. 
Section XVI, Medical Climatology and De- 
mography, officers, list of, 1. 
XVII, Psychological Medicine and 
Nervous Diseases, officers, list of, 
225. 
XVIII, Dental and Oral Surgery, offi- 
cers, list of, 421. 
vote of thanks to executive 
committee and secretaries 
of, 707. 
Shepard, Dr. L. D., 605, 619. 
Shoemaker, Dr. John V., 737. 
Shriver, Dr. F. M., 725, 728. 
Shumway, Dr. T. D., 708, 710. 
Shuttleworth, Dr. G. E., 362. 
Sickness and temperature, tables of average,75, 
76, 78. 
Sinclair, T. & Son (Lithographers), 764. 
Sitherwood, Dr. Geo. D., 689. 
Six years' tooth, 605. 
Sjoberg, Dr. Ernst, 424. 
Smallpox, chart of temperature, atmospheric, 
in relation to, 69. 
Smart, Dr. Charles, 172. 
Smith, Dr. Frank F., 81. 
Dr. Henry H., 735. 
M. E., 710. 
Spaulding, Dr. W. A., 582, 716. 
Spinal cord and ganglia, changes in, after am- 
putation, 314. 
Spitzka, Dr. E. C., 264, 313, 318, 385, 388, 
406. 
Sprinkel, Dr. G. A., 721. 
Stack, Dr., 689. 
Starr, Dr. A. R., 717. 
St. Louis, meeting of the executive committee 
at, 749, 754. 
Stomatitis, aphthous, and its origin, 623. 
Storey, Dr. J. C., 446, 546, 585, 689. 
Stowell, Dr. S. S., 724. 
Structure, evolution, function, control of, 670. 
Subscribers to the Transactions, 763. 
Sudduth, Dr. W. X., £19, 528. 
Surgery, Oral and Dental, Section XVIII, offi- 
cers, list of, 421. 
Swartwout, Dr. E. L., 720. 
Swiss Alps, climate of, in pulmonary cases, 125. 
Syphilis, acute, insanity associated with, 370, 
373. 
associated with general paralysis, 392. 
congenital, 361, 
inherited, 360, 361, 362, 366. 
pathology of, 408. 
producing epilepsy, 387. 
mental weakness, 389. 
relation of, to insanity, 359, 374, 375, 
379. 
Syria, native treatment of disease in, 218. 
Table of average sickness and temperature, 75, 
76, 78. 
deaths and temperature. 77. 
of bacteria at certain elevations, 42. 
of bacteria in air of l'hôpital de la Pit- 
tié, Paris, 93. 
of cases, relation of insanity to syphilis, 
375-379. 
of deaths from bronchitis, 50. 
pneumonia, 50. 
of deaths from bronchitis and pneumo- 
nia, 51. 
of deformities in jaws, 552-555. 
of influenza, 60. 
of men and women employed in asylums, 
237. 
of meteorological conditions, 164. 
of meteorological conditions affecting 
prevalence of scarlatina, 94. 
of moisture, 31, 32. 
of moisture and dryness, 40. 
record of weather at Asheville, N. C., in 
1886, 198-201. 
showing mode of care of insane in Great 
Britain and U. S., 248-252. 
Taft, Dr. Jonathan (President Section XVIII), 
421, 422, 423, 430, 483, 
484, 527, 563, 565, 585, 
657, 705. 
address of, 424. 
Talbot, Dr. E. S., 550, 585. 
Teeth and jaws, irregularities of, 550. 
artificial, articulation of, 658. 
comparative pathology of, 586. 
development, photo-micrographs of, 521. 
irregularities of, 625. 
irregularity of, cause of pain in temporo- 
maxillary joint, 547. 
matrices as adjuncts in filling, 484. 
pulpless and abscessed, curability of by 
immediate method, 680. 
pulpless, management of, 474, 680. 
Temporo-maxillary joint, operation for neural- 
gia of, 651. 
pain in, from irregu- 
larity of teeth, 547. 
Thackston, Dr. W. W. H., 422. 
Therapeutics, dental, use of air in, 447. 
Thermal and mineral springs of California, 117. 
Thermometer as a climatological instrument, 
172. 
Thompson, Dr. Alton H., 670, 674. 
Timme, Dr. C. A., 715, 720. 770 
INDEX TO VOLUME V. 
Tonsillitis, chart of temperature, atmospheric, 
in relation to, 62. 
Tooth of six years, 605. 
Topography, medical, of California, 141. 
Truman, Dr. James, 471. 
Tuke, Dr. D. Hack, 238. 
Tuttle, Dr. W. L., 80. 
United States, care of insane in, relative to 
employment of mechanical restraint, 238. 
Urinary calculus, 159. 
geographical distribution of, 
151. 
Vital statistics and medical geography, 179. 
Walker, Dr. Joseph, 444, 446. 
Walton, Thos. C., U. S. N., 45. 
Wardner, Dr. Horace, 273. 
Warner, Dr. Francis, 416. 
Washington, D. C., meeting of Executive Com- 
mittee at, 744, 756, 757. 
Wassail, J. W., 709. 
Waters, Dr. T. S., 716, 727. 
minerai, American, 109. 
classification of, 99, 100. 
therapeutic action of, 98. 
Weeks, Dr. T. E., 484, 717. 
Wernich, Von, Dr. Agathon, 165. 
Whitefield, Dr. Geo. W., 446, 472, 710, 712. 
Wigglesworth, Dr. Joseph, 373. 
Wise, Dr. P. M., 412. 
Wise, Dr. A. Tucker, 125. 
Wolverton, Dr. T., U. S. N., 96. 
Woodhouse, Dr. R. Hall, 712. 
Woodruff, W. H., 721. 
Woods, Dr. George W., 202. 
Yellowlees, Dr. David, 308, 405. 
Younger, Dr. W. J., 445, 446, 691, 712, 715. TRANSACTIONS 
OF THE 
International Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
BY 
JOHN B. HAMILTON, M. D., 
Secretary-general. 
VOLUME V. 
WASHINGTON, D. C., U. S. A. 
1887.